NHS England Primary Care Prescribing Guidance

NHS England Primary Care Prescribing Guidance

In July 2017, NHS Clinical Commissioners (NHSCC) and NHS England published a public consultation. This sought views for proposals on 18 medicines which they suggested should no longer be routinely prescribed  in primary care. It also sought views on whether a wider list of 3,200 products that are available over-the-counter, without prescription, should be considered appropriate for future restriction. The consultation closed in October 2017.

Following consideration of the responses to the consultation, in November 2017 NHS England announced the publication of guidance to CCGs proposing that certain treatments should no longer being routinely prescribed.

The NHS England Board also decided a full consultation should be held in early 2018 on a proposal that the prescribing of over-the-counter (OTC) products, currently prescribed at NHS expense, should be restricted in the future; a consultation on this topic commenced on 20th December 2017.

Click on a heading below for more information.

PSNC response to the first Consultation

A PSNC response was submitted to the consultation in October 2017.

In its response PSNC supported the NHS England and NHS Clinical Commissioners (NHSCC) proposals for restricting the prescribing of a group of 18 medicines which were considered not to be cost effective, as evidence-based clinical rationales were provided.

PSNC outlined its concern in its response on the ongoing consideration of future restrictions on the prescribing of OTC products about the range of potentially unintended consequences and other issues that may occur as a result of these proposals. Of particular concern was the impact of any changes for those on low incomes, potentially leading to increased use of more expensive urgent care services and increased health inequalities.

PSNC recommended in its response that NHS England and NHSCC consider how national coverage of pharmacy minor ailments services, potentially restricted to people and families that are currently exempt from NHS prescription charges on income grounds, may provide benefits for both patients and the NHS, whilst at the same time avoiding the unintended consequences of implementing a blanket restriction on prescribing OTC medicines for some of the most vulnerable groups within society.

Guidance on the prescribing of Low Value Medicines

NHSCC and NHS England published the proposal on 18 medicines which they suggest should no longer be routinely prescribed  in primary care because they are either:

  • clinically ineffective, unsafe or not cost effective; or
  • the NHS can offer a clinically-proven alternative for patients.

NHSCC and NHS England noted that while many doctors and other prescribers are no longer prescribing these 18 medicines for patients, the evidence shows that there is variation across the country.

Following consideration of the responses to the consultation, NHS England issued guidance to GPs and CCGs on 30 November 2017 following Board agreement to “remove ineffective, unsafe and low clinical value treatments, such as some dietary supplements herbal treatments and homeopathy, and restricting the use of a further 11, saving up to £141 million a year.”

A joint clinical working group considered the responses to the consultation and agreed that the recommendations for the 18 products consulted on should either remain unchanged (13 products outlined below) or be modified or clarified in five cases (Liothyronine, Travel Vaccines, Lidocaine Plasters and Immediate Release Fentanyl).

The following treatments are included with the guidance as recommended for no longer being routinely prescribed:

  • Homeopathy – no clear or robust evidence to support its use;
  • Herbal treatments – no clear or robust evidence to support its use;
  • Omega-3 Fatty Acid Compounds (fish oil) – essential fatty acids which can be obtained through diet, low clinical effectiveness;
  • Co-proxamol – had its marketing authorisation withdrawn due to safety concerns;
  • Rubefacients (excluding topical NSAIDS) – limited evidence;
  • Lutein and Antioxidants – used to treat the eye condition age related macular degeneration, low clinical effectiveness; and
  • Glucosamine and Chondroitin – used for joint pain, low clinical effectiveness.

Further information, the guidance to CCGs and the full list of affected products

Conditions for which OTC items should not routinely be prescribed

On 20th December 2017 published a consultation on proposals to “rein in prescriptions” for a number of products that are available ‘over-the-counter’ (OTC). The intention is to produce consistent national guidance for CCGs to refer prescribers to.

Views are now being sought on stopping the routine prescribing for 33 minor conditions, as well as on probiotics and vitamins and minerals. The prescribing of products have been chosen because they meet one of the following criteria:

  • They treat a condition which is self-limiting and therefore does not require treatment;
  • They treat a condition which could be managed by self-care, i.e. a person suffering does not normally need to seek medical care; or
  • They have low clinical effectiveness but high cost to the NHS, e.g. vitamins/minerals and probiotics.

The proposals would not affect the prescribing of items for chronic conditions or minor illnesses that are symptomatic or a side effect of something more serious, NHS England said.

Interested parties have until 14th March 2018 to respond via the public consultation on the NHS England website. PSNC considered its response to the consultation at its January 2018 meeting and it will publish its consultation response shortly, as it may help inform the responses of LPCs and pharmacy contractors to the consultation.

Summary of the proposals (from the PSNC January 2018 meeting agenda)

Summary presentation of the proposals prepared for the January 2018 PSNC meeting

Commenting on the publication of the consultation document, Alastair Buxton, Director of NHS Services at PSNC, said:

“As the NHS grapples with its funding crisis, it is becoming more important than ever that we develop support for self-care, so that people can manage their health without the need to visit their GP or hospital. Once again as it launches this consultation the NHS looks to community pharmacies to do this, promoting them as a first port of call and a place for patients to go for advice and self-care treatments.

This is right, as pharmacies offer advice and treatment at convenient locations and long opening hours, without the need for an appointment. But those looking to transfer the burden from GP practices and urgent care towards pharmacy must acknowledge that without proper resourcing, community pharmacy will also not be able to manage. The current financial pressures facing community pharmacies mean their ability to soak up pressures on the health service is already faltering. Many are struggling to survive.

Community pharmacies can do much more to help, but they are not an infinite resource. Without recognition and support community pharmacies will be unable to provide the safety net that the NHS so desperately needs and wants to rely on.

As well as the impact on community pharmacies, we are particularly concerned about the impact of any changes for those on low incomes. For these families the NHS provides a vital service which, if removed, could lead to increased use of more expensive urgent care services and increased health inequalities. PSNC recommends that NHS England considers how national coverage of pharmacy minor ailments services, potentially restricted to people and families that are currently exempt from NHS prescription charges on income grounds, may provide benefits for both patients and the NHS, whilst at the same time avoiding the unintended consequences of implementing a blanket restriction on prescribing OTC medicines for some of the most vulnerable groups within society.”

 



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