Green Elms Prescribing Report 27.11.09

Green  Elms  Practice   PCT  Remedial  Notice:  RM/CM5     Repeat  Prescribing  Review   27  November  2009     Dr  Mark  Greenhalgh   Medical  Director,  ChilversMcCrea  Healthcare       Background     This  brief  report  summarises  a  review  of  the  repeat  prescribing  processes  at  Green  Elms   Health  Centre  carried  out  in  response  to  NHS  North  East  Essex  Remedial  Notice   RM/CM5,  dated  7th  October  2009.     As  part  of  a  wider  review,  Dr  Greenhalgh  visited  the  practice  with  Dr  McCrea  on  23rd   November  2009.  Interviews  with  staff  and  examination  of  the  systems  and  processes   were  undertaken.  Repeat  prescribing  was  assessed  against  the  existing  ChilversMcCrea   Healthcare  Repeat  Prescribing  Policy,  dated  January  2009.     Between  April  2002  and  December  2006,  Dr  Greenhalgh  was  Prescribing  Lead  at  Epping   Forest  /  West  Essex  PCT  and  is  a  Partner  at  Keyhealth  Medical  Centre.     Repeat  Prescribing     The  review  and  this  report  have  been  structured  to  reflect  the  framework  of  the  CMH   repeat  prescribing  policy,  which  sets  out  four  stages  for  control  and  management:     1. Initiation  /  Request   2. Production  /  Authorisation   3. Clinical  control  /  Review   4. Management  Control     1.  General     CMH  Standards:     In  general  the  policy  emphasises  that  a  GP  should  retain  active  involvement  throughout   the  process  and  should  not  delegate  any  entire  part  of  the  processes  to  ancillary  staff.  In   particular,  the  policy  states  that  the  following  should  be  entirely  the  responsibility  of  the   GP.     • Initiation   • Authorisation   • Clinical  control  /  review     Compliance  at  Green  Elms:     The  overall  nature  of  repeat  prescribing  has  not  complied  fully  with  the  standard  set  out   in  the  policy  in  the  sense  that  it  could  be  demonstrated  that  prescription  requests  would  

be  initiated  and  agreed  /  issued  without  full  and  active  involvement  of  a  GP.  This  has   included  the  signing  of  prescriptions  for  newly  requested  medicine,  prepared  by   ancillary  staff,  without  recourse  to  the  medical  record  or  communication  with  the   patient  by  the  signing  doctor.     2.  Initiation    /  Request     CMH  Standards:     The  policy  requires  that  the  decision  to  put  a  drug  on  the  repeat  list  for  a  patient  must   always  be  made  by  a  doctor  after  appropriate  review  and  that  care  should  be  taken  to   ensure  accuracy,  suitability  and  be  part  of  the  computerised  record.  The  standard   requires  for  patients  to  be  provided  with  a  printed  repeat  slip  and  to  be  actively   involved  and  responsible  in  requesting  their  medication.  The  policy  does  not  allow  for   telephone  requests,  except  under  exceptional  circumstances  and  for  housebound   patients.    The  policy  requires  patients  to  be  encouraged  to  advise  if  their  medication  is   no  longer  needed.       Compliance  at  Green  Elms:     Many  new  patients’  medication  is  entered  by  the  GP  at  initial  consultation  and  it  is   assumed  for  the  purposes  of  this  report  that  suitable  checks  and  assessments  have  been   performed  by  the  GP  at  that  time.     Some  new  patients  to  the  Practice  are  in  possession  of  a  Part  B  (printed  repeat  list)  from   their  previous  surgery,  and  in  these  cases  it  has  been  usual  for  the  repeat  medication  to   be  entered  into  the  clinical  system  by  the  prescription  clerk.  In  these  cases,  it  would  not   usually  be  the  case  that  a  doctor  routinely  or  systematically  checked  the  medicine  before   being  issued.     Where  a  doctor  has  decided  that  an  acute  prescription  is  suitable  for  transferring  to   being  a  repeat  medicine,  the  usual  review  period  defaults  to  six  months,  which  is  an   appropriate  default.  This  process  was  not  directly  assessed  as  part  of  the  review,  either   by  audit  or  interview,  since  most  of  the  doctors  at  the  practice  have  only  recently  come   into  post.     Patients  seem  to  be  aware  that  their  medication  requests  should  be  in  writing  and  there   was  no  impression  gained  that  telephone  requests  were  routine,  which  is  as  it  should  be.   The  processes  for  ensuring  the  secure  handling  of  requests  have  recently  been   improved,  significantly  reducing  the  loss  of  request  slips,  improving  the  confidentiality   of  information  and  cutting  down  on  time  wasted  by  having  to  search  for  missing  slips   and  handle  queries.     Green  Elms  has  not  fully  complied  with  the  standard  set  out  in  the  policy,  since  while  all   repeat  medication  is  handled  via  the  computerised  record  system,  with  requests   handled  for  the  most  part  in  writing,  it  could  not  be  demonstrated  that  the  suitability   and  accuracy  of  all  repeat  medication  has  been  checked  by  a  doctor  after  appropriate   review  for  all  patients.  Patients  do  routinely  receive  a  printed  request  slip  and  initiate   their  own  requests.  Recent  improvements  to  handling  requests  have  been  made.    

3.  Production  /  Authorisation     CMH  Standards:     The  policy  requires  that  requests  be  made  using  pre-­‐printed  forms  rather  than  being   handwritten  to  minimise  errors,  that  compliance  checking  is  undertaken  in  order  to   highlight  under  or  over  use  and  that  the  process  is  the  responsibility  of  a  prescriber.   Attention  is  drawn  to  early  requests  as  an  indication  to  check  over-­‐use.  While  allowing   the  routine  production  of  prescriptions  by  a  receptionist  for  subsequent  signing,  the   policy  sets  out  situations  where  the  record  should  always  be  consulted,  including:   review  period  expiry,  request  for  medication  not  previously  taken  by  the  patient,   requests  for  certain  specified  drugs,  recent  issue  less  than  one  month  previously  and  all   controlled  drugs.  The  standard  also  sets  out  and  reflects  accepted  good  practice  for   handling  of  prescriptions.     Compliance  at  Green  Elms:     The  practice  has  generally  complied  with  the  standard  by  issuing  Part  B  slips,  and  the   prescription  clerk  is  in  the  habit  of  flagging  up  over-­‐use  when  requests  are  made  early.   However,  no  systematic  attention  is  being  given  to  identifying  under-­‐use.  This  can  be   done  at  a  variety  of  points,  including  during  medication  review  and  chronic  disease   management  checks,  neither  of  which  have  been  demonstrated  to  be  reliably  nor   regularly  carried  out  across  all  common  chronic  disease  areas.  (This  is  significant,  for   example,  in  asthma  management  or  hypertension  control).     It  is  unclear  whether  the  records  have  been  reliably  consulted  in  accordance  with  the   policy  standard  under  the  situations  required,  although  it  is  likely  /  possible  that  this   has  not  always  been  done.  It  is  the  case  though,  that  new  drug  requests  have  been  made,   and  actioned  through  the  prescribing  system,  without  a  corresponding  clinical  note   being  made  by  the  doctor.  Prescriptions  have  been  prepared  by  the  prescribing  clerk  for   signature,  typically  accompanied  by  a  sticky  note  stating  the  reason  for  the  request.  It   was  not  demonstrated  that  these  explanatory  notes  have  made  it  into  the  clinical  record,   either  directly  or  indirectly,  or  that  the  authorising  prescriber  has  necessarily  taken   proper  (full,  active,  informed)  clinical  responsibility  for  the  issue  of  the  drug.  This  is  an   important  area  where  Green  Elms  appears  not  to  have  adhered  to  CMH  policy  standards.     Other  aspects  of  prescription  handling  have  generally  been  good.  Concerns  were   expressed,  and  audit  has  revealed,  that  whilst  prescriptions  have  been  generated  and   collected  by  local  pharmacies,  they  have  not  always  been  accounted  for  afterwards.  The   practice  has  adopted  an  approach  of  ensuring  that  re-­‐printed  prescriptions  are  marked   as  duplicate  and  anecdotally  this  has  reduced  the  problem.    Uncollected  repeat   prescriptions  are  handled  correctly  and  not  stored  past  four  weeks.       4.  Clinical  Control  /  Review     CMH  Standards:     The  policy  emphasises  that  this  is  a  clinical  responsibility,  to  be  exercised  mainly  by   prescribers.  The  standard  is  for  28-­‐day  cycles  and  supply,  with  a  small  number  of   suitable  exceptions.  Supply  is  required  to  be  synchronised  where  possible.  The  policy   requires  that  all  medication  be  reviewed  when  a  patient  is  discharged  from  hospital  and  

makes  the  point  that  this  is  a  vulnerable  time  for  errors  to  be  made,  since  safe  practice   relies  upon  good  communication  between  hospital,  GP  and  patient.  The  CMH  standard  is   that  a  doctor  amends  the  record  personally,  in  order  to  ratify  the  decision  and  to  re-­‐ authorise.  The  same  principles  apply  to  clinic  letters,  which  may  specify  a  change  in   medication.     The  policy  draws  attention  to  various  considerations  to  be  borne  in  mind  by  the   reviewer  of  repeat  medication,  including  optimising  control  of  the  condition,  avoiding   unnecessary  medication,  compliance,  monitoring  requirements  and  cost  factors.     Compliance  at  Green  Elms:     It  would  appear  that  28-­‐day  prescribing  is  the  norm,  however,  this  can  easily  be   confirmed  by  assessment  of  ePACT  prescribing  data,  which  was  not  reviewed  at  this   visit.     There  has  been  no  system  to  review  medication  changes  resulting  from  either  hospital   discharge  or  clinic  attendance.  Although  incoming  letters  have  been  viewed  and  often   initialled  by  a  doctor,  in  most  cases  it  seems  to  be  the  case  that  medication  changes  are   not  made  at  the  time.  A  more  usual  scenario  described  is  that  the  patient  has   subsequently  advised  that  their  dispensed  medication  does  not  match  what  they  were   told  at  discharge  or  clinic,  following  which  the  receptionist  has  asked  for  a  doctor  to   make  a  change  on  the  prescribing  system  and  a  new  replacement  prescription  has  been   issued  with  the  changes.  This  is  an  area  of  significant  clinical  risk,  which  can  depend   upon  a  patient  recognising  and  remembering  that  there  is  a  discrepancy  and  then   bringing  it  to  the  attention  of  the  practice.  It  also  contributes  to  waste  and  increased   cost.     There  has  not  been  any  system  for  drug  monitoring,  e.g.  blood  tests  required  for  routine   safety  checking  (typical  examples  would  include  checking  U&Es  for  patients  on  ACE   inhibitors  or  LFTs  for  patients  on  methotrexate).  The  practice  has  relied  upon  individual   doctors  remembering  to  do  these  tests  either  when  seeing  patients  or  when  carrying  out   a  medication  review.     The  practice  has  not  demonstrated  any  systematic  organisation  of  medication  reviews,   appearing  to  rely  instead  on  ad-­‐hoc  review  on  an  opportunistic  basis.  Discussion  with   the  clinical  staff  who  have  been  at  the  practice  for  several  years  seems  to  reflect  a   concern  about  the  difficulty  of  including  medication  review  during  normal  consultations   and  may  go  towards  explaining  the  low  level  of  recorded  review.  This  in  turn  will  have   tended  to  impact  negatively  upon  any  specific  prescribing  changes  needed,  including   abuse  /  dependency  risks  (e.g.  benzodiazepines),  cost  considerations  (e.g.  PPIs),  safety   concerns  (e.g.  Cox  II  inhibitors  etc)  and  general  good  prescribing  practice.       Taken  together,  the  absence  of  demonstrable  systems  for  review  and  monitoring  of   medication  represent  a  significantly  lower  standard  of  practice  at  Green  Elms  than  that   laid  out  in  the  CMH  repeat  prescribing  policy.  This  will  have  contributed  to  clinical  risk.    

5.  Management  Control     CMH  Standards:     Responsibility  for  management  control  is  placed  with  the  practice  supervisor  and  then   to  a  doctor  or  nurse  in  the  absence  of  the  supervisor.  The  policy  requires  that  practice   staff  involved  with  the  preparation  of  repeat  prescriptions  should  be  appropriately   trained  in  all  aspects,  including  protocols  and  responsibilities,  with  an  emphasis  on  the   need  for  accuracy.  The  policy  addresses  the  need  for  communication,  secure  storage  and   handling,  data  security  (including  backup)  and  specifies  annual  audit  of  repeat   prescribing.  The  policy  describes  relevant  aspects  of  good  practice  in  setting  up  and   operating  a  repeat  prescribing  system,  including  when  to  involve  a  doctor  and  when  to   review  repeat  medication.     Compliance  at  Green  Elms:     There  was  little  evidence  that  the  functions  of  a  practice  supervisor  had  been  carried  out   with  regard  to  management  of  the  repeat  prescribing  system.  Insofar  as  there  has  not   been  an  identified  prescribing  lead  in  the  practice,  the  clinical  responsibilities  for   management  of  the  repeat  prescribing  system  have  not  rested  with  one  doctor  in  an   accountable  way.  The  repeat  prescribing  clerk  is  not  formally  trained.  There  were  no   protocols  available  for  review  in  the  practice  in  support  of  the  CMH  policy.     It  appears  that  communication  with  local  pharmacies  has  been  improving,  leading  to  a   better  experience  for  patients,  involving  less  risk  and  frustration.  The  practice  clinical   system,  including  the  prescribing  record,  is  backed  up  as  part  of  the  NHS  SystmOne   remote  infrastructure.     Other  points  include:  Stored,  signed  FP10  prescriptions  have  not  been  stored  in  a  locked   container.  There  is  no  evidence  of  annual  repeat  prescribing  audit.     Staff  have  been  encouraged  to  use  the  ‘tasks’  messaging  function  of  the  clinical  system,   which  ensures  that  queries  and  actions  are  logged  with  time  and  date,  and  recorded  as   part  of  the  auditable  patient  record.     Overall,  Green  Elms  has  not  demonstrated  management  control  in  keeping  with  the   standards  set  out  in  the  CMH  Repeat  Prescribing  Policy.     Conclusions     Review  of  the  practice  repeat  prescribing  systems  and  their  management  at  Green  Elms   has  confirmed  that  concerns  about  compliance  with  acceptable  standards  appear  to   have  been  justified.     In  all  stages  of  the  repeat  prescribing  process  and  over  a  period  of  several  years,  Green   Elms  has  failed  to  demonstrate  that  it  has  met  the  standards  set  by  CMH  in  its  policy   document.  Historically,  this  appears  largely  to  be  due  to  the  lack  of  management   controls  either  at  practice  supervisor  level  or  by  named  and  accountable  clinical  staff   taking  a  lead  on  prescribing.    

Recommendations  &  Comments     1. Repeat  dispensing.  This  would  be  a  useful  way  of  making  the  repeat  process   smoother  and  more  reliable  for  patients.  However,  it  is  an  absolute  pre-­‐condition   that  any  patient  whose  medication  is  set  up  for  repeat  dispensing  has  been  fully   reviewed  and  meets  the  conditions  required  for  a  local  repeat  dispensing  system.   Until  that  is  the  case  for  a  significant  number  of  patients,  it  will  not  easily  be   possible  for  this  to  happen.   2. Repeat  prescribing  protocols.  The  practice  should  adopt  and  use  brief  and   simple  protocols  for  the  handling  of  repeat  prescribing,  based  upon  the  good   practice  already  laid  out  in  the  CMH  policy  document.   3. New  medication  requests.  A  doctor  must  fully  and  properly  review  new   medication  requests  for  items  not  already  on  the  repeat  list.  A  clinical  note   should  be  made  on  the  computerised  record  system  by  the  prescriber,  stating  the   clinical  indication  and  rationale.   4. Signing  of  prescriptions  -­  awareness.  Doctors  at  Green  Elms  should  be   reminded  that  the  signing  of  a  repeat  prescription  is  a  significant  responsibility   and  not  a  thoughtless  exercise.  The  doctor  /  prescriber  should  be  satisfied  that   systems  are  in  place  to  ensure  that  the  original  decision  was  clinically  sound,  that   continuing  to  prescribe  is  clinically  justified  and  that  appropriate  safety   mechanisms  are  in  place  to  review  the  medication.  If  the  doctor  is  not  satisfied  of   this  and  /  or  has  not  put  himself  or  herself  in  a  position  to  be  reassured  of  this,   then  he  or  she  is  at  least  jointly  responsible  for  any  harmful  or  adverse  event   which  may  occur.   5. Discharge  /  hospital  clinic  medication.  A  checking  process  to  ensure  that  all   discharge  and  clinic  letters  have  been  actively  reviewed  for  medication  changes   must  be  put  in  place.  Periodic  audit  to  demonstrate  that  this  is  happening  should   be  undertaken.   6. Drug  monitoring.  Patients  who  are  taking  medication  that  requires  monitoring   should  be  identified,  using  a  defined  search  on  the  clinical  system.  This  should  be   according  to  a  list  agreed  with  the  local  PCT  prescribing  advisor.  Monthly  recall   should  be  done  for  patients  due  for  testing  either  prospectively  on  an   opportunistic  basis  during  consultations  or  by  calling  patients  to  attend  for  tests.   Periodic  audit  to  demonstrate  that  this  is  happening  should  be  undertaken.   7. Prescribing  Clerk  training.  Arrangements  should  be  made  to  provide  training   for  the  member  of  staff  routinely  assigned  to  handle  repeat  prescribing.   8. Secure  storage.  Prescriptions  should  be  stored  in  a  secure  locked  container   when  not  being  actively  handled  or  under  direct  supervision.   9. Practice  Prescribing  Lead.  The  practice  should  appoint  a  permanent  member  of   the  clinical  team  as  prescribing  lead,  who  should  ensure  the  use  of  protocols.  This   clinician  should  ensure  that  prescribing  matters  are  discussed  at  clinical   meetings  as  a  way  of  sharing  responsibility  for  this  key  area  of  improvement.   10. Medication  reviews.  Under  the  leadership  of  the  newly  appointed  practice   prescribing  lead,  Green  Elms  must  make  efforts  to  arrange  a  systematic  ‘catch  up’   for  the  bulk  of  outstanding  medication  reviews  over  a  reasonable  period  of  time,   e.g.  six  months  would  be  desirable,  but  greater  than  twelve  months  would   probably  not  be  acceptable.  Notwithstanding  the  time  and  effort  /  cost  that  this   will  take,  this  single  task  can  considerably  reduce  the  burden  of  unnecessary   medication,  reduce  risk,  improve  QOF  points  and  form  the  basis  for  better  future   medicines  management  within  the  practice.    

Recent  Improvements     Repeat  prescribing  was  discussed  with  the  current  interim  practice  manager  who  is   overseeing  many  changes  at  Green  Elms.  This  revealed  that  a  number  of  recent  changes   have  already  been  made  to  improve  the  way  the  process  works,  including:     • Repeat  request  slips  –  provision  of  a  secure  ‘post  box’  for  request  slips,   minimising  loss  and  improving  confidentiality.     • Guidance  for  the  prescribing  clerk  -­‐  better  handling  of  new  medication  requests.   Discussion  on  the  possibility  of  undertaking  an  NVQ  related  to  prescribing.     • Messages  for  tasks  being  relayed  via  the  ‘tasks’  function  on  the  clinical  system,   improving  audit,  record  keeping  and  efficiency.  Old  out  of  date  tasks  have  been   cleared  off,  making  current  messages  more  relevant.     • Requiring  local  pharmacy  staff  to  sign  confirming  receipt  of  individual   prescriptions  at  the  point  of  collection.