Prescriptions

A survey conducted by Coeliac UK in 2006 found that over 90 per cent of people with coeliac diseaseA condition where a person is unable to eat gluten as it makes their body attack itself. obtained gluten-freeWhen a food has less than 20 parts per million (ppm) of gluten so it is safe for people with coeliac disease to eat. food on prescription. It is important that prescribers are aware of adequate amounts and types of foods they should be prescribing for their patients.

What is available?

There are a wide number of foods available on prescription made by a number of manufacturers. Foods available vary but can include specially manufactured breads, rolls, pastas, flour and bread mixes, pizza bases, crackers and oats. Luxury items such as chocolate biscuits are not available on prescription but can be purchased from supermarkets or health food stores. Sweet biscuits and cake mixes are being restricted in some areas.

A list of prescribable glutenA protein that is found in the cereals wheat, barley and rye. -free foods can be found in the monthly index of medical specialties (MIMS), the British national formulary (BNFBritish National Formulary - a joint publication of the British Medical Association and the Royal Pharmaceutical Society. It is published biannually and includes key information on the selection, prescribing, dispensing and administration of medicines. Medicines generally prescribed in the UK are covered and those considered less suitable for prescribing are clearly identified.), the Drug Tariff, Coeliac UK's Food and Drink DirectoryOur annual Directory of gluten-free food and drink which manufacturers voluntarily submit to. and by downloading our prescribable list.

As there are so many gluten-free foods available it is a good idea to try a variety before setting up a repeat prescription. Some manufacturers offer sample packs, so patients can try their products before deciding what they would like to receive on a regular basis.

How much to prescribe?

Guidelines are available to assist GPsGeneral Practitioner, or local doctor, dietitians, pharmacists and practice nurses in the decision making process when prescribing gluten-free foods. 'Gluten-free foods: a prescribing guide' was produced in association with the British Dietetic Association (BDABritish Dietetic Association - the professional association for dietitians in the UK.), the Primary Care Society for Gastroenterology (PCSGThe Primary Care Society for Gastroenterology is a membership organisations for gastroenterologists who work in primary care. It provides input on commissioning or clinical governance from a primary care perspective.), and Coeliac UK.

The 2004 Prescribing guidelines are based on:

• a review of consumption data from the National Diet and Nutrition Surveys (1)
• consideration of the Eat Well Plate (Previously known as the Balance of Good Health model)
• a target that gluten-free substitute foods provide 15 per cent of total energy (total CHO should provide 50 per cent total energy which also includes naturally gluten-free foods such as rice and potatoes, intrinsic and milk sugars as well as gluten-free prescribable foods).

The guidelines provide reasonable amounts of gluten-free food patients should get on prescription, calculated in units, based on requirements of different age groups and sexes.

Gluten-free foods have been given a unit value (see tables below).

Additional amounts are added for high activity levels, breastfeeding and the third trimester of pregnancy.

Example:

A male aged 15-59 years requires 18 units per month.
This could be made up of:

• 10 x 400g loaves of bread (=10 units)
• 1 x 2 pack pizza bases (=1 unit)
• 1 x 500g pasta (=2 units)
• 2 x 200g crackers (=2 units)
• 1 x 200g sweet biscuits (=1 unit)
• 1 x 500g flour mix (=2 units).

Cost of prescriptions

People with coeliac disease in England do not receive prescriptions free of charge, unless they are exempt for another reason (for example, based on age or income).  

Patients will usually need to pay a separate prescription charge for each item of gluten-free food. The prescription charge in England is £7.40.  

Pre-payment certificates

Patients who have to pay for more than three prescription items in three months, or 14 items in 12 months, could save money by buying a pre-payment certificate (PPC). A PPC covers the cost of all items on prescriptions (including medications). 
 
Information regarding current pre-payment certificate costs and forms can be obtained from a pharmacy or from the Department of Health website.

Criteria for exemption

People who fall into the following categories are entitled to free prescriptions:

• children under 16
• students under 19 and in full-time education (the place of study must be registered with the Department for Education and Skills)
• adults over 60.

People who get the following benefits:

• income Support
• pension Credit Guarantee Credit
• income-based Jobseekers Allowance
• working Families Tax credit reduced by £70 or less
• disabled Persons Tax Credit reduced by £70 or less.

People who have one of the following:

• tax credit NHS Exemption Certificate
• maternity Exemption Certificate (for expectant mothers or if you have given birth in the last 12 months)
• medical Exemption Certificate
• valid War Pensioner Exemption Certificate (and the prescription is for your accepted disablement)
• HC2 or HC3 Certificate - you may qualify for help if you have a low income.

Students who are 19 years of age and over should be encouraged to see if they are entitled to free prescriptions or help towards prescription costs under the NHS Low Income Scheme. To apply for help under the scheme, people need to complete an HC1 form which is available from a local students union, some dentists and opticians, GP surgeries or requested online where it will be posted out.

Coeliac UK position on gluten-free prescribing

The types of food available across the country can vary and not all products on the ACBSThe Advisory Committee of Borderline Substances is responsible for deciding what products go onto the presciptions list. lists are be available in all Primary Care Trusts (PCTs). Some PCTs have been reviewing their policies on gluten-free prescribing due to the current economic situation and healthy eating initiatives. This may have resulted in changes to what you are able to prescribe at a local level.

Coeliac UK feels strongly that gluten-free prescribing is an essential NHS service that should be available to all patients.

We feel that the numbers of units recommended in the guidelines above should be treated as the norm and should only be exceeded in exceptional circumstances for clinical reasons e.g. if patients are underweight or unable to meet nutritional requirements.

We also recognise that there is a need for a review of the ACBS approved list with more of a focus on staple foods, nutritional composition and ethnic diversity. Staple foods such as breads (including fresh bread), pasta, flour, crackers and crispbread listed by the ACBS should remain available.

We cannot make a special case of support for prescribing biscuits and cake mixes. They are not staple foods and their use is not consistent with healthy eating recommendations.

Coeliac UK recommend that the 2004 guidelines should be used in conjunction with the revised Coeliac UK gluten-free prescribing policy.

Coeliac UK understands the financial pressures in the NHS and we are happy to work with PCTs to ensure a balance is struck between budgetary concerns of the PCTs and the continued support for people with coeliac disease by local healthcare teams. Contact us at dietetics@coeliac.org.uk if you would like further information on prescriptions.

References

1. 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.