Post by Silly Yak on Feb 19, 2011 9:18:01 GMT
Prescribing of gluten-free foods: Coeliac UK’s position
The range of gluten-free products on prescription has increased since prescriptions began in the late 1960’s. The prescribing practices have also become variable with some people receiving more gluten-free food on prescription than others. Here we focus on the Coeliac UK’s position on gluten-free prescribing, national guidance for healthcare professionals on reasonable amounts of food on prescription and pharmacy supply of gluten-free foods on prescription.
National guidance
Gluten-free prescribing guidelines were produced for healthcare professionals in 2004, in a collaboration between Coeliac UK, the Primary Care Society for Gastroenterology and the British Dietetic Association. (1) The national guidelines set out minimum amounts of gluten-free food per individual per month as units based on nutritional recommendations.
These guidelines are based on;
national nutritional recommendations and make assumptions that in addition to gluten-free food on prescription individuals eat naturally gluten-free carbohydrate food such as rice and potatoes
consumption data from the National Diet and Nutrition Surveys (2) and from individual records of NHS patients with coeliac disease
the eat well plate where carbohydrates should provide 50% of total energy.
Importance of prescriptions
Sourcing affordable gluten-free foods can be an obstacle for people with coeliac disease and make it more difficult for patients to maintain their diet. Although, increasingly, gluten-free staple products are available in supermarkets they continue to be significantly more expensive than standard staple foods. Coeliac UK has been tracking prices of gluten-free specialist foods and has found that gluten-free breads and flour mixes can be four times more expensive than standard products. The BSG review paper on the management of adults with coeliac disease states ‘patient adherence to a gluten-free diet has repeatedly been shown to be poor with 20-80% admitting to either occasional or prolonged lapses (3).
What products should be available on prescription?
Type of products available
Coeliac UK supports access to gluten-free products approved by the Advisory Committee on Borderline Substances (ACBS) to be on prescription as an essential part of the clinical treatment of coeliac disease. However, we also take the view that the ACBS list should be reviewed to focus on essential staple foods such as bread, flour and pasta.
From our discussions with over 50 of the PCTs in England and Health Boards in Scotland, Wales and Northern Ireland a key issue is the prescribing of gluten-free cake mix and sweet biscuits. It is difficult to put forward a strong argument to support these items on prescription as these products are now widely available in shops and are not thought essential to the diet. They are also contrary to the NHS policy about healthy eating.
Number of products available
Some PCTs have also been looking at guidance around the number of products people receive on prescription. The number of gluten-free products people receive on prescription varies from patient to patient. Some people may be receiving in excess of the national guidelines and some people may fall short. As discussed earlier the unit recommendations from 2004 guidance are based on national nutritional recommendations. We feel that the amount of products prescribed should follow this guidance and the number of units available should only be exceeded in exceptional circumstances on the advice of the healthcare team.
Clinicians discretion
We stress the importance of the clinician’s discretion in cases where nutritional intake is at risk. There may be cases where crackers are recommended instead of bread for older patients with dental problems or biscuits are recommended for individuals who are underweight or additional units are recommended in patients with additional calorie requirements. Dietitians are best placed to assess individual requirements.
PRESSURE ON PRESCRIBING BUDGETS - COELIAC UK’S POSITION
PCTs have been taking action to cut costs and manage budgets during the last few years. This has resulted in restrictions in gluten-free prescribing. Coeliac UK understands the need for financial controls in light of the tough economic situation but gluten-free prescribing is an essential NHS service that should be available to all patients with coeliac disease.
Staple foods such as breads (including fresh bread), pasta, flours, crisp breads and pizza bases listed by the ACBS should remain available.
Cake mixes should no longer be available and sweet biscuits should only be considered in exceptional circumstances on clinical advice.
The number of units recommended in the 2004 guidelines should be treated as the norm.
Alternative gluten-free supply schemes
With tightening budgets, Coeliac UK has been working with PCTs to look at new ways of managing the supply of gluten-free foods on prescription.
Pharmacy supply schemes
Within the NHS, gluten-free prescribing schemes are being led by community pharmacists. Initial audits of these schemes in Northamptonshire and Allerdale (Cumbria) have demonstrated real cost reductions of 20% in gluten-free prescribing. This is due to better control of the products and the associated costs. The schemes have been shown to save GP time and provide a better service to patients. Throughout 2010, Coeliac UK has worked with the National Pharmacy Association and the Prescribing Services Negotiating Committee, to develop a business case to support such schemes. We hope to promote this further in 2011.
Dietetic service on prescribing
Rotherham PCT has set up a dietetic run service where the dietitians hold the budget for gluten-free prescribing. People with coeliac disease will see a dietitian for annual review. The dietitian will write an initial prescription and patients will contact the dietitian for repeat prescriptions.
Voucher schemes
Discussions have been underway in some areas about the introduction of a payment system or voucher scheme giving patients a monthly payment to offset the additional cost of gluten-free staple foods.
What you can do
Coeliac UK are keen to support schemes which help people with coeliac disease follow the gluten-free diet and meet the ongoing needs of the patients and the PCTs. We would like to hear from any healthcare professionals involved in changes to gluten-free prescribing. Please keep Coeliac UK informed on changes in your area by emailing dietetics@coeliac.org.uk or contacting us on 0845 305 2060.
Further information
1. BDA, PCSG, Coeliac UK (2004) Gluten-free foods: a prescribing guide. www.coeliac.org.uk/healthcare-professionals/prescriptions
2. The National Diet & Nutrition Survey: adults aged 19 to 64 years (2002) Types and quantities of foods consumed. A survey carried out in Great Britain on behalf of the Food Standards Agency and the Departments of Health by the Social Survey Division of the Office for National Statistics and Medical Research Council Human Nutrition Research.
3. British Society of Gastroenterology (2010) The Management of adults with coeliac disease. www.bsg.org.uk/sections/small-bowel-nutrition-articles/bsg-guidance-on-coeliac-disease-2010.html
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