Guidance on Prescribing of Gluten-Free Products within Primary Care on NHS Prescription (for Adults)

Transcription

1 Guidance on Prescribing of Gluten-Free Products within Primary Care on NHS Prescription (for Adults) This guidance applies to all prescribers, both medical and non-medical. NHS Shropshire Clinical Commissioning Group (NHS SCCG) has agreed that the prescribing of gluten-free food for patients (aged over 16 years) with a clinical diagnosis of coeliac disease or other gluten enteropathy will be limited to: bread, fresh bread, bread mix, flour, flour mix and pasta only prescribing specified quantities fresh bread should be limited to list in table 3 children have been excluded from the guidance (please see section 3.4/5) What this means for patients is: Your GP should not prescribe outside the policy criteria on NHS prescription because doing so would not represent optimal use of limited NHS resources. If you wish to use a product other than one your GP is able to prescribe you are free to purchase your own supply.

2 INTRODUCTION 1.1 Background NHS Shropshire Clinical Commissioning Group (NHS SCCG) has a legal responsibility to provide comprehensive, effective and accessible health services to its population within finite resources. The supply of gluten-free products on prescription has been under discussion for some time at local, regional and national levels. The drivers for this discussion include the need to maximise the best and most equitable use of finite NHS resources, ensuring both coeliac and non-coeliac patients are treated fairly. The current system of supply of gluten-free foods on FP-10 prescription was established 40 years ago when gluten-free foods were not readily available in supermarkets and shops. NHS SCCG had in the past prescribed a considerable range of gluten-free foods at NHS cost. The list included bread, bread mixes, pasta, pizza bases, breakfast cereals, crackers, muffins, pastries, pancakes, cake mixes, biscuits, cakes etc. Primary care spent in excess of 250,000 in 2010/11 on these products. This means that NHS SCCG was amongst those areas in the West Midlands that spend the most on gluten-free foods. Coeliac disease is an inflammatory condition of the small intestinal mucosa that is induced by the ingestion of gluten which improves clinically and histologically when gluten is excluded from the diet. (British Society of Gastroenterology, 2010). Patients suffering from coeliac and other diseases related to gluten intolerance need to adhere to a lifelong gluten free diet. Many foods are naturally free of gluten, which mainly exists in cereal products such as those made from wheat. Gluten free foods are defined as Borderline Substances in the Drug Tariff and may be prescribed to patients with established gluten enteropathy. Coeliac UK, a charity supported by the Primary Care Society for Gastroenterology and the British Dietetic Association, has produced guidelines outlining the quantities of specialised foods required by coeliac patients depending on their age and levels of physical activity. The quantities recommended in the Shropshire Guidelines are the same as those in the guidelines produced by Coeliac UK. The quantities recommended in the guidelines are higher than those needed by many patients. Additional dietary requirements should be achieved by choosing healthy foods which are naturally gluten free. The price the NHS pays for gluten-free food is significantly higher than that charged by supermarkets. For example, gluten-free biscuits prescribed on FP10 prescription would cost the taxpayer whereas an equivalent product is available in super markets for around 96p. Some brands are considerably more expensive than others. Prices are in Appendix 6.1 in the BNF. A wide variety of gluten free food can be purchased at all supermarkets. The Department of Health produced an information sheet called Gluten-free foods local options in This provides guidance around the supply of gluten-free food to patients. Under the heading of How Much Food, it recommends PCTs (superseded by CCGs) reach agreement with local GPs on the supply of gluten-fee food at NHS expense. 2

3 1.2 Purpose In the current financial climate we have to make some difficult choices about the products that we allow on NHS prescription. The purpose of this guidance is to support the standardisation of prescribing of gluten-free foods in primary care, ensuring best practice and consistency across all GP practices. The guidance applies people (aged over 16 years) with coeliacs disease requiring gluten-free food. 1.3 Scope GP practices in NHS SCCG to incorporate this guidance into their practice procedures. 2. DUTIES The Primary Care Support Team will assist practices to review their prescribing in line with; and provide support where necessary; to implement this guidance. 3. PROCEDURE 3.1 Diagnosis All patients receiving prescriptions for gluten-free foods should have a confirmed clinical diagnosis of coeliac disease, dermatitis herpatiformis or steatorrhoea due to gluten sensitivity. Gluten-free products have ACBS (Advisory Committee on Borderline Substances) approval allowing them to be prescribed for patients with these conditions only. FP10 prescriptions must be annotated with ACBS. Any gluten-free foods prescribed for patients without a confirmed diagnosis should no longer be prescribed at the taxpayer s expense. 3.2 General Advice to patients 1. Increase physical activity 2. Reduce/quit smoking 3. Reduce alcohol consumption Dietary advice is available from Coeliac UK. Coeliac UK based their recommendations on the National Diet and Nutrition Surveys and the Eatwell Plate produced by the Food Standards Agency. The guidelines are based on the Eatwell plate model and for gluten-free foods to provide 15% total energy (total carbohydrate should provide 50% total energy which includes naturally gluten-free foods such as rice, potatoes and suitable rice or corn based breakfast cereals, intrinsic and milk sugars as well as gluten-free prescribable foods). NICE published a clinical guideline on Coeliac Disease in May This does not provide any dietary advice. 3

4 3.3 Prescribing of gluten-free foods on NHS prescriptions The range of products available for prescribing nationally is listed in Part XV of the Drug Tariff (borderline substances). Only bread (including fresh bread as listed in table 3), bread mix, flour, flour mix and pasta are prescribed on NHS prescription at the taxpayers expense. NHS SCCG has reviewed the products that are available on prescription to include some brands of fresh bread and rolls. This is because handling charges that were applied to fresh gluten free bread have been removed for some brands. The cost of these products is now comparable with long life gluten free products. Prescribing should be for a maximum of ONE MONTH. Large quantities of gluten-free foods should not be prescribed as many products are difficult to store and expiry dates vary causing excessive wastage. 3.4 Prescribing guidance 1. Confirm all patients that are to be prescribed Gluten-Free products have a diagnosis of gluten sensitivity, coeliac disease or Dermatitis Herpetiformis. Check this diagnosis is confirmed by either a blood test or endoscopy. (Prescribing for patients with IBS or wheat intolerance is not allowed on the NHS) 2. Follow the Coeliac UK list (summarised in table 1 below) only as a guide to calculate the amount of units the patient will be allowed to request in a 28 day period. Patients are likely to require less on NHS prescription as they may be purchasing other products (crackers, biscuits, cakes, pizza bases) from supermarkets, so it may be best practice to check their usual consumption of bread and pasta and prescribe accordingly. 3. Whilst crisp breads are allowed on a NHS prescription, they are not recommended for prescribing by NHS SCCG on the grounds that the supermarkets have competitively priced Gluten-Free products readily available. 4. Whilst certain biscuits, crackers and cakes are allowed on a NHS prescription NHS SCCG does NOT support the prescribing of these items. This decision has been based on the grounds of supporting healthy lifestyles and the fact that Gluten-Free products are available at competitive prices in supermarkets. 5. Children aged less than 16 years are excluded from this policy. They should be assessed by a paediatric dietician on diagnosis and their changing nutritional requirements supported by regular review at the paediatric coeliac clinic. Therefore, they may be supplied with appropriate quantities of gluten-free foods from the range available following guidance on quantities below. NB/ Children s obesity obtained from the National Child Measurement Programme show that in 2008/09, 9.2% of reception age children and 17.5% of year 6 children were obese. In 2009/10, 10.3% of reception age children and 17.6% of year 6 children were obese. 4

5 Table 1: Guide to the number of units (calculated based on energy and nutrient requirements of different age groups and genders) supported by NHS Shropshire Clinical Commissioning Group for prescribing each month Table 2: Putting Guidelines into practice - a quick guide for practices Product Unit Prescribe Product Unit Prescribe 400g Bread 1 Yes 200g Rolls (4) 1/2 No 350g Baguette (2) 7/8 Yes 300g Pizza bases (2) 1 No 500g Pasta 2 Yes 200g Crackers 1 No 500g Bread Mix 2 Yes 150g Tea biscuits 3/4 No 500g Flour (P) 2 Yes 150g Digestive biscuits 3/5 No 500g Flour (SR) 2 Yes Luxury Biscuits 1/2 No 200g Crisp Bread 1 No Breakfast cereals - No Ready Meals - No Table 3: Fresh Gluten Free Items These items are ONLY available as 8 units. Juvela G/F Fresh Fibre Loaf (Sliced) Juvela G/F Fresh White Loaf (Sliced) Genius G/F Brown Bread (Sliced) Genius G/F White Bread (Sliced) Genius G/F Brown Unsliced Bread Genius G/F White Unsliced Bread Glutafin G/F Select Fresh Brown Bread (Sliced) Glutafin G/F Select Fresh White Bread (Sliced) This guidance means patients with coeliac disease are provided with a range of gluten-free staples (bread, bread mix, flour, flour mix and pasta) free of charge on NHS prescription. Whilst certain biscuits, crackers and cakes are allowed on a NHS prescription this guidance does not support the prescribing of these items. This decision is based on the grounds of supporting healthy lifestyles. Indeed, audits of patients receiving gluten-free products on prescription carried out in practices in NHS SCCG have revealed patients with Body Mass Indices (BMI) exceeding healthy limits. Patients who are overweight should reduce their total intake including carbohydrate intake in order to achieve weight loss. This guidance means patients with coeliac disease are provided with a range of gluten-free staples on NHS prescription. References 1. The National Diet & Nutrition Survey: Adults aged 19 to 64 years. Types and quantities of foods consumed. A survey carried out in Great Britain on behalf of the Food Standards Agency and the Department of Health by the Social Survey Division of the Office for National Statistics and Medical Research Council Human Nutrition Research NHS Wirral Prescribing Policy: Gluten free foods Coeliac UK The Department of Health 5. The Eatwell plate. 5