The eight treatments are the latest in a range of medicines and services that NHS England has said should not be routinely prescribed, because they are of “low clinical effectiveness” or “more cost-effective products are available”.
Items it now considers to be of “low priority for NHS funding” are:
- emollient bath and shower preparations for dry and pruritic skin conditions
- minocycline for acne
- silk garments
- blood glucose testing strips for people with type 2 diabetes that cost more than £10 for 50 strips
- needles for pre-filled and reusable insulin pens that cost more than £5 per 100 needles (see more below).
Launching a public consultation last week (November 28), NHS England said: “In 2017, the cost of prescriptions dispensed in the community was £9.17 billion and we know that across England there is significant variation in what is being prescribed and to whom.
“In addition, patients continue to receive medicines which have been proven to be ineffective or in some cases dangerous, and/or for which there are other more effective, safer and/or cheaper alternatives.”
The proposals aim to “address unwarranted variation” in prescribing and “provide clear national advice to make local prescribing practices more effective”. Any savings will be reinvested back into patient care, NHS England said.
RPS: Emollients restrictions will impact a lot of patients
Royal Pharmaceutical Society (RPS) English board chair Sandra Gidley said many of the latest proposed restrictions “will have little impact” and “it is clearly right and proper that the NHS makes the best use of tax-payers’ money”.
“However, emollient bath and shower products are widely prescribed and this restriction will impact a large number of patients,” she warned.
“While this could be seen as an opportunity for pharmacists to sell the products, the reality is that pharmacists could be in the firing line if wider communications around this are not good. There is also the risk of unintended consequences if patients look for cheap alternatives,” Ms Gidley added.
“A large part of the burden of explaining these changes will fall to the unpaid pharmacy teams at a time when their time and expertise could be better spent.”
Contractor: Likely to impact lower-income patients
Nat Mitchell, pharmacist and director of JWW Allison & Sons Ltd in Cockermouth, said his local surgery is already “making moves” to limit certain items on prescription, including emollients, but he has yet to see this affect patients’ use of the products.
A couple of patients who receive silk garments on prescription “infrequently” will be unhappy if they can no longer receive them, he added.
“Although this will undoubtedly cause some upset among patients, it does tend to fit with the self-care agenda that is being promoted,” Mr Mitchell said.
However, “I do wonder how some lower-income patients will afford to buy these items, as they can be quite expensive”.
The NHS England consultation closes on February 28, 2019.
Which items is NHS England considering restricting on primary care prescriptions and why?
Items considered to be of “low clinical effectiveness”:
Amiodarone: “Amiodarone has an important place in the treatment of severe cardiac rhythm disorders, where other treatments either cannot be used or have failed,” NHS England said.
However, “it has potential major toxicity and its use requires monitoring both clinically and via laboratory testing”. It therefore should only be prescribed in “exceptional circumstances” by a specialist, in cooperation with a multidisciplinary team.
Dronedarone: “Dronedarone was originally approved to prevent atrial fibrillation from coming back or to lower the heart rate in adults who have had or have non-permanent atrial fibrillation. In September 2011 this indication was restricted to the maintenance of normal heart rhythm in ‘persistent’ or ‘paroxysmal’ atrial fibrillation after normal heart rhythm has been restored,” NHS England explained.
The drug should only be prescribed for new patients in “exceptional circumstances” and “must be initiated by a specialist”, the commissioner stressed.
Emollient bath and shower preparations for dry and pruritic skin conditions: A study from May 2018 found “no evidence of clinical benefit” for bath emollients in the standard management of childhood eczema, NHS England said, therefore they should not be prescribed for any new patient, and “deprescribing” should be encouraged for existing patients. “Leave-on” emollients can be prescribed as an alternative if needed, it added.
Minocycline for acne: “Minocycline is mainly used for acne, however there are various safety risks associated with its use,” such as drug-induced lupus, skin pigmentation and hepatitis, NHS England said. It recommended it not be prescribed for new patients.
Silk garments: Evidence relating to the use of silk garments for skin conditions “is weak and of low quality”, NHS England said. A 2017 trial by the University of Nottingham concluded “that using silk garments for the management of eczema is unlikely to be cost-effective for the NHS”, NHS England said.
Items where more cost-effective products are available:
Aliskiren: The National Institute for health and Care Excellence states there is insufficient evidence of the effectiveness of this renin inhibitor for use in resistant hypertension, NHS England said. While it is considered clinically effective, there are cheaper alternatives, it added.
Blood glucose testing strips for people with type 2 diabetes that cost more than £10 for 50 strips: “There are currently over 40 different types of blood glucose test strips available in the UK” ranging in price from £5.45 to £16.53, NHS England said. Prescribers should consider more cost-effective alternatives to packs of 50 strips that cost more than £10.
Needles for pre-filled and reusable insulin pens that cost more than £5 per 100 needles: “There are many different types of insulin pen needles available at a varying cost from £3.95 to £30.08 for 100,” NHS England said. “The 4mm needle [is considered] to be the safest pen needle for adults and children regardless of age, gender and body mass index.”
It recommended insulin pen needles that cost more than £5 per 100 needles no longer be prescribed for any new diabetes patient.
Source: Items which should not routinely be prescribed in primary care: an update and a consultation on further guidance for CCGs, November 2018.
Last year, C+D hosted a roundtable debate to discuss what plans to scrap certain treatments – including gluten-free items – from prescriptions would mean for pharmacists, patients, and the wider NHS. Listen to it below, and subscribe to all of C+D's podcasts here.