Self Care

Dudley CCG Prescribing Policy

Medicines optimisation is key to achieving the best outcomes for patients. The Royal Pharmaceutical Society good practice guide on medicines optimisation outlines principles to help patients get the most out of their medicines.

It is possible to write NHS prescriptions for products which have no or limited clinical value. This means that valuable NHS resources could be spent on products for which there is no clear clinical benefit demonstrated by clinical trial data, some products are not licensed medicines and some provide a clinical benefit in a limited number of people with a limited range of conditions.

Dudley CCG has reviewed the prescribing of medicines and prescribable products available on the NHS, considering the views of both the public and clinicians during a twelve week consultation period. Following this public consultation Dudley CCG has decided that medicines deemed to be of no clinical value and not suitable for prescribing for adults and children within Dudley are referred to as the “The Do Not Prescribe List”.

There is also a group of medicines that are considered not suitable for routine prescribing but may be suitable for a particular patient population; this group is classed as “The Prescribe with Restrictions List”. 

As a result of the public consultation, Dudley CCG has committed to develop an enhanced Minor Ailments Scheme which will enable people living in Dudley registered with a Dudley GP to access community pharmacy services to support them to manage minor ailments. This will mean that whilst community pharmacy expertise is utilised, general practice time and resources can be freed to focus on managing more complex patients. It is anticipated that this revised Minor Ailments Scheme will become available from March 2018.

Policy Aims

The aim of this policy is that:

• The prescribing of products of no clinical value is stopped. Those products included in this category are featured in the Do Not Prescribe List in Appendix 1. (See policy document)
• The prescribing of products that are deemed not cost effective is stopped. Those products included in this category are featured in the Do Not Prescribe List in Appendix 1. (See policy document)
• The prescribing of products not suitable for routine prescribing will be reviewed and prescribing outside of the restrictions will be stopped. Those products and conditions included in this category are featured in the Prescribe with Restrictions List in Appendix 2. (See policy document)
• The CCG prescribing budget is utilised on evidence based medicines and interventions.
• Patients will be supported to understand more about their medicines and to make choices about prevention, self-care and healthy living, where possible being directed to Community Pharmacy who can provide advice on medicines and supply either over the counter or via the Minor Ailments Scheme. Those products which are deemed suitable for inclusion in a Minor Ailments Scheme are listed in Appendix 3. (See policy document)
• It becomes routine practice to signpost patients to further help with their medicines and to local patient support groups.

GENERAL GUIDANCE

Each of the three lists of products will be reviewed on a regular basis (at least every six months) by the Dudley CCG Prescribing Sub Committee.

This policy will be available on the Dudley CCG formulary site and all prescribers within Dudley are encouraged to refer to the formulary site where a current list of products is published: www.dudleyformulary.nhs.uk.

1. The Do Not Prescribe List

It is Dudley CCG policy that the prescribing of products of no or low clinical value is stopped.  The rationale for the Dudley Formulary means that those products which may demonstrate clinical effectiveness but which are deemed not cost effective are not prescribed in Dudley; therefore they may have a lower place in value. For example particular brands of medicines, in these cases Dudley formulary offers cost effective alternatives for prescription. Those products included in this category are featured in the Do Not Prescribe List in Appendix1 (See policy document).

Many of the products in this category are not licensed drugs under the Medicines Act. This means that they have not undergone the stringent testing laid down by the regulatory authorities to confirm their safety, quality and efficacy. In many cases there is no summary of product characteristics (SPC) for prescribers to consult and hence no indemnity for prescribers should the treatment cause harm.

Many of these products are classed as ‘food substitutes’ and are not covered by the Advisory Council for Borderline Substances (ACBS) regulations and/or do not appear in the current British National Formulary (BNF) or the Drug Tariff. They are often not manufactured to the same high pharmaceutical standards used for licensed medicines; hence there is no guarantee of consistency in formulation and potency. These treatments have not undergone rigorous clinical trials to demonstrate that they are effective. It is inappropriate to direct NHS resources towards products that do not have proven efficacy or safety in preference to licensed medicines.

Within this category there are treatments that are clinically and cost effective when used in some patients, but not when used more widely. Also, some treatments are clinically effective but are not considered to be a good use of NHS resources. If prescribing is deemed to be clinically necessary, only those products listed in the Dudley CCG formulary should be prescribed.

Clinicians will be required to consider whether the benefit of prescribing a treatment for an individual justifies the expense to the NHS. Such judgements should be based purely on clinical factors and should not be influenced by socio-economic aspects such as the patient’s ability to purchase.

From publication of this policy, all prescribers within Dudley will be asked not to prescribe products in this list. This will be supported by promotional materials and communications messages to reinforce the reason behind the CCG decision.

Prescribing of products on this list will be monitored at GP practice level on a monthly basis.

2. The Prescribe with Restrictions List

It is Dudley CCG policy that the prescribing of products not suitable for routine prescribing will be reviewed and prescribing outside of the restrictions will be stopped. Those products and conditions included in this category are featured in the Prescribe with Restrictions List in Appendix 2 (See policy document).

From publication of this policy, all prescribers within Dudley will be asked to review patients who currently receive products that are included in this list. Following individual review based on clinical need, prescribers may either refer for specialist advice, continue to prescribe within the guidance provided in Appendix 2 (See policy document) or stop prescribing. This will be supported by promotional materials and communications messages to reinforce the reason behind the CCG decision.

Prescribing of products on this list will be monitored at GP practice level on a monthly basis.

3. Products suitable for inclusion in a Minor Ailments Scheme

Patients will be supported to understand more about their medicines and to make choices about prevention, self-care and healthy living, where possible being directed to community pharmacy who can provide advice on medicines and supply either over the counter or via the Minor Ailments Scheme.  Some products which are used to manage minor ailments can be purchased very cheaply from community pharmacy and in some cases supermarkets and retail establishments. Prescriptions for self-care medicines will no longer available from the GP*.

Those products which are deemed suitable for inclusion in a Minor Ailments Scheme and which can be purchased by patients without the need for an NHS prescription are listed in Appendix 3. During 2017 we will be working to develop the existing Minor Ailments Scheme currently commissioned by NHSE from community pharmacy to enable us to provide an enhanced level of care from community pharmacy from March 2018.

Implementation of policy:

• The implementation of the Prescribing Policy will be phased in over the course this financial year 2017/18
• Practices will be supported with leaflets, posters and other materials to help inform and support their patients. The leaflets should be utilised when having conversations with patients, promoting self-care and the Minor Ailment Scheme (Pharmacy First).
• The Minor Ailment Scheme (Pharmacy First) is a service offered by local community pharmacies for Patients. The local pharmacy will be able to support patients to understand more about their medicines and to make choices about prevention, self-care and healthy living. Community pharmacy can provide advice on medicines and supply either over the counter or via the Minor Ailments Scheme. This scheme is free for those patients that do not currently pay for their prescriptions.  Some products which are used to manage minor ailments can be purchased very cheaply from community pharmacy and in some cases supermarkets and retail establishments**.  
• Each week there will be a focus on medicines and products that will be required to be reviewed by the practice.
• Practice Based Pharmacists will help facilitate this process by running EMISWeb searches to help identify these patients.
• Implementation of this policy needs to be agreed by individual practices and clinicians. Communication of such changes need to be agreed by the practice and patient notified accordingly.

*Clinicians must meet the clinical need of the patient, the term ‘prescribing’does include directing someone to purchase over the counter items and to self-care.

**The Pharmacy First scheme is a voluntary scheme open for participation by all community pharmacies, however it may not be available for patients on all occasions due to unforeseen circumstances.