My interest in repeat prescribing dates back to 1988, when I was in a two-man partnership. Patients needing repeat medication would phone the receptionist, list their requirements, which she would write, long-hand, onto a prescription. At the end of the surgery, with no more than a cursory glance at the forms, the doctor would sign them all. Some of the patients had been on multiple drugs for many years, and never been reviewed.
When circumstances led me to move into new premises and become single-handed, I decided to tackle this problem of the management of chronic illness and repeat prescribing. I bought a computer and entered all my patient histories, consultations and prescriptions.
In 1992, I decided to audit my repeat prescriptions, having identified seven reasons why a regular review of repeat prescribing was necessary, and illustrated them with examples from patients in the practice.
1. The patient's circumstances may change, altering the need for medication. For example:
- A hypertensive's blood pressure dropped spontaneously when he retired from his stressful job.
- A woman no longer needed iron because she had gone through the menopause and her periods had stopped.
- A patient had been admitted to residential care, and because of an improved diet, no longer needed vitamin supplements.
2. The patient's condition may improve spontaneously and no longer require therapy. For example:
- A patient's rheumatoid arthritis had 'burnt out', so she no longer needed analgesia.
- A patient's depression had lifted.
3. The prescribed drug may be producing symptomatic, or occult side-effects. For example:
- A patient on diuretics, whose potassium deficiency was causing muscle weakness.
- A patient who continued to use steroid cream for submammary thrush.
- A patient who developed gout while on bendrofluazide.
- A patient who had become anaemic through taking non-steroidal anti-inflammatory drugs.
4. An expensive drug may have continued to be prescribed despite the availability of cheaper alternatives. Examples were legion!
5. The doctor may have forgotten the long-term medication, and be more likely to add a contraindicated acute medication. For example:
- Beta-blockers to an asthmatic on inhalers
- Mefloquine with calcium-channel blockers
- Erythromycin with terfenadine
6. The patient may have forgotten the original indication for his medication, and so be taking it inappropriately. For example:
- Using 'water tablets' (diuretics) for dysuria
- Using prochlorperazine for 'dizziness' caused by hypotension
- Using steroid inhalers sporadically, as an acute medication for asthma.
7. The patient may be abusing the drug either knowingly, or inadvertently, or be failing to take adequate medication, resulting in suboptimal therapy. For example:
- Patients addicted to sleeping tablets or codeine linctus
- A patient who stopped his hypotensives because he 'felt fine.'
It was clear that audit was needed.
All patients receiving repeat medication were entered onto the computer, and were asked to see the nurse when they next needed a repeat prescription. Over the next 6 months, 118 patients receiving a total of 434 drugs were seen.
A protocol was written for these initial visits (see Figure 1, below).
|Figure 1: Protocol for repeat medication checks|
For each patient, the nurse identified investigations that were relevant to each drug the patient was taking, e.g. a full blood count if the drug could cause anaemia, or liver function tests if it could affect the liver. She also noted additional relevant investigations, such as blood pressure, urine checks and peak flow readings.
She then listed all the tests she carried out, and which ones were abnormal. Examples of abnormal test results found are listed in Figure 2 (below).
|Figure 2: Abnormal blood test results at initial assessments|
Medications were changed as appropriate. Reasons for change included:
- Patient request
- Too high a dose
- Symptoms uncontrolled
- Drug side-effects
- Ineffective medication
- Expensive drug
- Potential interaction
- Abnormal blood tests, or other investigations
- Branded prescription.
We continued until all patients on repeat prescription had seen the nurse for an initial assessment, and their medication had been adjusted when necessary.
The process was repeated for each patient 6 months and 12 months after his/her original assessment.
At the second and third assessments, it became evident that patients had fewer side-effects and abnormal test results, necessitating fewer changes to their medication.
Subsequently I trawled through the BNF, established a practice formulary, and, following the BNF categories, listed all drugs that I might ever issue as a repeat prescription. Under each drug I noted important contraindications, and potential, relevant side-effects, together with all blood tests and investigations necessary to detect any adverse effect of the drug.
An example showing the section on gastrointestinal drugs is reproduced in Figure 3 (below).
|Figure 3: First page of Dr Butler's repeat prescribing protocol|
The nurse established a repeat prescribing log book, which was set out as shown in Figure 4 (below), and I review this weekly.
|Figure 4: Page from the repeat prescribing log book|
In this way, all sorts of useful information, such as family or social problems, side-effects of medication, or change in clinical condition, can be passed between doctor and nurse. It ensures that all necessary action is taken, and avoids any misunderstanding as to who is responsible for action.
The district nurses also use this protocol. We inform them when the patient is due for a review, and give them a photocopy of a list of all their drugs, potential side-effects, and necessary investigations. Thus home-bound patients also benefit from regular review.
The local nursing home staff have been taught how to use the protocol, and all medication in the home is monitored in the same way.
- All chronic illness, except diet-controlled diabetes, is likely to be accompanied by repeat prescriptions. This protocol ensures that all patients with a chronic disease are seen and monitored regularly by the nurse, who refers to the doctor if necessary. Patients with hypertension or diabetes are reviewed annually by the doctor.
- Iatrogenic illness is avoided.
- Patients understand their illnesses and their treatment, and are much better equipped to monitor themselves.
- Patients know when they are going to see the nurse, and thus make fewer intermediate appointments.
- The doctor benefits from reduced workload because of effective delegation, and anticipatory intervention.
- The practice benefits from regular contact with the patients, thereby avoiding crisis intervention.
- There is improved team working, as every member has a role to play.
The NHS benefits because cheaper drugs are used more efficiently, and unnecessary or ineffective medication is avoided. My PACT costs are nearly half the national average.
Vast quantities of drugs are consumed every day. Many of them are unnecessary, potentially harmful and expensive. This simple protocol effectively addresses this problem, reducing costs, side-effects, and ultimately workload.
It encompasses practically all chronic illness, enabling repeat prescriptions for these conditions to be managed effectively and safely by a competent nurse.
Copies of the protocol are available on disk from:
Dr Hazel Butler
Orchard End Surgery
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