Repeat prescribing

Sometimes, you may be involved in authorising or actioning repeat prescriptions and acute requests for another prescriber’s patients.

You should use your professional judgement in these situations to decide what actions to take. You may find our Pharmacists in general practice: repeat prescribing position statement useful.

Our Repeat prescribing toolkit can be used to help practices improve the consistency of repeat prescribing processes and support this with training resources.

If you’re asked to authorise or action repeat prescriptions and acute requests, or prescribe outside your scope of practice or for another prescriber’s patients, consider:

Prescribing safely

• Are you taking a person-centred and safe approach? (See our guide on prescribing safely and confidently – to be added soon.)
  • It may be helpful to have a formulary of the medicines you prescribe to discuss with the practice GPs, or have a protocol in place that includes when to refer people.
• Have you assessed the person yourself? (Our prescribing resources page (to be added soon) can provide support with reviews and history taking.)
  • Have you checked if there has been any change in the person’s medical history or medicines, and are they taking the medicines as prescribed?
  • Do you have access to the person’s clinical records, and are you able to document and justify your reasons for prescribing? (For further information on documentation, see our guide on clinical documentation.)

Prescribing competently

• As a prescriber, you’re responsible and accountable for each prescription you sign.
• Can you demonstrate competency and confidence in the medicines and conditions you are prescribing for? Don’t forget to log these in your e-Portfolio.
  • If you need to improve anywhere, our PDP guide and template (to be added soon) can help you.
• Are you able to provide information to the person or carer and answer any queries and concerns they may have?
• Do you have knowledge in the clinical areas, or the medicines and evidence-based treatment options you are prescribing?
  • Do you know what monitoring and review is required? Do you have access to any relevant investigations/test results, do you have the permissions to raise them, and can you interpret them?
  • Do you know what the red flags are and when to refer?
• Your peers and prescribing colleagues can share how they have safely dealt with similar scenarios.

Prescribing within your scope

• You may want to speak to your employer about their expectations of you, your job role and responsibilities (see the Primary Care Pharmacy Association (PCPA) website for job descriptions).
  • Openly discuss your scope and competency with your employer and the current skills you bring to the team.
  • If you’ll be practising outside your scope, discuss what you need (e.g., training) to help you develop competency in this new area.
  • If you’re not comfortable signing repeat prescriptions without first reviewing the person, relay your concerns to your employers and discuss why you feel your skill set may not be best suited to this role.
    • Explain that it may be beneficial to the practice for you to work on other roles, such as setting up medication review clinics and prescribing in your area of competence.
    • You could discuss how to achieve this in the future, perhaps by constructing a training plan or work shadowing to increase your competency.
    • Our PDP guide and template can help you plan your training.
• Have you checked if your activities are covered by your indemnity provider – employer and/or individual?

What the guidance says

• GMC guidance on good practice in prescribing and managing medicines and devices says: “You are responsible for the prescriptions you sign. You are also accountable for your decisions and actions when supplying or administering medicines and devices, and when authorising or instructing others to do so.”
• NHS England guidance on responsibility for prescribing between primary and secondary/tertiary care says: “Prescribers are responsible for the prescriptions they sign and they must be prepared to explain and justify their decisions and actions,” and “Legal responsibility for prescribing lies with the doctor or health professional who signs the prescription, and it is the responsibility of the individual prescriber to prescribe within their own level of competence.”
• The British Medical Association (BMA) guidance on prescribing in general practice says: “When a non-GP prescriber initiates a new drug, they accept responsibility for that prescription, but usually have no method of reissuing repeats and so that responsibility invariably falls on GPs. When faced with a request from the patient for a repeat prescription initiated from outside the practice, GPs should review the patient and set up a repeat prescription if appropriate or refer the patient back to initial prescriber.”
• GPhC’s In practice: Guidance for pharmacist prescribers advises: “Pharmacist prescribers must prescribe only within the limits of their knowledge, skills and area of competence.” They should also: “make prescribing decisions based on the needs of the person and not because of commercial interests or pressure from people, colleagues, employers or pharmaceutical companies.”

Prescribing for yourself, close family or friends

It’s generally considered poor practice to prescribe for yourself or for people you have a close personal relationship with. Before doing so, use your professional judgement and consider:

Objectivity

• Can you remain objective when treating yourself or close family and friends? Your professional judgement may be impaired or influenced by the person you are prescribing for.
• Can you conduct a proper clinical assessment on yourself, close friends or family?
• The close family or friend may not feel comfortable discussing all their other medicines or sharing their full medical records with you due to your relationship and may prefer to be seen by another prescriber.
• Are you sure that the medicine or prescription is needed?
• Does the medicine have potential for misuse?

Documentation and monitoring

• Do you have access to the person’s clinical records, for example, to check for drug interactions?
• How will your prescribing be documented so other healthcare professionals involved in the person’s care can access them, such as their regular GP? Are you able to justify your reasons for prescribing?
• If there are any monitoring requirements for the medicine, how will this be arranged and who will take responsibility?

External input

• Would a discussion with the dispensing pharmacist be more appropriate? They could suggest other options, such as an emergency supply or supply through a patient group direction.
• Would the dispensing pharmacist be satisfied dispensing a prescription you have self-prescribed?
• Are there any guidelines from your professional indemnity provider, regulator, professional body, or local policies on prescribing for yourself, close family members and friends?

What the guidance says

• GPhC advises within their guidance for pharmacist prescribers that: “Pharmacist prescribers must not prescribe for themselves or for anyone with whom they have a close personal relationship (such as family members, friends or colleagues), other than in exceptional circumstances.”
• GMC advises within their guidance on good medical practice that doctors must: “Wherever possible, avoid providing medical care to yourself or anyone with whom you have a close personal relationship.”
• The Nursing and Midwifery Council (NMC) advises within their NMC Code that nurses must: “Wherever possible, avoid prescribing for yourself or for anyone with whom you have a close personal relationship.”
• The Department of Health advises within their archived guidance, Improving patients’ access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England, that: “Pharmacist Independent Prescribers must not prescribe any medicine for themselves. Neither should they prescribe a medicine for anyone with whom they have a close personal or emotional relationship, other than in an exceptional circumstance.”
• NHS Scotland advises within their guidance on non medical prescribing in Scotland: implementation guide for nurses that: “Nurse independent prescribers must not prescribe any medicine for themselves. Neither should they prescribe a drug for anyone with whom they have a close personal or emotional relationship, other than in an exceptional circumstance.”

Prescribing and dispensing/administering to the same person

The prescribing and supply of medicines prescribed should normally remain separate functions performed by separate healthcare professionals to protect patient safety.

Here are some considerations involved in prescribing and dispensing for the same person:

• Are there any regulatory and professional standards and guidance you need to follow?
• Patient safety is improved by the opportunity for a second healthcare professional to check clinical appropriateness. You could discuss alternative options with the person needing the medicine, such as dispensing at an alternative pharmacy.
  • Is there is another pharmacist working the following day at the same pharmacy that could dispense/supply the medicines instead? The person can pick up the medicines the next day, if convenient.
  • Another pharmacist at a different pharmacy could check clinical appropriateness and pick up on any potential errors, for example, allergies and interactions.
• In exceptional circumstances where you need to prescribe and dispense to the same person, practice to ensure a safe supply. You can do this by:
  • Following a procedure.
  • Conducting a risk assessment.
  • Taking a mental break between prescribing and dispensing activities.
• Maintaining a full audit trail and documenting reasons for decisions is good practice and could include annotating the prescription.