Doctors call for national rules on OTC prescribingBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1442 (Published 22 March 2017) Cite this as: BMJ 2017;356:j1442
Cost cutting plans from clinical commissioning groups (CCGs) to limit GPs’ prescribing of over-the-counter (OTC) medicines have sparked debate among doctors and prompted calls for national guidance.
In a letter to local GPs on 13 March 2017 obtained by The BMJ, Lambeth CCG set out new plans to limit GP prescriptions of OTC medicines as part of a push to save money by promoting self care. This follows similar moves by a string of CCGs including Bristol,1 Lincolnshire,2 and Essex.3
Azeem Majeed, head of the department of primary care and public health at Imperial College London and a GP in Lambeth, said he was concerned that policies were being applied on an “ad hoc” basis by CCGs and called for them to be set by national policy makers. He warned that such policies could disproportionately affect poorer patients who are less able to buy medicines over the counter.
But Clare Gerada, former chair of the Royal College of General Practitioners and also a GP in Lambeth, said that she backed the policy because of the high cost to the NHS of prescribing drugs that patients can buy more cheaply in pharmacies and supermarkets.
Lambeth CCG’s letter listed 22 therapeutic areas in which it proposes to limit prescriptions of OTC medicines, subject to consultation (see box below). These include analgesics for short term use, topical steroids, antifungal treatments, and eye treatments.
It stated, “Lambeth CCG spends around £1m a year on self care over the counter medicines. These products can be easily purchased from a supermarket or pharmacy e.g. paracetamol, cough and cold remedies and hay fever medicines. Some of these medicines also have limited clinical value.”
The CCG also intends to stop GPs from prescribing malaria chemoprophylaxis medicines and some travel vaccines on the NHS. It emphasised that promoting self care was part of the South East London sustainability and transformation plan.
But Majeed said he was concerned that policies were being applied unevenly and that they could disproportionately affect poorer patients.
“There is a case for some drugs being removed from the NHS, but in my view that should be done nationally with a full public consultation and not just ad hoc by different CCGs,” he said. “If each CCG has its own lists of drugs [that] it doesn’t want doctors to prescribe, there will be considerable variation, thereby leading to ‘postcode prescribing.’”
Majeed also warned that GPs could be vulnerable if a patient complained about being denied access to treatment. “Legally, if a doctor doesn’t issue a prescription and a patient complains, it’s the doctor who has to defend that complaint,” he said.
Gerada said that she agreed with the policy but that it was important for national policy makers to communicate plans clearly so that patients did not blame GPs for being unable to access certain medicines.
“Where it costs the state 10 times the amount to give something that most people can afford, I’ve always bawled about it. I think the sooner we get the public involved in understanding the real cost of medicines, the better,” she said. “But who is going to protect us when patients kick off? It should be the Department of Health. There needs to be a massive advertising campaign.”
Adrian McLachlan, chair of NHS Lambeth CCG, said, “Our aim is to free up clinician time for those local people who have more complex healthcare needs and who need more active support in managing their health.
“The proposals, if taken forward as guidance, do not impinge on the primacy of GP clinical judgment when considering whether it is acceptable to ask a patient to purchase their medication. From the experience of other CCGs that have implemented a self care strategy, patients have easily been able to grasp the principles around promoting self care.”
Michelle Drage, chief executive of Londonwide LMCs, said that asking GPs to assess patients’ ability to pay for OTC medicines places “an unnecessary strain” on the doctor-patient relationship.
Drage said, “If the NHS believes it can no longer afford to pay for prescriptions for certain OTC medicines there needs to be a decision to produce a definitive list of these at a national level, rather than leaving each CCG to come up with its own plan, or dumping the risk onto hard pressed GPs, nurses, and practice staff. This would have the added benefit of freeing up precious consultation time for those who most need it.”
David Paynton, the Royal College of General Practitioners’ national clinical lead for commissioning, said that, although the college supported the concept of self care, GPs must retain the flexibility to prescribe as they see fit.
He said, “My worry about all of this is that it translates into blanket restrictions, and then there is potential for confrontation and for unintended consequences.”
NHS England did not comment on the plans.
Proposed areas to limit prescriptions
Vitamins and minerals
Analgesics for short term use
Eye treatments/lubricating products
Laxatives for short term use (<72 hrs)
Topical steroids for short term use (<1 wk) in bites/stings, mild dermatitis, etc
Mouthwash and mouth ulcer treatment
All cough and cold remedies
Anti-diarrhoeal medicine for short term use (<72 hrs)
Head lice treatment and scabies treatment
Haemorrhoidal preparations for short term use (5-7 days)
Wart and verruca treatments
Topical acne treatment
Cold sore treatment
Ear wax removers
Nappy rash treatment
Herbal and complementary supplements
Source: Lambeth CCG