Repeat prescribing in general practiceBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7089 (Published 03 November 2011) Cite this as: BMJ 2011;343:d7089
- Anthony J Avery, professor of primary healthcare
- 1Division of Primary Care, School of Community Health Sciences, University of Nottingham Medical School, Nottingham NG7 2UH, UK
Almost all general practices in developed countries have systems for issuing repeat prescriptions to patients without the need for a consultation. In many countries, including the United Kingdom, the process is aided by clinical computer systems. What do we know about the quality and safety of repeat prescribing, and what is the role of general practice receptionists in the process? In the linked study (doi:10.1136/bmj.d6788) Swinglehurst and colleagues explore and compare organisational routines for repeat prescribing in four UK general practices.1
In the 1980s and 1990s several studies highlighted the scale of repeat prescribing in various European countries.2 A study of 115 general practices in the UK showed that in 1993 75% of prescriptions issued were for repeat items, with this figure rising to around 90% in patients aged 75 years or more.3 Recent information is lacking, but the proportion of items issued as repeats has probably increased over the past two decades along with the expansion in prescribing for long term conditions in general practice.
A systematic review identified 14 randomised controlled trials of interventions aimed at improving the care of patients on repeat drugs,2 and at least one more trial has been published since.4 Remarkably, all of these interventions involved drug review. Although some evidence has been published on the benefits of pharmacists in drug review,2 little or no information is available on other aspects of the repeat prescribing process, including the role of reception staff.
One cross sectional study examined the repeat prescribing processes in 57 randomly selected general practices in Leeds, UK.5 The study identified problems with the control of repeat prescriptions, including receptionists putting drugs on to repeat “purely on the basis that they have been prescribed before” and hospital initiated drugs being added without authorisation from a doctor. Little detailed examination of repeat prescribing has occurred since this time, so Swinglehurst and colleagues provide a timely insight into this important process.1
The authors used an ethnographic approach to assess organisational routines for repeat prescribing in four UK general practices with diverse organisational characteristics. All of the practices used electronic health records to support the repeat prescribing process, and a host of different policies and approaches were seen. In one practice the protocol seemed to be followed to the letter and general practitioners had to deal with all “exceptions,” which (remarkably) accounted for around half of all requests; in others, reception staff had considerable latitude to use their knowledge and judgment to issue requests for prescriptions that were not on the repeat list, or to alter repeats.
Although some people will find these results worrying, Swinglehurst and colleagues argue convincingly that “one size does not fit all” when it comes to repeat prescribing.1 They show that the categories of past, current, and repeat prescriptions are “more fluid and negotiated than the technology implies or previous research has suggested” and imply that a rigid approach based on rules may not be necessary or appropriate. They also argue that although there is potential for error from general practitioners being asked to endorse actions initiated by a receptionist, patient safety is likely to benefit from receptionists being actively engaged in the repeat prescribing routine.
Nevertheless, a key question is whether there are core principles that should guide all practices, including the scope and limits of receptionists’ responsibilities? It seems reasonable to encourage well trained receptionists to use their initiative in repeat prescribing, but practices need to ensure that members of staff do not step beyond their levels of knowledge and competence. A major worry is that any mistake made by a receptionist when issuing an unauthorised prescription is at risk of being signed off by the general practitioner. However, despite concerns raised in the literature,5 there is little evidence that the high levels of autonomy and engagement shown by some receptionists is a cause for concern.1 Nevertheless errors do occur in the repeat prescribing process and we need further research to find out why.6
How should these issues be addressed? Firstly, the risks and benefits associated with different approaches to repeat prescribing need to be quantified, including the varying roles of receptionists and the impact of new technologies such as electronic repeat dispensing.7 Secondly, it will be important to establish whether prescribing error rates vary greatly between general practices. If they do, the complex factors identified by Swinglehurst and colleagues need to be taken into account when designing and testing interventions aimed at improving safety. This might then produce better evidence to help guide general practices on the best ways of running their repeat prescribing systems to ensure safety while being responsive to patients’ requests.
Cite this as: BMJ 2011;343:d7089
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.