With the Government’s healthcare reform consultation document, “Your Health, Your Life”¹ and the recent campaign promoting Family Medicine and Primary Care as the first point of contact and for continuity of care, it is likely that the demand of primary healthcare service will increase; therefore there is a continuous pressure for an effective and efficient way to deliver high quality care within the limited resources. In this issue of The Hong Kong Practitioner, a pilot study on clinical risks/outcomes of a “Repeat Prescription” programme tries to answer the question of whether repeat prescribing could potentially be beneficial and feasible in our public primary care setting.

Worldwide, there is no single best method of delivering repeat prescriptions. In some countries, such programmes are led by nurse practitioners; others, are led by pharmacists or dispensers. For example, in the United Kingdom, patients under the National Health Service can get a repeat prescription online and choose where they want to collect the medicine and from which selected pharmacy or have the medicine delivered.² Questions such as: "Who would be in a position to review the patients if it is not the doctors" or "When should the patients be reviewed" and issues such as refill adherence,³ need to be addressed.

The first assumption for such arrangement is that only stable patients can receive repeat prescriptions. But then what is the universal definition of being “stable”? Can “stable” conditions be readily assessed by the available health parameters and not changed with time?

Another question is what advantages and limitations are associated with the additional service of repeat prescriptions provided by other healthcare professionals such as pharmacists or nurse practitioners versus follow-ups with family doctors at longer intervals and having longer drug duration. Subsequent questions are how long before a doctor should review a patient with chronic disease even if the condition is stable, and what needs to be done at each follow-up consultation. Clinical judgment and share of responsibility as to which patients can receive repeat prescribing without seeing the doctors needs to be clearly spelt out.

One potential drawback is that while repeat prescriptions may help solve the problem of long waiting time to see a doctor, the doctor-patient relationship can be affected. Apart from ensuring that the patient’s condition is clinically stable and achieving health parameters targets, what else can or should be done at a doctor’s consultation? During the sharing session in a recent teaching of a Master course at the University of Hong Kong, a patient with diabetes mellitus for more than 10 years and was known to be under “stable” condition was asked if she would prefer to see a doctor or a nurse for follow-ups for her diabetes mellitus. She chose to see a doctor, as it would give her a sense of reassurance. It is well known in the literature that the presence of a doctor could act as a medicine,⁴ and the effectiveness of such an event is based on the well-established doctor-patient relationship. On the other hand, some patients may value more the holistic and comprehensive care provided by the primary care team instead of just care provided by one single doctor. Thus, research studies taking into account patients’ perspectives are required in the local setting in order to help pave way for the most appropriate primary care delivery model.

Another argument is that if “repeat prescription” can save some time for the doctor, the doctor can spend more time with patients on some other tasks such as on lifestyle assessment or smoking cessation, which is the focus of another article in this issue. While the detrimental health effects of smoking have been proven beyond doubts, it was found that the recording of smoking status and details about smoking cessation and counseling advice were poor, that these are not even coded in the Clinical Management System. In this article, it also shows that a simple audit exercise not only can identify weaknesses in our routine care but can also potentially bring improvements in our standard of care. This audit is one example of translating theory (e.g. the ⁵A’s framework in smoking cessation) into practice. Although the number of smokers who quitted smoking was not the main target in this audit exercise, it is encouraging to see that there were four who managed to quit smoking in the second audit cycle compared to none in the first cycle.

The third article also looked at how theoretical evidence could be translated into clinical practice. The paper discussed how the family doctors can translate the Reference Framework⁵ recommendations on hypertension care into daily clinical practice. The reference framework is a consensus document endorsed by various stakeholders, including academic and professional bodies, as the most appropriate and feasible application of available evidence in primary healthcare in Hong Kong. The Reference Framework aims at providing a common reference to guide and coordinate healthcare for patients, from all healthcare professionals across different sectors for the provision of continuous, comprehensive and evidence-based care for hypertension in the community. As the reference framework is now accepted by all healthcare professionals, multifaceted strategies to actively engage primary healthcare professionals to adopt the recommendations within the framework are the key for successful implementation⁶ and worth further exploration. Following the recommendations within the framework helps to safeguard our standard of care while the individual needs and circumstances of each patient must be taken into account by the treating doctor.

While family doctors are trying their best to improve the objective health outcome indicators such as blood pressure and body mass index, flexibility in clinical practice must be allowed because each patient is an individual and the management plan cannot be simply taken out of one same mould. As a family doctor, who understands patients’ individual circumstances and needs, helping the patients to identify barriers and negotiate achievable targets are essential steps in successfully managing their chronic diseases.

While family doctors are working hard to raise the standards of care, they should also enable and equip their patients so that patients can take up more responsibility and take good care of themselves. Self-care and patient enablement are other areas that family doctors can focus on and help their patients manage their chronic diseases, especially if some workload of the doctors such as writing repeat prescriptions can be shared out by other health professionals like nurses or pharmacists who are actually within the same primary care team.