Proposal to reduce prescribing of medicines and products that can be purchased without a prescription

Transcription

1 Brent CCG Governing Body Proposal to reduce prescribing of medicines and products that can be purchased without a prescription SRO: Janet Cree, Managing Director, Hammersmith and Fulham CCG (this is an NWL-wide proposal) Author: Chris Corfield, Head of Medicines Management, CL, H&F, Hounslow and WL CCGs Presenter: Chris Corfield and Theodora Michael 24 July 2017 Executive summary This paper presents a proposal to reduce the prescribing in North West London (NWL) of medicines and products that can be purchased without a prescription. An earlier version of the proposal was supported by the NWL Collaboration Board. NWL CCG Governing Bodies approved a proposal to engage with stakeholders. Engagement took place in June The proposal has been amended in the light of that engagement; the amendments are set out in appendix 3. The proposal in this paper incorporates feedback suggested by respondents during that engagement. The Governing Body is asked to Subject to validation of the EQIA (validation session scheduled in early August) the Governing Body is asked to approve the proposal that GPs and other prescribers working in NWL should reduce prescribing of medicines and other products that can be purchased without a prescription, noting the guidance at appendices 1 and 2. Introduction The main drivers for the proposal are the need to save money and the importance of building self-care and encouraging people to take a greater responsibility for their health and wellbeing as outlined in the NWL STP: DA 1: Radically upgrading prevention and wellbeing DA 2: Eliminating unwanted variation and improving long term condition management Calls on healthcare funding continue to rise as some chronic and complex health conditions become more common and high cost new treatments become available. 1

2 The proposal has been shaped by a range of stakeholders including GPs and pharmacists, followed by a wider period of engagement with the public and other health professionals. A number of refinements to the proposal have been made in light of comments received (see appendix 3). Proposal That GPs and other prescribers working in NWL should reduce prescribing of medicines and other products that can be purchased without a prescription, noting the guidance and list of products at appendices 1 and 2. The aims of this proposal are to: 1. Encourage self-care when that would be clinically reasonable 2. Save money without adversely affecting quality of care 3. Empower patients to manage minor ailments with support from community pharmacy 4. Reduce patients reliance on prescribers for prescriptions 5. Reduce consultations for minor, self-limiting conditions 6. Avoid exacerbating health inequalities. Clinical judgement should be used when considering whether it is acceptable to ask patients to purchase their medication, e.g. paracetamol when required for headache can be purchased, however regular full dose paracetamol for chronic osteoarthritis may be less suitable for purchase due to the quantities involved. The General Medical Council s Good practice in prescribing and managing medicines and devices (2013) includes: Prescribing is used to describe many related activities, including.advising patients on the purchase of over the counter medicines. Legal advice related to the proposals The proposals are consistent with legal advice obtained for NWL CCGs. Copies of this advice, which is legally privileged, have been provided to NWL CCG Chairs. Finances and resources that would be required to implement the proposal For communications material (posters, leaflets, etc.) - approximately 40,000 ( 5,000 per CCG). Financial indication NWL CCGs spent approximately 13.7m on the products at appendix 2 in

3 Risk adjustment of the savings estimate (24% x 13.7m) is based on Greenwich s experience in saving 24% of their pre-intervention expenditure using an intervention that is arguably lower intensity than our proposed guidance to prescribers (appendix 1). Part year effect if the proposals are approved, savings will start in August. We have assumed a ramp up with 50% of future monthly savings in August, i.e. that NWL will get 7.5/12 x full year saving in = 2.06m. If these savings are spread out proportionately across NWL, the saving for Brent CCG might be 7.5/12 x 24% x 2.22m (our expenditure on the products in 2016) = 333,000. Appendices 1. Guidance for GPs and other prescribers. 2. Table of the medicines and products these proposals relate to, with reasonable criteria for prescribing. 3. Summary report of the June 2017 engagement. 4. Equalities and health inequalities impact assessment. 3

4 Appendix 1 Guidance for GPs and other prescribers 1. Consider whether the patient has an indication for using the medicine or product, with the likely benefit outweighing the likely risk. A list of reasonable criteria for using the products is supplied; the criteria are indicative (appendix 2). 2. If use of the product is indicated, inform the patient* that it can be purchased without a prescription and ask if they will buy it. If the patient s answer is no (i.e. the patient* is unable or unwilling to purchase the product), the product should be prescribed. 3. Give the patient* an information sheet produced by NWL CCGs about purchasing over the counter (OTC) medicines. 4. Note and implement a few exemptions to this recommendation. If use of a product from the list at appendix 2 is indicated for a person in one of the following groups, it should be prescribed: School age children, if the product needs to be given at school. Many schools will not administer medicines that do not have a dispensing label bearing the child s name and the dose Care home residents, if there is no facility to purchase medicines for residents who cannot visit shops themselves People with learning disabilities, unless a non-disabled carer is present at the consultation, who readily agrees to buy the product that is indicated Homeless people. *Or their parent or guardian if the patient is a child. In addition it is recommended that prescribers should not routinely prescribe these medicines or products: Antiperspirants Bath additives Colic treatments Cough & cold remedies Creams or suppositories for haemorrhoids (patient information leaflets will advise the user when to talk to a doctor or pharmacist) Herbal and complementary supplements Oral rehydration solution sachets OTC products for hair removal OTC wart and verruca treatments Teething gels Tonics Travel sickness tablets The proposed recommendations: 4

5 Entail asking patients if they will buy products, recognising that the answer can be yes or no. Do not ban any medicine or product from being prescribed. Do not require prescribers to ask patients about their financial circumstances. Enable every patient with an indication for a medicine or listed product to access it. 5

6 Appendix 2 medicines and products this proposal refers to Indicative reasonable criteria for prescribing the medicine or product for Notes people who are unable or unwilling to buy it include: Emollients Eczema or psoriasis Use of emollients can reduce the need for topical corticosteroids. Only use emollients on the NWL Integrated Formulary. Suitable quantities for adults for twice daily application for 1 week (BNF): face 15-30g; both hands 25-50g; both arms or legs g; trunk 400g Vitamins and mineral supplements Clinically diagnosed deficiency Vitamin B for alcoholics Pregnant women (if they do not get Healthy Start vitamins) Malabsorption, e.g. in cystic fibrosis Laxatives Lubricant products for dry eyes Paracetamol, ibuprofen, cocodamol 8/500 Chronic constipation; opioid induced constipation; children; pregnant women Severe untreated dry eye syndrome; Sjögren's syndrome Children with pyrexia (paracetamol or ibuprofen) Patients who need more tablets than can be purchased on one occasion (e.g. more than 32 paracetamol tablets) Severe untreated dry eye syndrome can damage the surface of the cornea (keratitis), making it vulnerable to potentially sight threatening ulceration and infection 16 paracetamol 500mg or ibuprofen 200mg tablets cost less than 50p in supermarkets Colic treatment NHS Choices advice: Bath additives Other emollients are generally a better choice. Bath additives make the bath slippery. Antihistamines Allergic rhinitis; urticaria; pruritus that responds to an antihistamine; angioedema Treatment of urticaria often requires doses of antihistamine above OTC licensed doses. Gluten free foods ACBS indications: established gluten-sensitive enteropathies including steatorrhoea due to gluten sensitivity, coeliac disease, and dermatitis herpetiformis. Only staple foods can be prescribed under ACBS rules: bread / rolls, breakfast cereals, crackers and crispbreads, flour / flour-type mixes, oats, pasta, pizza bases. Consider quantity being prescribed. Major supermarkets and other retailers stock a wide range of gluten free foods which often cost less to purchase than the NHS pays. Prescribable shampoos Corticosteroid nasal sprays for hayfever Severe seborrhoeic dermatitis Allergic rhinitis Beclometasone, budesonide, fluticasone and triamcinolone can be purchased OTC for up to 3 months treatment of seasonal allergic rhinitis 6

7 Indicative reasonable criteria for prescribing the medicine or product for Notes people who are unable or unwilling to buy it include: Antifungal skin products If the alternative would be antifungal tablets or capsules Immunosuppressed patients; when supervision of treatment is wise Loperamide for diarrhoea Chronic diarrhoea; stoma patients Loperamide can only be purchased over the counter for acute diarrhoea Prescribable sun creams Photoallergies or photosensitive diseases such as porphyria, lupus, Gunther s disease or chronic actinic dermatitis; DNA repair disease; skin cancer-prone genetic disorders such as xeroderma pigmentosum; patients on life-long It is also important for people with a history of skin cancer to use high factor sunscreen. Preparations with SPF less than 30 should not normally be prescribed. immunosuppressive therapy, or who are treated long-term with a photosensitizing drug such as azathioprine; photosensitivity caused by other, unavoidable, treatment Creams or suppositories for haemorrhoids Mouthwashes except Dentists may prescribe fluoride and antiseptic mouthwashes benzydamine Benzydamine mouthwash Painful inflammatory conditions of oropharynx Artificial saliva Dry mouth conditions; end of life Teething gels Oral rehydration solution sachets NHS Choices recommends diluted squash as an alternative to oral rehydration solution for dehydrated infants or children Chloramphenicol eye drops Infections requiring treatment when simple non-pharmaceutical measures have Can only be purchased for adults or children over 2 years failed to work Antacids When the alternative would be prescription of a more expensive or higher risk medicine Barrier creams Travel sickness tablets Cough & cold remedies Covering cream or powder OTC wart and verruca treatments Herbal and complementary supplements OTC cold sore treatment Stoma care; pressure areas; incontinence Preparations marked ACBS in the BNF are regarded as drugs when prescribed for postoperative scars and other deformities and as an adjunctive therapy in the relief of emotional disturbances due to disfiguring skin disease, such as vitiligo. Immunocompromised patients; terminally ill patients People with diabetes, impaired peripheral blood circulation, facial or anogenital warts should not self-treat 7

8 Indicative reasonable criteria for prescribing the medicine or product for Notes people who are unable or unwilling to buy it include: OTC acne treatment e.g. Acne Non-treatment can lead to mental health problems benzoyl peroxide Ear wax removers Hearing loss due to hard ear wax Threadworm tablets Threadworm infections All members of the family require treatment Antiperspirants Head lice treatment Homeless people with severe head lice For other patients encourage wet combing with a nit comb after application of conditioner Tonics OTC products for hair removal 8

9 Appendix 3 - June 2017 engagement See the summary report of the engagement which is presented as a separate file. We wanted respondents to tell us about any important considerations we may have missed, or anything we appeared not to have thought through. The engagement was successful in that respect and a number of refinements to the proposal have been made in light of comments received: Refinement The proposed recommendations have been reworded in an attempt to clarify them Hypoallergenic infant formulas for cow s milk allergy diagnosed by a doctor excluded from proposal Emollients reasonable criteria for prescribing amended from medium to severe eczema or psoriasis to eczema or psoriasis Prescribable sun creams - addition to reasonable criteria: as recommended by the British Association of Dermatologists response to the engagement, including photosensitivity caused by other, unavoidable, treatment Chloramphenicol eye drops add a note that this can only be purchased for adults or children over 2 years Acne treatment change title to OTC acne treatment e.g. benzoyl peroxide. Amend reasonable criteria for prescribing from moderate to severe acne to acne Antihistamines - addition to reasonable criteria: angioedema. Add note treatment of urticaria often requires doses of antihistamine above OTC licensed doses Headlice treatment add a reasonable criterion homeless people with severe Rationale A number of responses to the engagement seemed to misunderstand - or not understand with sufficient precision - what the proposed recommendations were The retail purchase price of these products ranges from approx 100 to over 500 for one month s supply. Any avoidable prescribing of these products is best addressed by a different intervention. Mild eczema that is not treated with emollient is not unlikely to worsen to medium or severe eczema. Many are likely to believe it is unreasonable to ask if a patient will buy sunscreen to treat the side effect of a prescription only medicine, for example Topical benzoyl peroxide is probably the only OTC medicine for acne that should be recommended. Because of the legacy of mental health problems that can follow acne, it seems wise to avoid the question of whether a patient has mild or moderate acne. British Association of Dermatologists response to the engagement. This is belt and braces as homeless people are excluded from the proposal - 9

10 headlice Mouthwashes other than benzydamine add dentists may prescribe antiseptic and fluoride mouthwashes School age children, if the product would have to be given at school excluded from proposal People with learning disabilities excluded from the proposal, unless seen with a non-disabled carer who readily agrees to buy the product that is indicated Homeless people excluded from proposal Care home residents, if there is no facility to purchase medicines for residents who cannot visit shops themselves excluded from proposal Choosing Wisely (the title used for the proposal before and during the engagement) cease use of this title. List of reasonable criteria for prescribing the products note added that the criteria are indicative see below. To reduce the impression that there are no reasonable indications for these. Many schools will not administer medicines that do not have a dispensing label bearing the child s name and the dose. The proposed recommendation to GPs is that they inform the patient that the medicine or product can be purchased and ask if they will buy it. This will only be possible if the patient can understand and answer the question, and buy the product if they answer yes. Likely to have multiple factors that together make it unlikely that indicated medicines would be purchased. (Some residential homes will have the capability to buy OTC medicines or products for a resident, using the resident s money) The title is being used by the Academy of Medical Royal Colleges for a different initiative Legal advice. Such lists are unlikely ever to be exhaustive. 10

11 Appendix 4 - Equality and health inequalities impact assessment (EQIA) See the EQIA which is presented as a separate file. Production of the full EQIA was commissioned from an independent provider, PHAST, a public health consultancy If the proposal presented in this paper is approved, we will continue to listen to the public and professionals during the implementation phase. As part of this, an EQIA validation session will take place on 8 August. This will help us to check that any planned mitigations are appropriate and likely to be adequate. 11