FREEDOM OF INFORMATION REQUEST - RESPONSE FOI Reference: OPTUM FOI SWL CCG

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1 FOI Team Optum Commissioning Support Services South Kesteven District Council Offices, St Peters Hill Grantham Lincolnshire, NG31 6PZ 24 th March 2017 Dear Requester FREEDOM OF INFORMATION REQUEST - RESPONSE FOI Reference: OPTUM FOI SWL CCG I refer to your received on 23 rd March I can confirm on behalf of NHS South West Lincolnshire Clinical Commissioning Groups (CCG) supported by Optum Commissioning Support Services, and in accordance with S.1 (1) of the Freedom of Information Act 2000 (FOIA) that we do hold the information you have requested. A response to each element of your request is detailed below: REQUEST and RESPONSE - Is hypoallergenic formula available on prescription for infants with CMPA (Cow s Milk Protein Allergy) by your Commissioning Group RESPONSE: Yes please see attached PACE Bulletin in Appendix One for details - Can you confirm that you will continue to provide this vitally important food for special medical purposes? RESPONSE: We have no plans to further restrict the prescribing of infant formula and baby milks at this time I trust that this answers your queries with the information we currently hold, but if we can be of any further assistance please do not hesitate to contact the FOI Team. If you are dissatisfied with the handling of your request, you have the right to ask for an internal review. Internal review requests should be submitted within two months of the date of receipt of the response to your original letter and should be addressed to Optum Commissioning Support Service FOI TEAM South Kesteven District Council Offices St. Peter s Hill Grantham NG31 6PZ If you are not content with the outcome of your complaint, you may apply directly to the Information Commissioner for a decision. Generally, the ICO cannot make a decision unless you have exhausted the complaints procedure provided by the CCGs.

2 The Information Commissioner can be contacted at: Information Commissioners Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF, telephone , All information we have provided is subject to the provisions of the Re-use of Public Sector Information Regulations Accordingly, if the information has been made available for reuse under the Open Government Licence (OGL) a request to re-use is not required, but the licence conditions must be met. You must not re-use any previously unreleased information without having the consent from the CCG. Should you wish to re-use previously unreleased information then you must make your request in writing ( will suffice) to the FOI Lead. All requests for re-use will be responded to within 20 working days of receipt. Yours faithfully FOI Team On behalf of NHS South West Lincolnshire CCG

3 Appendix One Arden and Greater East Midlands Commissioning Support Unit in association with Lincolnshire Clinical Commissioning Groups, Lincolnshire Community Health Services, United Lincolnshire Hospitals Trust and Lincolnshire Partnership Foundation Trust Volume 11; Number 3 February 2017 PRESCRIBING SPECIALIST INFANT FORMULAE AND BABY MILKS In response to the Lincolnshire Medicines Management public consultation late last year, 64% of respondents felt that prescribing of baby milks and infant formulae should be restricted in some way as part of a reprioritization of NHS spending to better meet the escalating demand for healthcare. After careful consideration, the Lincolnshire CCGs have decided to restrict the prescribing of baby milks and infant formulae for the following indications: lactose intolerance, gastro-oesophageal reflux disease (GORD) and colic. Lactose intolerance They are all available to buy from supermarkets and other retailers.

4 Aptamil Anti-Reflux Milk Powder and Cow & Gate Anti-Reflux Milk Powder) are designated RED-RED and should no longer be prescribed. These products should not be used in conjunction with other thickening agents such as Infant Gaviscon or Carobel as over-thickening of the stomach contents can occur. Enfamil AR Pre-Thickened Formula and SMA Staydown Infant Milk) are designated RED-RED and should no longer be prescribed. They are all available to buy from supermarkets and other retailers. These products should not be used in conjunction with other thickening agents such as Infant Gaviscon or Carobel as overthickening of the stomach contents can occur; they should also not be given concurrently with ranitidine or proton pump inhibitors. As they thicken in the stomach rather than the bottle there is no need to use a large hole (fast flow) teat. The following products should no longer be prescribed and are designated RED-RED: Aptamil Comfort Formula Powder and SMA Comfort Infant Milk. They are all available to buy from supermarkets and other retailers. Healthy Start is a voucher scheme aimed at people who are pregnant or have children under the age of four. People could qualify if they are on benefits, or are pregnant and under 18. The website provides further information on who is eligible and how to apply. Healthy Start provides free vouchers every week to spend on milk, plain fresh and frozen fruit and vegetables, and infant formula milk. It also entitles eligible people to free vitamin supplements. A wide range of specialist baby milks and infant formulae can still be prescribed in Lincolnshire (see Apprndix 1) Restricted Products Lactose Intolerance Infant Formulae Low lactose/lactose free formula Enfamil O-Lac with Lipil, SMA Lactose Free Baby Milk, Aptamil Lactose Free Milk Powder. Soya formula SMA WySoy Gastro-Oesophageal Reflux Disease (GORD) Infant Formulae Thickened Formula: Aptamil Anti-Reflux Milk Powder Cow & Gate Anti-Reflux Milk Powder Thickening Formula: Enfamil AR Pre-Thickened Formula SMA Staydown Infant Milk Colic Infant Formulae Aptamil Comfort Formula Notes A GP will need to diagnose the condition and may need to refer to a dietitian for advice on a lactose free diet. Symptoms usually resolve within 8 weeks. All of the products listed have been designated RED-RED and should no longer be prescribed. They are all available to buy from supermarkets and other retailers. Prices may vary. Bottle-fed babies experiencing GORD could benefit from thickened formula or thickening formula on GP advice. If cow s milk protein allergy exists with GORD, specialist advice from a dietitian is necessary and a specialist cow s milk free formula should be prescribed. See Appendix 1 for examples of cow s milk protein-free formula that may be prescribed. All of the products listed have been designated RED-RED and should no longer be prescribed. They are all available to buy from supermarkets and other retailers. Prices may vary. Both of these products have been designated RED-RED and should no longer be prescribed. They are all available to

5 Powder SMA Comfort Infant Milk buy from supermarkets and other retailers. Prices may vary. Lincolnshire Medicines Management Consultation From October 4 th to November 18 th 2016, the Lincolnshire CCGs conducted a public consultation designed to gauge opinion around proposals to restrict the prescribing of certain products that are also available to buy (for example, over-the-counter medicines, gluten free foods, some baby milks and infant formulae and some s). The aim was to gauge public opinion around the best way to manage increasingly constrained NHS budgets while at the same time ensuring optimal management for those with the highest need. The question posed around prescribing of baby milks and infant formulae was as follows: On reviewing this response, the Lincolnshire CCGs have taken the decision to restrict the prescribing of baby milks and infant formulae. PACEF Recommendation In response to the Lincolnshire Medicines Management public consultation late last year, 64% of respondents felt that prescribing of baby milks and infant formulae should be restricted in some way as part of a reprioritization of NHS spending to better meet the escalating demand for healthcare. After careful consideration, the Lincolnshire CCGs have decided to restrict the prescribing of baby milks and infant formulae for the following indications: lactose intolerance, gastro-oesophageal reflux disease and colic. Lactose Intolerance The following products should no longer be prescribed: Enfamil O-Lac with LIPL SMA Lactose Free Baby Milk, SMA WySoy,

6 Aptamil Lactose Free Milk Powder The following products should no longer be prescribed and are designated RED-RED: Enfamil O-Lac with LIPL, SMA Lactose Free Baby Milk, SMA WySoy and Aptamil Lactose Free Milk Powder. The following products should no longer be prescribed: Pre-Thickened Formula: Aptamil Anti-Reflux Milk Powder Cow & Gate Anti-Reflux Milk Powder

7 Thickening Formula: Enfamil AR Pre-Thickened Formula SMA Staydown Infant Milk Aptamil Anti-Reflux Milk Powder and Cow & Gate Anti-Reflux Milk Powder) are designated RED-RED and should no longer be prescribed. These products should not be used in conjunction with other thickening agents such as Infant Gaviscon or Carobel as over-thickening of the stomach contents can occur. Enfamil AR Pre-Thickened Formula and SMA Staydown Infant Milk) are designated RED-RED and should no longer be prescribed. These products should not be used in conjunction with other thickening agents such as Infant Gaviscon or Carobel as overthickening of the stomach contents can occur; they should also not be given concurrently with ranitidine or proton pump inhibitors. As they thicken in the stomach rather than the bottle there is no need to use a large hole (fast flow) teat.

8 The following products should no longer be prescribed and are designated RED-RED: Aptamil Anti-Reflux Milk Powder and Cow & Gate Anti-Reflux Milk Powder) and Enfamil AR Pre-Thickened Formula and SMA Staydown Infant Milk). Aptamil Comfort Formula Powder SMA Comfort Infant Milk The following products should no longer be prescribed and are designated RED-RED: Aptamil Comfort Formula Powder and SMA Comfort Infant Milk. Healthy Start provides free vouchers every week to spend on milk, plain fresh and frozen fruit and vegetables, and infant formula milk. It also entitles eligible people to free vitamin supplements. Healthy Start is aimed at people who are pregnant or have children under the age of four. People could qualify if they are on benefits, or are pregnant and under 18. The website provides further information on who is eligible and how to apply. In relation to infant formula milk, this must be infant formula milk that is based on cow s milk and says on the packaging that it can be used from birth. Vouchers cannot be used on infant formulas that are not based on cow s milk such as soya formulas and goat s milk formulas or on any follow-on formulas that say on the packaging that they are for babies aged six months or older. Appendix 1 What specialist baby milks and formulae can still be prescribed in Lincolnshire? Cow s Milk Protein Free Formulae Extensively Hydrolysed Formula (Hydrolysate Formula) Products Althera (contains lactose) Aptamil Pepti 1 and 2 (contains lactose) Nutramigen 1 with LGG Nutramigen 2 with LGG Drug Tariff approved ACBS indications Complete nutritional support from birth or supplementary feeding from 6 months and up to 3 years for the dietary management of cow s milk protein allergy and/or multiple food protein allergies. For the dietary management of cow s milk allergy with/or without lactose intolerance. For the dietary management of cow s milk allergy with/or without lactose intolerance. Similac Alimentum As a sole source of nutrition or as a for infants and young children with cow s milk protein allergy and other conditions where an extensively hydrolised formula is indicated. Amino Acid Based Formula Neocate LCP For the dietary management of cow s milk allergy, multiple food protein allergies and other conditions where an elemental diet is

9 Other Formulae under the guidance of a dietitian or paediatrician (this is not an exhaustive list) Nutramigen Puramino Neocate Active (unflavoured and blackcurrant flavour) (for older children) Neocate Advance (unflavoured, banana, vanilla and strawberryvanilla) (for older children) Fortini Fortini 1.0 Multi Fibre (banana, chocolate, strawberry and vanilla flavours) Fortini Creamy Fruit Multi Fibre (berry fruit and summer fruit flavours) Fortini Multi Fibre (berry fruit and summer fruit flavours) Fortini Smoothie Multi Fibre Frebini Frebini Energy Drink (strawberry and banana flavours) recommended. For use in the management of severe protein intolerance, multiple food intolerance and other gastrointestinal disorders where an amino acid based diet is specifically indicated for infants and young children. Proven whole protein allergy, short bowel syndrome, intractable malabsorption and other gastrointestinal disorders where an elemental diet is specifically indicated. Proven whole protein allergy, short bowel syndrome, intractable malabsorption and other gastrointestinal disorders where an elemental diet is specifically indicated. For use as a necessary for: Disease-related malnutrition, and growth any child under one year. Disease-related malnutrition and growth failure. For the dietary management of and growth failure. For use as a necessary for: Disease-related malnutrition, and growth any child under one year. For use as a necessary for: Disease-related malnutrition, and growth any child under one year. for children aged 1-10 years or 8-30kg for: Short bowel syndrome, intractable malabsorption, pre-operative patients who are undernourished, patients with proven inflammatory bowel disease, following total gastrectomy, dysphagia, bowel fistulae, disease-related malnutrition and/or growth any children under one year. As a sole source of nutrition or as a for children aged 1-6 years with and/or growth failure, proven inflammatory bowel disease, following total gastrectomy, short bowel syndrome, intractable malabsorption, dysphagia, bowel fistulae and

10 Frebini Energy Fibre Infatrini Infatrini Peptisorb MCT Enhanced products (e.g. Cow and Gate Pepti-Junior) Nutrini Nutrini Energy Nutrini Energy Multifibre Nutrini Low Energy Multifibre Nutrini Multifibre for the pre-operative patients who are malnourished. Not to be prescribed for any children under one year. As a sole source of nutrition or as a for children aged 1-10 years with and/or growth failure, proven inflammatory bowel disease, following total gastrectomy, short bowel syndrome, intractable malabsorption, dysphagia, bowel fistulae and for the pre-operative patients who are malnourished. Not to be prescribed for any children under one year. Disease-related malnutrition, malabsorption and growth failure in infancy. Short bowel syndrome, intractable malabsorption, inflammatory bowel disease, bowel fistulae, disease-related malnutrition, intolerance to whole protein feeds. for: short bowel syndrome, intractable malabsorption, preoperative undernourished, dysphagia, bowel fistulae, disease-related malnutrition and/or growth any children under one year. for: short bowel syndrome, intractable malabsorption, preoperative undernourished, patients with proven inflammatory bowel disease, following total gastrectomy, dysphagia, bowel fistulae, disease-related malnutrition and/or growth any children under one year. Short bowel syndrome, intractable malabsorption, preoperative undernourished, total gastrectomy, dysphagia, and growth failure. Short bowel syndrome, intractable malabsorption, preoperative undernourished, total gastrectomy, dysphagia, and growth failure.

11 Nutrini Peptisorb Nutriprem 2 Powder Paediasure Paediasure Fibre Paediasure Peptide for: short bowel syndrome, intractable malabsorption, preoperative undernourished, patients with proven inflammatory bowel disease, following total gastrectomy, dysphagia, bowel fistulae, disease-related malnutrition and/or growth any children under one year for: short bowel syndrome, intractable malabsorption, preoperative undernourished, patients with proven inflammatory bowel disease, following total gastrectomy, dysphagia, bowel fistulae, disease-related malnutrition and/or growth failure. Approved for children aged between one and six years. Suitable for catch-up growth in pre-term infants (i.e. less than 35 weeks at birth) and small for gestational age infants, until 6 months corrected age. for children aged 1 to 10 years or 8 to 30kg for: short bowel syndrome, intractable malabsorption, pre-operative patients who are undernourished, dysphagia, bowel fistulae, and/or growth failure. Not to be prescribed for any child under one year. for children aged 1 to 10 years or 8 to 30kg for: short bowel syndrome, intractable malabsorption, pre-operative patients who are undernourished, dysphagia, bowel fistulae, and/or growth failure. Not to be prescribed for any child under one year. For children weighing 8 to 30kg with disease related malnutrition and/or growth failure, short bowel syndrome, intractable malabsorption, bowel fistulae, dysphagia, inflammatory bowel disease, total gastrectomy and for the pre-operative

12 Paediasure Plus Paediasure Plus Fibre Paediasure Plus Juce Similac High Energy SMA Gold Prem 2 SMA High Energy Plus Specialist Formula for specific clinical conditions. malnourished. for children aged 1 to 10 years or 8 to 30kg for: short bowel syndrome, intractable malabsorption, pre-operative patients who are undernourished, dysphagia, bowel fistulae, and/or growth failure. Not to be prescribed for any child under one year. nutrition or as a nutritional supplement for children aged 1 to 10 years or 8 to 30kg with disease related malnutrition and/or growth failure, short bowel syndrome, intractable mal-absorption, dysphagia, bowel fistulae and for the preoperative malnourished. Not to be prescribed for any child under one year. For use as a nutritional supplement for children weighing 8 30kg with disease related malnutrition and/or growth failure. As a sole source of nutrition or as a for infants and young children up to 8kg body weight who have faltering growth, increased energy requirements and/or require a fluid restriction. Catch up growth in preterm infants and small for gestational age babies on discharge from hospital until 6 months corrected age. It may be used as the sole source of nutrition until complementary feeding commences Disease-related malnutrition, malabsorption and growth failure in infancy. NB The Malnutrition Universal Screening Tool (MUST) has no role in the nutritional screening of children. Acknowlegements Many thanks to Katy McMillan from the ULH Dietetics Team for her invaluable specialist help and advice during the development of this Bulletin. Stephen Gibson Head of Prescribing and Medicines Optimisation Arden and Greater East Midlands Commissioning Support Unit February 2017.