Formulary for Gluten-Free foods for Adults and Children Why have the prescribing guidelines changed? The cost of gluten-free (GF) items at the supermarket is much lower than the price the NHS is charged. The range and price of GF foods available from shops is constantly improving. The NHS is spending around 24.7 million a year on GF (epact data April to June 2014). WHCCG total Gluten Free Spend Aug14 to July15 Non-preferred products ( luxury items such as biscuits, pastries, breakfast cereals Breads and Flours Pasta Crackers, bread rolls and pizza bases 314,000 (100%) 28,700 (9%) 175,700 (56%) 34,600 (11%) 75,000 (24%) As a result it has been proposed that bread (including fresh), flour and pasta continue to remain on prescription. Surcharges were one of the problems faced when fresh bread was added onto prescription; however, this has now been resolved. GF bread and pasta remain more expensive for the consumer than their non GF equivalent. What is Coeliac Disease? Coeliac disease is an autoimmune disease triggered by gluten. Treatment is to follow a gluten free diet for life. Diagnosis: Coeliac disease should be diagnosed with a positive blood result (tissue transglutaminase TTG) and confirmed by a duodenal biopsy, taken while the patient is still consuming gluten Referral: On diagnosis referral should be made to a Dietitian for dietary input Review: Yearly by a health professional, as per NICE guidelines GF diet and recommended units of GF staple foods Gluten is a protein found in Wheat, Barley and Rye. Wheat is the most widely consumed cereal in the UK. The GF diet requires the elimination of staple foods including bread, flour and pasta. Gluten is also found in cakes, pastries and biscuits and also in foods that you may not expect, such as some sauces, soups, ready meals and sausages. Elimination of wheat, barley and rye-containing ingredients from the diet results in the removal of a number of staple foods. This can result in a restricted and potentially unbalanced nutritional intake. The amount of gluten-free staple food recommended as units is based on: People with coeliac disease including naturally GF staple foods (e.g. potato and rice) as well as GF specialist staple foods (e.g. GF bread and pasta) A review of consumption data from the National Diet and Nutrition Surveys to establish a benchmark for the reasonable amount of GF food on prescription Consideration of the Eatwell Plate model for balanced eating. Foods that can be prescribed on patient s request (7-13 units depending on age&gender see appendix for examples) Bread / Fresh bread, Flour, Pasta Foods that can be purchased by patients directly from supermarkets/online retailers (unless requested by a specialist health professional) Crackers, Crispbreads, Rolls, Breakfast cereals, Pizza bases GF foods are ACBS approved for the established sensitive gluten enteropathy including Coeliac Disease and Dermatitis Herpetiformis to help with the compliance of these conditions. These products should not be prescribed for Wheat intolerance. Consequences of non-compliance with a GF diet can lead to severe health conditions such as osteoporosis and lymphoma.
Age and gender GF staple monthly units recommendation Prescribable monthly units (about 75%) Child 1-3 10 7 Child 4-6 11 8 Child 7-10 13 10 Child 11-14 15 11 Child 15-18 18 13 Male 19-59 18 13 Male 60-74 16 12 Male 75+ 14 10 Female 19-74 14 10 Female 75+ 12 9 Breastfeeding Add 4 extra 3 3 rd trimester pregnancy Add 1 extra - High physical activity level Add 4 extra - See examples of Units allocation in Appendix 1 Unit is: 250g of Pasta 250g flour mix 400g bread/fresh 200g crackers / crispbreads 250g rolls/baguettes/naan 250g pizza base (2 bases) 300g breakfast cereals 500g of oats List of GF products available on prescription - Pasta Pasta Company name Pack Price / Price / GF / WF / DF/MF/Mzsize (g) pack ( ) Unit ( ) F* Buckwheat Penne / Spirals 250 2.93 2.93 GF WF Barkat Animal Shapes / Alphabet shapes / GF WF Macaroni / Spirals / Tagliatelle / 500 5.88 2.94 Spaghetti Spirals / Grains / Sagnette / Penne / GF 500 5.97 2.99 Mixed Bi-Alimenta Gnocchi 500 5.59 2.80 GF Tubetti 500 5.90 2.95 GF Dietary Specials Penn / Fusilli / Spaghetti 500 3.54 1.77 Lasagne / Macaroni / Shells / 454 4.88 2.69 GF WF, SF, MF, Mz-F Ener-G Spaghetti 447 5.03 2.81 GF WF, SF, MF, Mz-F Vermicelli 300 5.03 4.19 GF WF, SF, MF, Mz-F Lasagne / Tagliatelle 250 3.53 3.53 GF Glutafin Penne / Shells / Spirals / Spaghetti 500 6.73 3.37 GF Fibre Spaghetti 500 5.74 2.87 GF Fibre pasta spirals 500 5.70 2.85 GF Lasagne 250 3.68 3.68 GF Juvela Tagliatelle 250 3.47 3.47 GF Macaroni / Fusilli / Spaghetti 500 7.21 3.61 GF Penne (fibre) 500 6.61 3.31 GF Orgran Lasagne 150 3.75 6.25 GF Spirals 250 2.95 2.95 GF Rizopia Fusilli / Penne / Spaghetti 500 2.72 1.36 GF Lasagne 375 2.72 1.81 GF
List of GF products available on prescription Bread and flours Company name Breads (Not Fresh) Pack size (g) Price / pack ( ) Price / unit ( ) DF/GF/MF/Mz-F* /SF/WF* Lifestyle Un / Sliced: Brown / White / High fibre 400 2.82 2.82 GF Dietary Specials Multigrain loaf (white) 400 3.10 3.10 GF WF Ener G Six flour loaf 576 4.54 3.15 GF WF, SF, MF, Mz-F Barkat Wholemeal sliced 500 3.98 3.18 GF WF Juvela Unsliced/sliced - Fibre & White 400 3.54 3.54 GF Juvela Fibre Part Baked 400 3.80 3.80 GF Glutafin Sliced Fibre / White 400 3.85 3.85 GF WF Juvela White Part Baked 400 3.95 3.95 GF Proceli Brown rice 220 2.19 3.98 GF WF Ener G Six flour brown loaf (sliced) 600 6.22 4.17 GF WF, SF, MF, Mz-F Proceli Sandwich rice 200 2.19 4.38 GF WF Livwell Sliced White / Seeded 200 2.25 4.50 GF Ener G Brown or white rice bread 474 5.41 4.57 GF WF, SF, MF, Mz-F Barkat Sliced Rice Brown / White 500 5.73 4.58 GF WF Barkat Multigrain sliced 500 5.73 4.58 GF WF Proceli Sandwich 155 2.06 5.31 GF WF Proceli Sliced White 165 2.19 5.31 GF WF Fresh Bread Company Pack Price / Price / DF/GF/MF/Mz- name size (g) pack ( ) unit ( ) F/SF/WF* Brown / White Original (sliced) 400 2.77 2.77 GF WF DF Genius Brown /White Original (unsliced) 400 2.67 2.67 GF WF DF Brown / White Sandwich Bread (sliced) 535 3.59 2.68 GF WF DF Warburtons Sliced Brown / White 400 2.99 2.99 GF WF Fresh (Brown / White) or Glutafin 400 3.43 3.43 GF Sliced (Fibre / White) Select Sliced seeded loaf 400 3.72 3.72 GF Juvela Sliced fibre 400 3.39 3.39 GF Gluten-Free Sliced white 400 3.69 3.69 GF Above companies are the delivery details and contact numbers Genius - Fresh bread only No charge if ordered directly from (via Alliance wholesalers) 0845 8744000 Glutafin Available from UDG with no delivery charge 01773 510 123 Juvela - Fresh bread only Available from UDG with no delivery charge 01773 510 123 Warburtons Available from UDG with no delivery charge 01733 510 123
When considering the prescription of bread flour it is generally recommended to choose basic flour as first line as it is more cost effective and versatile for use. Although bread mix or multipurpose are commonly preferred as it contains sugar and milk powder which help the bread to rise. 1 st line - Bread mix / Flour 2 nd line - Bread mix / Flour Company Price / Price / DF/GF/MF/Mz- Pack size name pack ( ) Unit ( ) F/SF/WF* Brown rice flour 500g 1.58 0.79 GF WF, SF, MF, Mz-F Potato flour 500g 1.68 0.84 GF WF, SF, MF, Mz-F Innovative White rice flour 500g 1.68 0.84 GF WF, SF, MF, Mz-F Solutions Tapioca flour 500g 2.26 1.13 GF WF, SF, MF, Mz-F (Pure Gluten Free) Gluten-free blended flour 1kg 4.23 1.06 GF WF, SF, MF, Mz-F Teff brown flour 1kg 4.77 1.19 GF WF, SF, MF, Mz-F Teff white flour 1kg 4.77 1.19 GF WF, SF, MF, Mz-F Tobia Teff White / Brown 1kg 3.35 0.84 GF Proceli White flour 1kg 5.14 1.29 GF Company Pack Price / Price / DF/GF/MF/Mz- name size pack ( ) Unit ( ) F/SF/WF* Barkat Bread mix 500g 6.81 3.40 GF WF Flour 750g 6.98 2.33 GF WF Finax Fibre bread mix 1kg 9.92 2.48 GF Flour mix (regular/coarse) 900g 8.66 2.41 GF Glebe Farm Pizza mix 375g 1.99 1.33 GF Glutafin Select Bread mix, fibre, multipurpose mix (Fibre / White) 500g 6.66 3.33 GF Glutafin Bread mix, fibre, multipurpose mix Gluten- Free (Fibre / White) 500g 6.66 3.33 GF WF Heron Foods Bread mix 500g 8.96 4.48 GF Hi-fibre/Bread and cake mix 500g 8.96 4.48 GF WF Juvela Gluten- Free Mrs Crimble s Fibre / White / Harvest 500g 7.35 3.68 GF Bread 275g 1.04 0.95 GF Pastry 200g 1.04 1.30 GF Orgran Pizza and Pastry 375g 3.25 2.17 GF PK Foods (low protein) Flour mix 750g 10.71 3.57 GF Tritamyl White bread/flour 2kg 13.85 1.73 GF Brown bread 1kg 6.90 1.73 GF Ultra GF Flour mix 1kg 2.75 0.69 GF Wellfoods Flour plain 1kg 7.65 1.91 GF WF DF
List of manufacturers of gluten free fresh bread with reduced delivery charges Company Delivery charges Contact nber Barkat Innovative solutions (Pure Gluten Free) Lifestyle Orgran Procelli Wellfoods Delivery charge ranges from 6.50 to 10 depending on the size of the package. Pharmacists are able to order directly and will be charged via their main wholesaler (AAH/Unichem/Phoenix) Do not use mainstream wholesalers. Can be ordered directly from company. Delivery charges: >500g = 3.18 500g to 10kgs = 7.25 10kgs 25kgs = 14.40 Online order delivery charge: 6 items = 3.95, 12 items = 3.45, 18 items = 2.95 24 items or more there is no delivery charge. Direct order from pharmacies. For the first 6 months, the pharmacy has to use one of their recommended special wholesalers. After this period, the pharmacy can open an account with Lifestyle. Orders for less than 8 items will incur a delivery charge of 7.75 Available to order from Naturally Good Food. Delivery cost for order weight of up to 1kg is 3.15 Delivery cost for order weight above 1 kg is 6.50 All orders go through Ambe Medical (main wholesaler) Delivery charge from Ambe is 10 for orders below 75. Next day delivery. Flexible ordering arrangements Available via Unichem and AAH as a special order (with high carriage charges) or can be ordered directly from the company. Cost when ordered directly: Free for orders of 6 units or more Delivery charge of 7.50 0208 953 4444 01706 746713 0845 2701400 01455 556878 01732 760 900 01226 381712
Appendix: Example of monthly unit allocation for various patient groups adapted from CoeliacUK Age Group (years) Monthly units Recommendation 1 to 3 10 4 to 6 11 7 to 10 13 11-14 15 15-18 18 Male 19-59 18 Male 60-74 16 Male 75+ 14 Female 19-74 14 Female 75+ 12 Breast feeding 3 rd Trimester pregnancy Add 4 units Add 1 unit Monthly units to prescribe (about 75% of recommendations) 6 units of bread (2400g) or mix suitable for making bread (1500g) 1 unit of pasta (250g) 6 units bread (2400g) or mix suitable for making bread (1500g) 3 units of pasta (750g) 5 units of pasta (1250g) 5 units of pasta (1250g) 4 units of pasta (1000g) 7 units bread (2800g) or mix suitable for making bread (1500g) 1 unit of bread (440g) Purchasable monthly units (supermarket/online retailers) 2 units of breakfast cereal (600g) 1 unit of crackers (200g) 2 units of breakfast cereal (600g) 1 unit of pizza bases (250g) 1 unit of pizza bases (250g) 2 units of GF oats (1000g) 2 units of pizza bases (500g) 3 units of breakfast cereal (900g) 2 unit of crackers (400g) 3 units of breakfast cereal (900g) 2 units of pizza bases (500g) 2 units of GF oats (1000g) 2 units of GF oats (1000g) 2 units of breakfast cereal (600g) 1 units of GF oats (500g) 1 unit of crackers (200g) 1 unit of crackers (200g) References 1. NICE clinical guidelines 86 Coeliac Disease Recognition and assessment of coeliac disease May 2009 2. Coeliac UK - http://www.coeliac.org.uk/ 3. ACBS - Department of Health as Borderline Substances and may be prescribed at NHS expense for established gluten enteropathy with or without co-existing established wheat sensitivity. 4. British Society of Gastroenterology 5. NHS PrescQIPP - NHS PrescQIPP - Gluten Free Prescribing