Addictions

June 2014

Research

‘Your lack of organisation doesn’t constitute our emergency’ – repeat prescription management in general practice

Volume 43, No.6, June 2014 Pages 404-408

Belinda Garth

Meredith Temple-Smith

Malcolm Clark

Cathy Hutton

Elizabeth M Deveny

Ruby Biezen

Marie Pirotta

Background

The importance of quality and safety in repeat prescribing is well documented, but few studies have examined how practices manage urgent requests for repeat prescriptions and why patients require them urgently.

Methods

Twenty practice staff (receptionists, practice managers, general practitioners, practice nurse) from 10 general practices participated in semi-structured interviews, which were audio-recorded, transcribed and analysed thematically.

Results

Requests for same-day appointments for patients needing repeat prescriptions emerged as problematic for most clinics in our study. Reasons included convenience, lost prescriptions and running out of medication. Clinics gave patients appointments, left prescriptions for collection at reception or ran prescription clinics. A need emerged for GPs to support individual clinic policy on repeat prescriptions.

Discussion

Many urgent requests for repeat prescriptions are avoidable. Improvements are needed in the way repeat prescriptions are managed, pointing to a closer examination of general practice systems, the role of practice staff, pharmacists and patients.

Repeat prescribing is common in general practices in developed countries, where most have established systems to issue repeat prescriptions without face-to-face consultation with the patients.1 The importance of quality and safety in repeat prescribing is well documented2 as repeat prescriptions may be dangerous if an error is compounded over time.3,4 Appointments may decrease medicolegal risk by allowing general practitioners (GPs) to more closely monitor dosage and appropriateness of medications, especially once the repeat prescriptions have ‘reached their issue limit’.3 In Australia, GPs can write a prescription with enough repeats to last 6 months5 for patients on long-term medication. 

Pharmacists in Australia can dispense some prescription medication (statins and oral contraceptives only) without a valid prescription and without consultation with a patient’s GP (‘continued dispensing’).6,7 While this has the potential to alleviate some demand for face-to-face consultations for urgent repeat prescriptions, continued dispensing is not supported by the Australian Medical Association (AMA).7

There have been calls for further studies on the development and evaluation of repeat prescription management models.8 One New Zealand study9 noted that timely clinical review remains problematic and, to reduce errors in repeat prescribing, advocated a collaborative approach that included effective practice systems, patient involvement and pharmacy communication.

Other research from the UK and Europe on the management of repeat prescriptions focuses on the role of community pharmacists,10 refill adherence11 and different methods of ordering non-urgent repeat prescriptions.12 There is insufficient research examining how general practices manage same-day appointment requests for repeat prescriptions, particularly given the demonstrated importance of periodic face-to-face consultations.3,9

The Royal Australian College of General Practitioners (RACGP) requires practices to have flexible systems to accommodate urgent appointments.13 Demand for appointments is high and supply is limited,14 so managing requests for same-day appointments is an important issue.

In Australia, practices have flexibility for managing repeat prescription requests, as it is legal for GPs to write a prescription without seeing the patient (and charge a fee for this service, if they choose). GPs can only bill Medicare for a face-to-face consultation. High demand and a shortage of available appointments may prompt individual practices to develop their own systems to manage demand.

Our initial study15 investigated the systems used in a range of Australian general practices to manage requests for same-day appointments and explored perceptions of clinic staff managing these requests. Unexpectedly, we found a large proportion of same-day appointment requests were for repeat prescriptions. This finding prompted a secondary analysis16 of the data to specifically examine this emerging issue. The following research questions were used to guide analysis:

  • What reasons did patients reportedly give for requesting an urgent or same-day appointment for a repeat prescription?
  • What strategies did practices use to manage these requests?
  • How did practice staff perceive same-day requests for repeat prescriptions? Was it manageable/problematic?

Methods

The initial study

Semi-structured, in-depth interviews were conducted with clinic staff who had responsibility for managing requests for same-day appointments at 10 GP clinics (seven metropolitan and three regional) around Melbourne, Victoria. Recruitment was through the e-mail bulletin of the Victorian GP research network (VicReN). Interested practices responded to the bulletin (volunteer sampling).17 Some practices were approached on the basis of our knowledge of their clinics (purposive sampling) and participants were asked to nominate other clinics that might be interested in being involved (snowball sampling)17 to ensure diversity in practice characteristics (Table 1).

Table 1. Overview of participating clinics in Melbourne, Victoria
ClinicLocationTotal number of reception staff employed at clinic (number on duty at one time)Total number of nurses employed at the clinicTotal number of GPs employed at clinicStaff interviewed
A Outer urban 7–8 (2) 2 19 R, n=2
GP, n=1
B Outer urban 7 (3–4) 2 11 PM, n=1
C Inner urban 5 (2) 5 4 PM, n=1
R, n=1
D Central business district 3 (3) 0 6 GP, n = 1
R, n = 1
E Rural/regional 10 (3) 11 12-14 R, n = 1
NUR, n = 1
F Rural/regional 7 (3) 3 9 PM, n = 1
R, n = 1
G Inner urban 15 (3–5) 3 15 R, n = 2
H Rural/regional 4 (4) 12 10 PM, n = 1
R, n = 1
I Inner urban 4 (3) 4 12 PM, n = 1
R, n = 1
J Inner urban 3 (1–2) 1 4 PM, n = 1
R, n = 1
R, receptionist; GP, general practitioner; PM, practice/business manager; NUR, nurse

Data collection

The first author, an experienced qualitative researcher, conducted 20 interviews between December 2010 and April 2011. Participants, self-identified as having some responsibility for managing same-day appointment requests, included 11 receptionists, five practice managers, two GPs, one business manager and one nurse. Participants were interviewed in a private room at their clinic. Interviews lasted for 15–55 minutes (average 36 minutes) and were audio-recorded. An interview schedule was used to initiate and guide discussion.

Data analysis

As we were conducting a secondary analysis of data already collected from our initial study,15 all interview data had been transcribed and NVivo Version 9 used for data management. Our study was based on a modified grounded theory approach,18 where data were analysed with no preconceived categories and grouped into emerging themes using the method of constant comparison, without theory generation.18,19 Research questions (noted earlier) were used to guide analysis. Open coding was used initially, followed by grouping codes into thematic categories. These themes were used as a guide for further coding and continued to be refined until data collection was complete and no new information emerged (data saturation).18 To ensure credibility of interpretations, analyst triangulation19 was used where data analysis was conducted independently by three qualitative researchers (BG, ED, MTS) and then discussed with the research team to achieve consensus on common themes.

Ethics approval

This project was approved by The University of Melbourne, Human Research Ethics Committee (ID 1034624).

Results

Summary of results

Requests for same-day appointments for patients needing repeat prescriptions emerged as problematic for most clinics. One reported having an acceptable system for management of such requests but acknowledged this as an issue of ongoing interest; nine clinics reported it was a persistent concern.

Patients reported various reasons for their urgent need for a repeat prescription and there were a number of ways clinics managed these requests. Some clinics had a policy requiring patients to make an appointment. Some GPs perceived it to be less time-consuming to write a prescription without seeing the patient. Patients were reported to become frustrated if unable to make a same-day appointment to obtain a prescription. This frustration was exacerbated by inconsistent ways of handling the requests even within the same clinic. Some participants believed that patient education regarding practices’ expectations for repeat prescriptions was required.

Reasons patients reportedly gave for requesting a same-day appointment for repeat prescriptions

Clinic staff reported various reasons for patients requesting same-day appointments when they required repeat prescriptions. These included convenience, lost prescriptions, running low on medication (or completely out of medication) and forgetting to ask for prescriptions at a recent visit to their GP. These reasons were a source of frustration for practice staff:

‘[One of the GPs] taught us [the saying] … “Your lack of organisation doesn’t constitute our emergency”. You really wouldn’t want to say that, would you?! [laughing] But we’ve heard it enough that I remember it.’ (Clinic F receptionist).
‘You get those who say, "I'd like to see [the GP] this afternoon because it fits in … I've got to have this prescription today and this is my day off" …’ (Clinic G, receptionist).
‘…people being disorganised, losing scripts.’ (Clinic D, GP).
‘[Patient says] “I’ve run out of a script … I took my last [tablet] this morning.” You know just by the tone in their voice, it’s … medication they’ve got to take every day.' (Clinic H, receptionist).
‘… the patient had just seen a doctor recently … and they … forget to ask for that script in the appointment …’ (Clinic G, receptionist 1).

Strategies practices used to manage these requests

Appointment versus collecting prescription from reception

Most practices preferred patients to have an appointment for repeat prescriptions to enable GPs to monitor appropriate treatment and ensure regular assessment.

‘… the policy of the practice is you have to be seen if you want a script.’ (Clinic F, practice manager).
‘But we try and fit them in. We do very, very few script pick-ups … Giving a script without seeing a patient … it’s not how we operate here …’ (Clinic H, business manager).

When there were no available appointments, practices reported trying to ‘fit-in’ or ‘squeeze-in’ patients. Clinic staff perceived that many GPs were reluctant to write a prescription without seeing the patient and for some clinics this was a policy. However, some practices and individual GPs preferred to leave prescriptions at reception for patients to collect, perceiving this as less time consuming.

‘… if it’s [a repeat] script I’ll send a message to the doctor … the… patient will come in and just pick it up. … [otherwise the patient] has to wait 2 hours just for the script.’ (Clinic J, practice manager)
‘… by the end of the day, there are… quite a few phone calls [saying] "I need this prescription" … it’s unpaid work at the end of the day … and where some clinics would insist that’s done in an appointment, I don’t see the merit in that; personally, I’d much rather just do the prescription if that’s all that’s needing [to be] done and it’s 2 minutes of my time, rather than 15...’ (Clinic A, GP).

Running a clinic specifically for prescription renewal

Some practices set aside blocks of time for ‘quick-appointments’ or had specific ‘script-only-appointments’. One practice (Clinic D) was investigating a script clinic, and a receptionist from Clinic G had read about specific prescription clinics and thought they were a good idea. One practice tried ‘script-only’ appointments but found they did not work.

‘Between … 1 and 3 o'clock, or 1 and 2 o'clock, where all those patients, because they're only 5-minute appointments, just all come through and one doctor does all of that.’ (Clinic E, nurse).
‘… we did try a ‘scripts-only-[system]’ when we were very, very short of doctors … We booked … 10-minute appointments – we had four patients come in for just a script, but it’s never just a script. It just didn’t work.’ (Clinic F, practice manager).

Strategies for reducing the number of patients requesting same-day repeat prescriptions

Practices had various ways of attempting to reduce the number of patients requesting a same-day appointment for a repeat prescription (Table 2). Despite using these strategies, there was still a demand for same-day appointments for repeat prescriptions.

‘We advertise that we like 48 hours notice but the patient will ring up and say, oh, I’ve had no tablets yesterday and today; I need to be seen.’ (Clinic E, receptionist).
Table 2. Strategies used for reducing number of patients requesting same-day repeat prescription
StrategyExample
Telling the patient At the time of their request, telling the patient that for good medical care, it was preferred that they make an appointment 2 weeks before the prescription runs out.
Advertising practice guidelines for repeat prescriptions Clearly visible posters on the walls and doors of the clinic that state 48-hours notice is required for prescriptions.
Charge a fee Charge a $10 fee for a prescription that was requested on the same-day without an appointment.
Using an online system Using an online system (such as OzDocsOnline) where patients can request a repeat prescription. This is for non-urgent requests and can be written at a time convenient to
the GP.

Practice staff perceptions of same-day requests for repeat prescriptions

Frustration from patients

At times, it was not possible for practices to ‘fit-in’ a patient who required a repeat prescription (eg. if the GP triaged the issue as non-urgent). Some patients were reported to be frustrated and angry if they were not given a repeat prescription on the day they requested it. One practice manager (Clinic C) sometimes suggested patients ask the chemist for an ‘owing-script’ and then make the next available appointment with the GP. This practice manager also suggested to some patients to try to plan ahead for their repeat prescriptions, but found some patients were not always receptive to this.

‘… someone who’s running out of pills today, they’ve been disorganised and… don’t have an appointment, they can always come in and somebody will write them a prescription if they wait long enough … [The receptionists] sometimes have to say there’s nothing we can do … and the patient certainly doesn’t like it, so they tend to get a bit annoyed, abusive, swearing, physical on occasions...’ (Clinic A, GP)
‘One man said to me one day, I didn't want a lecture from you.’ (Clinic C, practice manager).

Staff reflections on patient expectations

Staff reported that patients often did not seem to understand why they might need an appointment for ‘just’ a repeat prescription, nor did they understand the issues involved in writing a prescription without an appointment (ie. writing a prescription requires a GP to review the patient record to ensure proper management, and that the patient’s one prescription was in addition to many other requests for prescriptions and paperwork for their GP that day and would probably be done without remuneration).

Additionally, patients were sometimes given mixed messages regarding whether they needed an appointment to get their prescription or whether they could collect it from reception without an appointment. This was frustrating for clinic staff. One receptionist noted the need for GPs to be consistent and educate patients when it comes to repeat prescriptions.

‘We’ve got classic patients … that go “well we don’t care what the receptionist says, we’ll just ask the doctor.” Then the doctor will do what they want… the policy of the practice is you have to be seen if you want a script … [and] reception staff follow that policy through…[but] it gets disjointed … we… have one particular doctor who continually [writes prescriptions] even though the policy of the practice isn’t to do that.’ (Clinic F, practice manager).
‘[There needs to be] consistency … I think … doctors have to educate the patients because the receptionists have … power [and then] get the abuse ...’ (Clinic K, receptionist).

Discussion

As far as we are aware, ours is the first study to identify urgent repeat prescriptions as a concern when managing same-day appointment requests in Australian general practice. Although specific to Australian practice, our study adds to the increasing body of international research3,8,9 that affirms the need for improvements in the way repeat prescriptions are managed and points to the importance of a closer examination of both general practice systems and the role of practice staff, pharmacists and patients.

Practices often had to ‘squeeze in’ patients to a full appointment schedule and staff expressed frustration when requests for same-day appointments were perceived as avoidable (eg. by making a forward appointment for known prescription needs). While most clinics required patients to have an appointment for repeat prescriptions, some allowed patients to collect their prescriptions without an appointment. Running a script-clinic was one attempt at streamlining the process, but keeping appointment times short was problematic (‘it’s never just a script’).

The preference of some clinics in our study to issue repeat prescriptions without a face-to-face consultation with the patient is a common practice.1,8 However, we found most clinics preferred face-to-face consultations even when that meant fitting-in patients to an already full appointment system. Monitoring medications was cited as the main reason for fitting-in patients. It is possible that GPs preferred this option because they are remunerated by Medicare only for a face-to-face consultation but this was not articulated by participants in our study (who were mostly practice staff and only two were GPs).

Some methods of managing repeat prescribing in the UK have involved community pharmacists.10 Few participants in our study mentioned working with pharmacists; it is uncertain whether GPs perceive a need for this, given that when discussing the National Health Bill,6 which allows continued dispensing by pharmacists, the AMA president stated, ‘The Bill is effectively fixing a problem that does not exist. GPs currently have arrangements in place to see patients who urgently need a consultation to renew prescriptions or get new prescriptions’.7 While most GP clinics in our study tried to accommodate flexible appointment systems15 or wrote prescriptions to be collected if appropriate, many acknowledged ‘urgent’ same-day requests for repeat prescriptions as an issue of concern, indicating a problem does exist and needs to be addressed.

The provision of same-day appointments for patients urgently seeking prescription renewal would decrease the likelihood of compounding potential prescribing errors; howerver, there were practical implications for providing a same-day appointment to every requesting patient. Our findings concur with a New Zealand study9 regarding the difficult nature of finding ‘semi-urgent appointment slots’ for patients who inadvertently run out of medication, and how this points to the importance of ‘adhering to reasonable time frames for clinical review [of repeat prescriptions]’. Ideally, patients would make an appointment for their next visit as they leave, thus ensuring their medications and prescriptions are managed in a timely way. But this does not always happen. Implicit in responses from the GPs and practice staff in our study is that they neither have the time nor the opportunity to see all patients who wish to consult them, highlighting workforce shortages currently affecting Australian general practice.14

Use of electronic systems may offer another option for GPs to alleviate the pressure of fitting in appointments to an already full appointment schedule. Electronic prescribing20 (not yet fully established nationwide) enables GPs to enter prescriptions electronically for dispensing by a pharmacy (similar in effect to leaving prescriptions at reception). Other online systems, such as OzDocsOnline (used by one GP in our study), allows patients to request repeat prescriptions from their GP online. However, OzDocsOnline is more suited to non-urgent requests (patients must remember to log in and request their prescription ahead of time, before they run out of medication). Other types of technology, such as short message service (SMS), have been used successfully in the UK for repeat prescription requests,12 but it was noted that ‘it would be premature to claim such an innovation might improve compliance by helping patients to reorder before rather than after their supplies run out’. Having technology-assisted options such as these may be useful for attending to patient requests, as long as they do not replace timely clinical review to ensure medications and dosages remain appropriate.

Strengths and limitations of the study

Our findings are limited because they are based on secondary analysis of data, which meant we were unable to more fully explore issues, as the data had already been collected. Despite this, the findings are grounded in the experiences of practices and reflect real experiences and concerns. Purposeful sampling enabled the study to include the experiences of a range of practice types (varying in size, location and social demographics) and our analysis reached data saturation17 (demonstrating internal validity). Interviewing a range of clinic staff enabled us to explore different viewpoints. In particular, interviewing receptionists provided unique insights and areas for improvement, such as the need for all clinic staff, including doctors, to be consistent with patients. Our study provides initial exploration of a new and important issue and provides direction for future research.

Implications for general practice

It is important for GPs and receptionists to work together to communicate a consistent message to patients. Reducing the number of patients requesting a same-day appointment for repeat prescriptions would relieve some of the pressure on appointment systems, freeing up time for medically urgent same-day needs. To do this, further research is required and needs patient, GP and pharmacist input to explore the role each has in effective management of medications.

Competing interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.

Acknowledgements

We would like to thank the practice managers who consented to their practice participating in our study, and the receptionists, practice managers and general practitioners who were interviewed. We also thank Dr Phyllis Min-Yu Lau, Dr Jenny Worboys and the VicReN committee members, in particular, Associate Professor Chris Hogan, Dr Hubert Van Doorn, Ms Judy Evans and Ms Lynne Walker, for their comments on earlier versions of this manuscript.

Funding for the study was from an RACGP Family Medical Case Education and Research Grant.

References

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Correspondence afp@racgp.org.au

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