1. Repeat Prescribing Toolkit introduction
1. Background
1.1. Purpose
2. Current guidance and research
3. Repeat prescribing utilisation
4. Patient safety
5. Other contributory factors
6. Co-production principles
7. Equality and impact
8. Roles and responsibilities
1 Background
In 2022/23, 1.18 billion prescription items were dispensed in primary care in England, and this number increases every year.1 The Department of Health and Social Care published the National Overprescribing Review, Good for you, good for us, good for everybody in 2021. This made 20 cross-system recommendations to help reduce overprescribing in England and to make patient care better and safer.2
Recommendation 7 asked the Royal College of General Practitioners (RCGP) and the Royal Pharmaceutical Society (RPS) to develop a national toolkit to help practice to improve the consistency of repeat prescribing processes and to support general practice (GP) practice reception and administration teams with training resources.
This focus on repeat prescribing is important as repeat prescriptions make up around three quarters of all prescription items dispensed.
In 2023, NHS England (NHSE) commissioned the Royal Pharmaceutical Society (RPS) and the Royal College of General Practitioners (RCGP) to develop this toolkit.
1.1 Purpose
Repeat prescribing systems vary between individual general practices and community pharmacies. Dispensing practices will have the additional dispensing component to their repeat prescribing process. The purpose of the toolkit is to set out what should be included within a good practice repeat prescribing system.
In recent years, general practices have come together to form Primary Care Networks (PCNs). In many areas PCNs have streamlined repeat prescribing systems across a number of practices but this is not universal and so this toolkit refers to general practice and/or PCNs.
The toolkit focusses on repeat medication only; acute medicines and appliances are not included within the scope of this work.
This repeat prescribing toolkit is NOT a clinical or prescribing guideline. However, it does identify some higher-risk clinical scenarios that practices or PCNs should pay particular attention to.
The toolkit takes the form of a self-assessment process (section 7), to enable a practice and/or a PCN to assess their local arrangements against the questions and then discuss and agree as a team where any gaps lie or where improvements can be made.
Practices may wish to undertake a full process-mapping exercise of their repeat prescribing system. Ideally, this will involve the whole team and include patients, carers and colleagues working in community pharmacy who are an essential part of the local repeat prescribing system. This is described further in section 3.
The RCGP/RPS repeat prescribing toolkit was developed with an expert working group of key stakeholders including GPs, pharmacists, pharmacy technicians, practice managers, integrated care board (ICB) medicines leads, patients and third-sector representatives. A summary of the group membership, the approach to this work and guiding principles are provided in annex A.
The scope of the work is set out in annex A.
While it will take time to discuss and complete the repeat prescribing self-assessment and address all the actions that come from the discussions, we are hopeful that all practices will engage on some level with the toolkit and self-assessment process to understand where any current risks lie.
The self-assessment process is best undertaken with a range of members of the practice team and with input from the local patient participation group (PPG) and community pharmacies. The resulting practice or PCN action plan will then shape the work to be done in the coming months. Practices are encouraged to adopt a quality improvement methodology, and support for this is described in section 3.
Practices are encouraged to review recent errors, mistakes, near misses and complaints related to the repeat prescribing process and discover how and why they happened.
See section 7 for the self-assessment toolkit.
Practices that have thoroughly assessed and process-mapped their activity have improved the management of their repeat prescribing and become more efficient.
For further support and good practice examples, including testimonials from practices and PCNs who have already completed this type of work, For further support and good practice examples, including testimonials from practices and PCNs who have already completed this type of work, see section 3 and section 6.
2 Current guidance and research
We conducted a background literature search (see annex B) and identified that between 2013 and 2023, there were a limited number of publications directly related to repeat prescribing processes in the UK. This work also highlighted that there is no contemporary, national guidance to inform good practice in England.
In 2004, the former National Prescribing Centre (NPC) published 'Saving time, helping patients – a good practice guide to quality repeat prescribing', which highlighted key areas of the repeat prescribing process, and suggested a model focussing on areas of production, management and clinical control that many practices adopted.3 However, this document was published before electronic repeat dispensing (eRD) or the electronic prescription service (EPS) were widely available.
The importance of a repeat prescribing system has since been described in paragraphs 98–102 of the current General Medical Council (GMC) guidance, 'Good practice in prescribing and managing medicines and devices', and is further iterated in their good practice standards.4, 5
The RPS Competency Framework for all Prescribers also advises prescribers to develop governance processes to support safe prescribing, citing repeat medicines as an example of a higher risk clinical situation.6
The Care Quality Commission Single Assessment Framework (SAF) includes a quality statement related to medicine optimisation which sets out the safety and legal requirements expected of organisations that prescribe medicines.
In 2017, Price et al described a risk management model that uncovered 62 important safety concerns relating to repeat prescribing systems in 48 general practices.7 This important work included locally held educational workshops and an introduction to process mapping of the repeat prescribing process.
Integrated care systems (ICS) may want to think about how this could be deployed locally to support practices in addressing repeat prescribing safety. For more on process mapping see section 3.
3 Repeat prescribing utilisation
Repeat prescriptions can be requested and issued in several ways, but the introduction of the Electronic Prescription Service (EPS) in England has helped to streamline this for both patients and practice staff. In 2022, over 95% of all prescriptions were issued electronically. The NHS Business Services Authority (BSA) EPS and eRD utilisation dashboards provide information on rates of EPS and eRD uptake and help to visualise trends across General practice, within and between ICS’ and across England.8
Patients can request repeat medication via the NHS app or directly with their practice through an online form. If preferred, there are non-digital routes for patients and carers, including manual paper-based forms. In some areas of the country, hub systems operate where patients may phone a dedicated phoneline manned by trained call handlers. Some community pharmacies also offer a managed repeat prescription service.
Prescriptions can be dispensed by a local community pharmacy, a dispensing practice or an online/remote pharmacy.
Table 1
|
Prescription destination
|
Total number of prescription items dispensed
|
% of total prescription items dispensed
|
|
Community pharmacy
|
89,998,175
|
86.4%
|
|
Dispensing doctor
|
6,415,836
|
6.2%
|
|
Distance selling pharmacy
|
6,223,292
|
6.0%
|
|
Personally administered items
|
510,519
|
0.5%
|
|
Appliance contractor
|
1,026,752
|
1.0%
|
|
Total
|
104,174,574
|
100% |
Table 1 shows prescription items in England and where they were dispensed in May 2024, taken from ePACT.9 This includes appliance contractors and items prescribed and administered within a practice.
4 Patient safety
A key driver behind this toolkit is to ensure the safety of patients receiving medicines on a repeat prescription. Medication errors can occur at different stages of the repeat prescription process; errors are usually attributed to weak systems or the impact of human factors.10
In 2018, the UK Department of Health funded research estimated that 237 million medication errors occur in England per year. Whilst many have little or no potential for harm, 66 million potentially clinically significant errors occur per year and 71% of these are in primary care. Primary care prescribing accounts for 33.9% of all potentially clinically significant errors.11
In 2019, the Care Quality Commission (CQC) published a report looking at common areas of risk in relation to medicines and highlighted the need for improvement in prescribing, monitoring and reviewing medicines.12 Case studies have shown where inadequate repeat medication processes can cause a patient harm and, in some instances, lead to patient death.13 This is described further in section 2.
In November 2018, a patient was discharged from hospital for a fractured radius. The patient was prescribed 100 mL of oral morphine sulphate 10 mg/5 mL solution by the hospital for acute pain relief.
After discharge from the hospital, in addition to their routine prescriptions, the patient began to receive 300 mL of oral morphine sulphate 10 mg/5 mL regularly on repeat prescription.
This continued, unchecked until March 2019.
Shortly after this, the patient died. Toxicology tests carried out as part of the coroner’s investigation revealed a fatal level of morphine in their blood.
At the inquest, the GP surgery gave evidence that this should not have happened and that there had been no formal review of this patient between 28 November 2018 and 29 March 2019.
The coroner also raised concern that the local community pharmacy had requested repeat prescriptions without seeking the view of the patient. The coroner requested that consideration be given to providing guidance to all pharmacists in England and Wales that when making a request for a prescription to a GP they should ensure that the wishes of the patient are obtained, save in circumstances where this is not possible such as where the patient lacks capacity.
The RPS guidance on repeat medicines is published here, and a pharmacy alert was published following this report (RPS members only).
5 Other contributory factors
In 2023, the Chief Medical Officer’s annual report, 'Health in an Ageing Society', highlighted the growing impact of multiple, long-term conditions in older age (multimorbidity) and the challenges of polypharmacy.14
Repeat prescribing systems need to adapt to meet the demands of a changing population and developments in the NHS. NHS IT systems and the opportunities provided by a growing number of non-medical prescribers working within primary care can help optimise processes to improve both safety and efficiency, but only with careful management and a good, local level understanding of the risks in current systems.
6 Co-production principles
Listening to patients’ experiences and taking the time to reflect on their individual stories is paramount to improving care and their use of medicines. Patient needs are better met when they are involved in an equal relationship, working together. Structured medication reviews provide an important opportunity to listen to and understand any issues, concerns and expectations that patients may have in relation to their medicines.
We would especially like to thank and acknowledge the patients involved in the co-production and design of the repeat prescribing toolkit.
"As a patient taking medicines long term, and along with others, I have been closely included and involved in the preparation of this information from the start through to the final version. Drawing on my experience of many conversations with patients from diverse communities I have done my best to include those views and experiences into these documents so that they help as many people as possible get the most benefit with the least harm from their medicines."
– Graham Prestwich – patient representative.
7 Equality and impact assessment
We have carried out an equality and health inequalities impact assessment (see annex C) with our analyses and conclusions.
8 Roles and responsibilities
A number of different organisations had roles to play in the successful implementation of this repeat prescribing toolkit.
A summary of these suggested roles/responsibilities is set out below:
NHSE
Promote the use of this tool via the national, regional and local networks, and ensure that PCN clinical directors are aware of its importance and context.
RCGP and RPS
Promote the importance of this toolkit with their members and highlight the impact it is aiming for, in relation to medication safety.
Ensure links to patient organisations are used to highlight the patient partnership agreement.
ICB
Ensure that local PCNs, GP practices, Local Medical Committees and Local Pharmaceutical Committees are aware of the toolkit and encourage them to engage with and complete the self-assessment.
ICBs could consider incentivising this activity via local prescribing incentive schemes or hold local workshops to ensure PCN and practice teams are aware of the context.
Primary care networks
Establish local meetings to work though the self-assessment and ensure that local leads for this work are appointed and supported to lead this work from self-assessment through to action and improvement.
Community pharmacies
Work with your local GP practices to share local good (and poor) practice and agree what will deliver improvement in repeat prescribing.
Patients and the public
Be aware that patients are part of the partnership with clinicians that will deliver good outcomes from repeat medicines. Read the patient partnership agreement, only order what you need and order your repeat medicines in a timely way.