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Why CCG repeat prescribing plans are not thought through

"Go back to the drawing board"

Plans to prevent pharmacies from ordering repeat prescriptions have not considered the consequences, says Benjamin D'Montigny

Repeat prescriptions are the core of every pharmacy business. They contribute to prescription numbers at the end of the month and they also give an indication of future dispensing figures, which can provide an idea of how busy the pharmacy will be. There are a lot of benefits to this, including knowing if staff levels need to be increased and whether a pharmacy is able to plan for service provision. 

When reading about the three clinical commissioning groups (CCGs) in the north west of England and East Anglia implementing schemes to stop pharmacies from reordering prescriptions, I considered this to be a knee-jerk reaction that casts pharmacy in a negative light.

I would be more inclined to look at the system that allows medicines to be prescribed excessively in the first place. Every pharmacy has a different way of ordering, every surgery has a different way of processing, and every prescriber has a different way of prescribing. There is a lack of unity, a lack of information, and a lack of communication.

Medicine wastage is often highlighted as a reason for pharmacists needing to change how they work, but is part of the responsibility also with the prescriber? When you see zopiclone on a monthly repeat, you begin to wonder how much effort has really been put into a patient’s treatment regime – considering it is intended for short-term use to treat insomnia for up to four weeks.

The CCGs have not considered the hard work pharmacy does in syncing medication so a patient doesn’t have to come in every other day. Or how adherence issues are identified, how items that are not available are requested with alternative suggestions already written down for approval. There is an awful lot pharmacy does to make the process work successfully for the patient. Pharmacies are champions of medicine supply. 

Many other questions spring from the CCG's plans. How would blister packs work? How would it affect care homes and house bound patients? How are “special measures” decided? How are medicines synced for 28-day cycles? There are many fatal flaws in their intrepidness.

If ordering through pharmacies was stopped overnight, my predictions are simple:

  1. Pharmacy phone lines would be swamped with patients who have run out of medications, attempting to arrange an urgent request, to which we’d have to say: "Unfortunately we have no control over ordering your medicines any more."
  2. Surgery phone lines would be swamped constantly – even more than they are currently – with patients demanding why their prescription hasn’t been sent to the pharmacy yet.
  3. Many patients would go without for various degrees of time, from a few days for the ones who are constantly after their scripts, to weeks for the housebound patient who “didn’t want to be an inconvenience".

If this is to go ahead, the ordering system as a whole will need an upgrade. We need to see at what stage a script request is at, delays that have occurred and the reasons why, and dates when it will be ready for collection/release onto the spine. We’d also need clear lines of communication with surgeries to deal with the inevitable stream of queries pharmacy would get. 

Go back to the drawing board, the idea is incomplete at best.

Benjamin D’Montigny is a locum dispenser working in the south of England

20 Comments

Fionn McDonald, Pharmacy Area manager/ Operations Manager

Over ordering comes from the mindset that 'a bird in the hand is worth two in the bush'; which essentially a mindset of imagined scarcity feeding greed that we've all seen in the run up to every bank holiday.

Removing a problematic, but workable solution but failing to produce an alternative solution is not a great long term strategy which is why I propose the following.

Enforcement of the use RA/RD prescribing and the end of 'branded generics' would be a better method to cut down on waste as it alays the classic patient fear of not getting a prescription on time because there's no mystery factor of will the surgery 'reject the request', will it arrive on time, will the item be in or will it be the item I'm expecting. 

Benjamin Leon D'Montigny, Non Pharmacist Branch Manager

I agree and can collaborate this as being a common reason I've been given many a time. I feel this is the correct road both surgery and pharmacy should be going down in terms of tackling medicine wastage through excessive prescribing.

Mark Galloway, Pharmacy

There is no doubt that medicines waste results from failures across the system including poor GP repeat prescribing systems, some patients often relinqueshing responsibility for their repeat medication entirely but also poor community phaermacy managed repeat systems.

Much of what you say focuses on the impact on community pharmacy rather than on patients. You highlight what might be in a number of very good community pharmacies but the average is, in my view, very average in respect of repeat prescription ordering.

When I was in community pharmacy there was none of this, yes we dealt with issues around repeat prescribing but invariably the patient ordered their own medication and was involved in the process. Unfortunately with so many managed repeat systems the patient often becomes a passive bystander as repeat list items are delivered to their door "no questions asked" month on month. This is unacceptable in my view.

Our own estimates for our CCG is that as many as 0.5M, of a total of just over 8M, prescription items per year are prescribed and dispensed which are not required and over 50% of all repeats are now ordered by the patient's pharmacy.

Re-empowering patients to take charge of their own medication needs is absolutely vital to improve prescribing quality and reduce waste.

In my view pharmacy should remove itself from the shackles of managing patients medication ordering to concentrate on delivering their core services to an even higher standard than they already provide.

This would improve their lives and those of their patients.

Mark Galloway

CCG Head of Medicines Management

 

Z ZZzzzz, Information Technology

Mark, I would be interested to hear your considered view of the Community Pharmacy Forward View document that was released a couple of days ago.  Page 10 supports managed repeats using eRD.  With CCGs trying to stop managed repeats does that mean like anything else PSNC has a vision for, this is just another dead duck.  How can you and the CCGs possibly trust pharmacist prescribers not to prescribe in the most cost inefficient way to the benefit of their employer.  As a future member of the NHS user-brigade I thought the pages 18 and 19 "Day in the life..." scenario was complete Utopia, and would love it to be true.  Within 5 years - they have to be kidding themselves.  Just think how long it has taken to get EPS to where it is now, and it still does not work properly or efficiently.  (I apologise for being slightly off topic, but I think the two are linked.  CCGs trying to get rid of managed repeats, and the CPFV document predicting nothing but managed repeats for LTCs.)

Benjamin Leon D'Montigny, Non Pharmacist Branch Manager

The necessity of reducing medication wastage in our NHS is completely without question, I completely agree, however my personal concerns stems from are we risking accessibility for our patients and leaving pharmacy without, at the very least, the tools required to facilitate empowering patients with managing their own healthcare, even with the basics such as having an audit trail of how any repeat is progressing?

So is something to consider a universially accessible order auditing system that can viewed by patient and pharmacy to enable that envitable question - "Do you have my prescription?". Think of it as an ordering SCR.

By removing ourselves from the shackles of ordering, and removing our hands from the wheel, we are also endangering the car to crash and burn without a comprehensive, universial ordering system in place which will be in my opinion of great benefit to patient regardless of how repeat ordering will develop.

Benjamin Leon D'Montigny, Non Pharmacist Branch Manager

*Duplicate*

Mark Galloway, Pharmacy

I don't see the issue with accessability as there are so many ways now of patients talking directly to their practice to order their prescriptions including on-line, texting, email, post and newer services provided by several CCGs on the contact centre model. We really do need to address the issue of poorly operated managed repeat systems as these have become part of the problem rather than being part of a solution, which they could be.

I would be in favour of a tracking system and to an extent we already have that with EPS. However there is no substitute for patient's taking control, placing their own order and then collecting, or having delivered, their prescription needs.

Our experience is that by doing that there is no car crash, to use your analogy, but an improved patient experience. This does not reflect badly on pharmacy as its position in the healthcare system is highly rated.

Nil desperandum!

Mark  

Dave Downham, Manager

There speaks a pharmacist no longer in practice. Please could you train my 84 year old grandmother how to text or how to use a computer? Or, I suppose, she could write a nice letter. It is very clear that some CCGs no longer trust those damned private sector pharmacies who are all out to make a fast buck while mercilessly ripping off the state.

Lancelot Spratt, Accuracy checking technician

My 88 year old grandad orders his scripts online using his iPad. Maybe you should teach your granny to order her scripts.

Fran Husson, Administration & Support

What an interesting discussion!!  First of all, I am a “patient” [a 72 year old with LTCs] but more importantly a Community Pharmacy champion and activist. Why? Because of my volunteer and outreach work on issues such as discharge from secondary care into the community, medicine optimisation, patient awareness of medicines, polypharmacy, let alone of drug resistant infection and finally my own experience following a complex and challenging [for my life saving acute care specialists] medical history.

Community pharmacy IS the front line for health treatment and care and very often, as I can observe in areas of London where home visiting nurses/health care workers have more or less vanished, the only tangible and efficacious community health service which assures dispensing and provision of medicines to the home of vulnerable patients, either directly or via trusted proxies.

To remove the facilitation of the repeat prescription process is simply criminal! Many patients with severe physical/mental deficits do need the responsible hand of the community pharmacist to manage the timely dispensing of their medications, as they need other services as well as guidance and advice at more or less any time, since pharmacies more or less function 24/7.

I fully agree with Angela Channing [first comment above] that patients should indeed be more activated, responsible and accountable for the management of their prescribed and OTC medicines.  But, even leaving asides factors relating to ageing population, we are far from attaining high level of health literacy and personal health accountability on the part of the public.  

Population health improvement needs the community pharmacy.  The community pharmacist is the medicines expert [and in many cases, the only one!] who can conduct a rigorous medication review with the patient; while nudging the patient into questioning why medicine X has been prescribed in the first place or has not been changed at his/her next GP consultation.  Discussing a repeat prescription with the patient is one hell of step on the road to helping patients better understand their medication regimen.

And yes, there is also that private consultation room in every pharmacy which is such a haven for the patient who feels either foolish or reticent at his/her zillions of questions about medications, side effects, symptoms etc…

Benjamin Leon D'Montigny, Non Pharmacist Branch Manager

It sounds like you're more engaged then the CCGs has ever been on issues. There's a lot of work that community pharmacy does and it's accessibility has been a long-standing benefit to patients for years now, you're quite right. Part of that accessibility is being able to order repeat medication. Optimisation and cost-savings are important for the NHS, but there are many better ways to do this and should never be at the detriment of patients like this scheme is.

Angela Channing, Community pharmacist

Ben, 20 yrs ago, people managed quite happily ordering and collecting their own scripts. Patients just need re-training. The problem today, in life, as much as in pharmacy, is that people have now become used to being told that someone else will do something for them, someone else will pay, someone else will...... etc, etc, etc. People have lost the ability to do things for themselves. Personally I blame Tony Blair and New Labour, but that's a whole other article!!!

Lancelot Spratt, Accuracy checking technician

Exactly. Pharmacies should have nothing to do with prescriptions until they are handed over either as pieces of paper or electronically. The patient should know that the ONLY way to get their drugs is to contact their GP by whatever means and order them. Pharmacies should simply do the supply. And no chasing up lost scripts, if it ain't in the pharmacy then it ain't our problem, see your GP.

Graham Morris, Design

When I sold my heavy dispensing pharmacy in 2002, we re-ordered only those scripts that we supplied MDS systems for. On re-ordering, we would contact the patient shortly before re-ordering, to ensure that no prescription changes had been initiated since our last script.

At no point in my professional life did a patient approach me, or their representative, to say it was impossible for them to order a repeat script from their surgery. Indeed, since my retirement, online streamlined ways of ordering repeat scripts and appointments have been developed. Also, the considerable uptake of mobile phones into the population leaves very few individuals or their representatives or carers incapable of ordering repeats themselves.

Having recently entered the crumbly zone over the last three years, I have managed my own requests for repeat medication, despite the continual offers from the pharmacy I use.  I refused, because I knew that the new medications prescribed might well not be successful in treating my condition. Indeed, a number of changes were necessary before an appropriate treatment was finally settled upon. If I had accepted the offer of ordering my prescription a month in advance of when it was needed, there would have indeed been unnecessary waste.

I am absolutely certain that repeat prescriptions should only be ordered by the pharmacy if the patient has been contacted a short period before requesting the repeat. I fully understand that this will cause consternation at head offices throughout the land who purport that this service is invaluable to patients, when secretly they know it is more a method of binding the patient to the business while simultaneously being invaluable to their bottom line!

I, agree with Angela Channing, that patients need re-training. It would appear that pharmacists are being encouraged to offer a service to patients that the vast majority are in a far better position to deduce what actually needs ordering near the time of ordering the repeat, rather than what they were asked for by the pharmacy weeks earlier.

From what I observe, the only additional service the patient now could possible need is for the pharmacist to visit their home, pour water into a glass and remind them to take their medication.

Benjamin Leon D'Montigny, Non Pharmacist Branch Manager

I agree that patients should be enpowered to manage their own healthcare. However I would also argue that we have a far different scenario then one 20 years ago. More items being prescribed year on year, less doctors, and an increased level of pressure on all fronts to meet targets. My concern comes from a lack of an effective alternative method for patients to request prescriptions, instead opting for, what will be seen by many patients, a prevention of access.

b t, Manager

"I would be more inclined to look at the system that allows medicines to be prescribed excessively in the first place."

 

I would be more inclined to look at WHY some pharmacies are operating such unethical systems and SOP's that order every item every month on a repeat slip.

Benjamin Leon D'Montigny, Non Pharmacist Branch Manager

I agree partially. Whilst us pharmacies should only be ordering what we are requested to, there is also a responsibility on the surgery to say no to the patient and be in control of what a patient's medication regime is. My example of Zopiclone being prescribed on a monthly basis stands to illustrate this point.

Stephen Eggleston, Community pharmacist

I have absolutely no problem telling a patient that we have no control over their repeat medication. Pharmacy puts in a heck of s lot of work to keep patients supplied with medicines in a timely manner. While many patients appreciate our efforts, there are, unfortunately, those patients who believe that is part of our job - and while you could argue that it is, it is not the main part of our job. Additionally, CCGs, it would appear, think pharmacies defraud the NHS by over-ordering prescriptions. I, for one, can say that we categorically only order what has been specifically requested by the patient. Yes, sometimes patients re-order too early but that is not our fault. And what do we get for our "playing by the rules?" - Our (legally?) defined profit undermined by the use of script switch, branded generics and prescribing of excessive quantities! So, am I going to cry if the GP is swamped - I don't think so. Will I rush around if a patient runs out of medicines? I will follow the locally defined protocol, as drawn up by the GP/CCG or whoever, as that is my professional obligation. However, I do envisage some unhappy patients. I do hope they will be unhappy with the right people

Benjamin Leon D'Montigny, Non Pharmacist Branch Manager

In this comes one of the critical questions I feel: When it inevitably fails for a patient, will the surgery in question be prepared to take responsibility? Personally, I'm not convinced.

Lancelot Spratt, Accuracy checking technician

The only reason for failure in a patient controlled order system is that the patient fails to order in time. In that case they should be referred to their GP for a script. Most will get the message if this system is adhered to for a few months. So order your script in time, by the most convenient method at your disposal, and collect it from your local pharmacy at an appropriate time. Or go through the hassle of going to your pharmacy for an emergency supply and be told to seek out your GP or out of hours service for a script, then bring it to the pharmacy and wait for it to be dispensed. Simples.

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