Clinical Indications in GP Repeat Prescribing

Which patients should a practice start with?

Patients over 75, then those over 65. The FAQs, prepared by Dr Masters in September 2006, say the best way to start is for the clinician, usually the GP, to “set simple targets by focusing on certain patient groups”, beginning with these age bands. Age banding is visible on the repeat prescriptions.

This stage can be very time-consuming, because many of these patients are on a large number of repeat prescriptions. The FAQ says these “will be the most useful in the long-term”.

Next come the groups in what the FAQ called the new GMS targets, such as patients with diabetes and heart disease. The FAQ adds that some practices simply added indications for any patient on more than four medication items.

Why start with older patients?

Because they often take many medicines. The About page notes that many elderly people are on over ten different medications, and “it is easy for them to become confused about what each medicine is for”. FAQ 2 says indications are particularly helpful for older patients and for those on numerous drugs, such as people with diabetes.

How are indications written?

As free text in the drug directions, ideally three or four words, such as “to lower blood pressure”, added as each repeat request comes in: that is how Highfield Surgery did it (FAQ 3). In a 2015 letter to the BJGP, Dr Masters gave the example “Take one daily to prevent gout” for allopurinol, and wrote: “Adding indication labelling to the drug instructions firmly links the drug with its clinical indication” (read the letter).

The Sample Directory, compiled at Highfield Surgery from the surgery’s repeat prescriptions, suggests wording. It is an example, not a working directory, so check each phrase before you use it. At present, clinicians add the indication as free text to the directions on the electronic prescription. In EMIS, the free text is stored and offered from a pick list on future issues of prescriptions, for all patients. There is no separate indication field.

How should patients be told?

FAQ 4 suggests mentioning clinical indications in the practice leaflet, “stressing the safety benefits in the repeat prescribing section”. Some indications are sensitive and should be agreed with the patient first; the prescribers’ page sets out the options.

Feedback at Highfield Surgery, the pilot practice, was “very positive”, FAQ 14 reports. In three years, only two patients asked for their wording to be changed, and two others asked for no indication.

How do you check coverage?

With a departure audit: a check of how many repeat items leave the surgery without a stated indication (FAQ 7). On Dr Masters’ audits page (April 2006), the standard set is 80%, and the prescription clerk checks a random selection of scripts on one day every six months. At Highfield Surgery, a check in January 2004 found indication labelling on 89%, and one in August 2004 on 100%.

A destination audit checks the other end of the route, such as the medicines listings at nursing or residential homes. See care homes and MAR charts.

FAQ 2 points to a quality marker in the 2004 GMS contract: for repeat medicines, an indication for the drug can be identified from the records, with a minimum standard of 80%. The current GMS contract and its quality indicators have no such marker.

All of these audits were carried out at Highfield Surgery. The figures come from different points as the practice built up its indications, so each is given here with what it measured. FAQ 3 says the pilot practice (5,800 patients) took one and a half years to reach 85% coverage; the compliance study reports 85% over a two-year period; and FAQ 17 says over 80% of Dr Masters’ repeat prescriptions carried an indication.

Do indications improve adherence?

Not proven. FAQ 6 says “at present there is no evidence that clinical indications assist with adherence”. Dr Masters’ single-practice compliance study (April 2006), written at Highfield Surgery, found average statin compliance of 93% over a year, and 91% when repeated in January 2006, in a practice with high levels of indications.

The authors list other possible reasons, including the enthusiasm of the doctors and nurses and cost-free prescriptions, and conclude that “prospective studies with controls should be undertaken”.

What else does a practice gain?

FAQ 7 says lists of indications linked to repeat prescriptions form “a rudimentary active patient summary list”, useful out of hours to emergency staff and to other visiting medical staff. FAQ 2 adds that in training practices, indications can help doctors and students who are learning the wide use of common drugs.

Where next?

It is courteous to tell your local pharmacies and care homes before you start. See for prescribers on time and confidentiality, community pharmacy on labels and reviews, and the FAQs.