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NHS considers scrapping gluten-free prescriptions

NHS Clinical Commissioners: Gluten-free foods are "readily and inexpensively" available
NHS Clinical Commissioners: Gluten-free foods are "readily and inexpensively" available

NHS England is considering scrapping gluten-free foods, pain medication fentanyl, and other drugs and services on prescription.

The decision to review certain medications is based on the recommendation of NHS Clinical Commissioners (NHSCC) – the independent organisation representing clinical commissioning groups (CCGs) in England – which identified 10 items and services as being “low priority” for NHS funding.

Removing these from prescriptions could release up to £128 million back into the health service to fund “high priority areas” such as mental health and primary care, NHSCC argued.

NHSCC split the 10 items into three categories – those where there is a "lack of evidence of robust clinical effectiveness"; products where a "more cost-effective" alternative is available; and those that are deemed low priority "due to the nature of the product". See the full list below.

It listed gluten-free foods in the third category because they are now "readily and inexpensively available" in supermarkets, it said in a statement today (March 28).

It described fentanyl, which is commonly used to treat severe chronic pain, as "much more expensive" in comparison to morphine. NHSCC estimates that the NHS spent £10.1million on the drug in the last 12 months.

Making the most of CCG budgets

Julie Woods, chief executive of NHSCC, said the financial challenges the NHS faces at the moment are “unprecedented”.

“This is not about cutting essential services or restricting access for patients to services they need, it is about allowing local clinical leaders to make the best and most efficient use of the money CCGs have available to spend,” Ms Wood said.

Simon Stevens, chief executive of NHS England, spoke about the plans in an interview with the Daily Mail today, in which he stressed the need to tackle “inefficiency and waste” in the health service.

“There’s £114m being spent on medicines for upset tummies, haemorrhoids, travel sickness and indigestion. That’s even before you get on to the £22m-plus on gluten-free that you can also now get at Morrisons, Lidl or Tesco,” Mr Stevens told the newspaper.

RPS "surprised" at homeopathy omission

In response to the prescribing review, Royal Pharmaceutical Society English pharmacy board chair Sandra Gidley said the announcement could be “interpreted as a attack” on the principle of providing treatment free at the point of use.

“We are concerned [about] how a blanket ban of products to treat life-long conditions such as coeliac disease and chronic pain could have unintended consequences.”

However, Ms Gidley acknowledged the need for the NHS to be cost-effective.

“We are surprised that homeopathy  which has no scientific evidence  is not on the list for review," Ms Gidley added.

What could the NHS stop funding and why?

Source: NHS Clinical Commissioners

1) Low clinical effectiveness 

Co-proxamol. In 2005, the Medicines and Healthcare products Regulatory Agency (MHRA)​ decided to withdraw the analgesic over a phased period – until the end of 2007 – to enable patients to move to suitable alternatives. However, there remains some prescribing of the imported product at an inflated price, NHSCC said.

Omega 3 and fish oils. These are licensed for elevated triglycerides, but the evidence is "weak", according to NHSCC. Nice recommends against prescribing them for primary prevention of cardiovascular events. There are additional potential savings in terms of reduced GP appointments, it added.

Lidocaine plasters. These are licensed for treatment of post-herpetic neuralgia. But there is “limited evidence”, said NHSCC, which pointed out that Nice does not recommend this product.

Rubefacients. The evidence available does not support the use of topical rubefacients (rubs and ointments) in acute or chronic musculoskeletal pain, NHSCC said. There are additional potential savings in terms of reduced GP appointments, it added.

2) More cost-effective products available

Liothyronine. This is used to treat underactive thyroid, but is costly and there is limited evidence of its effectiveness, NHSCC claimed. The vast majority of patients are controlled on the much cheaper levothyroxine, it added.

Tadalafil. An expensive alternative to sildenafil (Viagra), but with no evidence of superior effectiveness, NHSCC said. It is also licensed for treating lower urinary tract symptoms in men – but this is not recommended by Nice, except for clinical trials.

Doxazosin MR. A fourth-line drug for hypertension. The modified-release version is more expensive than the standard release, NHSCC explained.

Fentanyl. Typically used for breakthrough pain in palliative care, there is limited evidence of its superiority compared to morphine – even though it is much more expensive, NHSCC said.

3) Low priority for NHS funding

Some gluten-free foods. The range of gluten-free foods readily and inexpensively available in supermarkets is now much greater than when prescribing of the food on the NHS was introduced in the 1960s, NHSCC stressed. Many carbohydrate foods are naturally gluten-free – such as potatoes, rice and some noodles – and the cost to the NHS is greater than if bought direct by consumers, it claimed.

Travel vaccines. Only a small number of vaccines are allowed on the NHS, but many practices still prescribe them, NHSCC said.

24 Comments
Question: 
Do you agree with the ten "low priority" items?

Andrew Paxton, Community pharmacist

I think that GF products should be subsidised, not provided free.  While it is available on script, I shall still suggest paying patients get a Pre-payment Card.

janet maynard, Community pharmacist

Need to review the exempt system too - why should everyone with a need for thyroid have everything free!!!!!!!!

kimberly smith, Director

*This comment has been deleted for breaching C+D's community principles*

T. Pharm., Community pharmacist

About time.

Food should be obtained at your local supermarket - you don't see adults with nut or milk allergies obtaining prescriptions for specialised foods.

The GPs and Pharmacies shouldn't have any further input after diagnoses of this condition.

Furthermore, another way to abolish other silly prescription requests (e.g. paracetamol) is to charge all exempt prescriptions a flat rate of £1.

 

Janet Jones, Pharmacy technician

I wholeheartedly agree with a flat rate charge for all prescriptions. 

Valentine Trodd, Community pharmacist

Hear, hear!

Paul Samuels, Community pharmacist

Couldn't agree more!!

T. Pharm., Community pharmacist

.

Daniel Pharmacist, Community pharmacist

Ben - look at Paul Samuels' reply - there is a clinical need in some cases for these items and text books do not necessarily reflect what happens in the real world. I am not saying your information is incorrect, just that you can't ban items purely on cost ground if there may be a clinical need

Paul Samuels, Community pharmacist

Theoretically Ben is correct(according to guidelines) but my daughter is under the care of an emminent endocrinologist who is of the expert opinion that this is the most suitable treatment in her case & has reiterated this to her GP who is in total agreement.She had tried thyroxine but was unwell & unable to function properly whereas with liothyronine she lives a normal life .

One size does not fit all.

Valentine Trodd, Community pharmacist

About time too. Makes no sense that some CCGs have scrapped it whilst others haven't. Why isn't a decision made nationally? Either it's appropriate or it isn't.

A Hussain, Senior Management

It is down to the patient at times I agree, but I feel that scandalously priced products play a bigger role in excessive spending in the NHS.  I can't believe the prices we're paying for medications that should be tens of pounds cheaper than what they are.  But the government won't go after Big Pharma.  Token gesture with Pfizer/Flynn etc. and that was nailed on.

David Moore, Locum pharmacist

Kernow CCG has already banned gluten free products.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Surely, the argument is to tackle profiteering and over-charging by big pharma at source ... rather than restricting patient choice, or make patients pay for the government's failure in pharmaceutical regulation. The DH is lacking in focus.

Angela Channing, Community pharmacist

No.  It's about making the people of the UK wake up and realise the NHS is in dire straits.  They need to fund their own gluten free biscuits, their own paracetamol and their own  (*** name any other minor ailment medicine***).   It's called taking personal responsibility for their own minor aches and pains and self-limiting viral illnesses, not rushing to a Dr and expecting to be seen yesterday because they have a bit of a scratchy throat.   Nothing at all to do with the govt, the big pharma, profit-making or any other big issues you mention.   One simple issue.  RESPECT the NHS or lose it.  As for patient choice,  the choice is use the NHS sensibly and only when you need to, or start paying for it at source,  i.e. at the receptionist's desk and A&E counter. 

 

T. Pharm., Community pharmacist

100%.

 

The general public have abused this system for far too long. And they need to be made accountable for their own MINOR healthcare needs, and let healthcare proffesionals focus on those patient's who have more serious health issues.

Meera Sharma, Community pharmacist

Completely agree with you Angela - one only has to sit in at a GP practice to see the amount of silly requests that are made. I had one pt demanding her rights to have calpol for her child pxed to keep in the cupboard! It's about time people are deucated about responsibility for their own health, not exploit the NHS. I'm all for adding more items to this list - dry skin products, cough & cold items etc. By teh time you've added in a GP appt & admin time to genertae a prescription, the NHS cost is much more. Time for a wake-up call.

Shaun Steren, Pharmaceutical Adviser

Well said. I was waiting for preposterous suggestions by the net profit obsessives on how the system could be changed whilst (conveniently) maintaining dispensing fees. 

As you point out, this is about the cold hard reality - the NHS is in an extreme position. It can survive but only if waste within the system is confronted. Every person who works in the NHS and everybody who uses the NHS has to accept this. 

Certain areas of the NHS ought to get increased funding, indeed the total funding is going to have increase as a percentage of GDP (through taxation), but stamping out abuse and misuse is a significant element in all this. 

Those who deny this either profit from the current situation or are grandstanding to project their 'superior virtue'. The noughties debt-fuelled mega party is over - get used to it! 

Daniel Pharmacist, Community pharmacist

I find Liothyronine to be the strangest one on the list. We used to have a patient who couldn't tolerate levothyroxine and this was the only solution.

Surely most patients who are currently being prescribed liothyronine were given it as a 2nd line option when the first one was not suitable? I can't imagine it would be prescribed as first line.

Meera Sharma, Community pharmacist

You'd be surprised - in this day of the internet and people researching their own health, things get prescribed for "patient's distress".

Paul Samuels, Community pharmacist

My daughter is thyroxine intolerant--hence needs to take liothyronine--.in total agreement about cost--why has cost rocketed over last 2-3 years?Price in US is considerably cheaper?

In total agreement that all such products should be subject to price monitoring .

 

 

Ben Merriman, Community pharmacist

Shouldn't be prescribed at all - not licensed for maintenance treatment of hypothyroidism.  Situation compounded by hike in price by Concordia over several years.  Remove the brand name (Tertoxin) or a medicine and, as long as there's no competition, you can change the price from about £14 for 100 eight years ago to over £9 per tablet now.

Daniel Pharmacist, Community pharmacist

Even if not licensed that doesn't mean it isn't needed for patients who genuinely require it for treatment as we all know. Unlicensed medicines have their place, as does using medicines outside of their license.

Ben Merriman, Community pharmacist

Summary - "There is insufficient evidence to recommend monitoring serum T3 as a therapeutic target in hypothyroidism" and "there is insufficient evidence that combination therapy with L-T4 and L-T3 therapy is superior to L-T4 monotherapy"

"http://www.british-thyroid-association.org/sandbox/bta2016/bta_statement_on_the_management_of_primary_hypothyroidism.pdf"

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