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Why prescription assessment?
Although it is often a daunting prospect at the outset, self-appraisal in general practice enables continuing professional and personal development for each GP and helps to identify, analyse and plan future development needs.
The General Medical Council (GMC) good medical practice guidelines emphasise the need for appraisal and continuing personal development in general practice, and it is now an essential part of revalidation.
Prescribing is the most common intervention in the NHS across all sectors, and after staffing costs, accounts for the second highest area of NHS expenditure. Prescribing makes up a large portion of a GP's clinical care of a patient and is the most common therapeutic approach offered to patients. Around 2.7 million prescription items were dispensed per day in England in 2012, an average of 18.7 prescription items per head of population in the year (compared with 18.1 in 2011 and 12.4 in 2002). Similar trends can be found on the Information Services Division (ISD) Scotland website.
Studies find a high proportion of errors in primary care prescribing, although serious errors are unusual. A 2012 study in England commissioned by the GMC found errors in almost 5% of all prescriptions.Factors identified as being associated with a higher risk of errors were patient age below 15 or over 65 and a high number of medication items prescribed. Other factors thought to contribute to errors include the repeat prescribing system, the interface between hospital and GP, communication and patient adherence. These factors together with variable efficacy may mean many patients do not achieve optimum benefit from their medication. It is believed that electronic prescribing systems are improving prescribing safety and reducing errors.
Prescribing audits are carried out continually, at national, organisation, practice and individual level. Every GP needs to demonstrate that they prescribe effectively and safely, by regularly analysing and changing their practice where necessary.
- Improving patient safety.
- Developing a Personal Learning Plan for self-appraisal and the appraisal process.[6, 7]
- Fulfilling many criteria in different areas of the Quality and Outcomes Framework (QOF).
- Reducing prescribing costs by reducing unnecessary prescriptions (eg, antibiotics), making most efficient use of therapeutic agents, encouraging generic prescriptions within the bounds of bioavailability and reducing polypharmacy.[9, 10]
- Improving patient care and management and reducing noncompliance and waste. The cost of unused prescription medicines in community and primary care in England was estimated to be around £300 million in 2009.
Prescribing analysis and cost tabulation (PACT) data
As each GP is clinically and legally responsible for their own actions, it is important to consider your own prescribing. PACT data may be helpful in prescribing analysis. PACT is a series of reports which tells GPs what they have prescribed and how much their prescribing has cost. Until 2007, these were a series of hard copies, circulated regularly to GPs, but are now produced by NHS Prescribing Services in electronic web-based format (ePACT). Data can be compared by prescriber, by practice and by organisation in order to inform on prescribing costs and trends. It is updated monthly, six weeks after the end of the prescribing month.
Start with identifying if there are any areas that need addressing in the ePACT data; for example, do you consistently mismatch best practice, or overspend in a particular area of therapeutics? Your primary care organisation (PCO)/clinical commissioning group (CCG) prescribing adviser will be able to explain ePACT data to you and give you comparisons between your prescribing and those of neighbouring practices to help you focus on areas where you differ to your colleagues.
Medicines that a patient is receiving need to be clearly indicated in their record. Computer prescribing systems nowadays make this easy to demonstrate, as well as facilitating both regular patient medication reviews (see 'Practice prescription reviews', below) and analysis and audit. Computer records can highlight both overuse and underuse, enabling therapeutic failure or abuse and non-adherence issues to be addressed.
Many GPs use a formulary, which can be developed in-house but is more commonly developed by a locality according to local guidelines and national recommendations. Formularies can be set to revert to generic drug names, which may be cheaper than alternatives, remembering the exceptions of varying bioavailability where generic substitution is not recommended. Interactions, allergies and cautions can also be highlighted and act as a reminder for GPs to ensure patient safety. Many computer systems allow you to imbed locality guidelines into their prescribing function.
Formularies may also help to remind you of the first-line recommended treatment in any particular condition and may help as a memory aid to the many guidelines and recommendations that GPs are presented with.
Basing practice formularies on local guidelines requires local formulary committees to take a robust analytical approach. Nowadays the National Institute for Health and Care Excellence (NICE) is heavily involved in these cost-benefit, evidence-based decisions.
Systems which support GPs in prescribing audit and analysis, and in providing information which supports safe effective prescribing include:
- PCO/CCG prescribing advisers.
- Organisations such as the Scottish Intercollegiate Guidelines Network (SIGN) and the National Institute for Health and Care Excellence (NICE) can help with guidelines on prescribing and cost-effectiveness in the context of quality patient care.[13, 14]
- NICE produces clinical audit tools in many clinical areas, which are based on NICE guidance. Some of these may be relevant to prescribing audits. They contain data collection sheets, audit reports and action plan templates as well as the guidance-based standards.
- The Quality, Innovation, Productivity and Prevention (QIPP) prescribing comparator schemes, which provide local targets to which GP practices can aspire.
- The BNF and the BNF for children.
- The Medicines and Healthcare products Regulatory Agency (MHRA).
- The electronic Medicines Compendium (eMC).
- Monthly Index of Medical Specialities (MIMS) prescribing guides.
The types of goals to aim for when assessing prescribing systems were summarised by the Kings Fund reports into the quality of GP prescribing in 2011 and polypharmacy and medicine optimisation in 2013.[9, 20]They include demonstration of:
- Regular and effective medication reviews (see below).
- Regular audit of repeat prescription systems.
- Significant event reviews for prescribing errors.
- Use of systems to reduce medication error and potential for interaction.
- Ready access to up-to-date information about medicines.
- Uptake of electronic systems for transmission of prescriptions.
- Co-ordination between GP and hospital, and between GP and pharmacies.
- Extra support, and more frequent review, for those on six or more medications (polypharmacy).
- Cost-effective prescribing, including the use of decision support prescribing systems such as ScriptSwitch®.
- Use of generic prescribing where clinically appropriate.
- Robust training for new prescribers and prescribing support staff.
- Patients views and choices being explored and taken into account (eg, by patient surveys).
Practice repeat prescription reviews
As a GP, 50-75% of your prescriptions will be issued without a consultation, as repeat prescriptions.[5, 21]Regular review of this is essential for self-appraisal as well as to fulfil contractual and commissioning obligations. Repeat prescriptions should be reviewed on a regular basis, and documented clearly. The frequency of this review may vary slightly depending on the individual, the condition, the medication, and contractual and local commissioning guidelines. Polypharmacy is an increasing issue. NICE is considering six-monthly reviews as a future QOF target for those on more than six medications, but meanwhile it is good practice to review these individuals more regularly.
Prescribing audits in individual clinical areas are often undertaken as part of the QOF or local prescribing targets or key performance indicators (KPIs). These individual requirements in QOF areas such as chronic disease control and local and national enhanced services can be audited and the audits used as self-assessment as well as documentation for the contract.
For example, ensure that there is adequate recall for specific drug classes. An audit looking at your prescription of drugs with potentially serious side-effects and requiring ongoing monitoring would involve small numbers of patients but may prevent serious problems. Hospital letters do not always identify patients who require such monitoring in primary care. Examples include warfarin, amiodarone, lithium, penicillamine, sulfasalazine and methotrexate.
Many computer systems can run protocols in the background when prescriptions are issued to check that the necessary blood tests and monitoring are being performed (eg, whether there has been a lithium level in the previous six months and whether is was in the therapeutic range). Such automatic checks with suitable prompts may help to prescribe more safely.
All practices should have a repeat prescribing protocol, and this should be reviewed and audited on a regular basis. Many areas have standardised tools for this process, such as the Welsh national repeat prescribing audit. Repeat prescribing systems and reviews should involve all the relevant members of the primary healthcare team, including administrative/reception staff involved in the process, district nurses, prescribing nurses and community pharmacists. As well as carrying out medicine reviews on some patients, community pharmacists help ensure good prescribing practice and assist with patient adherence through explanation and education.
Further reading and references
Prescribing in General Practice in Scotland; Audit Scotland, Report prepared January 2013
Good Medical Practice - 2013; General Medical Council
Prescriptions Dispensed in the Community, Statistics for England - 2002-2012; Health and Social Care Information Centre
Community dispensing. Prescription cost analysis; NHS Information Services Division, Scotland
Avery AJ, Ghaleb M, Barber N, et al; The prevalence and nature of prescribing and monitoring errors in English general practice: a retrospective case note review. Br J Gen Pract. 2013 Aug63(613):e543-53. doi: 10.3399/bjgp13X670679.
Good practice in prescribing and managing medicines and devices; General Medical Council, February 2013
Supporting information for appraisal and revalidation; General Medical Council
Quality and Outcomes Framework (QOF); NICE 2011
Martin Duerden et al; Polypharmacy and medicines optimisation: Making it safe and sound, The Kings Fund, 28 Nov 2013
Denneboom W, Dautzenberg MG, Grol R, et al; Analysis of polypharmacy in older patients in primary care using a multidisciplinary expert panel. Br J Gen Pract. 2006 Jul56(528):504-10.
NHS Prescription services; NHS Business Services Authority
Clinical Audit; NICE implementation tools
The quality of GP prescribing in England; The Kings Fund, 2011
Welsh audit office report on primary care prescribing; Cardiff and Vale University Health Board, 28 January 2014