Gluten Free Prescribing in North Somerset and South Gloucestershire

Transcription

1 Gluten Free Prescribing in North Somerset and South Gloucestershire Introduction North Somerset and South Gloucestershire CCGs are committed to service users and the public being involved at the heart of our work. We will continue to listen and act upon patient and carer feedback at all stages of the commissioning cycle because we believe services are better when they are shaped by the experiences and aspirations of local people. This report sets out the feedback we have received during our engagement on Gluten Free food prescribing, and what we have done as a result. Background and objective of project For the past 40 years, the NHS has provided gluten-free (GF) food on prescription to patients diagnosed with coeliac disease, which started because the products were not easily available in supermarkets and were much more expensive compared to non GF foods. In recent years, awareness of coeliac disease has increased and the variety and availability of GF foods has increased, and their price decreased. The NHS has a limited budget and increasing demand for services and must evaluate every service that it pays for to make sure it offers good quality, value for money and a fair way of using resources. Many CCGs locally and nationally are therefore reviewing their position regarding prescribing of these items, giving consideration to whether they should restrict or stop prescribing. In North Somerset, GF foods cost the NHS approximately 145,000 per year. In South Gloucestershire, it costs approximately 170,000 per year. North Somerset and South Gloucestershire CCGs are jointly reviewing their guidance on GF prescribing and considered a proposal to stop prescribing to people aged over 18 and offer a limited list of staple foods (such as bread and pasta) to people aged under 18. We therefore wanted to hear views on this proposed guidance and undertook a consultation with local residents. Aim The aim of the engagement process was to ensure that the views and experiences of patients, families and carers and the wider public across North Somerset and South Gloucestershire were taken into account in shaping our gluten-free foods guidance. In this way we have sought to listen to the views of residents living with coeliac disease, as well as the wider public. 1

2 Objectives To ensure that residents in North Somerset and South Gloucestershire had the opportunity to influence and comment upon the proposed guidance To understand what the impact of this prescribing guidance might be for North Somerset and South Gloucestershire residents living with coeliac disease To ensure that any guidance which is published takes account of the views of patients and the public To provide timely feedback on engagement describing who we engaged, what we heard, and how the feedback has influenced the work To ensure that once we have reached a decision on future prescribing guidance for gluten free products, that we can facilitate a good understanding of the proposed prescribing guidance, where it is in operation, knowledge of how it applies to patients, what it might mean for them accessing these products, what people can expect from their GP practice, and how prescribing of these GF items impacts on the NHS Approach We firstly drafted an Equality Impact Assessment to inform the consultation, this helped us to identify particular stakeholder groups that we needed to engage with. We then developed an engagement and communication plan which set out the steps we would take to consult with the public. A presentation was taken to South Gloucestershire CCG s Improving Patient Experience Forum (IPEF). This allowed IPEF to comment on our engagement plan and suggest key groups that we should engage with, as well as allowing them to comment directly on our proposals. A report was jointly written and submitted to the Health Overview and Scrutiny Committees in North Somerset and South Gloucestershire setting out our plans for engagement on this issue and councillors were able to give their views. We developed an online survey available on both CCG websites, and additionally made paper copies available with a freepost return address. We also provided and telephone contact details as an alternative. The consultation ran for 5 weeks (the timeframe was extended from 4 weeks due to the halfterm holiday which fell during the consultation period.) The consultation and survey was actively promoted to a broad range of stakeholders, as set out below, by , with a reminder sent mid-way through the consultation period. The CCGs communications teams contacted the local media so that articles were included in local newspapers. Details were also included in the CCGs Stakeholder Newsletter and GP Newsletter. 2

3 Stakeholders: NHS England North Somerset & South Gloucestershire Local Authorities (includes Public Health and Citizens Panels) Acute trusts (North Bristol Trust & Weston Area Health Trust) - dietitians, consultant gastroenterologists Community services providers (Sirona care & health & North Somerset Community Partnership Mental health trusts Care organisations & community care providers (residential home and domiciliary care), GP Member practices Avon Local Medical Committee & Avon Local Pharmaceutical Committee CCG staff, including chief officers, clinical chairs, clinical leadership teams, lay members and chief finance officers British Dietetic Association Coeliac UK Media including Bristol Post, BBC, Twitter & Facebook Local MPs and parish council members Neighbouring CCGs (including BANES, Gloucestershire, Somerset, Swindon and Wiltshire) Patient Participation Groups Healthwatch Equalities groups Local libraries Charities such as Age Concern and Age UK 3

4 Findings We received 423 responses to our survey, both online and by post, and 23 letters and s. 62% of the responses to the survey were from patients with coeliac disease. 35 responses to the online survey were received from healthcare professionals, including GPs, dieticians, gastroenterologists and pharmacists. Patient with coeliac disease 8.3% 3.8% Parent or carer of a child with coeliac disease 12.1% 3.3% 10.4% 62.2% Carer or responding on behalf of someone with coeliac disease Not a patient with coeliac disease and not responding on behalf of someone with coeliac disease Clinician Other Question 1: Which of the following applies to you? 4

5 We received responses from patients registered at all of the practices in North Somerset and South Gloucestershire, as well as some responses from people outside of the area. The map of the postcodes supplied in the survey shows that we had replies from people living in all areas of North Somerset and South Gloucestershire. 68% of the responses were from people who currently receive gluten free foods on prescription. There were 8 more people who reported receiving gluten-free food on prescription than who said they were a patient with coeliac disease. It is possible that this is because people are getting gluten-free foods on prescription for their children, or people obtain gluten-free food on prescription without a diagnosis of coeliac disease. 31.2% 68.8% Yes No Question 4: Do you currently receive gluten free foods on prescription? 5

6 Most people (61%) who receive gluten free foods on prescription get a prescription once a month, with about a quarter (27%) having one every 2 months. 6.2% 3.6% 1.1% Once a month 27.6% 61.5% Every 2 months 4 times a year 1-4 times per year Less than once a year Question 5: How often do you get a prescription for GF foods? People who receive gluten free food on prescription do so because they feel that supermarket alternatives are expensive (79%), with about half (47%) believing it is the right of a patient with coeliac disease, and 40% because they receive free prescriptions. Only 20% of people thought that the range of products is limited where they live and 2% did not have access to the internet to order online from supermarkets. 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Supermarket alternatives are expensive It is the right I receive free of a patient prescriptions with coeliac disease Other (please specify) I am on a lowthe choice of income and GF foods is cannot afford limited where GF foods I live To ensure regular check-ups with my GP I do not have access to the internet to order online Question 6: Why do you choose to obtain GF food on prescription? The most popular items people have on prescription are fresh bread (65% of people), flour or bread mixes (63%) and pasta (60%). 6

7 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Fresh bread or bread rolls Flour or bread mix Pasta Crackers Pizza bases Part baked bread or bread rolls Porridge oats Cereals Other (please specify) Sweet biscuits or cakes Question 7: Which GF foods do you receive on prescription? There were a number of reasons that people did not obtain gluten-free foods on prescription. 15% of people were either not aware that it was available or had not yet been diagnosed as suffering from coeliac disease, 20% thought that it should not be available on prescription, about 20% felt that the choice of products is limited on prescription or that the selection in shops was better, and 4% thought that products were cheaper to buy in the shops. 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% I was not aware that GF food was available on prescription I have not yet been formally diagnosed with coeliac disease I don t agree that GF food should be available on prescription The choice of products on prescription is limited I prefer the choice or the products in the shops Products are cheaper to buy in the shops Other (please specify) Question 8: Why do you choose not to obtain GF food on prescription? 7

8 When asked which of the options they agreed with the most, just over 40% of respondents thought that only staple foods (such as bread and flour) should be available to patients with coeliac disease, 35% thought that food should be available to everyone with coeliac disease, 11% agreed with the CCGs preferred option of only prescribing gluten free food to patients aged under 18 and 10% thought that it should not be available to anyone. 11.4% 9.9% 43.4% 35.2% GF food should be available to everyone on prescription Staple GF foods (e.g. only bread, flour) should be available to everyone on prescription GF foods should be available only to under 18s on prescription GF food should not be available to anyone on prescription Question 9: Please select the one option you agree with the most 8

9 The last section of the survey asked respondents how much they agreed or disagreed with a particular statement. 62% of people agreed or strongly agreed that they understood the reasons why the CCGs were reviewing the provision of gluten free food on prescription 77% of people thought that it was appropriate that the NHS provided gluten free food on prescription 67% thought that not providing gluten free food on prescription would make it more difficult to follow a gluten free diet 73% disagreed or strongly disagreed with the statement that gluten free foods were affordable to buy in shops and supermarkets 19% of people felt gluten free foods in supermarkets were affordable 52% of people thought that gluten free foods were readily available and easy to find in their local area, and 25% of people neither agreed nor disagreed with this statement 75% disagreed or strongly disagreed with the CCGs preferred option to only prescribe gluten free food to patients under 18 22% of people agreed or strongly agreed with the CCGs plans to restrict prescribing 48% of people thought that there was enough support available to help patients with coeliac disease manage their diet, whereas 28% disagreed with this statement 40% 30% To what extent do you understand the reason that the CCGs are reviewing GF foods on prescription? 37% 25% 20% 10% 16% 11% 11% 0% Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 60% 50% 40% 30% 20% 10% 0% To what extent do you think It is appropriate that the NHS provides GF foods on prescription? 56% 21% 4% Strongly agree Agree Neither agree nor disagree 7% Disagree 11% Strongly disagree 9

10 50% 40% 30% 20% 10% 0% To what extent do you think that not prescribing GF foods will make it harder to follow a GF diet? 41% 26% Strongly agree Agree Neither agree nor disagree 10% 11% 13% Disagree Strongly disagree 50% 40% 30% 20% 10% 0% To what extent do you think that GF foods in supermarkets are affordable? 7% 12% 8% Strongly agree Agree Neither agree nor disagree 30% Disagree 42% Strongly disagree 40% To what extent do you think that GF foods are readily available and easy to find in your area? 36% 30% 25% 20% 17% 16% 10% 6% 0% Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 10

11 70% 60% 50% 40% 30% 20% 10% 0% To what extent do you support the CCGs preferred option to stop prescribing GF foods to people aged over 18? 17% 5% 4% Strongly agree Agree Neither agree nor disagree 16% Disagree 59% Strongly disagree 35% 30% 25% 20% 15% 10% 5% 0% To what extent do you think that there is enough information and support available for people to manage their diet and condition? 16% 32% 24% Strongly agree Agree Neither agree nor disagree 19% Disagree 9% Strongly disagree Feedback from people who do not have Coeliac Disease 12.1% of survey respondents (50 people, excluding clinicians), were not diagnosed themselves with Coeliac disease. 34% of these respondents thought that gluten free food should not be available to anyone 30% thought that gluten free foods should only be available to under-18s 6% thought only staple items should be prescribed 30% thought that gluten free prescriptions should be available to all 64% of these respondents agreed or strongly agreed with the statement To what extent do you support the CCGs preferred option to stop prescribing GF foods to people aged over 18? 50% of these respondents agreed or strongly agreed with the statement To what extent do you think that GF foods in supermarkets are affordable? 74% of these respondents agreed or strongly agreed with the statement To what extent do you think that GF foods are readily available and easy to find in your area? 62% of these respondents did not agree that not prescribing GF foods would make it harder to follow a GF diet. 11

12 Feedback from Clinicians 35 clinicians responded to our online survey; 23 of these were GPs, 4 pharmacists/pharmacy technicians, 3 dieticians, 1 gastroenterologist & 4 unknown. 73% of clinician respondents agreed or strongly agreed with the statement To what extent do you support the CCGs preferred option to stop prescribing GF foods to people aged over 18? 75% of clinicians responded that there is enough information and support available for people to manage their diet and condition 24.2% of clinicians felt that gluten free foods should not be prescribed to anyone 45.5% felt that gluten free foods should only be available to under-18s 21.2% felt that only staple products should be prescribed 9.1% felt that gluten free foods should be available to everyone on prescription. The responses broadly demonstrated support amongst local GPs for the CCGs plans to restrict prescribing, but identified that there is not support for the proposals from local dieticians or gastroenterologists, as detailed on the next page. If the patients are eating a balanced diet, they will be getting a full range of nutrients anyway. There is no evidence that prescribing gluten free food increases adherence to a gluten free diet. See national consultation Clinician comments in favour of a restriction on prescribing included: There are lots of other conditions where either restricted diets (lactose intolerance, low sugar) or the need to increase fruit and vegetable intake (which also can be more expensive when fresh), but we cannot expect everything to be on prescription, there has to be a limit. If given the choice between having to ensure that medicines only available on prescription are still available compared to non-prescription products that are available via other routes, it is sensible to approach these products first when financially under pressure. There are plenty of ways to follow a gluten free diet, without even using specialist gluten free products. Carbohydrates in the form of rice, potatoes, quinoa and buckwheat are cheap, healthy and naturally contain no gluten. There is a lot of information available online about how to shop for, and cook gluten free food. For people who do still want bread/pasta there are gluten free versions in all the supermarkets. They are more expensive than standard bread/pasta, however they are still very affordable compared to other types of food such as meat. I certainly don't believe the NHS should provide gluten free versions of "junk food" (for example biscuits and pizza bases). If the NHS is going to be supplying gluten free food to patients it should be whole grain, low in saturated fat and low sugar/salt, in line with dietary advice stated in the NICE guidelines (Obesity, cardiovascular disease, diabetes etc). Many people have dietary requirements and preferences which they fund themselves. There are ample gluten free products and alternative carbohydrates (like potatoes) that coeliac patients can buy like everyone else. The drain on NHS resources and GP time is unfair on other patients. The NHS should not be buying part of anyone's weekly shopping. The Local Medical Committee also supported the proposed restriction on prescribing. 12

13 Clinician comments against a restriction in prescribing: As a clinician running clinics for people with Coeliac Disease I feel this will cause some clients unnecessary hardship and in many cases cause poorer compliance which in the long term will add to the cost burden not lessen it, so is not a long term solution. "It is a challenging diet that is unsupported by the majority of services. Though there are a lot of gluten free options now a lot of them are aimed at the 'fad' diet and therefore not truly GF hence suitable for Coeliacs (e.g. cakes out on trays next to normal cakes). I feel that the lifestyle of Coeliac is complicated enough and that the flour etc is sufficiently more expensive that normal foods, alongside the fact that Coeliacs can't easily buy 'ready food' like others can. This all means that eating is a challenge and burden to Coeliacs - the result will either be that they don't follow the diet which will cost us more with complications in the long run - or that they don't eat enough and they become underweight. I agree that some people take advantage so we should limit how much each patient has. However I strongly believe that they should be able to get some food on prescription such as flour, pasta and bread/equivalent. " Feedback was received from specialist dieticians and gastroenterologists at Weston Area Healthcare Trust, North Bristol Trust, Bristol Children s hospital, Sirona care & health plus the British Specialist Nutrition Association and Coeliac UK by letter or in addition to the responses in the online survey. These responses are summarised along with comments from patients with Coeliac Disease below as the feedback was broadly congruent. Feedback from patients with coeliac disease, local gastroenterologists, local dieticians and Coeliac UK Affordability of Gluten Free Products Whilst people agreed that the range of gluten free products in supermarkets has increased, some people noted that gluten free foods are more expensive than gluten-containing equivalents in supermarkets and pack sizes are often smaller. People raised concerns about the impact on purchasing these items on family food budgets, and pensioners in particular pointed out the difficulties of affording these items on restricted budgets. Comments were made by people on low or fixed incomes that they felt GF foods on prescription are essential to help those unable to afford the products adhere to a GF diet. A concern was also raised about those living in poverty and reliant on foodbanks who may find it difficult to bear additional costs. There were several comments requesting that bread was kept as a staple in view of the higher cost of this particular item. Some survey respondents made alternative suggestions including that monthly prescribed quantities could be reduced or a more restricted formulary could be introduced. The CCGs were also asked to consider whether a voucher scheme or credit card system could be introduced. It was highlighted that those patients who pay for prescriptions may have purchased prescription pre-payment certificates. 13

14 Availability of Products Several respondents highlighted that gluten free foods are not readily available in budget supermarkets or convenience stores, with one respondent noting that it was more likely that those with less money might use these stores. There was a perception from some commentators that the range of GF goods available across some areas of NS and SG was poor which they believed could lead to people having to travel to other destinations. We also received feedback that the rural nature of the area means access to large supermarkets may not be easy, especially for those with mobility problems, limited transport options (e.g. no public transport or do not drive) or financial difficulties. A few respondents also highlighted that not all coeliacs will have internet access or social support to buy products and that there are patients with restricted mobility who rely on deliveries from their pharmacy. Product Quality We received comments, particularly from the dieticians who responded to the consultation, that gluten free products in supermarkets are not always very healthy. Patients gave feedback that it is difficult to read food labels to check products are really gluten free and that they felt they could rely on prescription products being strictly gluten free. There were lots of comments saying that bread is a staple in the UK diet; comments from the specialists were that replacing it with isocaloric portions of rice or potatoes may reduce iron and calcium intake. There were comments that removing important staples may have a negative effect on the nutrient content of the diet. Specialists also highlighted that prescribed foods are regulated to provide adequate micronutrients which help prevent long-term deficiencies and that if lower quality products are bought this could have a detrimental impact on health. Equality Comments were received from coeliacs which highlighted the fact that coeliac disease is a lifelong condition for which a gluten free diet is the only treatment. Concerns were raised that withdrawing prescriptions would mean no support for a lifelong condition which is not selfinflicted. There were strong feelings were that coeliac disease should be treated like any other medical condition; that the treatment should be prescribed and in this case the treatment is gluten free food. Respondents also highlighted the disparity between themselves and patients with other autoimmune diseases, such as type 1 diabetes, who receive prescriptions free, whereas coeliacs do not. Respondents also highlighted that while dietary intervention is part of treatment for type 2 diabetes, the dietary advice for diabetics is for a balanced diet which reflects that of the general population and therefore does not incur additional availability, accessibility or cost issues in the same way that coeliac disease does. 14

15 Several respondents, including Coeliac UK, recommended that monitoring should be undertaken to assess the impact of any policy changes and asked how this would occur. Adherence to a Gluten Free Diet Concerns were raised by respondents that people might resort to gluten containing foods if they were not supported with a prescription and that compliance issues could lead to increased complications, increased GP appointments and increased hospital investigations. Clinicians, the public and Coeliac UK highlighted that if left untreated, coeliac disease can lead to serious long-term complications such as osteoporosis, fertility problems and in rare cases, small bowel cancer. Dieticians additionally highlighted that a low energy density diet could lead to risk of growth faltering in children. It was highlighted that all patients should receive an annual review, as recommended in NICE NG20 & QS134. Local clinicians raised concerns about the possible impact on patients when they move from paediatric to adult services and would no longer get items prescribed; they felt adherence to a gluten free diet may become compromised e.g. due to the stresses of leaving the family home, further education or finding employment. Local clinicians also said that research has shown that patients whose access to prescribed products has been restricted have reported they feel less supported to manage their condition and that many patients do not have an annual review of their condition. There were several comments that prescribing gluten free foods supports people to adhere to the diet, therefore avoiding long term problems; so it is cost effective to prescribe these items in the longer term. Some respondents felt that stopping prescribing could prove to be a false economy and would not modernise the service that coeliac patients receive. Vulnerable Patient Groups Suggestions were made that paediatric patients, those with learning difficulties, and those on low incomes (e.g. income support, jobseekers allowance), including pensioners were identified as groups who should be considered for preferential support & ongoing prescribing. 15

16 Consideration of Feedback The two CCGs have considered the prices of staple gluten free foods in supermarkets and reviewed the cost information provided in the DoH document Consultation on the availability of gluten free foods on prescription in primary care. 1 This document and the CCGs own research does confirm that gluten free foods are more expensive that the gluten containing equivalents. However, the DoH document notes that a direct comparison may not be accurate as GF bread may be more nutritionally complete meaning a patient would require a lower quantity. 1 It is also noted that patients can choose to purchase products that are naturally gluten free; specially formulated products are not essential for adherence to a GF diet, and it would be safe to exclude gluten containing foods from their diet. Naturally GF foods include meat, fish, vegetables, fruit, rice, lentils and most dairy products. 1 There is also evidence that the NHS faces higher prices for formulated GF foods than patients, for example through increased delivery costs for fresh foods CCGs pay much more for the same products than consumers. 1 In terms of product availability, while not all stores will stock GF foods, they are more widely available than previously. Ranges are held in some convenience stores and budget supermarkets locally, although this is limited at the moment, but does include bread. Major supermarket chains offer home delivery services which could support patients with restricted mobility or who live in rural areas. If patients do not have internet access this could make accessing specially formulated GF foods more difficult, but these patients will still need to purchase other foods as part of their usual shopping and could select those products which are naturally gluten-free. Responses from non-coeliac patients and local GPs favoured restricting prescribing of gluten-free products so that the money used could be spent in other ways to benefit patients. CCGs have a responsibility to make best use of public funds and any savings made through restricting prescribing could be used to fund medicines that are only available on prescription, rather than foods available in supermarkets. The points made about adherence to a diet, annual review and prevention of long term complications are important. The CCGs agree that it is important that all patients have access to dietary advice and support on how to adhere to a gluten free diet in order to prevent complications and maintain health. The Department of Health states that there is a lack of evidence that suggests a link between the availability of foods on prescription and increased adherence to a GF diet. 1 Patients can access a dietician via their GP in both North Somerset and South Gloucestershire and the CCGs will provide signposting advice to help patients access support. All patients will be encouraged to attend their GP for an annual review of their condition. The NICE Quality Standard details the recommended monitoring that should occur and highlights that patients from living in socioeconomically deprived areas are less likely to attend an 16

17 annual review. 2 The CCGs will work with local GP practices to encourage as many people as possible to attend for their review. We recognise that there are vulnerable groups such as those on low incomes, who may potentially be impacted adversely by the proposed changes. A full Equality Impact Assessment and Quality Impact Assessment has been undertaken as part of the decision making process. The CCG has considered the risk to children of failure to thrive if a gluten free diet is not adhered to and therefore in the proposals identified that we would continue to fund prescribing of staple foods for under-18s. As requested by several respondents, we have considered other options such as voucher or credit card schemes. It has been decided not to adopt these locally as it would be costly to set up and patients might not be able to source their preferred products. Numerous other CCGs across the country have restricted or stopped prescribing of GF foods. Many of these changes have been made recently so there is little national evidence on the impact of restricting prescribing. The CCGs will assess the impact of any changes locally, through GP practice and patient surveys, 6 months after prescribing changes are implemented. We will also review our position once the results of the national consultation have been published. Summary & Recommendations We are grateful to all the people who have taken the time to respond to this engagement. The key points raised were: Affordability of products Availability of products, particularly in rural areas Assurance of product quality and nutritional value Support for adherence to a gluten free diet to prevent long term complications Support for vulnerable patient groups Assessment of the impact of any restriction on prescribing We have given the feedback we have received considerable consideration and although we acknowledge the concerns raised, the CCGs feel that our current prescribing guidance for gluten free foods is not an effective way of using limited NHS resources. The CCGs will therefore advise local GPs: That they should not routinely prescribe gluten free food items for coeliac patients aged over 18 years Prescriptions for patients under 18 years should be limited to staple foods in line with national guidance 3 The formulary will be updated to reflect these changes 17

18 From our engagement activity, we recognise that there are patient groups such as those on low incomes or particularly vulnerable patients who may potentially be adversely affected by the proposed changes. We have taken on board concerns that patients with coeliac disease are at risk of complications if they are not supported to maintain a gluten-free diet. The application of CCG prescribing recommendations are at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. The CCGs recognise that prescribers retain their clinical freedom and when exercising their judgement, are expected to take the CCG prescribing position fully into account, alongside the individual needs, preferences and values of their patients. We will provide GPs with guidance on prescribing for patients aged under 18 who will continue to have prescriptions, providing information on appropriate products and quantities. We will be writing to all affected patients with information about nutritional resources and contact details for organisations where they can get dietary advice. We will also contact local retailers and pharmacies to highlight the needs of local patients and encourage them to extend their range of gluten free products. The CCGs recognise that a small number of patients may request a refund for a prepayment certificate they have purchased, to help reduce the costs of NHS prescription charges. The CCGs will reimburse patients for the cost of their certificates and will refund the remaining months on a prepayment certificate i.e. to a maximum of 12 months. 18

19 Equalities Monitoring The survey received responses from a wide range of different age groups with a number of people from each age group responding Age (number of responses) Under Over 75 Nearly twice as many responses were received from women than from men. This reflects data from North Somerset and South Gloucestershire that shows that Coeliac disease is twice as common in women as in men. 3 Gender (number of responses) Female 137 Male 254 Prefer not to say 10% of respondents considered themselves to be disabled, and 3% preferred not to say. 19

20 Do you consider yourself to be disabled? (Number of 12 responses) 38 Yes No Prefer not to say 345 The majority of respondents identified themselves as white British, with one person identifying as black and minority ethnic, two as white minority ethnic and 11 as other, including white and Asian, European, Bangladeshi, mixed white and Irish Ethnic origin (number of responses) 1 Black and minority ethnic (non-white) White British White minority ethnic Other (please specify) 377 Most respondents identified themselves as heterosexual, with three people identifying as gay and two as bisexual. 20

21 Sexual orientation (number of responses) Heterosexual Bisexual Gay 347 Lesbian There were no responses received from people who currently or previously have identified themselves as trans or transgender. Do you or have you ever identified yourself as trans or transgender? Yes No 100.0% 21

22 We received responses from people with a wide range of religions or beliefs. What is your religion or belief? Please state Agnostic Anglican Animal Rights 0.4% 0.4% 0.4% 2.3% 0.4% 1.5% 1.2% 0.4% 0.4% 1.9% Atheist Buddhist Catholic 3.9% 0.4% Christadelphian 17.0% Christian Church of England 0.8% 1.5% 1.9% 0.4% 3.9% 27.8% Church of England / Buddhism Evangelical Christian Humanist Methodist Muslim 0.4% n/a none 32.8% Protestant Quaker Roman Catholic Spiritual Christian Spiritualist 22

23 References 1. Department of Health. March The Availability of Gluten Free Foods on Prescription in Primary Care. Consultation on the Availability of Gluten Free Foods on Prescription in Primary Care NICE Quality Standard QS134. October Coeliac Disease National Prescribing Guidelines. Coeliac UK. 23