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Oral thrush among 35 conditions NHS England restricts prescribing for

NHS England has decided to “curb prescribing” of over-the-counter (OTC) medicines used to treat 35 conditions, including oral thrush, dandruff and athlete’s foot.

The conditions identified – which include haemorrhoids, headlice, cystitis, and "aches and pains" (see full list below) – are considered “self-limiting and so do not need treatment, as it will heal or be cured of its own accord” or “lend [themselves] to self care”, NHS England said in its guidance published last week (March 29).

NHS England compiled the list following a public consultation that ran from December 2017 to March 2018.

Scrapping medicines from prescriptions if they are available cheaper over the counter from pharmacies “may save up to £136 million, once all discounts and clawbacks have been accounted for”, the commissioner added.

“We expect clinical commissioning groups (CCGs) to take the proposed guidance into account in formulating local polices, unless they can articulate a valid reason to do otherwise,” NHS England said.

“CCGs will also need to take account of their latest local pharmaceutical needs assessment and consider the impact of this guidance on rural areas and access to a pharmacy and pharmacy medicines,” it said.

Prescribers will still be advised to use their “clinical judgement” on whether to deviate from the guidance and prescribe certain medicines, the commissioner stressed.

Exceptions to prescribing restrictions

Following a wave of negative feedback about whether these proposals are fair on people with low incomes or chronic conditions, NHS England said it had expanded its proposals to scrap 18 treatments from prescriptions, including homeopathy, herbal remedies and fish oil.

Read which 18 treatments have been scrapped from prescriptions and the seven treatments which NHS England has recommended should be blacklisted by the Department of Health and Social Care here.

“We refined our approach to [also] develop restrictions based on type and severity of condition rather than products,” it explained last week.

Its latest guidance includes a range of exceptions which could allow some groups to still receive NHS treatment. These include “patients prescribed an OTC treatment for a long-term condition” – for example, inflammatory bowel disease – and patients who “red flag” symptoms “that suggest the condition is not minor” – for example, “indigestion with very bad pain” (see full list of exceptions below).

The commissioner also listed vitamins, minerals and probiotics in its prescribing guidance, as “items with low clinical effectiveness but a high cost to the NHS”. It advised CCGs to prescribe vitamins and minerals for “all types of medically diagnosed deficiency” and follow local policies when it comes to prescribing probiotics.

Pharmacy groups warn low-income patients disadvantaged

A total of 2,638 individuals responded to the consultation, including 454 “clinicians”. Among the concerns raised by the clinician respondents were the impact of the proposals on disabled and elderly patients and “those with long-term conditions requiring a large supply of prescribed OTC medication”, NHS England said.

In its response to the consultation, the National Pharmacy Association (NPA) suggested that a national minor ailments service, delivered through community pharmacies, could be set up to support the implementation of NHS England’s guidance.

“While it is right the NHS should examine access to treatments in the light of tight budgets, the measures could mean that society’s most disadvantaged no longer have access to certain treatments,” the NPA said in a statement last week.

“Some of the treatments on this list might only cost a couple of pounds privately, but for our poorest that’s a couple of pounds they cannot afford,” NPA policy manager Helga Mangion said.

“It establishes the worrying principle that it is fair for the NHS to remove a treatment that could be given to our most needy for free, just because that treatment is available privately.”

“The reality is doctors will not prescribe an item that is available over the counter for a lower cost, unless there is a clinical need, and this guidance merely exacerbates the UK’s growing health inequalities.”

Royal Pharmaceutical Society English board chair Sandra Gidley agreed that the NHS England guidance “might disadvantage patients on low incomes and people may be denied treatment because of their inability to pay”.

“We will continue to work closely with pharmacists to ensure effective implementation [of the guidance] and make sure that access to medicines is based on clinical needs,” she added.

Pharmaceutical Services Negotiating Committee (PSNC) NHS services director Alastair Buxton said the guidance is a “significant step” to reducing NHS costs.

“While it is likely to lead to reduction in prescription volume and the decommissioning of some minor ailments schemes, it could also present an opportunity for community pharmacy to build on its existing role in educating patients to help them to self care.”

In June 2017, C+D brought together industry leaders to discuss what NHS England’s plans to scrap certain treatments from prescriptions could mean for pharmacists, patients, and the wider NHS. Listen to the debate in full below:

35 conditions NHS England is restricting prescribing for

Acute sore throat except where "red flag" symptoms are identified
Infrequent cold sores of the lip – except where "red flag" symptoms are identified and or the patients immunocompromised
Conjunctivitis – except where "red flag" symptoms are identified
Coughs and colds and nasal congestion – except where "red flag" symptoms are identified
Cradle cap (seborrhoeic dermatitis – infants) – except if "causing distress to the infant and not improving"
Haemorrhoids – except where "red flag" symptoms are identified
Infant colic – except where "red flag" symptoms are identified
Mild cystitis – except where "red flag" symptoms are identified
Mild irritant dermatitis
Dandruff
Diarrhoea (adults)
Dry eyes/sore (tired) eyes
Earwax
Excessive sweating (hyperhidrosis)
Headlice
Indigestion and heartburn
Infrequent constipation
Infrequent migraine
Insect bites and stings
Mild acne
Mild dry skin
Sunburn
Sun protection 
except for "Advisory Committee on Borderline Substances (ACBS)-approved indication of photodermatoses (ie where skin protection should be prescribed)"
Mild to moderate hay fever/seasonal rhinitis
Minor burns and scalds 
"However, more serious burns always require professional medical attention"
Minor conditions associated with pain, discomfort and/fever (eg aches and sprains, headache, period pain, back pain)
Mouth ulcers
Nappy rash
Oral thrush
Prevention of dental caries
Ringworm/athlete's foot 
– except where "lymphoedema or history of lower-limb cellulitis" is identified.
Teething/mild toothache
Threadworms
Travel sickness
Warts and verrucae

Source: NHS England: Conditions for which OTC items should not routinely be prescribed in primary care: Guidance for CCGs

 

Scenarios where patients should continue to have their treatments prescribed

  • Patients prescribed an OTC treatment for a long-term condition (eg regular pain relief for chronic arthritis or treatments for inflammatory bowel disease)
  • For the treatment of more complex forms of minor illnesses (eg severe migraines that are unresponsive to OTC medicines)
  • For those patients who have symptoms that suggest the condition is not minor (ie those with red flag symptoms, for example, indigestion with very bad pain)
  • Treatment for complex patients (eg immunosuppressed patients)
  • Patients on prescription-only treatments
  • Patients prescribed OTC products to treat an adverse effect or symptom of a more complex illness and/or prescription only medications
  • Circumstances where the product licence doesn’t allow the product to be sold over the counter to certain groups of patients. This may vary by medicine, but could include babies, children and/or women who are pregnant or breastfeeding. Community pharmacists will be aware of what these are and can advise accordingly
  • Patients with a minor condition suitable for self care that has not responded sufficiently to treatment with an OTC product
  • Patients where the clinician considers that the presenting symptom is due to a condition that would not be considered a minor condition
  • Circumstances where the prescriber believes that in their clinical judgement, exceptional circumstances exist that warrant deviation from the recommendation to self care
  • Individual patients where the clinician considers that their ability to self manage is compromised as a consequence of medical, mental health or significant social vulnerability to the extent that their health and/or wellbeing could be adversely affected. Consideration should also be given to safeguarding issues.

Source: NHS England: Conditions for which OTC items should not routinely be prescribed in primary care: Guidance for CCGs

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