Over the counter prescriptions

Our response to a consultation on conditions for which over the counter items should not routinely be prescribed in primary care (March 2018).

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NHS England seeks the views on its proposals for national guidance for CCGs on the prescribing of ‘over the counter (OTC) products’ for 35 minor and/or self-limiting conditions, including conjunctivitis and dry eye. This guidance is intended to encourage people to self-care for minor self-treatable and/or self-limiting conditions only. While the College appreciates that care should be taken not to over-prescribe, and money should not be wasted on prescribing where clinical effectiveness is low, we are concerned that people on low incomes may not be able to afford the over-the-counter medicines and products they need to alleviate their symptoms, and that this guidance may affect the commissioning of MECS schemes.

Our full response

4. Have you read the document 'Conditions for which over the counter items should not routinely be prescribed in primary care: A consultation on guidance for CCGs'?

Yes

Equality and Health Inequalities

5. Do you feel there are any groups, protected by the Equality Act 2010, likely to be disproportionately affected by this work?

No

6. Do you feel there is any further evidence we should consider in our proposals on the potential impact on health inequalities experience by certain groups?

Yes

Please provide further information on why you think this might be the case:

People on low incomes may not be able to afford to buy over-the-counter medicines and products. We fully appreciate that there are issues across the whole of the NHS, not just in prescription medicines, but imposing blanket policies on GPs that don’t take into account demographic differences across the country, or allow for flexibility for individual patients, risk alienating the most vulnerable in society.

Proposals for CCG commissioning guidance

7. Do you agree with the three proposed categories for [items] or [conditions] as follows:

An item of low clinical effectiveness, where there is a lack of robust evidence for clinical effectiveness:

Agree

A condition that is self-limiting and does not require medical advice or treatment as it will clear up on its own:

Agree

A condition that is a minor illness and is suitable for self-care and treatment with items that can easily be purchased over the counter from a pharmacy:

Agree

General exceptions

8 Do you agree with the general exceptions proposed?

Circumstances where the product licence doesn’t allow the product to be sold over the counter to certain groups of patients:

Agree

Patients with a minor condition suitable for self-care that has not responded sufficiently to treatment with an OTC product:

Agree

Patients where the clinician considers that the presenting symptom is due to a condition that would not be considered a minor ailment:

Neither agree or disagree

Circumstances where the prescriber believes that in their clinical judgement, exceptional circumstances exist that warrant deviation from the recommendation to self-care:

Neither agree or disagree

Patients where the clinician considers that their ability to self-manage is compromised as a consequence of social, medical or mental health vulnerability to the extent that their health and/or wellbeing could be adversely affected if left to self-care:

Neither agree or disagree

Further exceptions

9 Should we include any other patient groups in the general exceptions?

Yes

Please provide further information:

Patients on low incomes. There is evidence that self-restriction of medications due to cost is common in seniors who lack prescription coverage, particularly among certain vulnerable groups. Seniors in these high-risk groups who have prescription coverage are much less likely to restrict their use of medications(1). There are also studies, where health care provision is not universally funded, that highlight the direct and indirect costs of dry eye treatment(2). These costs are significant in the context of the poorest in society and could drive further health inequalities.

(1) Steinman, M.A., Sands, L.P. & Covinsky, K.E. J GEN INTERN MED (2001) 16: 793.

(2) J Yu, CV Asche and CJ Fairchild. (2011) The economic burden of dry eye disease in the USA: A decision tree analysis

Drugs with limited evidence of clinical effectiveness

10 Do you agree with the recommendation to: Advise CCGs to support prescribers in advising patients that [item] should not be routinely prescribed in primary care due to limited evidence of clinical effectiveness?

Probiotics:

Agree

Vitamins and minerals:

Agree

Self-limiting conditions

11 Do you agree with the recommendation to: Advise CCGs to support prescribers in advising patients that a prescription for treatment of [condition] should not routinely be offered in primary care as the condition is self-limiting and will clear up on its own without the need for treatment?

Conjunctivitis:

Disagree

Please provide further information:

We are of the opinion that this advice would be used as a steer to commissioners that schemes to diagnose, manage and treat dry eye and conjunctivitis are not required, as people should use self-care measures and visit the pharmacy as stated in this proposal.

A high proportion of Minor Eye Conditions Schemes (MECS) appointments relate to dry eye and conjunctivitis, so we could reasonably see a commissioners decommissioning on that bases, without the acknowledgement that the MECS schemes differentially diagnose the red flag conditions and triage urgent pathologies that present with similar symptoms to conjunctivitis.

The most common reasons for patients needing a MECS assessment are ‘red eye’ (36.7% of patients), ‘painful white eye’ (11.1%), ‘flashes and floaters’ (10.2%)1. Ocular lubricants are most commonly supplied (29.7% of all patients seen through MECS), followed by topical antibiotic drops (12.1%) (1).

We would suggest adding in this consultation an acknowledgement of the role that optometrists play in self-care and management. Optometrists are the best placed professional to advise people on self care and the professional who people should go to if a condition in fact does not self limit or has a red flag. Both the dry eye and conjunctivitis sections should recognised optometrists as professionals who can help support peoples self care. Secondly optometrists should be stated in this document as the professional people should access if self care does not work, or if they have a red-flag symptom. This would support the aim of reducing unnecessary GP appointments.

(1)Evgenia Konstantakopoulou, Robert A Harper, David F Edgar, Genevieve Larkin, Sarah Janikoun, John G Lawrenson, Clinical safety of a minor eye conditions
scheme in England delivered by community optometrists, 10.1136/bmjophth-2017-000125 Published 20 February 2018

Minor ailments suitable for self- care

12 Do you agree with the recommendation to: Advise CCGs to support prescribers in advising patients that a prescription for treatment of [condition] should not routinely be offered in primary care as the condition is appropriate for self-care?

Dry eyes/sore (tired) eyes:

Disagree

Please provide further information:

See our previous comment.

Condition-specific exceptions

13 Are there any item or condition specific exceptions you feel should be included, in addition to those already proposed and the general exceptions covered earlier?

No

 

 

OK
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