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Repeat Dispensing Operations Manual

Version 1.0 May 2007 The North Yorkshire and York PCT Manual Version 1.0 has been adapted from the former Craven, Harrogate and Rural District PCT Manual Version 3 and Hambleton and Richmondshire PCT Version 4.2

Contact:
Medicines Management Team

North Yorkshire and York Primary Care Trust - Repeat Dispensing Operations Manual

Version Control
This document outlines simply and clearly the processes involved in batch repeat dispensing. It provides a clear pathway of the patient journey between the professionals.
This guide has been written using the following reference materials: Centre for Pharmacy Postgraduate Education (CPPE) Repeat Dispensing Arrangements in England training materials NHS Repeat Dispensing Schemes in England briefing paper from the Department of Health Medicines, Ethics & Practice, A Guide for Pharmacists from the Royal Pharmaceutical Society of Great Britain (Version 29, July 2005) West Gloucester Primary Care Trust Hull and East Yorkshire Primary Care Trust. Craven and Harrogate Rural District Primary Care Trust. Hambleton and Richmondshire Primary care Trust

The glossary and PPA requirements have been reproduced with the kind permission of the Centre for Pharmacy Postgraduate Education. The EMIS Information Sheets have been reproduced with the kind permission of EMIS.

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North Yorkshire and York Primary Care Trust - Repeat Dispensing Operations Manual

Contents
Introduction ............................................................................................................................. 5 Overview ................................................................................................................................. 6 Information for GPs Patient Selection ............................................................................................................... 7 Authorising (FP10) Prescription ........................................................................................ 9 Batch Issue (FP10) ......................................................................................................... 11 GP/Pharmacist Communication ...................................................................................... 12 Termination of Batches ................................................................................................... 13 Information for Surgery Staff Patient Initiation............................................................................................................... 14 Information for Pharmacists Patient Selection ............................................................................................................. 15 Authorising (FP10) Prescription ...................................................................................... 17 Batch Issue (FP10) ......................................................................................................... 19 Dispensing Prescriptions................................................................................................. 21 Pharmacy Payment......................................................................................................... 24 Dispensing Discretions.................................................................................................... 25 GP/Pharmacist Communication ...................................................................................... 26 Termination of Batches ................................................................................................... 27 Sorting and Submission of Forms to PPA....................................................................... 28 Ordering Forms ............................................................................................................... 29 Glossary .......................................................................................................................... 30 Repeat Dispensing Pharmacy Protocol .......................................................................... 32 Repeat Dispensing Practice Protocol.............................................................................. 34 Participating GPs and Practices...................................................................................... 35 Participating Pharmacies ................................................................................................ 36 Appendices A: Consent Form ........................................................................................................... 37 B: Patient Introduction Leaflet ....................................................................................... 39 C: Compliance Card ...................................................................................................... 40 D: Repeat Dispensing Log............................................................................................. 41 E: Pharmacy Repeat Dispensing Referral Form ........................................................... 42 F: GP Repeat Dispensing Referral Form ...................................................................... 43 G: EMIS/Protechnic Exeter Instructions......................................................................... 44 H: Drugs not included in the scheme ............................................................................. 45 I: Record of destroyed batch issues form..................................................................... 46 J: Penultimate prescriptions (Repeat Dispensing Scheme) .......................................... 47 K: Locum Agreement Form ........................................................................................... 48 L: Repeat Dispensing GP Practice Standard Operational Procedure ........................... 49 M: Repeat Dispensing Community Pharmacy Standard Operational Procedure........... 50

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Introduction
Welcome to the North Yorkshire and York Primary Care Trust (PCT) Repeat Dispensing service. This is an operations manual for GPs, pharmacists, all surgery and pharmacy staff members and anyone else who is actively involved in the repeat dispensing process. The manual is colour-coded for greater ease. Paper Colour White Blue Lilac Audience Everyone GPs, Surgery Staff Pharmacists and Staff

Please ensure all staff involved with the repeat dispensing process read this manual. This document not only contains the operational implementation of the statutory requirements but also contains best practices. All best practices are listed in shaded boxes. You are not required to implement the best practices, however, they are highly recommended. We have included them because we believe they will ease implementation and ongoing repeat dispensing processes. Once you and your colleagues have finished reading the manual, please discuss the repeat dispensing processes amongst yourselves and resolve any questions that may arise with a member of the Medicines management Team at North Yorkshire and York Primary Care Trust. Keep the manual at hand for questions that arise during day-to-day repeat dispensing activities. If you need additional copies of the manual, the PCT is happy to provide them, please contact the Medicines Management Team (details below). If you have questions that are not answered by this manual, please contact:

Medicines Management
North Yorkshire and York Primary Care Trust The Hamlet Hornbeam Park Harrogate HG2 8RE Tel: 01423 815150 Fax: 01423 859600

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Overview

The graphic above represents a high-level overview of the repeat dispensing scheme. Each step along the middle line is explained in detail in this manual. It is important to remember - there is a good deal of flexibility in every step of the

process. The primary purposes of this service are: 1) to simplify the repeat dispensing process for patients whilst maintaining clinical review and safety reduce GP practice workload.

2)

Practices should be adopted that ensure the successful fulfilment of these goals.

REMEMBER KEEP COMMUNICATION LOOPS CLOSED

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Patient Selection
Information for GPs
1. Select patients that you feel would benefit from the scheme. Repeat dispensing is not suitable for all patients. It is for patients (adults or children):

in a stable condition on long-term medication(s).

You are the ultimate decision-maker. No patient may enter the scheme without his/her GP approval. Examples of ways to use the repeat dispensing scheme: patient taking Levo-thyroxine who has required no recent dose adjustments within the last three months and is unlikely to require a review for twelve months: 1 authorising prescription 12 batches of 28 days. patient taking two or three items to control hypertension, requires no further titration of doses, stabilised for at least three months and requires a review in six months: 1 authorising prescription 6 batches of 28 days medication. Patient taking hay fever medication as needed: 1 authorising prescription 5 batches of 28 tablets (patient can receive monthly allocation of medication as and when needed within one year of authorising prescription generation date). Patient takes analgesics when required. Some medicines that are not taken regularly, but on a when required (prn) basis, either with other regular medicines or alone can still be considered as part of the Repeat Dispensing process. Where patients take regular medication and prn medication, consider supplying on separate authorising and batch prescriptions e.g. one prescription with regular medicines, one prescription with prn medicines.

: Repeat dispensing is not a solution for Monitored Dosage Systems (MDS) supply. 2. It is best to introduce patients to the scheme in manageable increments. Start with small numbers while staff gain familiarity with the scheme. Initially, apply strict inclusion and exclusion criteria. These could be based upon any number of characteristics (such as number of medicines being taken, age, whether the patient has a carer, etc).

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Patient Selection (continued)


Information for GPs
3. Work with your local pharmacists to identify good candidates for the scheme. If you feel comfortable that the pharmacist understands the inclusion criteria, you could ask the pharmacist to introduce patients to the scheme (by talking the patient through the Patient Introduction Leaflet, Appendix B). 4. As guidance, North Yorkshire and York PCT have developed the following criteria for patient selection, which has been approved by our prescribing leads.

Selection Criteria
1. The GP must decide which patients can participate in the scheme. 2. The inclusion and exclusion criteria must be considered. Inclusion criteria all patients must comply with these criteria: willing to participate patients living in own home in stable condition no recent hospitalisation on long-term medication that is unchanged for three months prior to the scheme regularly attends the same pharmacy patients are competent at managing their own compliance. Exclusion criteria any of the following must be excluded: patient refusal in unstable condition requiring frequent changes to their medication prescribed controlled drugs (Schedule 2 and 3) terminal illness dispensing patients (for the moment).

As the long-term prescribing of hypnotics and anxiolytics is discouraged, serious consideration must be given to patients prescribed these medicines as to their suitability. However, if the balance for patient benefit favours inclusion and the patient meets all other inclusive criteria, then they may be incorporated onto the scheme. 3. Other health care professionals may suggest suitable patients for the scheme but this must be discussed with the GP before it is discussed with the patient. Tip Repeat dispensing pilots have identified patients on thyroxine, antihypertensive, or diabetics stabilized on oral hypoglycaemic medication, as ideal candidates for early consideration.
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Authorising (FP10) Prescription


Information for GPs
Authorising (FP10) Prescription

The prescription medicines with the instalment interval (if given)

Number of batch issues that accompany the authorising prescription

GP signature

This is an example of the Authorising (FP10) Prescription. The authorising prescription is the legal authority to supply the medication. The reverse side is the same as the normal FP10. This form must be computer generated. 1. Before you put the patient on an authorising prescription, please first synchronise the existing medicines. This will help to avoid drug wastage. 2. Complete the form within the EMIS/Protechnic Exeter/Torex/In-house system choosing the patients drugs and/or appliances that are needed more than once. You may list several items on the authorising prescription form. Controlled drugs listed in the Restrictions on the following page are not allowed. For directions on generating the authorising prescription and batch issues in EMIS/Protechnic Exeter see Appendix G. 3. Choose the number of occasions that the drugs/appliances may be provided. This will determine the number of batch issues printed. Remember, an authorising prescription may not last longer than one calendar year. 4. Do not specify an instalment interval unless clinically necessary. An instalment interval restricts the amount of medicines that a patient may have at one time, for example, listing dispense every 28 days. Without an instalment interval, the pharmacist has more leeway to handle unusual situations such as holiday supply. In these situations, pharmacists may use their professional judgement to dispense instalments at an appropriate time. If the GP does specify an instalment interval, such as dispense
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Authorising (FP10) Prescription (continued)


Information for GPs
every 28 days, authorising number of issues = 6, then the patient would have to visit the GP to receive a one-off prescription for his/her holiday period. 5. The standard expiry of an authorising prescription is one year from the date it was generated. The EMIS/Protechnic Exeter software does not allow you to issue a prescription for more than one year. 6. Sign the Authorising Prescription only. : The patient does not complete details on the authorising prescription, but will do so on the batch issues at each collection from the pharmacy.

Restrictions : Schedule 2 and 3 controlled drugs cannot be prescribed within the scheme. Schedule 2 includes the opiates, the major stimulants and quinalbarbitone. Schedule 3 includes a small number of minor stimulant drugs. You may agree to restrict other medicines as a policy in your practice. : Only computer-generated prescriptions may be used in the scheme - handwritten prescriptions are not acceptable. : Repeat dispensing services do not apply to bulk prescriptions. : Hypnotics and anxiolytics require further consideration. Patient benefit must outweigh the desire to reduce prescribing of this class of drugs.

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Batch Issue (FP10)


Information for GPs
Batch Issue (FP10)

The prescription medicines with the instalment interval (if given)

Batch number and total number of batches

Date the prescription was generated

This is an example of the Batch Issue (FP10). The batch issue enables the pharmacist to receive payment for the provision of repeat dispensing services. The reverse side is the same as the normal FP10. 1. The batch issue is generated by a computer with the associated authorising prescription and is generated on the same date as that prescription. It is not signed by the GP. 2. The patient must sign the declaration on the back of the batch issue before receiving each instalment. Patients may choose to keep batch issues in their possession or they may ask the pharmacist to store them. If the patient loses the batches, he/she must return to the GP for a new authorising prescription. The pharmacist will need to be informed. FOR THE PURPOSES OF SECURITY AND EFFICIENCY, PATIENTS SHOULD BE PERSUADED THAT BATCH PRESRIPTIONS BE STORED AT THE PHARMACY.

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GP/Pharmacist Communication
Information for GPs
For the repeat dispensing scheme to be successful, it will require excellent communication between GPs and pharmacists. This is not a one-off event but a lasting relationship. 1. Prior to implementing the scheme, meet with the pharmacists in your local area. At this meeting, discuss the following topics: The ideal patient profile this profile may change over time. At first the profile may be bound to strict inclusion and exclusion criteria so that you are not overwhelmed by the volume of work associated with introducing patients into the scheme. However, once the process becomes more familiar, the exclusion criteria may be relaxed to allow more patients to enter the scheme. A monthly target - of the number of patients that you would like to introduce into the scheme this will control the workload for staff members. Ideally, 50 patients in a sixmonth period, for an average sized surgery. Communication procedures these are important for not only generally communicating about the scheme but also discussing patient-specific matters. You must ensure that surgery staff knows the pharmacists name, or a regular member of staff in the dispensary so that telephone calls are not unnecessarily delayed. Share your telephone numbers, fax numbers and email addresses. Agree upon the best method of communication as well as the best communication time. REMEMBER KEEP COMMUNICATION LOOPS CLOSED Method of synchronising the prescriptions certain patients may be good candidates for the service but have medicines on varying schedules. The pharmacist may be able to help you to synchronise these medicines. Discuss this possibility and determine the best path of action, with your community pharmacist, prescribing advisor or technician.

Document these agreements and review them on a regular basis.


2. Invite your local pharmacists to practice meetings as appropriate. This will facilitate regular communication. 3. Report any patient-specific medicine changes to the pharmacist. These include any change to the type, quantity, strength or dosage of drugs or appliances ordered on that persons authorising prescription. It also includes any concerns that you may have that the items are no longer appropriate or safe for the patient. A Repeat Dispensing Referral Form (Appendix F) has been produced to assist you in contacting the pharmacist for common types of communication. The Pharmacist also has a standard Referral Form (Appendix E).
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Termination of Batches
Information for GPs
There are many instances where Batch Issues may be terminated without being filled. Some of these include: change in patients medication loss of batch issues patient decides to leave GP practice patient decides to change pharmacy patient does not collect remaining batches the authorising prescription has expired.

In all of these instances, there must be communication between GP and pharmacist so that appropriate action may be taken. 1. If you know that the patients batch issues have become invalid, contact the pharmacist. 2. The pharmacist will destroy the remaining batch issues, and record the destruction on the form (Appendix I).

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Patient Initiation
Information for Surgery Staff
Once the GP has decided that the patient is suitable for the scheme: 1. Ask the patient if he/she has a regular pharmacy. 2. Introduce the patient to the scheme. Give the patient an Introduction Leaflet (Appendix B). Explain the benefits of the scheme and the new way that the patient may now receive his/her medicines. Explain that his/her medications may not be dispensed at another pharmacy without returning to the surgery for a new authorising prescription.

3. Record the patients pharmacy choice in the patient record. 4. Give the patient a Consent Form (Appendix A) to sign. Keep one copy in the surgery, scan into computer if preferred. Give one copy to the patient for personal records.

5. Inform the patient about a Compliance Card (Appendix C) which will be completed by the pharmacist and given to the patient. Patient Consent Form (Appendix A) Introduction Leaflet (Appendix B)

Compliance Card (Appendix C)

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Patient Selection
Information for Pharmacists
1. Discuss patient selection with your local GPs. recommendations for suitable candidates. Some GPs may want your

However, some GPs may prefer to handle patient selection independently. Patient selection has ramifications of increased workload for surgery staff as patients are introduced to the scheme and their medicines are synchronised. Talk to your local GPs before you talk to any patients. Recommend patients that you feel would benefit from the scheme. Repeat dispensing is not suitable for all patients. It is for patients who are: in a stable condition on long-term medication(s).

The GP is the ultimate decision-maker. No patient may enter the scheme without his/her GP approval.
: Repeat dispensing is not meant to be a solution for Monitored Dosage Systems (MDS) supply.

2. As guidance, North Yorkshire and York PCT have developed the following criteria for patient selection, which has been approved by our prescribing leads.

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Patient Selection (continued)


Information for Pharmacists Selection Criteria
3. The GP must decide which patients can participate in the scheme. 4. The inclusion and exclusion criteria must be considered. Inclusion criteria all patients must comply with these criteria: willing to participate patients living in own home in stable condition no recent hospitalisation on long-term medication that is unchanged for three months prior to the scheme regularly attends the same pharmacy patients are competent at managing their own compliance. Exclusion criteria any of the following must be excluded: patient refusal in unstable condition requiring frequent changes to their medication prescribed controlled drugs (Schedule 2 and 3) terminal illness dispensing patients (for the moment).

As the long-term prescribing of hypnotics and anxiolytics is discouraged, serious consideration must be given to patients prescribed these medicines as to their suitability. However, if the balance for patient benefit favours inclusion and the patient meets all other inclusive criteria, then they may be incorporated onto the scheme. 5. Other health care professionals may suggest suitable patients for the scheme but this must be discussed with the GP before it is discussed with the patient.

Tip Repeat dispensing pilots have identified patients on thyroxine, antihypertensive, or diabetics stabilized on oral hypoglycaemic medication, as ideal candidates for early consideration.

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Authorising (FP10) Prescription


Information for Pharmacists
Authorising (FP10) Prescription

The prescription medicines with the instalment interval (if given)

Number of batch issues that accompany the Authorising Prescription

GP signature

Date the prescription was generated

This is an example of the Authorising (FP10) Prescription. The authorising prescription is the legal authority to supply the medication. It is not submitted for payment. The reverse side is the same as the normal FP10. This form must be computer generated. 1. The first time that you receive an authorising prescription from the patient, ask the patient if he/she would like you to store the batch issues in the pharmacy. Please

encourage the patient to store the batch issues at the pharmacy.


2. Stamp the authorising prescription with the pharmacys stamp and endorse it. 3. In addition to your normal prescription checks, pay close attention to two pieces of information on the form. Instalment Interval The GP may designate an instalment interval on the authorising prescription and batch issues such as dispense every 28 days. If this is listed, you are not allowed to dispense the next batch of the prescription until the 28th day or after. You will need to track this information so that batches are not dispensed prematurely. Prescription Date An authorising prescription is valid for 12 months from the date it was generated. The first batch issue must be dispensed for the first time within 6 months of the generation date. Batch issues are no longer valid 12 months after the generation date.
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Authorising (FP10) Prescription (continued)


Information for Pharmacists
4. Keep the authorising prescription in the pharmacy until all batches have been dispensed or it is no longer valid (for example, a drug dosage has changed, it has expired, etc). 5. Send the authorising prescription to the PPA for processing (see Sorting and Submission of Forms to PPA Section). : The patient does not sign the authorising prescription; the patient signs the batch issues.

Restrictions : Schedule 2 and 3 controlled drugs cannot be prescribed within the scheme. Schedule 2 includes the opiates, the major stimulants and quinalbarbitone. Schedule 3 includes a small number of minor stimulant drugs. Only computer-generated prescriptions may be used in the scheme - handwritten prescriptions are not acceptable. Repeat dispensing services do not apply to bulk prescriptions. Hypnotics and anxiolytics require further consideration. Patient benefit must outweigh the desire to reduce prescribing of this class of drugs.

: :

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Batch Issue (FP10)


Information for Pharmacists
Batch Issue (FP10)

The prescription medicines with the instalment interval (if given)

Batch number and total number of batches

Date the prescription was generated

This is an example of the Batch Issue (FP10). The batch issue enables the pharmacist to receive payment for the provision of repeat dispensing services. The reverse side is the same as the normal FP10.
1. Before giving the patient his/her medicines, ask the patient to sign the declaration on the

back of the batch issue. The batch issue is not signed by the GP.
2. Encourage the patient to leave the batch issues at the pharmacy. This will

alleviate problems of lost or stolen batch issues.


3. Store the batch issues in a secure location. 4. If the patient loses the batches, he/she must return to the GP for a new authorising prescription.
5. The batch issues do not need to be dispensed in order. If a patient chooses to keep

the batch issues and brings the batch issues into the pharmacy in the wrong order (for example, brings in 6 of 12 before 4 of 12), dispense as normal. However, it is considered good practice to dispense the batch issues in order (see page 29).

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Batch Issue (FP10) (continued)


Information for Pharmacists
6. You may only dispense medicines from batch issues where you hold the matching authorising prescription. If a patient brings in a batch issue and you do not hold the authorising prescription, you must apply your judgement whether this is a genuine mistake (and inform the patient he/she must go back to their original pharmacy) or if this is a possible stolen prescription (and alert the appropriate authorities). 7. In addition to your normal prescription checks, pay close attention to two pieces of information on the form: Instalment Interval The GP may designate an instalment interval on the authorising prescription and batch issues such as dispense every 28 days. If this is listed, you are not allowed to dispense the next batch of the prescription until the 28th day or after. You will need to track this information so that batches are not dispensed prematurely. Prescription Date An authorising prescription is valid for 12 months from the date it was generated. The first batch issue must be dispensed for the first time within 6 months of the generation date. Batch issues are no longer valid 12 months after the generation date. 8. Endorse the batch issue. 9. This batch issue is sent to the PPA as an invoice for payment. Please see Sorting and Submission of Forms to the PPA section (page 28).

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Dispensing Prescriptions
Information for Pharmacists
The method of requesting a repeat is flexible you may allow patients to request them in person, by telephone or by any other suitable method. An authorising prescription has to be dispensed for the first time within six months of it being written. 1. Before providing any repeat items to the patient, you, the pharmacist, must personally ensure that: the patient is taking or using medicines appropriately the patient is not suffering from any side effects from their treatment which indicate the need or desirability of a review of their treatment the patients medication regime or health has not changed in a way that indicates the need or desirability of a review of their treatment since the repeatable prescription was issued. 2. If at any time you are concerned about the safety or appropriateness of a repeat prescription: inform the patient to make an appointment with his/her GP contact the GP directly. 3. You may always refuse to provide the drugs or appliances but must inform the GP of your rationale. 4. Before providing any repeat items to the patient, you must always check that: your pharmacy holds the authorising prescription a satisfactory batch issue has been presented by the patient or is held by the pharmacy the GP has signed the authorising prescription the batch issue matches the authorising prescription (the batch issue has not been altered) the authorising prescription has not expired. 5. Endorse the batch issue with the quantity of drug provided and the provision date. 6. Ask the patient to sign the batch issue before providing the repeat items. 7. Update the patients compliance card with the date that he/she should pick up the next batch of medicines. 8. If you are dispensing the penultimate batch issue, inform the patient that he/she will need to schedule an appointment with the doctor. (Appendix J)

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Dispensing Prescriptions (continued)


Information for Pharmacists
All the usual terms of service issues around fraudulent prescriptions, standard of dispensed products, point of dispensing checks, endorsements, complaints and reasonable time to supply the prescription will need to apply at each dispensing episode. As a condition of providing repeat dispensing services, all participating pharmacies ensure that all pharmacists employed within the pharmacy (including locums) have been suitably informed of repeat dispensing procedures. Repeat Dispensing Log You will need to track patients repeat prescription information so that you will know when a patient has missed a batch. Report any missed batches to the GP. To assist you, the PCT has created a Repeat Dispensing Log (Appendix D). This log will help you to dispense medicines in anticipation of the patient request. It will also provide data to measure the schemes success. The PCT will use this form to monitor contractors RD supervision.

The first time a patient brings in his/her authorising prescription, note in the log the Patients ID (from the PMR), GP name, the batch number (number 1 in this case), total number of batches, the date the prescription was dispensed (which will be the current date) and the next anticipated supply date. You may wish to enter into your diary or calendar the patients next supply date as a reminder. Within a couple of days of the anticipated supply date, dispense the repeat medicines and have them waiting on a shelf for the patient. At this point, write a new entry into the Repeat Dispensing Log, entering the Patient ID, GP name, batch number, number of batches and leave the rest of the fields blank.

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Dispensing Prescriptions (continued)


Information for Pharmacists
If the patient does not collect his/her medicines within a reasonable time period, phone the patient. If the patient still does not come into the pharmacy, notify the GP. Endorse the Batch Issue as Not Dispensed and record the return of medication back to stock. When the patient does collect, ensure compliance is maintained and there are no adverse events due to medication before you provide the medicines. Enter the dispense date and the next anticipated supply date. Also check that the prior supply due was collected.

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Pharmacy Payment
Information for Pharmacists
1. The fee structure for community pharmacists includes:

Annual Repeat Dispensing Payment is a nationally agreed annual rate of payment to all community pharmacy contractors divided into 12 single monthly payments (Drug Tariff Part VIA).

2. Each dispensed batch issue (FP10) will be submitted for reimbursement at the end of the month in the normal way to the PPA. There will be a new order detailing the method for sorting and submitting the batch issues in the end of month batch. A new FP34C will be automatically issued to pharmacists by the PPA which will highlight this new order.
3. Pharmacists will have to submit the legal repeat authorising prescription (FP10) to PPA

for storage when all of the batch issues have been dispensed, it has expired or the medication is no longer required.

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Dispensing Discretions
Information for Pharmacists
There are certain dispensing discretions that would make sense to accompany the implementation of repeat dispensing, for example dose optimisation. However, since these require changes to the Medicines Act of 1968, these discretions will not be allowed until the legislation is changed. 1. Delete an Item from a Batch Issue You are allowed to delete an item from a batch issue if the medicine is not needed by the patient. This would follow the same procedures as with traditional dispensing you would cross the item off the Batch Issue and mark it ND (not dispensed). 2. Dispensing Intervals There are no controls around dispensing intervals unless the GP specifically marks the prescription with an instalment interval such as dispense every 28 days. Since in most cases the dispensing interval will not be specified, you could dispense all batch issues at once. However, this would violate the intent of repeat dispensing. The pharmacist must regularly counsel the patient on his/her use of medicines. If this process does not take place there is clearly a danger to the patients health and safety, not to mention huge cost implications due to high levels of waste medication. The PCT will randomly audit for these occurrences.

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GP/Pharmacist Communication
Information for Pharmacists
For the repeat dispensing scheme to be successful, it will require excellent communication between GPs and pharmacists. This is not a one-off event but a lasting relationship.
1. Prior to implementing the scheme, meet with your local area GPs, or at the very least

have a conversation on the telephone. At this meeting, discuss the following topics:

The ideal patient profile this profile may change over time. At first the profile may
be bound to strict inclusion and exclusion criteria so that the surgery is not overwhelmed by the volume of work associated with introducing patients into the scheme.

A monthly target of the number of patients that the GP would like to introduce into
the scheme this will control the workload of surgery staff members.

Communication procedures these are important for not only generally


communicating about the scheme but also discussing patient-specific matters. Ensure that the pharmacy staff is familiar with the local GPs and surgery staff so that telephone calls are not unnecessarily delayed. Share your telephone numbers, fax numbers and email addresses. Agree upon the best method of communication as well as the best communication time.

Method of synchronising the prescriptions certain patients may be good


candidates for the service but may have medicines on varying schedules. The GP may appreciate your help to synchronise these medicines. Discuss this possibility and determine the best path of action.

Document these agreements and review them on a regular basis. 2. You will now be monitoring how patients use medicines on a regular basis. Report back any concerns you have to the GP. Please use the Pharmacy Repeat Dispensing Referral Form (Appendix E) for issuing and recording formal communication with the patients GP practice. GPs have their own version of a referral document to facilitate communication to pharmacies (Appendix F).

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Termination of Batches
Information for Pharmacists
There are many instances where Batch Issues may be terminated without being filled. Some of these include: change in patients medicine(s) loss of batch issues patient decides to leave GP practice patient decides to change pharmacy patient does not collect remaining batches the authorising prescription has expired.

In all of these instances, there must be communication between GP and pharmacist so that appropriate action may be taken. 1. If you know that the patients batch issues have become invalid, contact the GP. 2. Destroy the remaining batch issues and record, (Appendix I). Local arrangements may dictate that unused prescriptions are returned to the prescriber and if so, the returned batches recorded. 3. Send the authorising prescription to the PPA. The PCT will randomly audit pharmacies to ensure the proper handling of invalid batch issues.

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Sorting and Submission of Forms to PPA


Information for Pharmacists
FP34C (Pharmacy Contractor) Failure to comply with these requirements may result in payments to contractors being unavoidably delayed. 1. Complete one invoice only per month. 2. Prescription forms must be sorted as follows: 2.1 2.2 into patient charge group, i.e. exempt, paid and paid at old rate within each group into the following order, starting from the top: 2.2.1 forms referred back from previous month(s) 2.2.2 forms FP10 MDA by prescriber surname 2.2.3 forms FP10D 2.2.4 forms FP10P/NC or SS with PN indicator by prescribing nurse surname 2.2.5 forms FP10P/NC or SS with CN indicator by prescribing nurse surname 2.2.6 forms FP10P/NC or SS with SP indicator by prescriber surname 2.2.7 forms FP10SS/NC Hospital Forms 2.2.8 (Repeat Dispensing) First Batch issue forms(s) (FP10SS) i.e. 1 of x by prescriber 2.2.9 (Repeat Dispensing) Batch issue form(s) (FP10SS) e.g. 2 of x, 3 of x, etc. by prescriber surname 2.2.10 all other FP10 forms by prescriber surname (NB any prescribers with fewer than 20 forms can be placed into a miscellaneous section at the end of each group).

3. All of the following forms must be kept separate from the FP10 prescriptions (submitted for processing and reimbursement as in paragraph 2) and collated by form type as follows: 3.1 repeat Authorising forms.

Pharmacies will need to submit the legal repeat authorising prescription when all batch issues have been dispensed, it has expired, or the medication is no longer required. These will need to be submitted in a separate bundle to the PPA the month after they are no longer required by the pharmacy for dispensing.

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Ordering Forms
The forms needed for repeat dispensing will be available to order from Ryedale House (the normal supplier of GP prescription forms). All forms are free of charge. Forms available from North Yorkshire Family Health Services (4th Floor, Ryedale House, 60 Piccadilly, York, YO1 9PE): FP10SS Patient Consent Form (RD01) (Appendix A) Patient Introduction Leaflet (RD02) (Appendix B) Forms available directly from this document (please photocopy): Patient Compliance Card (Appendix C) Repeat Dispensing Log (Appendix D) Pharmacist Repeat Dispensing Referral Form (Appendix E) GP Repeat Dispensing Referral Form (Appendix F) Record of destroyed batch issues form (Appendix I) Penultimate prescriptions (Repeat Dispensing Scheme) (Appendix J) Locum Agreement Form (Appendix K)

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Glossary
Authorising FP10 Prescription The authorising prescription will authorise a set number of repeats through the production of batch issue FP10s. The authorising prescription must be signed by the General Practitioner (GP) or Nurse Practitioner (NP), but the patient does not have to sign the declaration on the back of the prescription form. Batch Issue (FP10) A batch issue is essentially an invoice submitted by the pharmacist to the PPA for payment purposes. Batch issues will be supplied with each authorising prescription for use in the Repeat Dispensing Arrangements. A batch issue is not a legal prescription and will not be signed by the prescriber. It must, however, be signed on the back by the patient in the normal way at the time of dispensing. Dose Optimisation This involves giving patients the most appropriate strength of their prescribed medication which reduces the number of tablets/capsules they have to take and can decrease prescribing costs. Patient Consent Patients have to be made aware that information relating to their condition and prescription will be shared between the GP and the pharmacist. Patients will need to sign consent forms that will be filed or scanned in their medical notes and retained within the GP practice. This is in keeping with the Caldicott Committee Recommendations. Primary Care Trust Free standing statutory Trust responsible for health services in a geographical area in England. Prescription Pricing Authority (PPA) The PPA are responsible for pricing all NHS prescriptions, providing reimbursement and remuneration to pharmacists and other dispensing contractors and collating and producing prescription cost and analysis (PACT) data. Within the repeat dispensing arrangements, the PPA will be responsible for handling batch issues as they are submitted and storing the authorising prescriptions a the end of the repeat period. Patient Medication Record These are computer-based records maintained within the pharmacies that patients use. Most pharmacists will keep a record of all patient items dispensed, both private and NHS, from doctors, dentists and nurse prescribers within any care setting (community, drug misuse and hospital). Some pharmacists will also keep records of medication purchased from the pharmacy (OTC), especially where this is relevant to the medical condition eg aspirin. Repeat Dispensing The process by which a prescription is dispensed in several intervals rather than all at once.
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Repeat Dispensing Pharmacy Protocol


Pharmacy procedure A standard proforma must be completed by the pharmacy giving confirmation to the PCT that they wish to participate in the scheme. The pharmacy will only be able to accept repeat dispensing prescriptions from GP practices who are participating in the scheme. A prescription has to be dispensed for the first time within 6 months of the date of being generated and is valid for 12 months from being generated. Pharmacies can only participate in the scheme if they are accredited. Pharmacies can only accept repeatable prescriptions and batch issues that have been computer generated. Handwritten prescriptions will not be accepted by the pharmacy. Handwritten amendments or additions to computerised repeatable prescriptions must not be accepted. The repeat dispensing scheme does not apply to controlled drugs in Schedules 1, 2 and 3. (See Appendix H) The pharmacist and at least one key member of staff must be aware of the protocol and procedure for repeat dispensing and must have completed the PCT approved training pack. It is the responsibility of the repeat dispensing pharmacy that provides the service to ensure that any pharmacist employed in connection with the Repeat Dispensing (RD) has received appropriate information that maintains continuing high quality service provision. The locum must sign and date the declaration form (Appendix K) and fax a copy to the PCT. All the usual aspects governing supply, as laid down in the Medicines and Ethics Guide, apply to each repeat dispensing. Consent Written consent must be obtained by the practice from the patient and a record of this will be kept at the practice. A record must be kept in the patients notes of the pharmacy nominated by the patient. The patient will then be able to: leave the repeatable prescription and batch issues with the practice for collection by the pharmacy of their choice or take the repeatable prescription and batch issues to the pharmacy of their choice who is participating in the scheme. It is strongly recommended that patients leave batch issues with the pharmacy. Safety and Storage A pharmacist should store securely at the premises from which s/he provides pharmaceutical services: repeatable prescriptions batch issues relating to medicines or appliances which have been provided, and

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Repeat Dispensing Pharmacy Protocol (continued)


if requested to do so, batch issues relating to medicines or appliances which have not yet been provided.

Until such time as s/he is required in accordance with the Drug Tariff, to send the repeatable prescription or batch issues to the PPA. Communication Procedure A local communication protocol must be in place between practices and local pharmacies. Communication should follow locally agreed policies. All paperwork associated with repeat dispensing should be stored for a minimum of two years. Interview and Counselling Counselling of the patient must be carried out at each repeat dispensing to ensure the patient: has an understanding of their medication is compliant is not experiencing any side effects re-enforce health promotion issues check any recent over the counter purchases refer patient back to GP for any new problems, using the appropriate method of communication if a patient is unable to collect their prescription, and wishes to send a representative, they must contact the pharmacy to enable the pharmacist to conduct an interview or counsel the patient over the telephone. It is the responsibility of the pharmacist to inform patients when they require a further repeatable prescription and batch issues. At the second to last prescription the pharmacist must refer the patient back to the practice for a medication review and remind the patient that any blood monitoring requirements should be done a week before their review. At the last batch issue the pharmacist must check with the patient that they have had or arranged an appointment with their GP. Remind the patient that they have no further batch issues (Appendix J).

Incident Reporting Incidents should be reported using the pharmacy SOP. reporting to the Medicines Management Team: North Yorkshire and York Primary Care Trust The Hamlet Hornbeam Park Harrogate Tel: 01423 815150 HG2 8RE Fax: 01423 859600

The PCT encourages direct

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Repeat Dispensing Practice Protocol


Practice Procedure The practice must have access to computer systems and software that will produce repeatable prescriptions and batch issues as specified in the regulations. Repeatable prescriptions and batch issues must be computer generated. Handwritten prescriptions will not be accepted by the pharmacy. Handwritten amendments or additions to computerised repeatable prescriptions will not be accepted. Consent Written consent must be obtained from patients wishing to participate in the scheme. A copy of the consent form should be kept with the patients notes or scanned for paperless practices. A record must be kept in the patients notes of the pharmacy nominated by the patient. Patients to be given the choice: 1. leave the repeatable prescription and batch issues with the practice for collection by the pharmacy of the patients choice or 2. take the repeatable prescription and batch issues to the pharmacy of their choice who is participating in the scheme. It is strongly recommended that the patient leaves the batch issues with the pharmacy. Recommendations GPs are recommended not to specify dispensing intervals, thereby allowing pharmacists to use professional judgement to dispense appropriately for situations e.g. holidays. Prescriptions should be for 28 days or as agreed in the practices Repeat Prescribing Policy. PRN medicines should be issued on separate repeatable prescriptions and batch issues. After the initial medication review a diary date must be entered onto the computer with the date of the next full clinical medication review. 28-day supplies require thirteen batch prescriptions to cover a twelve-month period. Exclusion Criteria The scheme cannot be used for 7 days prescriptions. Patients who are prescribed controlled drugs (including Schedule 1, 2 or 3) will not be eligible for the scheme. ( Appendix H) Bulk prescriptions cannot be included in the scheme. Red drugs are excluded from the scheme. Patients who are absent from this country for a period of more than two months should not be included on the scheme.

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Repeat Dispensing Practice Protocol (continued)


Communication procedure A local communication protocol must be in place between practices and local pharmacies. Communication should follow locally agreed policies. The GP or practice must notify the nominated pharmacy immediately if there are any changes to the patients medication: change of dosage change in medication change in administration times or if a patient leaves the practice or if a patient dies if a patients does not wish to participate in the scheme any longer. Communication should follow locally agreed policies. Incident Reporting Incidents should be reported using the pharmacy SOP. reporting to the Medicines Management Team: North Yorkshire and York Primary Care Trust The Hamlet Hornbeam Park Harrogate Tel: 01423 815150 HG2 8RE Fax: 01423 859600

The PCT encourages direct

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Participating GPs and Practices


Practice Contact Address Tel/Fax/Email

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Participating Pharmacies
Pharmacy Contact Address Tel/Fax/Email Initiated Service?

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Appendix A: Consent Form


For ordering details, see page 30.

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Appendix A: Consent Form (continued)

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Appendix B: Patient Introduction Leaflet


For ordering details, see page 30.

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Appendix C: Compliance Card


This form should be photocopied onto white card. A master copy can be found at the back of this document.

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Appendix D: Repeat Dispensing Log


This form should be photocopied (back to back) onto white paper. A master copy can be found at the back of this document.

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Appendix E: Pharmacy Repeat Dispensing Referral Form


This form should be photocopied onto white paper. A master copy can be found at the back of this document.

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Appendix F: GP Repeat Dispensing Referral Form


This form should be photocopied onto white paper. A master copy can be found at the back of this document.

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Appendix G: EMIS/Protechnic Exeter Instructions


EMIS
Batch Issue Prescription To issue repeat prescription : Press : I for issue Select items : A, B, C etc Select :A for b(A)tch issue Type in chemist as appropriate Dispensing Interval? : enter for none, or 1M, 2M if required. (not recommended) Number of Issues: default 6 but can change to whatever appropriate. (next med rev date). Enter. Prescriptions printed. 1st copy RA (authorisation) to be signed by GP. Further copies, RD as many as requested:1 of 6, 2 of 6 etc. Do not sign. Staple together on far right (repeat request slips).

Chemist Name of chemist required on patients record. NOTE on consultation screen: Press A: add Press P: problem Press 8BM4 or type in repeat dispensing. Enter Type in name of designate Pharmacy of the patients choice. Press F8 to file.

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Appendix H: Drugs not included in the scheme


List of Controlled Drugs and hypnotics and anxiolytics drugs not included in the scheme.

Schedule 1
Cannabis Lysergide (LSD)

Schedule 2
Diamorphine (Heroin) Morphine Pethidine Secobarbital Glutethimide Amphetamine Cocaine Methadone Oxycodone

Schedule 3
Barbiturates (excluding Secobabital) Buprenorphine Diethypropion Flunitrazepam Mazindol Meprobamate Pentazocine Phentermine Temazepam

Schedule 4 and Hypnotics and Anxiolytics (require risk vs. benefit assessment) As the long-term prescribing of hypnotics and anxiolytics is discouraged, serious consideration must be given to patients prescribed these medicines as to their suitability. However, if the balance for patient benefit favours inclusion and the patient meets all other inclusive criteria, then they may be incorporated onto the scheme. Diazepam Nitrazepam Lorazepam Lormetazepam Chlordiazepoxide Alprazolam Oxazepam Zaleplon Zopiclone Zolpidem Loprazolam Buspirone

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Appendix I: Record of destroyed batch issues form


This form should be photocopied (back to back) onto white paper. A master copy can be found at the back of this document.

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Appendix J: Penultimate Prescriptions (Repeat Dispensing Scheme)


This leaflet should be photocopied onto pink paper. A master copy can be found at the back of this document.

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Appendix K: Locum Agreement Form


This form should be photocopied onto white paper. A master copy can be found at the back of this document.

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Appendix L: Repeat Dispensing GP Practice Standard Operational Procedure

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Appendix M: Repeat Dispensing Community Pharmacy Standard Operational Procedure

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Appendix M: Repeat Dispensing Community Pharmacy Standard Operational Procedure (cont)


Repeat Dispensing Community Pharmacy Standard Operational Procedure (continued)
Sorting and submission of forms to the PPA
FP34C (Pharmacy Contractor) 1. Complete one invoice only per month. 2. Prescription forms must be sorted as follows: 2.1 Into patient charge group, i.e. exempt, paid and paid at old rate. 2.2 Within each group into the following order, starting from the top: 2.2.1 Forms referred back from previous month(s). 2.2.2 Forms FP10 MDA by prescriber surname. 2.2.3 Forms FP10D. 2.2.4 Forms FP10P/NC or SS with PN indicator by prescribing nurse surname. 2.2.5 Forms FP10P/NC or SS with CN indicator by prescribing nurse surname. 2.2.6 Forms FP10P/NC or SS with SP indicator by prescriber surname. 2.2.7 Forms FP10SS/NC Hospital Forms. 2.2.8 (Repeat Dispensing) First Batch issue forms(s) (FP10SS) i.e. 1 of x by prescriber. 2.2.9 (Repeat Dispensing) Batch issue form(s) (FP10SS) e.g. 2 of x, 3 of x, etc. by prescriber surname. 2.2.10 All other FP10 forms by prescriber surname. (NB any prescribers with fewer than 20 forms can be placed into a miscellaneous section at the end of each group.) All of the following forms must be kept separate from the FP10 prescriptions (submitted for processing and reimbursement as in paragraph 2) and collated by form type as follows: 3.1 Repeat Authorising forms.

3.

Pharmacies will need to submit the legal repeat authorising prescription when all batch issues have been dispensed, it has expired, or the medication is no longer required. These will need to be submitted in a separate bundle to the PPA the month after they are no longer required by the pharmacy for dispensing.

Please note: If a batch prescription is no longer valid because the patient does not need the item or items, the GP has ceased treatment or it is no longer covered by an authorising prescription, then in ALL cases you must destroy the relevant batch issues and not submit the to the PPA .

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