The Pharmaceutical Journal
Vol 270 No 7235 p200
8 February 2003

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One year on: has it been the right medicine for Scotland? summary

Repeat dispensing will merge with ETP and medicines management

Master and slave prescriptions await dispensing at Elie Pharmacy, Fife. To extend the scheme nationally, paper prescriptions will need to be replaced by electronic ones and dispensing integrated with medicines management

If repeat dispensing is to become an established service it will need to be integrated with medicines management, supplementary prescribing and electronic prescriptions as part of a new philosophy of care, Alison Strath believes.

As well as piloting repeat dispensing at the pharmacy in the coastal village of Elie in Fife, which she owns with her husband, Ms Strath is also principal pharmaceutical officer at the Scottish Executive Health Department (SEHD) charged with overseeing implementation of the Scottish pharmaceutical care strategy.

For the Elie pilot, software at the local medical practice has been amended to issue batches of up to six "master and slave" prescriptions for patients taking part (56-day prescriptions can also be issued). The master prescription contains the complete quantity for the six-month period and instructions for dispensing in instalments. The master prescription is signed by the prescriber and is pre-endorsed with the final quantity to be supplied. It is the last of the six to be dispensed. The other five numbered forms are preprinted with the quantity and instructions for each instalment but are not signed. The forms each contain a maximum of two items (rather than the normal three) and a barcode of the type being used in the Scottish electronic transfer of prescriptions (ETP) pilot. In addition, patients are given a compliance form which they use to indicate which items they want to collect on each occasion and a diagnosis form which they can hand to the pharmacist if they wish.

Ms Strath says the compliance forms are a helpful reminder to the pharmacist of which patients are in the scheme. They can also be used to measure trends in medicine use. An example of this is the frequency of requests for asthma inhalers, which may not always need replacing monthly.

"Patients give consent to join the scheme and for agreed diagnosis data to be shared. The diagnosis forms allow this sharing and also promotes the idea that the patient record belongs to the patient. To date, no patient has refused to allow sharing," she says.

Two modifications have been made to help the scheme run smoothly. First, the repeats work on six-month horizons. So if a patient has a new medication added, the system calculates the quantity needed to reach the end of the current block (rather than just adding six-months worth). As a result, the instalments do not get out of sync. Second, the prescriber can put items, such as inhalers, that might not be required each time, on a separate prescription form. "The one problem we have not cracked yet is what happens when a patient has a medicine stopped or discontinued. You get some feedback from the fact that it is not being ordered on the compliance form, but we want to use the NHSnet so that a message is sent to the pharmacy when this happens," Ms Strath says.

Patients appreciate the service

"Repeat dispensing takes away patients' worries about running out of medicines," Ms Strath says, adding that patients are pleased to see their GP and pharmacist working together. A further 12 GP practices and 16 pharmacies, including multiples, in north east Fife will join the scheme in April.

Paper prescriptions have helped make the repeat dispensing pilot work, but it is easy to see how they could quickly overwhelm busy pharmacies if the scheme was to become commonplace. "Prescriptions are an anomaly for the way pharmacists will work in the future," Ms Strath says. "We need to look at prescribing events, not just prescriptions."

The aim is to bring together supplementary prescribing for chronic conditions with repeat dispensing and ETP, or e-pharmacy. In this way, pharmacists will generate the necessary prescriptions as the patients need them.

"We are looking at this as part of a programme of activity and we are discussing with the Scottish Pharmaceutical General Council how it might be funded. There will still be a need to remunerate pharmacists for the medicines supplied."

Ms Strath adds that it is intended that both community and hospital pharmacists will be part of the first training programme for supplementary prescribing in Scotland later this year. "We want to get repeat dispensing ready for them so that they have the tools needed for managing chronic conditions." It is hoped that the next release of the GPASS software, which is used in 85 per cent of GP surgeries in Scotland, will be "repeat dispensing ready". Talks are also taking place with pharmacy software suppliers and the Scottish ETP project team.

A critical stage

"Repeat dispensing is a critical stage. If we can get this underpinned by ETP it will make the biggest difference to pharmacists, GPs and the Prescription Pricing Division. It shifts a large amount of work from GPs to pharmacists while helping pharmacists plan their workload and stock control. We need to make sure we get the practice right and then design the IT around that," she says.

Discussions have begun on a new contract for community pharmacists in Scotland with the aim of it being implemented in 2005. It is likely to focus much more on services rather than volume of dispensing. The challenge will be to define a new chronic medicines management service taking in the work started in Elie.