NHS England’s review of “low value” prescription items has the potential to save up to £400 million a year, but what will the cost be to patients, and the knock-on effect for community pharmacy?

From gluten-free foods to omega-3 supplements and travel vaccines, NHS England has set out its proposals to try to trim £400 million a year from the drugs budget by removing a number of “low clinical value or priority” lines from the list of items that are available on prescription.

A first consultation focuses on 10 items, including fentanyl (predicted saving: £10.13 million), travel vaccines (£9.47 million) and gluten-free foods (£21.88 million). A second consultation will review a wider range of items, including pain relief, hayfever, indigestion and suncream.

Combined, the two groups of items could produce savings of about £400 million a year, which NHS England chief executive Simon Stevens says could be spent on “innovative new drugs” rather than “wasting it on these kind of items”.

While few would argue with streamlining the prescribing budget, there are other effects to consider. John Smith, PAGB chief executive, has argued that appropriate prescribing of the items under discussion in certain circumstances and based on sound clinical judgement does still have a place, and that NHS England should not simply opt for “a one-size-fits-all solution”, because “any change in prescribing policy may have a disproportionate effect on vulnerable groups”.

Richard Bradley, pharmacy director at Boots UK, says a critical consideration is ensuring medicines and other essential healthcare items are free at the point of care to the most vulnerable in society.

“This fundamental principle of our health system means that the ability to pay should never be a barrier to accessing treatments that can alleviate distressing symptoms,” he says.

However, NPA chief pharmacist Leyla Hannbeck stresses that there are decisions regularly being made on whether medications are cost effective for the NHS, and there is always the potential for clinical impacts on patients when the decision is made as to whether or not a medication is prescribable on NHS prescriptions. “The most publicised cases tend to be in relation to new cancer medications, and unfortunately, due to the lack of evidence and cost effectiveness, some new treatments will not be funded by the NHS which will ultimately impact the patient,” she says.

It’s not just vulnerable people who are at risk of missing out should the suggested changes come into play. The wider interactions that customers can have with the community pharmacy team could be in jeopardy if a patient no longer needs to visit the pharmacy for an item, according to Dawn Williams, who leads the Careway team from AAH Pharmaceuticals.

“When a customer visits a pharmacy to pick up a prescription, it gives them access to experts who can provide advice and guidance that can have a wider ranging impact on their overall health”, she comments, “which may lead to you identifying other potential products or services that they need or could benefit from.”

Impact on pharmacy

Ms Hannbeck says the move has the potential to have both positive and negative impact on community pharmacy. “In terms of negative impacts, the main one would be a reduction in prescription items and therefore income through dispensing,” she says. However, she sees a benefit to reducing the prescribing of such items if the savings “can then be filtered back into the NHS, potentially benefiting pharmacy if funding is increased, for example if the savings are used to fund new services available from pharmacies”.

Some losses may not be inevitable. Ms Hannbeck says it is doubtful that pharmacies would be able to attract over-the-counter sales of gluten-free products “as pharmacies may not be able offer competitive prices or stock large ranges of gluten-free products, in comparison to supermarkets.”

Mandeep Mudhar, director of marketing and professional development at Numark, points out possible opportunity. “There are lots of different types of gluten-free products and it is highly unlikely that a supermarket will sell all of them [plus] many of these are specialist products (often with short use-by dates) where only a qualified pharmacist or trained health professional can give relevant advice and information in order for the patient to fully benefit from them,” he says.

For Jane Devenish, NHS standards and service pharmacist at Well, the removal of some of these products makes sense, but not others. “Omega-3 is no longer recommended for prevention of cardiovascular disease due to a lack of evidence, and so it would seem logical to restrict prescribing,” she says. “But gluten-free foods are different. Eating a gluten-free diet is the only treatment for coeliac disease. This autoimmune disease can cause problems such as osteoporosis, vitamin deficiencies, intestinal cancer and ulcers if not treated. Although gluten-free foods are available in many different locations, they can be more expensive to buy and we’d be concerned that people may choose to skip them and opt for the cheaper wheat products.”

Her solution would be “a more balanced approach”, such as the Cumbria Gluten Free Service, where pharmacists can supply a limited formulary of bread, flour and pasta with controlled volumes so that the NHS strikes a balance between paying out for foods now and the patient suffering ill health due to poor treatment compliance. “This service also identifies when the patient is due for their annual review, and prompts them to take up the opportunity for this important check,” she says.

Travel health opportunity

With travel vaccines also on the list, this could give community pharmacies more incentive to set up their own private travel vaccine clinics, but it might also encourage other providers to do the same.

Ms Devenish says because travel vaccines are not prescribed on NHS prescription in large volumes at present, she would not expect to see “a significant difference” to community pharmacy prescriptions. However, for vaccines that are available free of charge such as typhoid or hepatitis A – to prevent diseases that could be transmitted within the UK if contracted abroad – she says the financial and personal cost of these diseases far outweighs the cost of vaccination. “I’d be interested to review the figures on how much this would really save the NHS,” she says. “While there is an argument that this cost should be built into budgeting for a holiday, there is a risk that if the vaccines were not free of charge then people would go without.”

For Ms Hannbeck, this presents an opportunity for pharmacy. “If travel vaccines are deemed unsuitable for prescribing on the NHS, then it would most definitely lead to an increased demand for such services and pharmacies are ideal to provide such services,” she says.

“Clearly, other providers will seize the opportunity to fill the gap in the market which could lead to more competitive prices, but this should not deter pharmacies from developing and expanding their services.”
Mr Mudhar agrees that although there is a plethora of private providers offering a travel service, including many GP practices, there is “absolutely no reason why a pharmacy cannot provide this service as well”. However, he warns that patient choice will determine where these services are made available, so making a success of it “all comes down to how you differentiate yourself”.

In fact, community pharmacy has the potential to “completely dominate” this market suggests Ms Hannbeck, due to a number of benefits to providing travel clinics – and other services – over other providers. For example, pharmacies have long opening hours and weekend opening times in accessible locations, and, more often than not, no appointment is needed. Pharmacists are ‘medicine experts’ and are trusted healthcare providers within the community, and so pharmacies may be viewed by the public as their first choice for vaccinations and travel medicines over other private providers.”

Mr Bradley says it is too soon to speculate on what the consequences of this review will be, but feels that there remains a need for a nationally commissioned minor ailments scheme for England. “We recognise that there is a clear need to find more cost-effective ways of delivering access to simple treatments for minor conditions than through GP prescribing,” he says. “But it is disappointing that some of the most at-need patients seem to be being diverted to pharmacy on a self-pay basis as a way of achieving this. We believe a more effective solution would be in these patients being supported by the provision of a consistent, nationally commissioned minor ailments and advice service,” he says.

Whatever the outcome, building a long-term relationship with customers and patients will build loyalty to your pharmacy and keep them coming back to you for years to come, says Ms Williams. “It’s not about driving extra sales (though this is an added benefit), she says. “It’s about identifying what’s best for the customer and providing a tailored healthcare service. The real benefit to patients from getting these items from a pharmacy is the interaction they have with dedicated healthcare professionals. Here they can receive consultations, advice and support as well as signposting to other services. These are the kinds of interactions that customers in a supermarket and other non-clinical environments would be missing out on.”