RCCG/GB/17/035 Promotion of Self Care Briefing Document 1. Introduction The proposal aims to promote self-care through the purchasing of medications and products from local pharmacies for the treatment of minor ailments. This would lead to a reduction in the cost of prescriptions/fp10s for over the counter medicines (OTC) and is in line with what has been implemented by other CCGs nationally. Locally, prescribing of over the counter medicines has been discussed in patient groups and medicine management forums in relation to financial savings as well as the self-care agenda. The total cost of prescribing OTC medicines for Nottingham North and East (NNE), Rushcliffe and Nottingham West (NW) CCGs in 2015 was 1,966,265. For NNE the total costs were 886,402 with costs per practice ranging from 9,922 to 92,685 per year. For NW the total costs were 511,291 ranging from to 12,128 to 85,359 and Rushcliffe were 568,571 ranging from 14,592 to 107,696. The first half of 2016 indicates an average reduction of approximately 10% across the CCGs. A small local audit also indicated a potential for 10 percent cost reduction. Estimated savings, across the three south CCGs based on this 10% figure, are 196,626. In order to inform the proposal and the decision as to how to implement, patient and public involvement has been carried out through focus groups, practice patient groups and a survey. On the whole, the patient engagement responses indicate that patients are comfortable with this proposal. Where there are concerns, they are particularly focused on the following: Vulnerable patients who may not be have access or be able to access or afford over the counter medicines Worry the plan will be extended to include patients with long-term conditions That the decision must be widely communicated and have GP support It is recognised that referring patients to their community pharmacist for over the counter medicines aligns with the Five Year Forward View and using the skills and competencies of this profession, as well as promoting self-care. Community Pharmacists are well placed to give patients advice on minor ailments and this fits with self-care as well as NHS England s proposals to enhance the offering from community pharmacists as part of the wider health and social care economy. Within NNE and NW CCG areas there is also a minor ailment service, Pharmacy First, delivered through community pharmacies enabling patients who are exempt from prescription charges to receive treatment for minor ailments. This service is not offered within the boundaries of Rushcliffe CCG and this will be considered as part of the Equality Impact Assessment. 2. Proposal The proposal which we engaged on takes into consideration the following: We are recommending to GP practices that they do not issue a prescription for a number of OTC medicines in the treatment of minor ailments and in relation to self-care. Patients 16 February 2017 1
are instead to be advised on the purchase of over the counter medicines and other remedies. It is proposed that patient leaflets are made available. It includes three areas: Area 1 - paracetamol, ibuprofen and medicines of limited clinical value; Area 2 - vitamins and Area 3 - antihistamines, gastro-intestinal medicines and skin creams. Other over the counter medicines that have limited clinical value should not be prescribed on an FP10. The prescribing of vitamins and minerals is not supported unless for actual vitamin/mineral deficiency. Certain antihistamines, skin creams and antacids should be purchased from the community pharmacy. It is proposed that through a communications and engagement plan, the CCGs will guide GPs to consider when to prescribe OTC medicines and will re-educate patients to use their local services more efficiently and effectively. Engagement will indicate what resources would be beneficial to support self-care, i.e. patient leaflets, NHS Choices. 2.1 Area 1 Paracetamol/Ibuprofen and Medicines of Limited Clinical Value Paracetamol/Ibuprofen The local CCG spend on paracetamol and ibuprofen is 35% of over the counter spend despite the availability of these medicines in local supermarkets and pharmacists. It is proposed that patients should purchase paracetamol and ibuprofen 200mg for mild to moderate short term pain. The following is a list of ailments where providing a prescription for paracetamol and ibuprofen 200mg will not be recommended: headache, migraine, toothache/teething pain, earache, period pain, bruising, minor injuries, strains and sprains, backache, muscle aches and joint pains along with other common ailments such as colds, flu and fever. Patients who use large volumes 4-6 hourly for the management of chronic pain conditions should continue to receive paracetamol or ibuprofen on prescription. Spend for NNE in 2015 was 311,149, Rushcliffe was 181,878 and Nottingham West was 200,854. After carrying out a small audit, it is expected that 10% of prescriptions relate to minor ailments and self-care. It is therefore proposed that a 10% saving on the prescribing budget could be made through promotion of self-care. Medicines with Limited Clinical Value OTC medication that has low clinical evidence and where through the formulary, it may already be recommended that some are not prescribed (grey drugs) on FP10 are also proposed to be advised to be purchased. This includes antifungal nail paint, lutein and antioxidant vitamins, omega 3 fatty acids and other fish oils. Other products that could be included are cold sore treatments (topical), cough and cold remedies, infantile colic treatments, and rubefacients excluding NSAIDs. Patients will be advised that these medications are available at their local pharmacy. Spend for NNE is 110,386, Rushcliffe is 61,129 and Nottingham West is 41,198. Work on this area has already been completed previously in each of the CCG s therefore while patients already on these medicines will be reviewed, it is estimated that a 10% saving will be made. 16 February 2017 2
2.2 Area 2 Over the Counter Medicines: Vitamins Providing a prescription for vitamins and minerals is a low clinical priority and may only be appropriate where there is an ACBS approved indication only in the management of actual or potential vitamin or mineral deficiency and not as dietary supplements or as a general pick me up. The proposal includes vitamins that are approved to prescribe and those that are not. Those that are not recommended on prescription include cod liver oil, vitamin B (as a pick me up), vitamin B compound tablets, Riboflavin (B2), vitamin C, vitamin D (maintenance), folic acid supplementation, tonics, homeopathic remedies, general multivitamins, abidec, and dalivit. Patients can be advised that these medications are available at their local pharmacy. The current spend on vitamins for NNE is 40,091, NW is 45,828 and Rushcliffe is 40,240. 2.3 Area 3 Condition Related Over the Counter Medicines This includes antihistamines, skin creams and gastro-intestinal medicines. The proposal is that patients should purchase: 1. Antihistamines for mild to moderate hay fever. 2. Over the counter medicines for skin conditions including shower gels, benzoyl peroxide, shampoos and emollients. 3. Over the counter medicines for Gastro-intestinal conditions, including antacids and alginates In all cases patients requiring prescription only medicines or larger quantities to manage chronic conditions will continue to receive supplies on prescription. The potential for savings are estimated to be 10% of current spend. The annual spend in 2015 and potential savings on condition related over the counter medicines across NNE, West and Rushcliffe is and broken down by each CCG is as follows: CCG GI Spend Skin Spend Antihistamine spend NNE 65,988 126,452 86,277 NW 40,014 81,964 44,690 Rushcliffe 45,308 99,224 50,739 3. Good Practice in Prescribing The different areas will be in the form of a recommendation to GP Practices in order to ensure that they maintain their duty of care, taking into consideration clinical and social need. The proposal therefore acknowledges that GPs are responsible for prescribing decisions and supporting information will be provided to ensure they can justify these. The proposal is seeking to exhort GPs to direct patients to their local community pharmacy or supermarket where their request or complaint is in relation to vitamins for maintenance and /or is sufficiently minor to be self-managed with an over the counter version. 16 February 2017 3
The proposal takes into consideration the General Medical Council s Good Practice in Prescribing and Managing Medicines and Devices (updated December 2014). In particular, the following elements relate to the proposal: Prescribing is used to describe many related activities, including supply of prescription only medicines, prescribing medicines, devices and dressings on the NHS and advising patients on the purchase of over the counter medicines and other remedies. GPs must make good use of the resources available to them If you are unsure about interactions or other aspects of prescribing and medicines management you should seek advice from experienced colleagues, including pharmacists, prescribing advisers and clinical pharmacologists It is sometimes difficult, because of time pressures, to give patients as much information as you or they would like. To help with this, you should consider the role that other members of the healthcare team, including pharmacists, might play. Pharmacists can undertake medicines reviews, explain how to take medicines and offer advice on interactions and side effects. You should work with pharmacists in your organisation and/or locality to avoid the risks of overburdening or confusing patients with excessive or inconsistent information. 4. Communications and Engagement A communications and engagement plan has been produced to support the proposal. Patient and Public Engagement Patient and public engagement is imperative in relation to both gaining feedback and changing behaviour/re-educating patients. Engagement started on Monday 19 December 2016 and ran through to Friday 3 February 2017. Through the focus groups and surveys patients have gained a greater awareness of the NHS costs for over the counter medicines alongside opportunities for self-care. Please see engagement report (Appendix 1). Communications Plan The communications plan will cover all stakeholders. With respect to patients and carers, the communications plan covers the engagement phase and how best to generate feedback. It also covers educating the public and changing patient behaviour, including using a patient information leaflet. The three CCGs patient and public involvement committees/councils and Practice Patient Participation Groups will be used to help promote key messages. Other key stakeholders include community pharmacies, care homes and GP practices themselves. With respect to community pharmacies the CCGs are linking in with the LPN as well as carrying out local engagement with pharmacies. For care homes, guides will be provided and for GP practices themselves, information will be provided to MMFs and promotional material will be made available for waiting rooms. The objectives of the communications plan include: Transparent and realistic communication about the need for changes to prescribing The need for financial decisions balanced by an evidenced based approach Facts about prescribing including to dispel myths 16 February 2017 4
To promote self-care messages Outline how patient and public feedback has informed the policy Manage messages from the media, taking into consideration responses in relation to other CCGs. 5. CCG Guideline A CCG level guideline has been written around the promotion of self-care for the conditions related to the medicines listed above (Appendix 2). 6. Recommendation The Governing Body is asked to: APPROVE the promotion of self-care through the purchasing of medications and products from local pharmacies for the treatment of minor ailments. NOTE the Patient Engagement Report NOTE the guidelines for prescribers on over the counter medicines. 16 February 2017 5