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Prescribing

NHS England publishes new prescribing guidance in bid to save millions of pounds

A range of treatments, including homeopathy, antioxidants and other supplements, will no longer be routinely prescribed with the aim of saving the NHS £140m a year.

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Prescribers in primary care should not initiate paracetamol and tramadol combination product for any new patient

NHS England has published national guidance on a range of medicines which should no longer be routinely prescribed in primary care.

It follows a consultation between July and October this year which sought views from the public, patients and professionals on whether 18 products, identified as either of low clinical value, clinically effective but low priority, or those where cheaper alternatives are available, should be prescribed.

At a meeting, held in London on 30 November 2017, NHS England board members agreed that draft recommendations for all 18 products, which include homeopathy and travel vaccinations, should remain unchanged or be modified or clarified “to ensure people receive the safest and most effective treatment available, and save the NHS up to £141 million a year”.

Treatments that will no longer be routinely prescribed at all include homeopathy, herbal treatments, omega-3 fatty acid compounds (fish oil), co-proxamol, rubefacients, lutein and antioxidants, and glucosamine and chondroitin.

In the case of five medicines, liothyronine, travel vaccines, lidocaine plasters and immediate-release fentanyl, the board agreed that, based on responses to the consultation, the recommendations should be modified or clarified (see table).

The board also agreed to launch a consultation on curbing prescriptions for some 3,200 over-the-counter (OTC) products such as paracetamol, cough mixtures, cold treatments, laxative and sun cream lotions.

According to NHS figures, GPs issued approximately 1.1 billion prescription items at a cost of £9.2bn in 2015–2016. Experts say approximately £190m a year could be saved by cutting prescriptions for minor, short-term conditions, many of which are self limiting (such as diarrhoea and constipation, head lice and mild acne) or cause no long-term effect on health.

But, while welcoming the proposals to restrict prescribing of medicines where there are safer or more effective alternatives, the Royal Pharmaceutical Society (RPS) has voiced “great concern” over the proposals on OTC medicines, saying it risks “exacerbating existing health inequalities and causing ill health among our most vulnerable and deprived communities, who cannot afford to pay for treatments”.

Sandra Gidley, RPS England chair, said: “Such a move would also violate Principle 2 of the NHS Constitution, which clearly states that ‘Access to NHS services is based on clinical need, not an individual’s ability to pay’ and would fundamentally alter the relationship between patients and the NHS.”

She said the RPS would respond to the consultation when it is published next year.

Chief executive of NHS England Simon Stevens said: “The NHS is one of the most efficient health services in the world but we’re determined to make taxpayers’ money go further. The NHS should not be paying for low value treatments and it’s right that we look at reducing prescriptions for medicines that patients can buy for a fraction of the price the NHS pays.”

Table 1: NHS England final recommendations for NHS prescribing of medicines of ‘low clinical value’
Product Draft recommendationsFinal recommendations after consultation
Source: NHS England
Co-proxamol 1) Advise CCGs that prescribers in primary care should not initiate co-proxamol for any new patient 
2) Advise CCGs to support prescribers in deprescribing co-proxamol in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change
3) Advise CCGs that if, in exceptional circumstances, there is a clinical need for co-proxamol to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional 
No change 
Dosulepin1) Advise CCGs that prescribers in primary care should not initiate dosulepin for any new patient
2) Advise CCGs to support prescribers in deprescribing dosulepin in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change
3) Advise CCGs that if, in exceptional circumstances, there is a clinical need for dosulepin to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional 
No change 
Prolonged-release doxazosin 1) Advise CCGs that prescribers in primary care should not initiate prolonged-release doxazosin for any new patient
2) Advise CCGs to support prescribers in deprescribing prolonged-release doxazosin in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change.
3) Advise CCGs that if, in exceptional circumstances, there is a clinical need for prolonged-release doxazosin to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional 
Recommendation 3 removed 
Immediate- release fentanyl 1) Advise CCGs that prescribers in primary care should not initiate immediate release fentanyl for any new patient 
2) Advise CCGs to support prescribers in deprescribing immediate-release fentanyl in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change 
3) Advise CCGs that if, in exceptional circumstances, there is a clinical need for immediate-release fentanyl to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional 
Additional information to be added: defined exemption and clarification for use as outlined in NICE guidance for palliative care 
Glucosamine and chondroitin 1) Advise CCGs that prescribers in primary care should not initiate glucosamine and chondroitin for any new patient 
2) Advise CCGs to support prescribers in deprescribing Glucosamine and Chondroitin in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change 
No change 
Herbal treatments 1) Advise CCGs that prescribers in primary care should not initiate herbal items for any new patient 
2) Advise CCGs to support prescribers in deprescribing herbal items in all patients and where appropriate, ensure the availability of relevant services to facilitate this change 
No change 
Homeopathy 1) Advise CCGs that prescribers in primary care should not initiate homeopathic items for any new patient 
2) Advise CCGs to support prescribers in deprescribing homeopathic items in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change 
No change 
Lidocaine plasters 1) Advise CCGs that prescribers in primary care should not initiate lidocaine plasters for any new patient 
2) Advise CCGs to support prescribers in deprescribing lidocaine plasters in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change
3) Advise CCGs that if, in exceptional circumstances, there is a clinical need for lidocaine plasters to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional 
Additional information to be added: defined exemption and clarification for the use of lidocaine plasters in post herpetic neuralgia (PHN) only, for which it is licensed in adults and for which there is some evidence of efficacy 
Liothyronine 1) Advise CCGs that prescribers in primary care should not initiate liothyronine for any new patient 
2) Advise CCGs to support prescribers in deprescribing liothyronine in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change
3) Advise CCGs that if, in exceptional circumstances, there is a clinical need for liothyronine to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional 
Change: prescribing of liothyronine in appropriate patients should be initiated by a consultant endocrinologist in the NHS, and deprescribing in ‘all’ patients is not appropriate as there are recognised exceptions. 
Lutein and antioxidants 1) Advise CCGs that prescribers in primary care should not initiate lutein and antioxidants for any new patient 
2) Advise CCGs to support prescribers in deprescribing lutein and antioxidants in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change 
No change 
Omega-3 fatty acid compounds 1) Advise CCGs that prescribers in primary care should not initiate omega-3 fatty acids for any new patient 
2) Advise CCGs to support prescribers in deprescribing omega-3 fatty acids in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change 
No change 
Oxycodone and naloxone combination product 1) Advise CCGs that prescribers in primary care should not initiate oxycodone and naloxone combination product for any new patient 
2) Advise CCGs to support prescribers in deprescribing oxycodone and naloxone combination product in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change
3) Advise CCGs that if, in exceptional circumstances, there is a clinical need for oxycodone and naloxone combination product to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional 
No change 
Paracetamol and tramadol combination product 1) Advise CCGs that prescribers in primary care should not initiate paracetamol and tramadol combination product for any new patient 
2) Advise CCGs to support prescribers in deprescribing paracetamol and tramadol combination product in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change 
No change 
Perindopril arginine 1) Advise CCGs that prescribers in primary care should not initiate perindopril arginine for any new patient 
2) Advise CCGs to support prescribers in deprescribing perindopril arginine in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change 
No change 
Rubefacients (excluding topical NSAIDs) 1) Advise CCGs that prescribers in primary care should not initiate rubefacients (excluding topical NSAIDs) for any new patient 
2) Advise CCGs to support prescribers in deprescribing rubefacients (excluding topical NSAIDs) in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change 
No change
Once daily tadalafil 1) Advise CCGs that prescribers in primary care should not initiate once daily tadalafil for any new patient 
2) Advise CCGs to support prescribers in deprescribing once daily tadalafil in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change 
No change 
Vaccines administered exclusively for the purposes of travel 1) Advise CCGs that prescribers in primary care should not initiate the stated travel vaccines for any new patient Wording of guidance amended to reduce confusion around ‘travel vaccines’ 
Trimipramine 1) Advise CCGs that prescribers in primary care should not initiate trimipramine for any new patient 
2) Advise CCGs to support prescribers in deprescribing trimpramine in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change
3) Advise CCGs that if, in exceptional circumstances, there is a clinical need for trimipramine to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional. 
Recommendation 3 removed 

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2017.20204042

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