In July 2017, NHS England launched a consultation on items which should not be routinely prescribed in primary care, followed by a consultation on conditions for which over the counter (OTC) items should not routinely be prescribed in primary care. This was part of a drive to reduce prescribing of OTC medicines to save the NHS money, and included items for conditions that are considered to be self-limiting and do not need treatment as they will heal of their own accord, and those which lend themselves to self-care and can be treated by an OTC medicine.
The BMA responded to both consultations, supporting the efforts to educate patients about self-care of minor ailments, and encouraging the appropriate use of effective medicines that are available from community pharmacies or other retail outlets. We also expressed support for the provision of minor ailment schemes within pharmacies, the decommissioning of which in many areas is likely to drive up prescribing rates. However, we believed that without changes to the GMS regulations GPs will be at risk of complaint from patients or criticism from their CCGs. In addition, we were concerned about the impact this will have on vulnerable groups and the potential widening of health inequalities.
After reviewing the consultation responses, in March 2018 NHS England published revised commissioning guidance for CCGs on reducing prescribing of OTC medicines for minor, short-term health concerns (including items of low clinical effectiveness, which are of high cost to the NHS, e.g. probiotics and vitamins).
Download the guidance
What conditions are affected?
NHS England recommended that treatment for the following 35 minor conditions and two items of limited clinical effectiveness, should not routinely be prescribed in primary care:
Accute sore throat
- Infrequent cold sores of the lip
- Coughs/colds/nasal congestion
- Cradle cap (infants)
- Infant colic
- Mild cystitis
- Mild irritant dermatitis
- Diarrhoea (adults)
- Dry eyes/sore (tired) eyes
- Excessive sweating (hyperhidrosis)
- Head lice
- Indigestion and heartburn
- Infrequent constipation
- Infrequent migraine
- Insect bites and stings
- Mild acne
- Mild dry skin
- Sun protection
- Mild to moderate hay fever
- Minor burns and scalds
- Minor conditions associated with pain, discomfort and/or fever
- Mouth ulcers
- Nappy rash
- Oral thrush
- Prevention of dental caries
- Ringworm/athletes foot
- Teething/mild toothache
- Travel sickness
- Warts and verrucae
- Vitamins and minerals
What expectations are there?
This initiative is for short term minor illnesses only, so long term repeat prescribing is excluded. The guidance also lists a number of general exceptions, where it is recommended that patients should continue to have their treatments prescribed, which are outlined below (full list p12-13):
- Patients prescribed an OTC treatment for a long-term condition
- For the treatment of more complex forms of minor illnesses
- For patients that have symptoms that suggest the condition is not minor
- Treatment for complex patients (e.g. immunosuppressed patients)
- Patients on prescription only treatments.
- Patients prescribed OTC products to treat an adverse effect or symptom of a more complex illness and/or prescription only medications
- Circumstances where the product licence doesn’t allow the product to be sold over the counter to certain groups of patients (e.g. children, pregnant or breast-feeding women)
- Patients with a minor condition suitable for self-care that has not responded sufficiently to treatment with an OTC product.
- Patients where the clinician considers that the presenting symptom is due to a condition that would not be considered a minor condition.
- Circumstances where the prescriber believes that in their clinical judgement, exceptional circumstances exist that warrant deviation from the recommendation to self-care.
- Patients where the clinician considers that their ability to self-manage is compromised as a consequence of medical, mental health or significant social vulnerability to the extent that their health or wellbeing could be adversely affected, if reliant on self-care.
What is the BMA position?
With respect to low value medicines, we support efforts to encourage cost effective prescribing, but believe that substances that are ineffective or have significant safety concerns should be formally placed on the blacklist of drugs unavailable on the NHS.
For OTC medicines, we believe that it is already an intrinsic part of a GP’s job to help patients to care for their own minor illnesses, and to explain the availability and proper use of overthe-counter preparations. The NHS England guidance for CCGs, is useful for those situations where advice about self-care may be all that a patient needs. However, as there has been no change to the regulations that govern GP prescribing, although GPs need to be mindful of this guidance published by NHSE, it cannot be used by Clinical Commissioning Groups to ban all such treatments.
GPs must continue to treat patients according to their individual circumstances and needs, and that includes issuing prescriptions where there are reasons why self-care is inappropriate. This guidance does make it clear that such requirements continue to apply in individual situations. We welcome the recognition of the need for flexibility within the guidance but it is vital that these are preserved in local implementation of this policy by CCGs.
What is the contractual position?
Concerns have been expressed that GPs refusing to issue a prescription for a medication that has been judged to be required may be in breach of their contractual obligations, as below paragraph of the GMS contract:
14.2.2. Subject to clause 14.2.4 and 14.2.5 and to clauses 14.6 to 14.7 a prescriber shall order any drugs, medicines or appliances which are needed for the treatment of any patient who is receiving treatment under the Contract by— (a) issuing to that patient a non-electronic prescription form or nonelectronic repeatable prescription completed in accordance with clause 14.2.8; or (b) where clause 14.3 applies, creating and transmitting an electronic prescription.
In order to address this, NHS England issues a 'letter of comfort' to GPs assuring them that they would not be in breach of their terms of service by such action. However, GPs would still need to act within their professional obligations and would need to be certain that their patient did not fall into any of the recognised exceptions, and this letter does not remove the possibility of complain from a patient that a prescription should have been provided.
What should prescribers in general practice do?
- Continue to make the care of the patient first concern
- Advise patients if that treatment for their condition is available over the counter
- Provide an FP10 if, in the opinion of the GP, not to do so may put the patient at risk of not having necessary treatment.
Further information about prescribing is available in our updated guidance on prescribing
in general practice.