Greater Manchester LPC response to national consultation on items which should not routinely be prescribed in primary care

Local Pharmaceutical Committees (LPCs) are the recognised statutory bodies that represent community pharmacy contractors in discussions about locally commissioned pharmacy services and about the role of the sector in the wider health and care system in their defined region. They also provide advice and support to pharmacy contractors to help them deliver both nationally and locally commissioned services. Every community pharmacy with an NHS contract is represented by the relevant LPC for their area.
Greater Manchester LPC (GMLPC) is the largest LPC in the country representing the 627 community pharmacy contractors in Bury, Glossop, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford and Wigan.
On 21 July 2017, NHS England published their consultation on items which should not routinely be prescribed in primary care. Their intention is to implement statutory guidance for clinical commissioning groups when formulating local polices, and for prescribers to reflect local policies in their prescribing practice. The consultation notes that the guidance does not remove the clinical discretion of the prescriber in accordance with their professional duties.
The major part of this consultation focuses on 18 specific items and the process of identifying and including these items. Chapter five of the consultation then focuses on medicines that are readily available to purchase over the counter (OTC).
GMLPC agrees with the recommendations made for the 18 items identified because these medicines are either dangerous or not the most effective treatment available. We believe there is a national way of restricting use of medicines namely the blacklist and that this should be used and enforced across both primary and secondary care to prevent a postcode lottery where some area’s implementation of guidance or policy differs to others on access to these medicines. If the evidence is indeed overwhelming, these medicines should not be available for use within the NHS. For items that have some valid uses but the majority of current uses are not compliant with that, then the Selected List System exists to both remind prescribers of their restriction and justify the reason for withholding a prescription.
GMLPC does take issue with the items within chapter five. Our stance mirrors that of the Royal Pharmaceutical Society (RPS) and is aligned to that of the GPs and patients.
We should not be restricting access to these medicines for those who cannot afford to purchase them. Greater Manchester contains some of the most deprived areas in the country and altering the principle that care is free at the point of delivery would be damaging to people living within those areas. This is against principle 2 of the NHS Constitution, which clearly states that ‘Access to NHS services is based on clinical need, not an individual’s ability to pay’. We believe that this is a fundamental change of principle within our NHS and that decision should be made by Parliament and not implemented at will by Clinical Commissioning Groups.
Our strongly belief that the impact of such a removal has not been properly assessed. This assessment must examine the impact at multiple levels: individual citizens, the community, GPs, Urgent Care and other health services. It must also cover the unintended consequences of the decision. These could include the prescribing of more complicated medicines than necessary with a higher risk profile and cost than the simple drugs where prescribing is discouraged. Whilst we know that the prescribers will do their best to comply with guidelines, there will be occasions when they recognise the need to supply to someone who is ill and cannot afford to self-medicate.
The pressures put upon vulnerable people and their carers must be considered. The impact of removing paracetamol from prescription without also looking at the restrictions on supply amounts could lead to multiple unnecessary extra visits to pharmacies every week for a relative or carer as a patient who requires regular paracetamol can only purchase a maximum of 12 days’ supply at one time.
Self-care should be encouraged and enabled. NHS Minor Ailment services would be a way to promote access for these medicines without putting unnecessary stress on GPs and other prescribers. We believe this service would also reduce the pressure on urgent care and a Cost Benefit Analysis by New Economy of our own Greater Manchester Minor Ailment service has shown the service to have a positive net value to the health system.