New Repeat Prescribing Guidelines

Repeat prescriptions

by piglet22 - 2024-10-11 07:20:35

Hello Penguin

Being a long term repeat prescription user with about 8 items on 2-monthly requests, I've a good idea how it works.

The actual requesting through to collecting the medication (or anything else on repeat prescription) is quite good. IF you are computer confident. I can sit in bed, get the phone out, navigate to the surgery or NHS app, order items, watch the progress of the request and collect straight from the pharmacy a day or two later.

All a lot better than going to the surgery (they don't do phone requests) and no paper passes hands.

What is in serious decline, is the reviewing of long-term medication. There has always been a system in place where periodically, medication on repeats, had to be reviewed, usually by one of the GPs. To be honest, it was a pain and really served no purpose than being there. Sometimes it was rushed phone call, but if reviewing means seeing how patients are doing with their different pills and asking them, that never happened.

My surgery is part of what was going to be a large health hub made up from the four existing surgeries. There were ambitious plans for new buildings, all on-site facilities like physiotherapy, even a pharmacy. A one-stop polyclinic.

That was many years ago. Covid put paid to those plans, and a couple of trees - National Park - arguments about buses etc., means that absolutely nothing has been done. It's also on an old industrial site with hazards like asbestos and it floods.

What this means is that they had taken on a lot of these additional posts but with nowhere to put them.

They had a clinical pharmacist who I saw once and never again. She at least looked at the list, but made no changes or suggestions.

So repeat requests go on just like before, a nuisance if a review crops up, never speak to anyone, requests authorised.

For all I know, the medication might not be correct now. The only consolation is I don't have to pay for it.

As one GP said decades ago when he prescribed Atenolol, "you'll probably be on it for life"

Yet every year we go through the charade of medication reviews.

PS

Isn't Labour doing well?

First significant policy, hit the pensioners. Take away £200 to keep warm, 55p a day.

How mean and thoughtless can they be? Probably a lot more.

I doubt they will be in power long enough to make any changes that will make things better in the NHS to the point we can say "Isn't that wonderful?"

I wouldn't put it past them to charge daily rental for your pacemaker.

Oh Dear!

by Penguin - 2024-10-11 07:37:23

Sorry Piglet, that obviously hit a nerve with you. Labour's policy on winter heating payments to pensioners has hit a nerve with millions of others too and I sympathise. It's not been a great start. 

However, re: this topic if the majority of prescribing is for repeat medications, surely you must agree that it's sensible to have a system in place that reviews how long a medication can be safely prescribed for; which identifies why it was originally prescribed and what might have changed; whether it's still effective and whether or not it's still necessary?  

Of course

by piglet22 - 2024-10-11 08:54:52

The £10 Xmas bonus will be next. Why stop at 55p a day when you can make it 55.3p?

One prison place (£1000 per week) would pay four State pensions.

Of course they should be reviewed properly, but it doesn't happen. When a GP says to you "I haven't got time to look at that", you know they are in trouble.

My surgery went through a peak where they actively looked at your health. The was a 30-minute Well Man clinic with nurse once a year. That didn't last long. The annual blood test shortly after your birthday is being stretched beyond 12-months.

I'm sure that at least one medication does nothing. Amitryptiline was prescribed when they stopped Halcyon.

Ideally, if someone prescribes a treatment like a medication, you might think it would be followed up after a few weeks. If I changed a bulb in the vehicle, I might check it was still working. In my old line of work, installing remote monitors, I would check them several times a day, because its proper functioning had my name and reputation on it, and I would get the blame if it went wrong.

The guy who prescribed Atenolol and Amitryptiline has long since gone, but no-one questioned it's repeat status. It was the hospital that changed it to Bisoprolol and 9-months on, they don't check it either, even if it isn't needed at that high dose any more. I reviewed it and chopped the pills in half.

Piglet

by Penguin - 2024-10-11 09:30:30

....and that's a few reasons for why the guidelines are a good thing (for patients) IMO.  I don't know whether they will save time as suggested or not, and whether or not GPs will then have more time for the kind of checks that you suggest and which I remember too.  You'd need to ask someone working in that profession for their point of view.  There are some doctors' comments listed after the article. The first comment is favourable and suggests that the guidelines will save time and resources.  I haven't read the others yet. 

Repeat Prescribing Practices

by Gemita - 2024-10-11 11:05:12

Penguin,

Changes are happening already at our Surgery.  Recently I was contacted by a nurse to say that she needed to see my husband for a blood pressure check in order to continue to safely prescribe his blood pressure meds.  She said this was now an annual requirement.  I explained that I had a blood pressure monitor and that I could take readings for her to save time but she said firmly no; he would need to attend surgery. 

I think it is time that we had proper reviews in place of how we manage repeat prescriptions to ensure that patients are not harmed, particularly the vulnerable elderly who are likely to be most affected from taking multiple medicines at the same time.  However, I do have a problem with trust, trust that my general practice staff will have the time to take care of my medication and to stop meds that are not absolutely necessary.  I personally have had to continue to ask for medication reviews even for my anticoagulant, medication adjustments and for some meds no longer needed, to be removed from my repeat prescriptions, so anything that improves this situation is welcome Penguin.

As an example, recently my EP switched my medication from a beta blocker to a calcium channel blocker and specifically advised my doctor to prescribe the same manufacturer brand and once daily dose, since modified release med levels may differ between brands.  When I looked online at my prescriptions list, I discovered that my GP Pharmacy had prescribed a different manufacturer brand and worse, two tablets a day instead of once daily dosing.  If I hadn’t been able to check my own prescriptions and to follow up with my Pharmacist, this wouldn’t perhaps have been dealt with so quickly, or at all.  I feel therefore concerned for those who are unable to look after themselves or to take advantage of online services.

I expect we will be required to play an ever increasing role in managing our prescriptions and other aspects of our care online in the future.  This is fine by me and for those of us who can manage to do so, but many elderly patients may struggle to keep up. 

Piglet

by Gemita - 2024-10-12 03:31:03

Amitriptyline is an antidepressant but often used for pain relief or perhaps insomnia? 

With a heart condition I would be extremely concerned to stay on this med long term since it can cause abnormal heart rhythms. 

I was given a low dose of this med for pain relief many years ago but couldn’t tolerate it because of rhythm disturbances.  Precautions need to be taken with a history of arrhythmias, particularly with any degree of heart block.

Gemita and Penguin

by piglet22 - 2024-10-12 08:07:04

Penguin

Thanks for raising this subject.

There must be a lot of people in the UK who use the repeat prescription service. I just checked my surgery website and there is nothing about the changes and not much about repeats, full stop.

If they call it a review, then at least review it. To my mind that means spending time with the patient, going through each and every item on repeat, asking some questions, is it appropriate, is it working?

It doesn't happen.

An example. I was prescribed Zantac or Ranitidine for excess acid. Then it was unavailable. Looking at BBC News just now, there's an article about it. Glaxo Smith Kline setting aside £2.2bn for cancer claims. Nothing mentioned by the surgery why it was withdrawn yet they must have prescribed it many times to many people.

I guess thorough reviews or lack of are the victims of the demand and supply problem.

It will be interesting to see how the guidelines affect practice. I'm sceptical. Recently I had to supply a sample of urine for suspected UTI. Their website publishes a protocol for UTI sampling etc.

Was it followed? Of course not. All I got was "can you bring a sample in?" then the receptionist telling me she couldn't take it as it wasn't sterile.

Gemita

Many years ago, I was working all hours, the company was in turmoil and sleep suffered.

The GP prescribed Halcion. Depression was never mentioned. That was withdrawn and Amitriptyline substituted. I got the impression it was a safe, multipurpose medication. In fact a later GP said "you can take up to 7 of these". I wouldn't take 7 of anything.

I do read the information leaflets, but you might think that someone would put obvious heart rhythm problems and side effects together. You trust your GP to have taken it into account possible problems.

I don't think Amitriptyline does much for me, so might try a week or two without.

I think you are quite right. we do need to look after our own health, taking readings etc, but it needs to go hand in hand with professional advice.

How things have changed in primary care. My original surgery had two GPs, a nurse and a couple of admin people. Now it's part of a conglomerate of surgeries with 119 staff.

The GP who prescribed the Halcion in the first place was responsible for not taking my early symptoms of heart block seriously, delaying referral and treatment by months.

Going back further, Mogadon was once prescribed and at university around exam revision time, there were tales of the university GP prescribing amphetamines. Sure enough, I enquired and soon had a bottle of what was known as Doc K***'s Jungle Juice, a solution of amphetamine. Extraordinary.

Reminds you of the Stones "Mothers Little Helper" Doctor please, some more of these.

Piglet

by Gemita - 2024-10-12 08:47:12

I think you have a good relationship with your GP, so have a word with him/her about your need for Amitriptyline?  I wouldn't stop it on your own or suddenly without medical advice.  An antidepressant at any dose is a powerful med, so take care, especially if you have been on it for years.

My neighbour was on it but keeps losing her balance, so her GP stopped Amitriptyline which has helped her.   She seems to be able to restart/discontinue this med as needed for pain relief, but not without medical supervision

Interesting

by Penguin - 2024-10-12 15:52:54

Piglet & Gemita, 

It’s a shame that you both feel sceptical, but understandable if you’ve had the problems that you list.  Perhaps it would be good to give the RCGP and the RPS a break here? If the Royal Societies and their members have been consulted by NHS England when putting these guidelines together (and it’s to be hoped that they have! they should have been able to pass on the experiences of patients like you, whilst recognising the cost of repeat prescribing to the NHS and what they can and can't achieve. I’m sure that they are only too aware of their responsibility to ensure that they advise and prescribe wisely and safely and I'm sure they want to do so.

These are, however, guidelines only from what I can gather.  I assume that’s why ‘suggestions’ for a smoother running system are offered up in the article (?).  If anyone knows otherwise please say. 

I’m sorry to hear that you have suffered with work related mental health issues Piglet and I continue to be amazed Gemita, by the responsibility you take on for your own health and that of your nearest and dearest.  I’m not so sure that the latter is always a good thing, and although I agree that it’s wise to be alert, it’s surely better to have a system in place that takes away that responsibility from you when you have so much to deal with already and do not have the right qualifications to understand all of the possible consequences / interactions. 

Thank you both for your interesting contributions. 

Right qualifications?

by Gemita - 2024-10-13 08:07:16

Knowing the patient well is perhaps the most important qualification of all.

Taking on responsibility for our own health is of course necessary for all of us, especially in the current climate when we are all being asked to take on more and more in the way of self monitoring and reporting.  

I don’t think a system can ever be put in place to replace the commitment, care, responsibility that a carer takes on, but if the new guidelines give some respite and help, then I will of course support them.  When time permits, I already attend our GP Surgery Patients Participation Group, so I try to give something back.

Your words that I do not have the right qualifications to understand all of the possible consequences/interactions of prescribing and/or perhaps withholding medication is an offensive statement to me as a carer.  I have the qualification of “experience” to draw on which is far more important.  I have tolerance, understanding, patience too.   My health providers encourage me to do more, to trust in my own judgement, to keep the observations going like regular blood pressure and glucose checks and to have these handy when I next consult them.  I am actually being asked to withhold or to give insulin on an as needed basis to treat a crisis or to prevent one, so please be careful how you use words like not having the right qualifications to do the job.  I suspect many carers out there would be equally offended.

Getting back to your post, I sincerely hope Penguin that we will all be better off in the UK after a review of repeat prescribing.  It is something that needs to be done to stop wastage, to save time, but more importantly to ensure that patients are not left on meds indefinitely thinking they are doing some good when in fact they may be causing more in the way of harm.

No Offence Intended

by Penguin - 2024-10-13 15:27:59

It was not my intention to undermine the role and care delivered by family and carers.  I agree that the care provided is very often more caring, timely and personalised than that provided by a professional and I don’t underestimate the challenges that you describe one little bit. 

However, this thread is not about carers. It is about medicine taking back responsibility for situations, such as the ‘pill cutting’ and dose reduction incident that Piglet describes, and for this to happen in lieu of a timely and appropriate medical review.

Having to make decisions about medication and it’s suitability for your own situation is uncomfortable and may even be perilous at times. Caring provides similar challenges and that is why I drew comparisons. 

Taking charge of situations and tasks yourself when you don't have professional training must be daunting. It is these situations that I am referring to - and which you refer to too in your reply. E.g. ‘I am being asked to ….’  I accept fully that your situation must come into even sharper focus than the situation described by Piglet because you are taking on responsibility, not just for yourself, but for somebody else too. 

Carers do so out of necessity but also out of love, and that’s a wonderful gift to the person they care for.