Repeat Prescribing Toolkit

2.1 Preventing avoidable harm

Regulation 28, Prevention of Future Deaths (PFD) reports (commonly known as coroners’ letters) are issued to an organisation or individuals where the coroner believes that action should be taken to prevent further deaths. Approximately half of all deaths in England and Wales are referred to HM Coroner. Since 1984, it has been a statutory duty to report about deaths with a view to preventing future deaths¹³.

In April 2023, a study was published looking at the preventable deaths involving medicines. This work reviewed coroners’ reports from 2013–2022¹⁸. One in five coroner-reported, preventable deaths involved medicines. It identified that medicines cause over 1,700 preventable deaths annually in England and of the 704 PFD reports, the most common medicines involved were:

• Opioids (22%)
• Antidepressants (9.7%)
• Hypnotics (9.2%).

Coroners expressed concerns around the major themes of patient safety and communication, including minor themes of monitoring and communication between organisations.

For these reasons, general practice and community pharmacies should ensure that all high-risk medicines and particularly opioids, antidepressants and hypnotic medicines are treated very carefully where they are to be prescribed as a repeat medication. The practice, the pharmacy and the patient should all be clear about the arrangements for ordering and monitoring such medicines as well as frequency of and purpose of a thorough, structured medication review.

Published reports are available via the Courts and Tribunals Judiciary website.

Clear themes in all the reports reviewed include:

• Antidepressants, opioids for chronic, non-cancer pain and benzodiazepines were prescribed ‘on repeat’ but review of the ongoing need for these high-risk repeat medicines was limited
• Practices were not always aware of how much medicine was being ordered and so patients were able to gain access to large quantities of, and/or request very frequently, these higher-risk repeat medicines relatively easily
• Opioids and antidepressants were prescribed to vulnerable patients where the risk of intentional or unintentional overdose was high.

Practices should think carefully about their arrangements for repeat prescribing of these classes of medicines when they complete the repeat prescribing self-assessment.

Patients should be afforded regular and very careful review of their medicines and the decision to repeat prescribe these high-risk medicines may need to be considered on an individual basis. Some patients may benefit from a written agreement with the practice to help support safety, and a clear review timeline, e.g., three monthly.

Practices and local pharmacies should discuss and agree how concerns about suspected over ordering of these medicines (especially for vulnerable people) should be communicated and how these concerns will be acted upon.

To help PCNs to assess the consistency of their opioid prescribing, the Health Innovation Wessex opioid checklist for PCNs is included in section 6, good practice examples.

The risk of not supplying

Sadly, there have also been reports of deaths caused when rigid adherence to an agreed repeat medicine process has led to patients being unable to access their highly essential medicines; practices will wish to consider how teams will assess and respond to individual requests for high risk, highly essential medicines, to ensure that the risk of not supplying is balanced against the risk of on-going supply. 

2.2 Antimicrobials on repeat prescription

Antimicrobial resistance (AMR) currently poses one of the biggest threats to healthcare as we know it. Overuse of antibiotics drives AMR, which is associated with over 35,000 deaths each year in the United Kingdom¹⁹. The cost impact of avoidable antibiotic exposure for respiratory tract infection in primary care in the UK, due to adverse events and re-consultations, has been estimated at £238 million annually²⁰.

In general practices in England, 10% of antibiotics are prescribed for 0.5% of registered patients, equating to 10 or more prescriptions per year for this vulnerable patient cohort experiencing recurrent infection²¹.

Prescribing data indicate large variations across general practices in England in the proportion of patients repeatedly exposed to antibiotics, indicating a potential opportunity for improvement. Evidence-based resources for healthcare professionals have been developed to facilitate structured medication reviews (SMR) with patients to promote interventions to reduce future risk of recurrent infection.

Antimicrobials need to be thought of as high-risk in relation to being repeated. Repeated courses of antibiotics, although common practice, may have limited benefit and can increase the risk of:

• Antimicrobial resistance
• Hospitalisation.

Research from the University of Manchester showed that patients who have had nine or more antibiotic prescriptions for common infections in the previous three years are 2.26 times more likely to go to hospital with another infection in three or more months²².

Older patients and those with multiple long-term conditions and morbidities are at a higher risk of repeat antimicrobial prescribing. Chronic obstructive pulmonary disease and urinary tract infections have been highlighted as the most common conditions linked to repeat antimicrobial prescribing²³.

Patients who do have a clinical need for the long-term use of an antimicrobial should have a clear indication for this in their notes and their ongoing need for the antimicrobial thoroughly assessed on a regular basis. For example, the NICE guideline for recurrent urinary tract infection recommends a six-monthly review of the ongoing need for the antimicrobial.

Practices should think carefully about their arrangements for repeat prescribing of antibiotics and ensure a clear indication is recorded in the notes where ongoing supply is deemed appropriate, with a specified review date.

The RCGP have produced the Target Toolkit Hub to support more responsible use of antimicrobials.

Good-practice examples in relation to antimicrobial prescribing are included in section 6.

2.3 Multiple medicines (polypharmacy)

Over a million people in England receive ten or more medicines on repeat prescription²⁴. Evidence shows that up to 16.5% of admissions to hospital can be caused by adverse drug reactions (ADR) with polypharmacy and multimorbidity important factors contributing to this. Reducing inappropriate polypharmacy should be a major aim for preventing ADR¹⁷.

The RPS has previously produced guidance on polypharmacy.

When a new medicine is prescribed for a person already taking other medicines on repeat, a thorough check is needed to ensure any side effects, interactions and contra-indications have been considered. There are digital solutions to help with this in the GP clinical record system, but they can be overlooked.

General practices and/or PCNs should discuss how these warning and alert systems are used, including those suggesting over or under use of repeat medicines. This is covered in the self assessment questions.

Practices are advised to make use of the nationally commissioned new medicines service (NMS) from their local community pharmacies.

An SMR (defined below), is the best tested intervention to reduce polypharmacy. Practices and PCNs should have systems in place to identify patients taking multiple medicines, and high-risk repeat medication, and have a process to invite them for a structured medication review with a healthcare professional. They should incorporate shared decision making into the SMR to ensure that patients are fully engaged with the process and are able to express any issues, concerns and expectations related to their medicines.

See section 5.3 for evidence-based materials, available in a range of languages, to help to engage patients with the SMR process. These materials have been co-designed with patients and have been shown to increase the uptake of SMRs and reduce the number of patients who do not attend their SMR.

2.4 Medication reviews

Millions of people have the experience of receiving a repeat medication, and each year they receive a form of medication review to check that their repeat medication(s) are still appropriate and safe. However, some patients have reported that they don’t have any checks to their repeat medication and this, rightly, worries them.

In addition, there is still much confusion, even in primary care about the term ‘medication review’ and exactly what this should comprise. The generic term ‘medication review’ means different things to different people – for example, must the patient be present, how often should they happen, how detailed should it be, how long should be allocated for the appointment?

To try to address this, we have developed three broad terms for the different levels of medication review and how we think they should happen.

Simple repeat medication check (clinical re-authorisation)

• A check that the medication(s) for a single condition (e.g., asthma) or multiple allied conditions (e.g., cardiovascular diseases) were clinically checked and authorised as suitable repeat medication(s), and for how long
• The medication(s) would have ideally been clinically checked within a patient consultation or via a desktop review
• The authorisation for each medication should be either time-limited by setting the date of the next authorisation (e.g., a maximum of 12 months) or limited by the number of repeats allowed. The quantity of medication should be synchronised with the number of days issued (e.g., 56 tablets if prescribed one tablet twice a day and on a 28-day cycle) or made clear it is for use as required (e.g., 60 sachets for PRN use if repeat medication is needed)
• This review should be clearly visible within the repeat medication section of the clinical record system.

Medication review

• A holistic, clinical review of all medications for all of a patient’s conditions, ensuring any long-term condition/Quality and Outcomes Frameworks (QOF) reviews and/or relevant blood tests for safe prescribing have been undertaken or are scheduled at the required intervals
• This can be undertaken as desk-based review but ideally should be face to face or via a telephone or video consultation
• All the repeat medication should be time-limited by setting the date of the next repeat authorisation or limited by setting the number of repeats allowed
• The review should be clearly visible within the repeat medication section of the clinical record system and ideally all authorisation durations should be synchronised to coincide with the next medication review
• A systematized nomenclature of medicine clinical terms (SNOMED CT/read code) for a medication review should be recorded in the clinical record and include a clear date when the next medication review is due.

Structured medication review (SMR)

• An SMR is defined by NICE as a critical examination of a patient’s medicines with the objective of reaching an agreement with the patient (or their carer) as part of a shared decision-making process about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste²⁵
• Ideally an SMR should be undertaken face to face with the patient but can be via telephone or video call
• All the repeat medication should be time-limited by setting the date of the next repeat authorisation or limited by setting the number of repeats allowed
• This review should be visible within the repeat medication section of the clinical record system and ideally all authorisation durations should be synchronised to coincide with the next medication review
• A SNOMED CT (read code) for a structured medication review should be recorded in the clinical record allowing visibility for all and including a clear date when the next SMR is due (SNOMED code 1239511000000100 SystmOne Read Code Y282b).

2.5 Suggested questions for practices to consider in relation to higher-risk medicines or higher-risk patient scenarios

Higher-risk repeat medicines

1. Do administrative staff have a list of medicines classed as higher risk in relation to repeat requests that they know to manage more carefully (suggestions included in Box 1)
2. How is the repeat process for higher-risk medicines managed? Is it different to that for lower-risk medicines?
3. Careful consideration should be given before any higher-risk medicines (but especially opioids and antimicrobials) are prescribed on repeat. Is this clear in the practice procedure?
4. Where long-term use of a moderate-risk medicine is a safety issue, how does the practice ensure that there will be regular medication reviews before repeats are issued?
5. What is the procedure if a patient does not engage with the medication review or monitoring process? Is this clear to all members of the practice staff and locums?
6. Is the frequency of planned medication reviews appropriate for the risk of the medicine, e.g., no longer than three months for high-dose opioids?
7. Are there robust arrangements in place to ensure regular structured medication reviews for older people taking ten or more medicines regularly on repeat?

High-risk and vulnerable patient groups

1. Is there a practice process to identify and monitor patients taking high-risk medicines on repeat?
2. Does the practice have an agreed process for patients or patient groups deemed to be at greater risk of harm from higher-risk repeat medicines (such as those with a history of substance abuse, the very old, patients with ‘frailty’, those prescribed ten or more medicines, those with learning difficulties and those who are reliant on others to order and collect their medicines)?

Process Mapping

There are many benefits to a robust repeat prescribing system³.

Benefits to patients and carers:

• The process is convenient, and patients can access the medicines they need in a timely manner
• There is a clear understanding and appreciation of the process
• Patients have confidence that they are receiving their medicines safely
• Patients are familiar with the purpose and importance of having a regular medication review and take the opportunity to share any issues, concerns and expectations related to their repeat medicines
• Patients are familiar with the purpose and importance of attending the practice for any required monitoring related to their repeat medication
• Patients are involved in decisions about their medicines and their care.

Benefits to practices:

• More streamlined, manageable workloads
• Reduced ‘failure demand’ through fewer queries and anomalous situations*
• Risks and safety issues can be better mitigated or managed
• More appropriate and efficient use of professional and practice staff time and skills
• Greater understanding of the process by everyone involved, including roles and responsibilities
• Improved communication and working relationships with other healthcare professionals, e.g. community pharmacy
• Easier implementation of other initiatives, which can further reduce work burden and improve quality of care, e.g., eRD (see section 9)
• Reassurance and confidence for prescribers that the processes behind their clinical responsibilities are well-organised and robust.

*_{Failure demand is the demand caused by a failure to do something or to do something right for the customer²⁶. In a healthcare setting, failure demand describes the failure to get it right for the patient the first time. Patients then come back, making further demands to resolve the issue, and thereby unnecessarily consuming practice or community pharmacy resources because the service they received was ineffective.}

Benefits to the wider NHS:

• Assurance that medicines are used in a safe, effective and appropriate manner
• More efficient use of resources (including workforce) within the NHS
• Reduced medicines waste
• Reduced potential for adverse incidents and harm to patients
• Reduced potential for abuse of the repeat prescribing system.

Process mapping is a technique to visually map workflows and processes. It is a useful tool to enable practices to understand their own repeat prescribing process, which can be made up of many separate procedures happening at the same time.

This concept was defined nationally in the 2004 National Prescribing Centre guidance and included a generalised repeat prescribing process map, illustrated in Figure 1.³ This resembles an underground rail network with a station marking each step, and some stations are common to different lines. This process map was published before the EPS or eRD were introduced.

It is important that each practice maps out their own local processes and overall system, ideally using protected learning time to do this as a collective group, with all members of the practice team represented and engaged – clinical, administrative and technical. Figure 2 shows some of the steps you may wish to include.

When undertaking process mapping, it is important to identify:

• Steps that are working well, and you want to keep
• Steps that are not adding value (or not improving safety) as these could be designed out of the new process
• Steps that could work better with a better process design. These could improve efficiency, safety or just make things simpler
• Where there are gaps in the process
• How escalation routes work, e.g., if requests need to move to a clinician
• Where a digital solution or clinical system functionality can be used to automate or simplify the step process
• Which role in the practice has the responsibility for completing each step, and consider if that is the most appropriate role.

Figure 1 – A map of the main elements of the repeat prescribing process

Reproduced with permission from NICE.

---

3.1 Process-mapping case studies

These case studies, available on the NHSE website (general practice case studies) showcase where process mapping and redesign have improved efficiency, reduced clinician and practice team time spent on repeats and improved patient satisfaction and safety.

Case study summary

168 GP appointments released a month after redesigning the repeat prescription and medication review process

A practice in Staffordshire with a patient population of over 11,800 carried out a process-mapping exercise of the different steps it took for the practice to deal with medication requests and reviews. They involved the whole practice team to ensure accurate and complete input.

Understanding where time was wasted and identifying issues with the current repeat prescribing processes helped get all staff on board to support the changes for improvement that the group put forward. All the staff engaged in understanding the problems with the current processes and proposed solutions. Patients were engaged and involved in the process.

Key impacts:

• Over 28 hours of GP time released per month
• 42 hours of reception team’s time released per month
• Patients benefited from a streamlined approach for medication reviews, better availability of appointments and improved patient experience.

---

Case study summary

Dispensary and administration/reception teams working together to release 55 hours per week

A practice in Surrey working across two sites, including a dispensary, were struggling with high repeat prescription demand, and wanted to develop a more efficient process to release staff time.

Both site teams listed all the tasks involved in their repeat prescribing process and the essential steps that were frequently not completed. 35% of dispensary tasks were missed, which included tasks relating to controlled drugs. 39% of administrative/reception jobs were missed, e.g., booking appointments for patients that need a medication review. The heavy workload meant the team were in reactive mode and unable to plan a better approach.

By completing a skills matrix of current staff, this highlighted where standard operating procedures (SOPs) needed to be updated. Process mapping helped the team to objectively query every step to identify waste and value/non-value-adding work. Following testing, the teams reported back positively on the new process and the changes made.

Key impacts:

• Approximately 11 hours per day of dispensary and admin/reception teams’ time was released across both sites
• Time released is improving the service provided at the dispensary, including more time for face-to-face contact with patients, staff training and supervision
• The admin/reception team are now more able to work on patient and practice operational improvements including staff training, patient education and signposting
• Patients feel reassured, supported and better informed.

---

Case study summary

Redesigning the annual patient review process

Two practices came together under a single organisation to redesign the annual medication review process and deliver a common approach across both sites.

Staff did not have a clear understanding of the process from start to finish. Reviews took place on an ad hoc basis, often initiated/requested by the clinicians. There was a significant lack of clarity regarding responsibilities and poor communication. Clinicians were unsure of the reception team’s role in the process and vice versa.

They used what was currently working well for each team, along with ideas of different and more efficient ways of working, and incorporated them into the new process. At every stage, there was discussion and consultation with the wider practice teams, and staff were given the opportunity to feedback and contribute to the changes being considered.

A single review process is now operating across both sites.

Key impacts:

• On course to achieve collective goal of over 3,100 reviews per year, leading to better patient monitoring
• Collaboration has improved understanding of others’ roles and responsibilities, and enhanced further joint working
• Patients are receiving a more proactive service and saving time by scheduling all relevant review appointments during one medication review appointment.

3.2 Process-mapping resources

The NHS has useful resources to support process mapping and the Primary and Community Transformation and Improvement team, which was introduced as part of the delivery plan for recovering access to primary care, can provide tailored support for practices to make changes and improvements to how they work.

Their website includes webinars, guides and other support.

The Primary Care Improvement Connect Future NHS Platform also contains a wealth of resources to support practices with quality improvement methodology and case studies.

Practical actions that general practices might consider include:

• Completing a skills matrix to map out current skills, strengths and weaknesses in the team – an example skills matrix template can be found on the improvement team website to help understand who in the team is trained to manage prescription requests and identify where further training is required
• Align patient medication review dates
• Introduce eRD where it is clinically appropriate. Benefits are particularly seen for those patients with stable conditions and medications, e.g., levothyroxine, and their medication review can be aligned to long-term condition checks. For more information on eRD, see section 9
• Work closely with local pharmacies around changes being undertaken (reducing unnecessary calls, emails, etc.)
• Seek the views of your patients via the PPG. See questions for the PPG in section 5.4
• For patients who choose not to use the NHS app to manage their medications, look to optimise other digital channels (e.g., practice websites) to improve their ordering experience and streamline their requests in an appropriate workflow (recognising that digital solutions will not be suitable for all patients)
• Practices should discuss their arrangements for the minority of patients who are unable to use the usual repeat prescription ordering arrangements. This may be because they cannot access or use the NHS app (or other digital ordering arrangements) or because of chaotic lifestyle arrangements, such as those caused when a person is homeless. Practices could consider assigning responsibility for managing these patients to a care co-ordinator (or similar) so that the arrangements support the patient and are efficient for the practice team
• Review the practice process for urgent repeat prescription requests and the reconciliation process if a request for a repeat medicine has been managed via NHS 111. See section 9.5 for emergency supply requests

PCNs provide an opportunity for constituent practices to collaborate in a wide variety of ways, including reviewing, developing and sharing repeat prescribing protocols to support more consistent arrangements.

Figure 2 – Repeat Prescription flow diagram

Suggestions to improve repeat prescribing in the future

This toolkit has been designed to encourage and support general practice and community pharmacies to reflect on their repeat prescribing systems so that improvements in medication safety and efficiencies can be made wherever possible.

Elements of an effective repeat prescribing system

The working group agreed that the repeat prescribing toolkit should centre around five key elements. These elements are vital to the safe and effective running of a repeat prescribing toolkit.

For a detailed explanation of each of the five elements and the repeat prescribing self-assessment questions, see section 7.

Figure 3

The repeat prescribing patient partnership agreement

Many patients take medicines as repeat prescriptions to help manage their long-term conditions. But it is not uncommon for patients to express their confusion about what all the medicines are for, when they are supposed to take them and their concerns about taking medicines for long periods of time.

The prescribing and taking of medicines should be seen as a partnership between the healthcare professional and the individual; both bringing their relevant expertise and experience and agreeing on the right way forward together – shared decision-making (SDM).

Safe and effective healthcare is achieved through a partnership between healthcare professionals and patients. The World Health Organisation encourages patients to be more actively involved in their own healthcare and use of medicines. They have a useful infographic for patients outlining the five moments for medication safety.

5.1 The NHS Constitution

To promote a good partnership between healthcare professionals and patients, it is important to recognise that patients can make a positive contribution to their own and their family’s health and wellbeing. To help patients and healthcare professionals work together, the NHS Constitution says:

“Please recognise that you can make a significant contribution to your own, and your family’s, good health and wellbeing, and take personal responsibility for it.

Please provide accurate information about your health condition and status.

Please follow the course of treatment which you have agreed, and talk to your clinician if you find this difficult.”

5.2 Supporting patients and their carers*

Prescribers and patients need to work together through shared decision-making to ensure that patients receive the right medicines for them and are engaged in the repeat prescribing process.

Below are key expectations to support patients in taking their medicines:

• Patients (or their carer, where appropriate) are at the centre of their care, especially in relation to the medicines they are prescribed
• Through shared decision-making, the benefits and risks of repeat medication need to be clearly understood
• Patients should be encouraged to share what is important to them in relation to their repeat medication
• As a key partner in their healthcare, patients should be supported and encouraged to take ownership and responsibility for their repeat medication. This includes the timely and safe ordering, collecting, storing and taking of medicines as prescribed
• Prescribers should confirm a patient’s understanding of, and reason for taking a repeat medication and discuss any concerns and expectations
• Pharmacies (and dispensing doctors) supplying medicines to patients should do so safely and ensure that key messages around how to use the medicines safely are communicated in a way that the patient understands
• Patients should be encouraged to share with their prescriber if they are not taking any of their repeat medication as intended and their reasons for that.

^{* Where a patient is unable to take responsibility for their medicines, it is assumed that this responsibility passes to their carer.}

5.3 Useful resources

The following materials have been designed with patients and tested in primary care in England. They have been shown to help patients engage in their repeat prescribing and make the most of their structured medication review:

• I Manage My Meds
• Me and My Medicines
• Resources to support patients having a structured medication review
• Are your Medicines Working for You?

5.4 Questions for the general practice patient participation group

1. Do you think the practice repeat prescribing process is clear and understood by most patients registered with this practice?
2. Would you describe the process as timely, safe and effective?
3. Are there any parts of the repeat prescribing process that patients think could be improved?

5.5 Resources to help patients to understand the repeat prescribing process

The following patient partnership agreement and the patient information leaflet have been designed with patients to help GP practices and community pharmacies ensure that more patients understand the repeat prescribing process and their own roles and responsibilities within it.

Repeat prescribing patient partnership agreement

An example/template patient information leaflet that practices may wish to use is included below.

The repeat prescription request and authorisation process – patient information (practice to complete)

What is a repeat prescription?

Some medicines may be required to be taken on an ongoing basis to help manage your long-term condition. This is a repeat prescription.

Usually, a one- or two-month supply can be issued on a prescription and be repeated over a timeframe agreed with you before you may need another appointment or medication review.

Some medicines require closer monitoring or blood tests between appointments to make sure the medicine or the dose is effective and safe for you.

Some medicines are not issued on repeat because they require more regular reviews. Examples include strong painkillers or sleeping tablets. Your prescribing healthcare professional will discuss this with you on an individual basis.

How do I request a repeat prescription?

Ways to request your repeat medication include:

1. Via the NHS app or NHS website – this is the fastest route as it goes straight to the practice inbox
2. Online via our website
3. In person – request forms are usually available in reception.

Usually, requests cannot be taken over the telephone (to avoid errors being made).

We may ask you to nominate a preferred pharmacy for your prescription to be sent to electronically. This is known as your ‘nominated community pharmacy’. If you are registered at a dispensing practice, the prescription will be printed in the dispensary.

How long will it take for my prescription request to be processed?

We aim to process your prescription request within [X please insert] working days.

This is due to the large number of requests we receive daily, and because there are several steps involved in ensuring the prescription request is safe to be authorised.

The prescription is then usually sent electronically to your chosen pharmacy or can be printed and collected.

There is the option to track your prescription request using the NHS app or website.

Please be aware that, particularly at busy times of year, for example, around bank holidays, you will need to order earlier than usual to receive your prescription on time.

There may be delays from time to time, but we always do our best to ensure you receive your medicines safely and on time.

How do repeat prescriptions work?

Urgent requests

Please try not to run out of your medicines. When you are running low, e.g., have two weeks’ supply remaining, please request the next prescription.

If you accidentally run low or run out, we will try to process your request as quickly as possible, but please remember that the request process must be carried out thoroughly and safely and that GP practice teams are extremely busy.

Emergency supply requests for medicine can be made from NHS 111 or 111 Online in an urgent situation. The pharmacy will check the GP record/National Care Record to ensure that they are not making duplicate supplies to ensure your safety and reduce waste.

What is a medication review, and what is a structured medication review?

A medication review is usually arranged annually, sometimes more frequently, depending on the medication or condition being treated. A structured medication review is a more in-depth discussion between you and a GP or pharmacist. It is an opportunity to understand how you are managing with your medicines and for you to share any worries or concerns you may have. 

See the Health Innovation Network’s helpful animation.

Medication reviews are important, even if you have been taking the same medication for a very long time. The medication review enables you to raise any questions or concerns you have with your prescriber. It is the opportunity to discuss the benefits and any unwanted effects of your medicines to ensure you are getting the best possible treatment.

Some medicines require tests to be carried out before your medicines can be safely re-authorised to you. For example, blood tests or blood pressure checks. If you have been asked to have any regular tests or monitoring, please book in for this before your medication review.

Messages on your prescriptions

Sometimes we will communicate with you via your prescription. For example, we may give you a reminder about forthcoming blood tests.

When you collect your prescription, the pharmacy will mention this. You can always ask your pharmacist to check for any messages that may have been sent with your prescription.

What is electronic repeat dispensing (eRD)?

Patients who are stable on their medication and up to date with blood tests or monitoring could have their prescription on an electronic repeat, called eRD.

eRD allows your GP or healthcare professional to authorise up to a year’s supply of your repeat medication. You can collect your prescription every month or every two months from the pharmacy without having to order it. eRD is reliable, secure and confidential. Your regular prescriptions are stored securely on the NHS database, so they’ll be ready at the pharmacy each time you need them.

Please speak to your healthcare professional during your next routine consultation, or talk to your pharmacist about whether you might be eligible for eRD.

The NHS Business Services Authority has more eRD information for patients.

How to avoid unnecessary medicines waste

Please do not over order your medication. Once issued by your pharmacy or dispensary, medication cannot be reused and will always be destroyed when returned to the pharmacy.

If we notice you are ordering medicines too frequently, we may advise that you have a medication review and stop further prescriptions until we have spoken to you.

See the NHS Dorset website for more information on medicines waste.

Good practice examples

As part of the toolkit development process, we and RCGP asked our networks to submit examples of repeat prescribing good practice.

In this section, we set out a number of these example to showcase how primary care teams have improved their repeat prescribing systems.

6.1 Example: Repeat medicines monitoring

Using the skill-mix across the PCN team and the searches available in it the GP clinical system, Symphony Healthcare has created a scorecard to provide a snapshot of performance across multiple indicators including high-risk medicines monitoring.  A standard operating procedure for recalling patients has been developed.

This supports an approach of proactively notifying patients when monitoring tests are due and reactively reminding them when issuing prescriptions.

6.2 Example: Reducing waste and improving environmental sustainability

ICB medicines waste campaign

Medicines use accounts for 25% of the NHS’ carbon footprint. NHS Dorset’s Medicines Optimisation Team have created useful resources to support patients when ordering repeat medicines to reduce waste with an ICB-wide ‘only order what you need’ campaign.

Repeat prescription item growth decreased by 2.7% in the trial period, saving approximately £350–550k.

Practices that participated saw a roughly 4% reduction in repeat prescription requests.

PCN prescription alignment project

Easington PCN developed a prescription alignment project to enable a reduction in patient travel and associated carbon emissions created from repeat prescribing in primary care.

The community pharmacies advertised the service and directed patients to the prescription alignment forms. The service was delivered by pharmacy technicians and allowed a review of the medication requested and escalation to pharmacists for medication review where needed.

6.3 Example: Utilising digital capability to reduce workload

eRD e-learning

NECS developed an e-learning package in collaboration with NHS Digital. This learning covers eRD and how the successful implementation of this can be of real benefit to GP practices, community pharmacy and patients. It also suggests a number of things to consider to enable the eRD process to be most effective, such as establishing a named lead for both the practice and the local pharmacy who will work together to overcome any issues, and the importance of starting small (patients on a stable regimen, with just one or two items on repeat) and growing the pool of target patients as confidence in the process grows.

Further resources for the implementation of eRD can be found at:

• NHSE, Electronic repeat dispensing (eRD)
• Health Innovation Wessex, Electronic repeat dispensing (eRD)

6.4 Example: QI improvement tools and case studies

A QI project undertaken by Citrus Health Primary Care Network

A QI project revealed significant challenges in managing repeat prescription processes at one of the surgeries in a six-practice PCN, highlighting high staff turnover, increased prescribing errors and staff burnout. The practice in a deprived area faced compounded issues due to poor patient attendance for monitoring, technological barriers, and inadequate local system amendments.

Implementing a new SOP and culture tailored to the practice’s specific needs, alongside upskilling staff and improving communication channels, resulted in a marked reduction in errors and a substantial decrease in workload.

1. Initial challenges identified:

• High task volumes: Q1: 9,117 tasks, Q2: 10,034 tasks, Q3: 9,022 tasks
• System/process errors: 73.53% of total errors
• Significant under-reporting of prescribing errors
• 90% of medication requests via telephone.

2. Solutions implemented:

• New SOP and upskilling of admin staff
• Ledger-based system for transparent task management
• Fortnightly multidisciplinary meetings
• Engagement with NHSBSA for eRD data
• Switched to patient-led ordering as default system.

3. Positive outcomes achieved:

• Tasks reduced by 70% in Q4 (3,436 tasks completed)
• System/process errors dropped to 0% in the second audit
• Clinical human errors reduced by 50%
• Improved staff morale and retention. 0 reception staff departures compared with 6 in the previous year
• Increased patient satisfaction with 45% reduction in complaints
• 100% of ARRS staff report improvement in wellbeing and attitude to work.

The goodwill of staff was propping up an outdated and broken system. Since changes have been implemented, patients have increasingly embraced the NHS app and eRD and processes have been working more smoothly.

QI examples provided by the Primary and Community Transformation and Improvement team.

Access to FutureNHS Platform is required.

• Case study on standardising medicines management: Improving management of repeat medication utilising staff within a PCN hub.

Bellingham Green, South Lewisham Group Practice, and the Jenner Practice in London, were receiving over 500 repeat prescription requests a week, some of which required a medication review.  Staff were struggling to manage the reviews, with some GP appointments wasted when monitoring and test results were not synchronised with the medication review date.

The PCN Pharmacy Hub stepped in to provide support and now manages most reviews across the practices.

Impact:

• 53 administrative hours saved per week across the three practices
• 32 GP hours saved per week, across the three practices
• Patients receive reviews and their medicines in a timelier manner
• This project highlights the importance of collaboration and teamworking across a PCN.

https://future.nhs.uk/PrimaryCareImprovementCONNECT/view?objectId=33868720

https://future.nhs.uk/PrimaryCareImprovementCONNECT/view?objectId=30823952

• Future NHS – guide to increasing use of the NHS app for ordering prescriptions
• Future NHS – webinars to support process reviews: Demand and Capacity series and Safe, Reliable Process Design.

6.5 Example: Supporting the safer prescribing of higher risk, repeat medicines

Opioids

Health Innovation Wessex, as part of the Medicine Safety Improvement Programme (MedSIP) worked in collaboration with local ICBs and PCNs to improve consistency of opioid prescribing for chronic, non-cancer pain.

The group have published a suite of resources, including two PCN opioid checklists to help PCNs check if they have all elements in place to safely prescribe opioids. In response to local clinicians, they developed tools to help start discussions with patients who have been prescribed opioids long-term but who may be concerned about why their GP wishes to stop their opioid for chronic, non-cancer pain.

Joined Up Care Derbyshire have also published a number of opioid resources for patients and clinicians. Working in collaboration with Health Innovation East Midlands, they have created a practice-level opioid quality improvement toolkit and ICS minimum standards for repeat prescribing of opioids for chronic, non-cancer pain.

Antipsychotics in people with dementia

A toolkit has been developed by London Clinical Networks and Yorkshire and Humber Clinical Networks to support safer and more appropriate prescribing and deprescribing of antipsychotic medication.

NICE has a number of decision aids to support conversations with patients, and there are key examples surrounding higher risk medicines, e.g., benzodiazepine or z drugs.

Antimicrobials on repeat prescription

The NHSE antimicrobial resistance team in the east of England have been championing a new COPD preventing exacerbations toolkit (PET) checklist with PCNs. The toolkit stemmed from a collaboration between NHSE and UKHSA to develop How to…? guides for PCN staff to support structured medication review of patients experiencing recurrent infection or exposed repeatedly to antibiotics. Two ‘how to’ guides have been completed (COPD exacerbation and acne) and are hosted on the RCGP TARGET website. Search strategies for GP systems have also been developed to identify this patient cohort.

6.6 Example: Engaging with patients

The following materials have been designed with patients and tested in primary care in England. They have been shown to help patients engage in their repeat prescribing and make the most of their structured medication review:

• I Manage My Meds
• Me and My Medicines
• The Health Innovation Network – Resources to support patients having a Structured Medication Review
• Health Innovation North East and North Cumbria – Are your Medicines Working for You?

6.7 Supporting vulnerable patient groups

Frailty

Medication review in people at risk of falls is often not straightforward as people will often have multiple co-morbidities, be older and/or living with frailty, hence medicines use in this population requires a balance between the risks and benefits of multiple treatments.

The National Falls Prevention Coordination Group have produced a document for helping to review medicines of people at risk of falls.

Frailty and repeat prescribing of oral nutritional supplements (ONS)

The evidence base for frailty and malnutrition in older adults suggests limited evidence for oral nutritional supplements (ONS), with the patient group from the NIHR study stating we should ‘exercise caution’ in prescribing.

It is acknowledged that there is oversupply, risk of overuse and subsequent discharge from hospital without full assessment. This creates a significant follow up challenge for primary care. If followed up proactively after discharge, 61% of patients discontinue ONS (Barnet MSK project 2024, unpublished data).

Conversely, unintentional weight loss is frightening for patients and families and a trial of ONS may be appropriate (e.g., if awaiting diagnostic tests), with review to assess both efficacy and appropriateness. Clinical malnutrition (unintentional weight loss) can be classed as organic or psychosocial but often has elements of both and an aetiology-based approach is recommended to avoid overprescribing.

In considering if a repeat ONS prescription is necessary, it is essential to revisit the rationale for initiation, goals and adequacy of assessment and dietary advice.

Hertfordshire and West Essex ICB have some resources available and the Association of UK Dieticians has guidance around eating, drinking and ageing well.

Best prescription practice:

• A standard operating procedure within practice or medicines management team to manage repeat prescription requests, e.g., to include a process for tube-fed patients using ONS
• Use of acute prescriptions (or repeats with directions for follow up or length of prescription)

SMRs in those taking multiple medicines

Many patients report that they are not clear about the purpose of an SMR and may not feel able to share their concerns about their repeat medicines. To address this, Bradford and Leeds universities, in collaboration with patients and the Health Innovation Network Polypharmacy Programme, have developed a range of materials to support patients with their understanding of an SMR and how to get the most out of it.

These materials have been translated into several languages and are freely available.

People living in care homes

The care home support team across Coventry and Warwickshire have developed resources to support repeat prescribing for their care home residents. This includes support for ‘proxy ordering’. Care homes are encouraged to try to use one system for ordering repeat medicines for residents who are unable to order their own medicines, where possible.

NHSE offers guidance for proxy ordering.

Repeat prescribing self-assessment toolkit

Over the last 20 years, a considerable burden has been placed on general practices and community pharmacies as the demand, workload and complexity of repeat prescribing and dispensing have increased.

During this time, we have also seen safety issues emerge that are related to patients being able to access repeat medicines for years without always having the recommended checks and in-depth medication reviews taking place.

This is especially relevant for opioids, antidepressants, benzodiazepines, gabapentinoids, antimicrobials, anticoagulants, lithium, methotrexate, azathioprine, leflunomide, diuretics, ACE inhibitors/A2RBs, ‘shared-care medicines’, teratogenic medicines for women of childbearing age and patients who take ten or more medicines. See higher risk medicines and scenarios described in Box 1.

This RCGP/RCPharm repeat prescribing self-assessment tool is aimed at helping each practice or PCN look critically at both the safety and efficiency of their repeat prescribing processes and agree as a practice team where to make improvements or address issues.

7.1 Completing the repeat prescribing self-assessment tool

The repeat prescribing self-assessment tool should ideally be discussed and completed in a practice or PCN meeting with both clinical and non-clinical staff present so that all perspectives can be heard. Where possible, local practice PPGs should also be involved. Everyone should be encouraged to be open about what is good about the current process, any gaps and where safety or efficiency in repeat prescribing can be improved and risks highlighted.

In addition, practice staff should speak to local community pharmacies to seek their input into areas where local arrangements cause problems or could be improved. Recent patient feedback (complaints or positive comments) should be highlighted during the discussions.

See questions for the general practice PPG in section 5.4.

There is a full appreciation of the current pressures in primary care. The first step for practices may be to discuss the self-assessment questions and be aware of issues or opportunities for improvement. If there are clear medication safety risks highlighted as part of the process, they should be addressed promptly.

However, for the majority of improvements, practices or PCNs may want to develop a repeat prescribing action plan (see section 7.6) which will be worked on over time by the whole practice team and external stakeholders, such as local community pharmacies and the PPG.

PCNs or practice pharmacists are well placed to lead this work, but improvements are most likely to happen where the whole practice team is involved in addressing any issues. Practice managers and prescribing lead GPs can play a key role in helping to keep up the momentum and support any changes. This work will need a team/PCN approach.

There is a wide variation in the way that repeat prescriptions are managed by individual practices. We appreciate that practices have very different capacity and capability challenges. To help with this, we have described ‘core’ questions for all practices to address and additional ‘advanced’ questions for practices/PCNs who wish to go further and ensure their repeat prescribing system is as robust as it can be.

7.2 Suggested steps for GP practices/PCNs to complete the repeat prescribing self-assessment

1. Appoint a practice/PCN lead for the repeat prescribing self-assessment process
2. Look at the oversupply dashboard hosted in ePACT2 (NHSBSA) to understand if there is an issue with oversupply in your practice
3. Convene a ‘repeat prescribing working group’ to discuss the toolkit and self-assess the practice against the questions. Ideally, both clinical and non-clinical staff should be invited
4. Review all responses
5. Agree on the key areas of action required and document these in the RCGP/RCPharm repeat prescribing action plan (see section 7.6)
6. Prioritise any key medication safety issues highlighted during the process
7. Work through the practice/PCN repeat prescribing action plan with SMART objectives assigned to members of the whole practice team, and timelines agreed to keep the work on track
8. Hold regular discussions to ensure actions are completed and new systems are tested. See section 3 for process mapping and support to deliver quality improvement
9. Where system-wide issues are affecting the safety or effectiveness of the repeat prescribing system, e.g., poor phlebotomy services causing a lack of access to timely blood test monitoring, these should be formally highlighted to the ICB
10. This process may take a number of months and require a number of PDSA (Plan Do Study Act) cycles.

Figure 4: Suggested steps for GP practices/PCNs to complete the repeat prescribing self-assessment

7.3 Elements of repeat prescribing

Research undertaken by Health Innovation East Midlands, which used a ‘human factors’ perspective to understand opioid repeat prescribing, identified three crucial areas that have the potential to enhance the efficiency of repeat prescribing systems:

1. Improve the functionality and use of the clinical systems
2. Ensure there is an effective and embedded work procedure that is understood and accessible to all staff members and patients
3. Create a manageable cognitive load/workload for clinical and non-clinical staff²⁷.

These themes should be used to shape the discussions around the self-assessment.

The working group agreed that the repeat prescribing toolkit should centre around five key elements (see figure 3). These elements are important for the safe and effective running of a repeat prescribing system.

Practices will vary in their clinical, technical, and administrative capacity and capability. In the current workforce environment, it is not always possible to optimise all elements. However, by completing the self-assessment toolkit, practices will be able to identify current gaps and highlight where processes can be improved to ensure medication safety and maximise efficiency. This will require an open and honest approach from the practice and will need dedicated time to do well. Practices that have gone through such processes report that they have seen the benefits of this work, including clinician time saved, fewer prescription queries and faster turnaround (see examples in section 3).

The five elements of repeat prescribing:

1. Organisational culture

A just, open and positive organisational culture will ensure that the practice operates in an environment where issues related to the safety and efficiency of the repeat prescribing system can be raised, discussed, addressed and monitored for improvement.

This is important for medication safety but can be challenging to achieve. It relates to the culture within the practice but also the relationships with local community pharmacies and the PPG, as well as the registered patient population (see NHSE patient safety strategy).

Part of creating a positive organisational culture includes ensuring that the general practice has ownership of creating an effective process that improves the system performance, supporting staff to carry out their work well and delivering a service that is safe and timely for the patients needing it.

2. Patient/carer

Patients and carers have a role to play in the safe and efficient operating of a repeat prescribing process. The roles and responsibilities needed to optimise this process are described in the repeat prescribing patient partnership agreement (see the patient partnership agreement in section 5).

3. Clinical

This is where the clinical decision to authorise the repeat prescription is made. This element will determine for how long medicines are to be repeated and how regularly they are to be reviewed, as well as any monitoring requirements.

The quality and regularity of the medication review are key to the safety of this element. Practices will need to think about their staff skill mix to ensure that the right clinicians are engaged in the medication authorisation and review processes. GMC professional standards state that ‘clinicians prescribing repeat medications should only do so with adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their need’²⁸.

Practices need to assess the quality of their medication reviews and if sufficient clinical input is allocated to patients receiving higher-risk medicines, in particular (see the glossary for authorisation/medication review and SMR definitions).

Patients prescribed higher risk medicines on repeat described in Box 1 should receive a regular, structured medication review to allow for their repeat medicines to be optimised and for any issues, concerns and expectations to be addressed. This will include any non-adherence, over or under ordering and any safety or monitoring issues.

Shared care arrangements

Good record keeping is an essential component of any clinical system and will ensure that all members of the team are sighted on the full clinical picture. Practices should ensure that, where medicines are prescribed elsewhere, clinical records are updated in a timely way. Guidance on how to do this is available from NHSE (Recording medicines prescribed elsewhere into the GP practice record).

Standardised shared care protocols are also available from NHSE.

4. Technical

Technical processes should be in place BEFORE a repeat medication is reauthorised to ensure that routine monitoring and follow up actions are highlighted and completed. Use digital systems to optimise the repeat prescribing process.

The technical element of the repeat prescribing system should include alerts to prescribers to highlight under or over ordering and should ensure that medicines that have been deprescribed cannot inadvertently be restarted without a clinician’s input. Technical optimisation, with respect to repeat prescribing, will ensure that all digital and technical systems are deployed and that precious clinical and administrative staff are not carrying out routine tasks that can be safely automated (see section 8.2 for SystmOne and EMIS examples).

The technical element of repeat prescribing also highlights the opportunity that wider deployment of technical staff, which may include pharmacy technicians, can offer to ensure that clinical staff resources are used sensibly.

5. Administrative

Administrative staff play a significant role in the day-to-day operation of the repeat prescribing system. They are at the forefront of managing queries and problems and often have oversight of the whole process. They need time for training in how to manage repeat prescriptions safely, as well as a thorough induction of how the practice operates the process. They need to work closely with community pharmacy colleagues.

Support and training are not provided to all administrative staff working on repeat medication, and yet this is a high-risk component of their role as well as a high-risk element of the process for the practice.

7.4 RCGP/RCPharm repeat prescribing practice self-assessment

Organisational culture

Core

1. Is there a written policy/standard operating procedure (SOP) to describe the planned process for repeat prescribing and medication reviews in the practice (is it fit for purpose, easy to access and easy to use)?
2. Is there training for all staff involved in the repeat prescribing process (administrative and clinical) to ensure they are aware of the policy/SOP and understand the practice/PCN repeat prescribing process? What about locum staff?
3. Who in the practice has overall responsibility for the repeat prescribing process?
4. Who in the practice has responsibility for the day-to-day running of the repeat prescribing process?
5. Is it clear how and who in the practice will deal with an issue, incident or complaint relating to repeat prescriptions?
6. Are practice staff clear about the roles and responsibilities of all staff members involved in the repeat prescribing process?
7. If any member of staff has a concern about the repeat prescribing process, is it clear how to raise issues and offer solutions, and is that effective?
8. Is the repeat prescribing process and how it works (including time associated within the practice and the community pharmacy), clearly communicated to patients, and are all patients clear about how they are to engage with it?
9. What is the mechanism for the practice to discuss how the current system is working?
10. In your discussions to review the repeat prescribing system, are the following included:
    • The input/views of local pharmacies and or the PCN community pharmacy lead?
    • How high-risk medicines and high-risk scenarios are managed and if this is working effectively?
    • Any recent incidents or complaints, and what can be learned from them?
    • How you measure if the current system is working? This should include the NHSBSA oversupply data and any local metrics on time taken for repeats.
11. Is dedicated time allocated to clinical and non-clinical staff to manage repeats?

Advanced

1. Is the repeat prescribing process treated as a risk activity, e.g., is it treated as a separate task, or is a dedicated room provided for administrative staff processing repeats? Is time given to clinical staff to deal with authorisation?
2. How well does the practice liaise with local community pharmacies to resolve any frequently occurring issues?
3. How has the practice learned from a recent repeat medication incident or complaint?
4. How has the practice process mapped and reviewed the workload associated with repeats? Was this for both clinical and non-clinical staff?
5. How is the practice using digital solutions to reduce workload? What else could be done? Is GP clinical system functionality optimised by all staff, and has the practice explored the use of eRD and the NHS app?
6. Are SMRs embedded in the culture of the practice and given the space and time required to undertake them? Are patients at higher risk of medicines-related harm prioritised for an SMR?
7. Is the burden of the repeat prescribing system on clinical staff regularly reviewed and revised if individuals are experiencing unsafe workloads? How is this assessed? Does the practice regularly collect and review data relating to the number of requests dealt with by the admin/pharmacy team/GPs?
8. Does the practice have a member of staff who can support patients who struggle to use the usual repeat prescribing process, such as those with learning difficulties, those unable to use digital processes and those where a chaotic lifestyle can make it harder to order and collect prescriptions, such as those with no fixed home address?

Clinical responsibilities

Core

1. When a medicine is moved from acute to repeat, is this decision explicitly recorded with a duration of the repeat documented?
2. Is the indication for a repeat medication clearly documented in the GP clinical system?
3. How are patients informed about any risks of longer-term use of the medicine(s) and the expected length of the prescription at initiation? Is this clearly documented in the notes?
4. Is there a separate process for higher-risk repeat medicines? (see box 1)
5. How are the responsibilities around repeat medicines communicated to patients (e.g., monitoring requirements, medication reviews and when medicines will not be repeated)?
6. How can community pharmacies speak to a member of the clinical practice team to ask questions about a repeat prescription from a clinical or safety perspective? Is this working well?
7. What systems are in place to monitor over ordering of repeat medicines (especially in relation to medicines with dependence-forming or overdose potential)?
8. What processes are in place to identify and manage under ordering of repeat medicines?
9. How are re-authorisations/medication reviews/SMRs (see definitions) incorporated into the repeat prescribing process, and what happens if the patient does not participate?
10. When medicines are recommended by secondary care, is there a clear and safe clinical authorisation process for discharge letters to be interpreted and medicines clinically authorised for repeat?
11. When medicines are stopped, is there a clear process to ensure they are removed from the repeat medicines list?
12. Is there a clear process of action for the Practice to respond to national medication alerts, such as national patient safety alerts or drug safety alerts that relate to medicines prescribed on repeat?

Advanced

1. Are terms such as ‘as directed’ or ‘when required’ avoided, especially when in relation to high-risk medicines? How is feedback provided to prescribers when clear directions are not provided?
2. Is there a clear process for dealing with prescription queries?
3. How are prescription queries monitored? Many prescription queries might indicate a process problem. The same patients querying each cycle might indicate they are unsure of the correct process. How are both scenarios addressed?
4. Have there been any serious incidents involving repeat medicines, and how were lessons learned?

Technical

Core

1. What is the process for requests for repeat prescriptions? How many ways can patients request repeats? Is this manageable for the practice? Is it safe and clear to patients?
2. How are repeat prescription requests triaged?
3. Is there a clear medicine resupply practice policy for support staff, e.g., it is within the medication review date documented on the system or it has a specified number of authorisations that are still within a valid time period?
4. How are checks made around monitoring requirements, such as blood tests?
5. How does the practice ensure monitoring requirements are adhered to before repeat prescriptions are re-authorised?
6. What is the practice’s process if a patient does not engage with monitoring arrangements? How is this communicated to patients?
7. How are large-scale requests managed (e.g., care homes)? Is this working well?
8. How are dose changes that are needed mid prescription-authorisation cycle made, so that the patient receives the new dose, and the clinical notes are updated to prevent older dosing schedules being prescribed inadvertently?
9. How does the practice identify and manage over-ordering of medicines (especially those with
   dependence-forming or overdose potential?)
10. How does the practice identify and monitor under ordering?
11. How does the practice manage discharge letters involving requests for repeat prescriptions? How are discharge issues flagged to clinicians?
12. How are ‘shared care’ arrangements for prescriptions managed safely? How is this documented so that all clinicians are aware of the full clinical picture?
13. Could the practice improve efficiency in how patients request repeats and receive medication requests?

Advanced

1. What (digital) functions of the clinical system are used to help with the efficiency of the practice’s repeat prescribing system? Do all staff consistently apply these functions?
2. Is there additional system functionality that is not deployed, and why?
3. What is the agreed process for interactions between the community pharmacy and the practice?
4. Is there a technical lead for repeat prescriptions who is responsible for monitoring workload, queries, system failures, inefficiencies and safety issues?
5. Does the practice regularly monitor the number of repeat requests per month and audit how the workload associated with the volume of requests falls to various team members (clinical and non-clinical)?
6. Does the practice monitor how many repeat prescription requests are made via 111? Is this excessive? ICB-level NHS 111 data is updated monthly. Could high usage of 111 indicate that there is a problem with your repeat prescribing process?

Administrative

Core

1. Who in the practice manages the day-to-day administrative duties of the repeat prescription processes?
2. Is there a very clear process where all relevant members of the administrative team understand their roles and the limits of what they are authorised to do?
3. How are administrative staff trained?
4. How are administrative staff supported in their repeat prescription roles?
5. Is there a process for dealing with queries that do not fit the usual process, and is this clear to administrative staff (e.g., ordered too early, essential blood tests not available, patient hasn’t had the medicine for a number of months or over ordering)?
6. Are the administrative staff aware of the risks of circumventing the agreed practice process to expedite
   prescription queries?

Advanced

1. Are the administrative team aware of which medicines are higher risk repeat medicines, how they are to be managed and how this might differ from the usual repeat process?
2. Are administrative staff given a quiet space to process repeat prescriptions with minimal interruptions?
3. Is there a dedicated phone line/extension for community pharmacies to contact the practice team in relation to prescription queries?
4. Does the practice regularly monitor the volume and nature of repeat ‘queries’, i.e., where the request or query does not follow the usual process agreed for repeats?

See patient questions in section 5.4.

7.5 Community pharmacy and dispensing practices

Community pharmacies and their local general practices need to work closely together to ensure the safe and efficient running of the repeat prescribing pathway. Both services have come under increasing pressure in recent years, but should still aim to engage regularly to ensure medicines are managed effectively for patients.

Pharmacies and general practices/PCNs should aim to meet to discuss this repeat prescribing self-assessment toolkit and how any local issues can be resolved or improved. Some PCNs will have a dedicated community pharmacy lead who can support this.

Both parts of the pathway (prescribing and dispensing) are complex and hugely challenging. Both partners need to recognise the constraints experienced by the other to try to ensure that patients are provided with a safe and efficient local process.

Key questions for community pharmacy teams to assess their repeat prescription provision:

1. Is your process for receiving and dispensing repeat prescriptions clear to your patients and local general practices?
2. Is the time needed for the safe dispensing of repeat medication communicated to patients, so they are aware of how far in advance to order their next supply?
3. Does your repeat prescribing process work equally well for all prescriptions from all local general practices?
4. How do you communicate urgent queries to the GP practice, and is there an audit trail in place for this?
5. How do you communicate non-urgent queries to the GP practice? Is this process effective? How do you audit this?
6. Have you worked with local GP practices to encourage the use of eRD and support implementation for patients who meet the criteria for this?
7. What role does the pharmacy play in ordering repeat medication for patients? Has this been agreed with local GP practices?
8. Is there a process for highlighting under/over ordering of medication to the GP practice?
9. How do you encourage patients to use digital solutions, such as the NHS app, to order and check on repeat prescriptions?
10. Do you have a clear process of action to respond to national alerts, such as national patient safety alerts of drug safety updates?

Dispensing practices

General practices in more rural areas offering a dispensing service should consider the following questions:

1. Are there SOPs in place within the dispensary covering the processes for repeat prescribing, covering roles, responsibilities and training of staff?
2. Is your process for receiving and dispensing repeat prescriptions clear to your patients?
3. Is the time for dispensing of repeat medication communicated to patients so they are aware how far in advance to order their next supply?
4. Do you encourage patients to use digital solutions such as the NHS app to order and check on repeat prescriptions?
5. What support and training are in place for dispensary staff who operate the repeat prescribing system?
6. Are all repeat prescriptions signed by the prescribing clinician before they are dispensed?

7.6 RCGP/RCPharm practice/PCN repeat prescribing action plan template

System issues to highlight to the ICB

Pathways issue to discuss with local pharmacies

Training Resources

Part of the National Overprescribing Review recommendation 7 work was to identify current gaps in training materials, particularly for non-clinical staff who may support the repeat prescribing process. Research highlighted the importance of non-clinical staff and the level of responsibility they have when processing repeat prescriptions².

The CQC states that to deliver safe, high-quality care and treatment, practices must take reasonable steps to support staff to do their jobs. Each general practice is responsible for determining what mandatory and additional training its staff need. They are also responsible for how this is delivered.

PrescQIPP

PrescQIPP is a non-profit NHS-funded organisation that provides evidence-based resources and tools. One of the tools they provide is e-learning materials for non-clinical staff called the Practice Medicines Co-ordinators course. This is a CPD-accredited course, accessed by creating an account on PrescQIPP using an NHS email address. It contains ten modules and should take approximately four hours to complete, utilising video presentations.

8.1 GP clinical system supplier training and resources

As part of the development of this repeat prescribing toolkit, we met with the two major GP clinical system suppliers and requested that they provide a resource page for practices to understand how to use their system to support safer and more efficient processes for repeat prescription systems. These resources can be found on the TPP learning management system repeat prescribing toolkit and the EMIS Medication Resources.

8.2 Quality improvement (QI) training

NHSE – An Introduction to Quality Improvement in General Practice

RCGP has a QI support guide for whole practice teams, training resources available for members and project case studies.

One of the future recommendations (see section 10 [UPDATE]) is for NHSE to consider a nationally available training module for general practice staff that supports the running of a safe and effective repeat prescribing process.

Tools to optimise repeat prescribing

To support practices and PCNs to improve the safety and efficiency in repeat prescribing systems, we are signposting to a range of tools and resources.

9.1 NHSE and NHS BSA Oversupply Dashboard

The NHS Business Services Authority (BSA) is home to all the prescribed and dispensed medicines data for England. Such detailed data allows us to understand the quality and quantity of prescribing in England, and in recent years has seen a number of ground-breaking dashboards, for example, those looking at the rates and type of polypharmacy in general practice.

NHSE and NHSBSA have recently developed a dashboard highlighting the scale of potential oversupply of medicines for a range of prescribing areas. This can support improvement initiatives, particularly around addressing inconsistencies with repeat prescribing processes, and help to minimise avoidable waste or the risk of harm to patients. Oversupply is when more medication is dispensed than should be typically needed or wanted by the patient.

This work supports recommendation 4 of the National Overprescribing Review, namely to “improve data for feedback to clinicians and commissioners to guide prioritisation and monitor success”².

The oversupply dashboard is available to all general practices and PCNs in England. The dashboard relates to a targeted number of therapeutic areas – typically those with a straightforward dosage schedule to highlight where cumulative amounts of prescribing are considered excessive for a 12-month period.

At launch, the dashboard will look at:

• Aspirin 75 mg
• Statins (solid oral)
• Glucose monitors/sensors
• Fixed dose inhalers
• Daily laxatives
• Blood glucose testing strips
• Oral nutritional supplements.

This is a list of medicines with a straightforward daily use quantity that could be indicative of an oversupply problem. It helps users to spot egregious amounts, quantities that might not be safe, or amounts that may add up to a lot of wasted medication. This can be used to identify issues relating to specific patients or to identify practices or wider geographies with wider systemic oversupply problems. The specific patient cohorts (e.g., patients on ten or more medicines) also provide an opportunity to prioritise initiatives such as structured medication reviews.

Practices and PCNs can register for ePACT2 on the NHSBSA website to access the oversupply dashboard.

Practices could use this data before and after completing the repeat prescribing toolkit action plan to gauge the effectiveness of any interventions.

9.2 Increasing and optimising digital functionality of the repeat prescribing system

It is recognised that different practices will be at different stages of digital maturity. However, the following principles are suggested to support the digital optimisation of the process.

Repeat medication ordering

1. Use of digital/online* order requests for repeat medicines should be maximised where possible, and variation in methods of accepting order requests should be minimised

*_{Digital/online refers to the NHS app, NHS.uk webpage, or third-party online ordering platform that delivers the request directly to the GP practice system.}

Receipt of repeat medicine order requests

2. IT workflows should be configured to allow timely and safe management of repeat medication order requests, with mechanisms in place to identify over ordering

Prescribing repeat medication

3. Risk of duplicate prescriptions or prescriptions issued too close together should be highlighted within clinical systems to avoid unintentional overprescribing
4. Use of EPS and prescribing IT system functionality should be optimised for prescribing repeatable medicines safely and efficiently.

9.2.1 Increasing utilisation of digital repeat prescription ordering

The number of appointments viewed or managed through the NHS app has more than doubled, from 1.95 million in November 2022 to 4.1 million in November 2023.

There were 10.7 million views of patient records in the app in November 2023, compared with 5.8 million in November 2022. There has been an increase in the number of over 50s signing up for the NHS app, following the introduction of new services, including vaccine bookings.

From 2023 to 2024, the number of digital repeat prescription requests in the NHS app rose by more than 45%, amounting to 3.1 million repeat prescription requests a month. A total of 77.5 million repeat prescription have been ordered through the app since the functionality was first introduced. Repeat ordering through the NHS app saves patients an average of 18 minutes with each online order, and each practice an average of three minutes per order received.

As the NHS app grows in both popularity and functionality, we hope to see increasing utilisation and assurance that digital becomes one of the main routes for repeat prescription ordering. This will bring clarity about the process to most patients and a more consistent approach to managing the influx of repeat order requests for most general practices.

However, we recognise that not all patients are able to use digital tools in this way, therefore additional arrangements will need to be made locally so that patients who cannot yet use the app or other online tools are able to order their prescriptions safely and effectively.

Developments we hope to see in the NHS app in the future include:

• The ability to track prescriptions and repeat prescription requests
• Better pharmacy nomination access
• The ability to track eRD prescriptions – the number of authorisations remaining, for example
• Improved repeat medication ordering journey.

Information for patients about the NHS app can be found on the NHSE website.

Age UK have guidance for older people using the internet, including how to order prescriptions.

9.3 System suppliers

GP clinical system suppliers have a significant role to play in increasing the functionality of repeat prescribing systems and identifying over or under ordering of repeat medication by patients.

System suppliers also have a responsibility to ensure that any new functionality aimed at improving repeat prescribing efficiency does not compromise medication safety or increase the risk to patients from authorising medicines to be repeated without the appropriate clinical checks.

9.4 eRD

First introduced in 2009, eRD is a non-compulsory method of dispensing prescriptions electronically. It means that patients who regularly get the same medicine do not need to visit their GP every time they need a repeat prescription. Instead, the prescription can be sent straight to their pharmacist for dispensing.

Using eRD, GPs can issue up to 12 months’ worth of regular prescriptions, which can be stored securely on the NHS database, so they are ready at the pharmacy each time a patient needs them.

eRD was rolled out nationally in April 2019 as part of the GP contract. Within three months, nearly 700,000 patients were using the repeat dispensing process, and today, over 1.2 million patients benefit from this service. It is estimated that eRD has helped manage increased pressure of the health service and saved over 90,000 hours of GP practice time – time that can be reinvested in patient care.

Practices can access data from the NHS BSA to identify patients who have taken the same medicines for ten out of the previous 12 months and therefore may be suitable for eRD. This data can be requested from the NHSBSA on the ‘requesting eRD data’ page.

Health Innovation Wessex have published a range of tools and guidance to help practices successfully deploy eRD.

9.5 Proxy ordering

Proxy access was developed to allow someone other than the patient to access and manage parts of their GP online services account. The proxy is given their own online access account (rather than using the patient’s login details). It is usually used by the parents of young children and recognised carers of adults. It can also to support CQC registered care homes and GP practices and pharmacists to work together to allow care home staff to order online repeat medication on behalf of residents.

Proxy ordering guidance can be found on the NHSE website.

9.6 Emergency supply requests

Emergency supply requests for medicine can be requested from NHS 111 or 111 Online where the patient is unable to receive a prescription for their regular repeat medication in a timely manner. NICE Emergency Supply of Medicine guidance should be followed.

Where appropriate, the pharmacist will advise the patient or their representative on the importance of ordering prescriptions in a timely manner from their GP practice and prevent the future need for emergency supplies. If an urgent supply is needed, the pharmacy should check the GP record/National Care Record to ensure that they are not making duplicate supplies to ensure patient safety and reduce waste.

9.7 Patient information leaflet

Further patient information is available in section 5 and the repeat prescription infographic.

Suggestions to improve repeat prescribing in the future

This toolkit has been designed to encourage and support general practice and community pharmacies to reflect on their repeat prescribing systems so that improvements in medication safety and efficiencies can be made wherever possible.

However, some areas were outside the scope of this working group to address. Examples include changes in commissioning responsibilities or regulatory arrangements.

To ensure the continued safety and efficiency of repeat prescribing systems, we make the following suggestions to improve repeat prescribing in the future:

1. Commissioners are encouraged to consider incentivisation for practices/PCNs and community pharmacies to engage with this work and complete the repeat prescribing self-assessment and action plan.

2. GP and pharmacy system suppliers are asked to provide greater functionality to help to recognise the oversupply and over ordering of repeat medication, particularly for higher-risk medicines, and help practices and pharmacies to identify and address it.

3. We encourage the NHSBSA and NHSE to further develop the oversupply tool to increase functionality to measure the oversupply of higher-risk medicines such as opioids, antidepressants, benzodiazepines and antimicrobials (see box 1).

4. The terms of service for NHS community pharmacies and the Community Pharmacy Contractual Framework could formally enable pharmacy teams to support patients to discuss how they are taking their medicines and raise any concerns with their community pharmacist at the point of dispensing. The development and commissioning of a community pharmacy service to help people who are struggling or unable to manage their repeat prescriptions effectively could be explored. Such a ‘repeat prescription review service’ could meet the needs of the large number of patients who express confusion about what medicines they have been asked to take and how to take them safely. Such a service could be tested to explore its impact on adherence and reducing the ordering of medicines that the patients are no longer taking.

5. eRD requires urgent modernisation to ensure it works smoothly and resolve some of the well-known challenges. In particular, the ability to amend doses in EPS (rather than having to cancel that item) would be a welcome improvement both in efficiency and safety. The improved functionality of the NHS app in relation to eRD tracking and monitoring would be a significant development. More broadly, the improved medicines and prescriptions functionality in the NHS app, especially but not solely in relation to eRD to optimise user experience and safety would be very welcome.

6. A national and accredited course should be made available for non-clinical staff who are essential in supporting the repeat prescribing process, and support given to GP practices to enable reception staff to have the time to complete such training.

7. There is a significant need for a greater information to inform the public of, and raise awareness of medication safety, medicines waste and the environmental impact of medicines. A national public awareness campaign should be considered by national organisations and royal colleges.

8. NHSE should be encouraged to expedite digital solutions to allow hospital discharge information relating to medicines to link into the patient record to create a digital audit trail of any medication changes.

9. Secondary care and specialist services are asked to make very clear to primary care on discharge of a patient from the hospital, the reasons for medicines to be prescribed on repeat, the indication and the intended duration of therapy. Any medicines stopped need to also be clearly documented with a reason for the cessation of therapy. Utilisation of the Discharge Medicines Service (DMS) in England is currently not fully optimised. The DMS enables hospitals to digitally share information about medication changes with the patient’s usual community pharmacy and has been shown to reduce readmission rates at 30, 60 and 90 days. Trusts and Community Pharmacies should make the most of this opportunity to reduce avoidable harm.

10. A clinical guideline should be commissioned to pull together, in one place, recommendations on the frequency of medication reviews for all higher-risk, repeat medications. This could be a role for NICE or Specialist Pharmacy Services.

11. Commissioners are asked to explore the formalisation and contractualisation of protected time to allow for discussion between general practice and community pharmacy. This needs to be set out nationally in relation to the repeat prescription pathway, to ensure that all parties are clear about their responsibilities.

12. The issue of ‘bulk authorisation’ of repeat prescriptions requires a more in-depth, national review. The functionality to bulk authorise repeat medicines has been developed by some but not all the GP system suppliers. However, the full medico-legal impact and risk of this development are unclear. A minimum set of standards and a risk assessment process for GP practices are urgently needed to ensure that the safety of authorisation of repeat medicines is maintained.

Glossary and Annexes

Annex B

Repeat Prescription Systems in England – Literature Search & Summary

Scope

The RCPharm and RCGP’s proposal to address Recommendation 7 of the National Overprescribing Review proposes the production of a national toolkit to aid repeat prescribing/dispensing and reduce overprescribing. The SRT were approached to assist with a literature search on “the best practice guidance for all repeat prescribing systems in England.” The agreed scope of this literature search included the following stages:

• Conduct a literature search on relevant databases, utilising key search terms
• Conduct a search for other relevant evidence, such as guidance documents, on repeat prescribing in the UK
• Collate and summarise the results from the literature search in a clear format
• Provide further guidance/advice on literature review writing if, and when, necessary.

Methodology Overview

SRT conducted searches using multiple databases (PubMed, Cochrane Library, and Google Scholar), as well as using standard search engines.

Only the results published between 2013 and 2023 are included in the final reporting. Once collated, the search outputs were reviewed and filtered for relevance and quality before the final information was compiled.

Outputs

The collated resources are grouped into the following categories: (a) research articles, (b) guidance and/or evaluation documents, and (c) grey literature. The documents are ordered by their original publication date, starting from the oldest and working to the most recently published resources.

Research Articles

Between 2013 and 2023, there were a limited number of publications directly related to repeat prescribing processes and/or eRD in the UK. Therefore, we expanded our search to include those which discuss the repeat prescription of specific medicines and repeat prescriptions and/or eRD in other countries.

Notably, publications that discuss the appropriateness and effectiveness of long- vs short-term prescriptions all conclude that there is insufficient evidence to support the claim that providing short-term prescription courses improves outcomes, despite previous UK recommendations.