Abstract
Background The service evaluation site is a specialist paediatric hospital providing tertiary care to large cohort of patients. Specialist clinics generate a high volume of outpatient prescriptions or primary care prescription requests. In accordance with NHS England recommendations,1 the paediatric formulary utilises a traffic light system to guide prescribers on with whom prescribing responsibility should usually fall. However, despite clear guidance, repeat prescriptions appear to often be prescribed inappropriately from tertiary care. It is important that drug therapy is provided from the appropriate setting and is convenient to access1 2; obtaining medications can cause families a great deal of stress.3 Repeat prescribing via tertiary care also has implications on hospital budgets, clinical staff time and pharmacy resources.
Aim The aim of the service evaluation was to assess the prevalence of the issue, ascertain common factors associated with inappropriate repeat prescribing and elicit the rationale.
Method Following a pilot period and amendments to the data collection form, a 2-week data collection period took place. Data was collected at the paediatric pharmacy prospectively by asking the person handing in a prescription if they had received the medication before and the reason that they obtain the medicine from hospital. Demographic and medication data (virtual or paper prescription, existence of a BNFC monograph, licensing of product, off-label usage, clinical specialty, age of patient and the patient’s CCG) were then collated retrospectively.
Results Data was then analysed for themes which found the following:
The formulary rating with the highest number of repeat prescription items was green (78/192 items, 40.6% of total).
Only 19.8% of prescription items have certainty of appropriateness (rated red).
Renal (nephrology and renal transplant) were the highest prescribers of green or amber-1 items, followed by rheumatology.
The most selected reason for obtaining a green item from hospital was that ‘they were here for an appointment so it was easier to collect now’ (41%).
The vast majority of green prescription items were licensed products (94.9%), used within their licensing (80.8%) and had a BNFC monograph (98.7%).
Conclusion Despite clear formulary ratings, a high number of green or amber-1 items were being prescribed in tertiary care, which should almost always be prescribed in the community, demonstrating a prevalent issue. Amber-2 or 3 items are more difficult to assess as they depend on individual circumstances. Theorised potential contributory factors to inappropriate repeat prescribing in tertiary care were not associated with increased repeat prescribing of green items. The results overall suggest that the issue arises more so from in-house and/or general paediatric prescribing culture, as opposed to wide-spread primary care refusal. Prescribing for patients because they have attended clinic and it is perceived as easier is a significant issue that should be addressed as it sets an inappropriate precedent and contributes to a wider paediatric prescribing issue.
References
NHS England. Responsibility for prescribing between primary, secondary and tertiary care [Internet]. England: NHSE; 2018 [updated 2018 Mar]. Available from: https://www.england.nhs.uk/publication/responsibility-for-prescribing-between-primary-and-secondary-tertiary-care/
Tse Y, Trivedi A, Mee A, et al. Improving the experience of obtaining repeat complex paediatric prescriptions in the UK. Arch Dis Child 2022;107:963–966 doi:10.1136/archdischild-2020–320912
Hussain NR, Davies JG, Tomlin S. Supply of unlicensed medicines to children: semi-structured interviews with carers. BMJ Paediatr Open [Internet]. 2017 Aug 23 1:e000051. https://bmjpaedsopen.bmj.com/content/1/1/e000051 (Accessed July 4 2023).
