The Pharmaceutical Journal
Vol 268 No 7204 p902
29 June 2002

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Repeat dispensing proposals — a case of the tail wagging the dog?

By Bob Gartside

The Department of Health has published its repeat dispensing proposals. These represent a fine advance except for the little matter of the nuts and bolts of the mechanism.

It is proposed that general practitioners' computers be reprogrammed to produce a single-month master prescription and several slave copies. Only the master will need to be signed by the GP; the slaves will have "Batch Issue 1 of X" "2 of X" etc, where X is any number between 2 and 11.

The patient will have to choose a pharmacy for the whole of the supply and take, at least, the master prescription there for the first dispensing. Further supplies will be obtained by taking the slave copies serially to the same pharmacy. Alternatively the patient can elect to deposit all the master and slave copies at the pharmacy to draw on at regular intervals. The pharmacy will retain the master copy until all copies have been dispensed, but can submit the slave copies at regular intervals for payment.

I am sure that when you are sitting round a committee table this looks a reasonable and workable scheme, provided you have not actually worked in a pharmacy lately, but there are major problems looming.

Potential problems

Consider first of all the patients who elect to look after their own slave prescriptions. Halfway through the treatment period they lose the remaining copies. Perhaps the dog has them, perhaps their treatment is changed, perhaps they simply mislay them. Their first port of call will undoubtedly be the pharmacy. "I'm due my July prescription but can't find it. You know what I take because I come here each month. What can you do for me?" Practising pharmacists will know the pitfalls and difficulties, and will know the extreme reluctance of many GPs to help out in these, or similar, circumstances. The workload for pharmacists is likely to increase greatly, and it will be difficult and, perhaps, unpleasant work.

If the patient's medication is changed mid-stream and he or she takes the new prescription to a different pharmacy the original pharmacy is left with a difficult choice. Presumably the submission of the master for pricing will cancel out any remaining slaves. Say then the GP tells the patient to revert to his original medication. No problem for patient or GP: the earlier repeat is lodged with a pharmacy. However by now the pharmacy has submitted the master thus cancelling all the remaining slaves. The GP is unwilling, as many are, to issue a further prescription on the not unreasonable grounds that they have already issued a 12-month prescription.

Or perhaps the patient merely went on an extended holiday, but the pharmacy thought he had died/moved away/or started to use a different pharmacy and submitted the master. It is unreasonable to expect pharmacies to hold master prescriptions for an extended period without payment, yet this is exactly the effect which this scheme will produce.

Let us now look at the alternative, where the pharmacy holds the master and all the slaves, and let us run out a few figures.

The average pharmacy dispenses 4,500 prescriptions per month, or 54,000 a year. Of these, 75 per cent are repeats and eligible for a repeat dispensing scheme. If only half of all repeat prescriptions finish up on this scheme, this will be a filing requirement of 20,000 documents (half of 75 per cent of 54,000). Prescriptions are dispensed at the rate of one every two minutes or thereabouts so our file retrieval has to be at something like one every five minutes from a filing cabinet containing 20,000 documents. I am sure it can be done, but not, perhaps, within the staffing and space budgets of most pharmacies.

There are other drawbacks to the proposed scheme. Because there will no longer be any two- and three-monthly repeat prescriptions, throughput of paper for the Prescription Pricing Authority is expected to increase by 20 per cent. Welsh Prescription Pricing still cannot catch up on its backlog of unpriced prescriptions and an addition of 20 per cent to its workload will produce something close to breakdown. One presumes that the PPA itself will experience severe difficulties, with consequent delays to payments to contractors. Yet there are grounds for believing that the details of this scheme actually stem from the PPA because it involves no changes in its pricing procedures.

All of these difficulties can doubtless be overcome if we are prepared to throw enough money at the problems, but the indications are that the Department of Health does not intend to increase the global sum at all. More work for less money is the all too familiar cry. But the major objection is that we have, once again, picked the worst of all possible schemes.

Alternative schemes

Here let me declare an interest. I am lead for the Welsh repeat dispensing pilot and have overcome all of these objections by proposing the use of a prescription form like FP10(MD) — the methadone form. This runs on existing programs and machinery without problems and by careful design of the details we can achieve a possible reduction of 10 per cent in the throughput of paper for prescription pricing. Audit trails and fraud prevention are at least equal to the DoH scheme, although neither is really good in this regard. The real problem with the Welsh proposed scheme is that it entails a different way of working for prescription pricing and this has been the major reason why our pilot did not start 12 months ago.

If, however, we took the trouble to look round the world, we would see that other people have already designed, debugged, and operated far more elegant schemes whose simplicity and user friendliness take the breath away. For example, the Australians use a master prescription held by the patient and at each repeat dispensing the pharmacy computer produces a copy which is authenticated by the patient at point of dispensing before it is submitted for pricing. (Submission is by e-claiming, the paper merely acting as an audit backup.) Only on final dispensing does the pharmacy take the prescription and submit it for pricing. Of course there are code numbers, etc, for security. This system has the great merit that the patient can choose the pharmacy for each repeat dispensing and in the examples I have watched is simple, quick, and efficient. Incidentally, Australian prescriptions are not legal unless they carry the patient's health service number to facilitate exemption checking — another simple and elegant solution to a problem which bedevils us here.

In France they use a patient's encrypted smart card that can only be written to when inserted in a doctor's computer which also contains the prescriber's personal smart card. In addition, the patient's smart card can only be read when in a pharmacy computer which contains the pharmacist's personal smart card. This is another elegant system, which also picks up the personation problem that we all know exists but about which we do not normally like to talk. The French system is talked of as becoming an EU standard, but of course we do not want to know anything of it.

In summary, the DoH is to be congratulated for producing a scheme at all, but we should all be uneasy at the possibility that one of the biggest changes in practice for many years has, effectively, been designed by the PPA: really a case of the tail wagging the dog.