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Prescription guidelines

Restricting what is allowed on prescription in England: views from healthcare professionals and patient groups

Pill under microscope lens

We ask healthcare professionals across primary care and patient groups for their thoughts on NHS England’s decision to review what GPs are allowed to prescribe.

As part of its plans to make savings of around £128m a year, NHS England has announced that it will review what drugs and products should no longer be allowed on prescription. NHS England is working with clinical commissioning leads to develop national guidelines that will set out which products are to be dropped from prescription. The intention is for more products to be added to the list as part of an ongoing government review.

We sought the views of primary healthcare professionals, pharmacy organisations, patient groups and a non-profit organisation:

 

Sandra Gidley, chair of the English Pharmacy Board, Royal Pharmaceutical Society

Sandra Gidley, chair of the English Pharmacy Board, Royal Pharmaceutical Society

Against the financial pressures and constraints the NHS is under, it would be hard to argue against the review of products allowed on prescription, especially those with low or no clinical evidence of effectiveness. However, I am surprised that certain treatments, such as homeopathy, which have no clinical mode of action or scientific evidence of efficacy, did not make the list for the first wave of review.

We are mindful that some patient groups and charities will see this as an attack on the principle of the NHS to provide treatment free at the point of use, regardless of the condition. It is important that serious consideration be given and that careful evaluations are made before products are removed from prescription. What we do not want to see are short-term savings being made but in the longer term, patients – having lost access to certain drugs and products – becoming more ill and it ending up costing the health service more to treat their condition.

I would personally like to see significant pharmacist representation in clinical commissioning groups reviewing the items available on prescription. Pharmacists have the best knowledge around drugs efficacy, cost-effectiveness and waste, and can greatly assist NHS England in making the right choice in deciding what should be removed from prescription.

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Clare Gerada, GP and former chair of the Royal College of General Practitioners (2010–2013)

Clare Gerada, GP and former chair of the Royal College of General Practitioners (2010–2013)

In essence, I agree with NHS England’s decision to review items that should be allowed on prescription, especially for acute self-limiting issues. This review could also help drive the government’s self-care initiative if patients are encouraged to purchase drugs directly from their pharmacies.

It concerns me that, when I issue, say, an antihistamine for my patients on prescription, the cost to the NHS is significantly higher than if a patient just purchased it from a pharmacy or indeed from their local supermarket. The other cost, apart from my and colleagues’ time, is that pharmacists, who are highly skilled professionals, have to spend time dispensing that drug, when they could easily sell them over the counter to patients instead of using up their dispensing resources.

When I was a young doctor, washing powder could be prescribed on prescription. It is vital we continue to review this to ensure the public’s money is being spent appropriately.

Of course, there needs to be a safety net for vulnerable patients to ensure they do not lose access to drugs as a result of this review, but having a publicly funded health system such as the NHS means we have to make sensitive decisions about funding.

Moreover, this review should be done at a national level and not locally. What I do not want to see are patients going to GPs complaining that other GPs in other locations are allowing certain items on prescription.

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Stephen Fishwick, head of communications, National Pharmacy Association

Stephen Fishwick, head of communications, National Pharmacy Association

It is understandable that the NHS wants to examine access to treatments, in the light of tight budgets. However, the government and health service commissioners must proceed with caution, because of the potential for unintended consequences, especially in poorer communities.

NHS managers must be careful to avoid gating out people with genuine health needs, especially those who may struggle to afford the price of drugs. There are already significant barriers to people on low incomes accessing NHS services and treatments. The government has a legal duty to reduce health inequalities and must take this into account.

Meanwhile, there are far greater cost-efficiencies to be made across the health system by helping people to make the best use of drugs prescribed for long-term conditions, with support from their local pharmacist.

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Nick Beavon, chief pharmacist, Wandsworth clinical commissioning group

Nick Beavon, chief pharmacist, Wandsworth clinical commissioning group

The role of pharmacists in clinical commissioning groups (CCGs) is to provide expert advice and support GPs to prescribe effectively. We do this by reviewing the clinical effectiveness and value of drugs and optimise their use. As we all know, the NHS is under huge financial pressure and the effectiveness and value of prescribing some drugs has been coming increasingly under scrutiny as announced by NHS England.

Many CCGs have already launched engagement and consultations with the public, patients and other stakeholders to consider the options in relation to which drugs may be purchased over the counter in certain cases, and the announcement by NHS England will generate further debate. Difficult decisions have to be made to protect the essential services in the NHS and those in greatest need and who are vulnerable.

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Simon Phillips, pharmacist manager, Manor Pharmacy, Wheathampstead

Simon Phillips, pharmacist manager, Manor Pharmacy, Wheathampstead

I agree on principle with a review of inefficient or wasteful prescribing and understand that the free-at-point-of-use ideal should not give a carte-blanche right to patients to receive anything on the NHS, which is already under huge pressure financially. However, it is hard to justify a huge reduction in community pharmacy funding while the NHS is still spending money on pseudoscience products such as homeopathy.

Moreover, I am concerned that a blanket ban on certain items is potentially a ”crude sledgehammer approach” that could do more harm than good in certain circumstances. Patients are unique and GPs need flexibility when prescribing. For example, I have several patients who see great benefit with using rubefacients and it would cause them much upset to have these removed from their prescription.

In terms of patients with coeliac disease (which have been highlighted by a number of media outlets), many clinical commissioning groups have already significantly reduced the amount of products allowed on prescription. In my area, gone are the days of ”pizza bases and flavoured naans” and my patients now only have a few pastas and breads to choose from. My concern here is how it will impact on patients from low socioeconomic backgrounds, some of whom currently rely on foodbanks. These patients will simply not be able to afford to buy their own gluten-free products.

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Tony Cartwright, retired pharmacist and member of Coeliac UK Health Advisory Network

Tony Cartwright, retired pharmacist and member of Coeliac UK Health Advisory Network

Although a consultation is mentioned by Simon Stevens, CEO of NHS England, in his interview with the Daily Mail on 27 March about the review items allowed on prescription, the whole tone of the article suggests that this is a fait accompli.

The only treatment for coeliac disease is a life-long gluten-free (GF) diet. Many patients struggle to maintain this diet, and GF food on prescription has been shown to aid adherence. Patients need to stick to their diet to avoid complications such as anaemia, osteoporosis, infertility and intestinal lymphoma.

Sadly, Stevens’ interview contains a number of points presumably intended to slant the response of healthcare professionals and the public to his proposal. These include:

  • That the price of supermarket GF food has come down substantially In fact, the price of GF bread has remained largely unchanged since 2008, and is up to six times the cost of similar-sized gluten-containing bread.
  • That GF items are now readily available Research shows that budget and convenience stores, which are relied on by the elderly and disabled, have practically no provision. Lidl does not routinely stock GF products.
  • That significant sums are spent on prescribing GF cakes and biscuits These items are not recommended in the national prescribing guidelines and cake is not included in the advisory committee on borderline substances list of products allowed for prescription.

Coeliac UK has been championing alternative cost-effective systems to support coeliac patients for some years. Constructive dialogue between the charity and NHS England would enable solutions to be found which do not impair the long-term health of patients.

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Michael Marshall, project director, Good Thinking Society, a non-profit organisation promoting scientific scepticism established by British science author Simon Singh in September 2012

Michael Marshall, project director, Good Thinking Society, a non-profit organisation promoting scientific scepticism established by British science author Simon Singh in September 2012

Although this policy from NHS England seems sensible, some of the interventions identified on their low-priority list do have a degree of effectiveness – unlike homeopathic remedies, which presumably will continue to enjoy an undeserved place on the list of permitted prescriptions. In 2015, following our legal correspondence, the Department of Health promised to review the prescription of homeopathy on the NHS. Given that we are waiting to see an indication that this promise will be fulfilled, to omit homeopathy from this list is disappointing and a significant missed opportunity.

People who currently receive prescriptions for a listed product that is effective but deemed low clinical value may look to the continued prescription of homeopathy with frustration and outrage. Until homeopathic remedies are similarly restricted from prescription, they’ll have a point. Homeopathy may not be the biggest drain of NHS resources, but it’s surely the most unequivocal, given its demonstrable ineffectiveness.

Simon Stevens, head of NHS England, has called NHS funding for homeopathy “absurd” an “an example of the sorts of things we want to see less of”. Julie Wood, chief executive of NHS Clinical Commissioners, reassured the public that homeopathy prescriptions will be addressed and reviewed in time. In an exercise where effective allocation of resources is the priority, the banning of treatments that have been demonstrated to be wholly ineffective should not be controversial or an afterthought, it should be fundamental and a priority.

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Liz McAnulty, chair of the Patients Association

Liz McAnulty, chair of the Patients Association

The NHS is right to consider and review which drugs it offers on prescription and to try to find efficiencies where possible. However, there is a risk that cost-effective and vital treatments will inadvertently become included in these new changes. It is therefore imperative that anyone who may be liable to having their drugs switched to alternatives must be fully consulted and informed about this before the change.

It is true that some drugs can be purchased more cheaply over the counter than through prescriptions. However, for families on lower incomes even a small increased cost can be tough to meet. Also, those who live with long-term conditions and require ongoing supplies of drugs may suffer acutely. We wish to be assured that any potential harm is properly mitigated.

We agree that public money should be spent as carefully and effectively as possible, but this drive for efficiencies is clearly linked to the financial pressures on the NHS and the inadequate funding settlement in the Budget for our health and social care system. Without further funds being designated to these areas, sustainability is not achievable and we risk a deeper crisis point by 2020.

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Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2017.20202583

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