Should gluten-free foods be available on prescription?BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.i6810 (Published 10 January 2017) Cite this as: BMJ 2017;356:i6810
- Matthew Kurien, clinical lecturer in gastroenterology1 2,
- Sarah Sleet, chief executive3,
- David S Sanders, professor of gastroenterology1 2,
- James Cave, general practitioner4
- 1Academic Unit of Gastroenterology, Departments of Infection and Immunity and Cardiovascular Science, University of Sheffield, UK
- 2Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
- 3Coeliac UK, High Wycombe, UK
- 4Newbury, UK
- Correspondence to: D S Sanders , J Cave
Yes—Matthew Kurien, Sarah Sleet, David Sanders
The NHS is facing unprecedented financial and operational pressures, with nearly two thirds of trusts in deficit.1 The UK’s healthcare spend as a proportion of gross domestic product is currently lower than that of its western European neighbours, exacerbating these pressures.2 The government has placed the onus of restoring financial balance with healthcare professionals by demanding improvements in productivity, efficiency, and rationing services.1
In this context prescription of gluten-free food might seem like an easy target for clinical commissioning groups (CCGs) trying to contain costs, but it unfairly discriminates against people with coeliac disease. In 2015, England annual prescriptions costs for gluten-free foods were £25.7m (€30m; $32m)—0.3% of the total NHS prescribing budget.3 Currently, about 40% of clinical commissioning groups are restricting or removing gluten-free food prescriptions,4 but Scotland, Wales, and Northern Ireland are not following suit.
Equality of access
A gluten-free diet is the only treatment for coeliac disease. Lifelong adherence to the gluten-free diet improves quality of life5 and reduces the risk of long term complications such as osteoporosis, vitamin D deficiency, iron deficiency, and (rarely) malignancy. Adhering to this diet is challenging and some evidence suggests it may be improved by access to gluten-free foods on prescription.6 Although gluten-free foods are available in supermarkets, they are often not found in local convenience or budget stores, disadvantaging poorer people and those with limited mobility.7 Furthermore, research shows that the average cost of gluten-free products is three to four times that of standard equivalent products.7 The National Institute for Health and Care Excellence’s quality standards for coeliac disease highlight the role of prescriptions to ensure that a gluten-free diet is affordable and accessible for all patients.8
Grotesque media distortions have portrayed the NHS as subsidising gluten-free junk food,9 but general practitioners can prescribe only staple foods approved by the Advisory Committee on Borderline Substances as appropriate for the person’s age and sex.
Are gluten-free substitutes necessary? Yes. Although more and more clinical commissioning groups insist that patients can simply switch to eating rice and potato alternatives, they fail to tackle the nutritional deficiencies of such alternatives. An isocalorific portion of rice contains 90% less iron and 82% less calcium than bread.10
Pernicious to this debate about prescription policies is the persistent comparisons drawn between coeliac disease and diabetes. However, both clinical advice and the policy position of the patient charity Diabetes UK is that people with diabetes derive no benefit from specialist foods.11 It makes no sense for clinical commissioners to argue that not providing non-beneficial food to one patient group justifies the same policy for essential food products for coeliac disease.
Alternative strategies to prescriptions, such as direct supply schemes from community pharmacies, or voucher allowances, may be a more efficient way of delivering NHS support. However, restricting or removing prescriptions is the dominant policy currently being implemented.
Costs of a quick win
Medical nihilism—that is, assuming medical intervention is futile—affects the wellbeing of patients with coeliac disease. Targeting gluten-free food prescriptions may reduce costs in the short term but there will be long term costs in terms of patient outcomes. Would clinical commissioning groups consider this if the treatment for coeliac disease was an immunosuppressive drug and not food?
There is no other example in the NHS of a disease that is having its treatment costs cut by 50-100%. If commissioners are prepared to mislead the public when consulting on gluten-free prescriptions, can we trust their evidence base for other important changes in service provision? Coeliac disease is the first condition to have such healthcare policy restrictions applied. If they are implemented throughout the NHS in England it is only a matter of time before other misunderstood diseases are dealt with similarly.
In the 1960s, when gluten-free food was first made available through prescription, it made sense to provide bread and other staples through the NHS to ensure the availability of supply for people with coeliac disease. But not now.
In 2016, it is ludicrous for the NHS to be treating a food product as a drug and to require GPs and pharmacists to behave as grocers. The system is bureaucratic, inefficient, expensive, and completely hopeless for people with coeliac disease and their families.
Complicated and expensive
The provision of food has never been more convenient, with a household typically visiting a supermarket each week and 25% visiting two or three times in a week.12 Online shopping and home delivery of food are increasingly popular. However, if you or a member of your household has coeliac disease, in addition to your supermarket shop, you must also organise the supply of your gluten-free products. This will require you to negotiate the complex rules imposed by the NHS governing what can be prescribed and how often, which you and your GP are likely to find stressful and confusing.
Once the prescribing rules have been navigated, your gluten-free products must be ordered and the prerequisite time allowed for the prescription to be generated. You may have to collect the prescription from your doctor and take it to a pharmacy, or it may be sent electronically to your nominated pharmacy. The pharmacist will then order the products from the wholesaler and await delivery. Invariably the order is in bulk, so (assuming it has arrived as planned) you will have a month’s supply of bread, pasta, and flour to store at home.
It’s a time consuming rigmarole and, for the NHS, a very expensive one. Walk into Tesco today and buy a 535 g Genius gluten-free brown sandwich loaf and it will cost you £2.70,13 and yet the NHS listed price for the same loaf is £3.73.14 The NHS with all its buying power is spending £1 more per loaf than the average Tesco customer. This is a scandal. And it goes further. The NHS pays anything up to £6.73 for 500 g of pasta, and yet 500 g of gluten-free pasta will cost just £1.20 at a supermarket. The eight basic gluten-free staples advised for people with coeliac disease are all cheaper from a supermarket than the NHS price. In addition, all prescription items attract a dispensing fee and sometimes out-of-pocket expenses, which are charged on top.
Alternatives to prescribing
In 2015, 1.6 million gluten-free items were dispensed by pharmacies in England (a fraction of the over one billion items they dispensed).15 If we stopped prescribing gluten-free products tomorrow GPs would be freed from the time consuming bureaucracy16 and the NHS would stop being ripped off.
A national voucher scheme or a personalised health budget could be provided to ensure that patients receive recompense for the extra expense of gluten-free products. This could be funded from the money saved by no longer paying for overpriced NHS gluten-free food. In addition, the price of gluten-free food might fall further once proper market forces were in play. Most importantly, people with coeliac disease who currently struggle with the logistics of a lifelong gluten-free diet and a cumbersome and antiquated supply system, would have the convenience and choice we all enjoy.17
Competing interests: All authors have read and understood BMJ policy on declaration of interests and declare the following interests: SS is the chief executive of Coeliac UK; DSS has received educational research grants from Dr Schaer (a gluten-free food manufacturer) and Tillotts Pharma (producer of a point-of-care test for coeliac disease) for investigator led studies; JC is editor of Drugs and Therapeutics Bulletin.
Provenance and peer review: Commissioned; externally peer reviewed.