Repeat prescribing and SMR overhaul as review finds one in 10 scrips unnecessary

Repeat prescribing and use of structured medication reviews in general practice are to be overhauled after a review found one in 10 prescription items issued in primary care may be unnecessary.

Prescribing concerns (Photo: Matt Cardy/Getty Images)
Prescribing concerns (Photo: Matt Cardy/Getty Images)

A government-commissioned review led by chief pharmaceutical officer Dr Keith Ridge found that 'it is possible that at least 10% of the total number of prescription items in primary care need not have been issued'.

Reductions in prescribing of antibiotics over recent years and work to tackle overprescribing in care homes suggested that 'a reduction in the volume of prescription items in primary care of 10% is realistic' - equivalent to around 110m items a year, the review said.

The review highlighted a sharp rise in overall prescription items issued in primary and community care in recent decades, rising from 10 per head in 1996 to 20 per head in 2016. It said numbers of patients on multiple medications had also risen markedly - with 15% of the population now taking five or more medicines daily, and 7% taking eight or more medicines daily.

NHS prescribing

Overprescribing is 'rarely the result of a faulty diagnosis', the review said, with the scale of the problem linked to 'weaknesses in the healthcare system and culture, not the skills or dedication of individual healthcare professionals'.

Problems that led to overprescribing reported by clinicians consulted as part of the review included the lack of availability or long waits for non-medical treatments, and a lack of co-ordination with prescribing decisions by other clinicians, including the absence of notes to explain why medications had been prescribed.

The review highlighted weaknesses in the 'exchange of information between primary and secondary care' and the inability of some hospital services to record prescribing electronically. It pointed to errors caused by delayed, incomplete or missing hospital discharge letters, the need for more evidence and guidance on non-medical treatment options, and concerns over healthcare targets that 'often focus only on a single condition', when patients need a holistic review.

Among recommendations backed in full by ministers, the review called on the RCGP to work with the Royal Pharmaceutical Society to 'develop a national toolkit to help practices improve the consistency of repeat prescribing processes and support this with training resources for GP practice reception and administration teams'.

Structured medication review

The review also called for an expansion of the use of structured medication reviews (SMRs) in primary care networks, targeted at 'groups most at risk of overprescribing' and with appointments lasting 'typically at least 30 minutes'.

Dr Ridge's report said it was important for repeat prescribing to be subject to effective review, but warned that there was currently 'no standard approach to processing repeat prescriptions within GP practices'.

Because of the sheer volume of requests received daily - with some practices receiving 'over 200 requests for repeat items a day' and GPs spending up to two hours a day dealing with repeat prescriptions - the report warned 'there is a risk of this becoming a tick-box exercise'.

Other key recommendations from the review include the appointment of a new national clinical director for prescribing, changes to 'improve patient records' and 'improve handovers between primary and secondary care' and cultural changes to promote shared decision making between patients and doctors.

Prescribing costs

Dr Ridge said: 'Medicines do people a lot of good and the practical measures set out in this report will help clinicians ensure people are getting the right type and amount of medication, which is better for patients and also benefits taxpayers, by preventing unnecessary spending on prescriptions.

'This report recognises the strong track record of the NHS in the evidence-based use of medicines, thanks to the clinical expertise of GPs and pharmacists and their teams, and our achievements to date in addressing overprescribing which is a global issue.

'Continuing to tackle overprescribing requires a whole system approach involving clinicians and patients, so we can continue to build the change we all wish to see in how medicines are used for the benefit of patients.'

Health and social care secretary Sajid Javid said: 'This is an incredibly important review which will have a lasting impact on people’s lives and improve the way medicines are prescribed.

'With 15% of people taking five or more medicines a day, in some cases to deal with the side effects of another medicine, more needs to be done to listen to patients and help clinical teams tackle overprescribing.'

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