Review of the Gluten-free Food Additional Pharmaceutical Service

5 Chapter 5: Prescribing Information and Analysis

Summary

• There is a wide variation in the number of prescribable GFF products across the different Health Boards and closer alignment of Health Board formularies is strongly recommended.
• Prescribing volume of GFF prescribed has increased by 31.6% and prescribing cost by only 4.6%.
• Prescribing volume increased across all GFF prescribed food categories. The greatest increase was in cereals then grains/ flours with growth over the last two consecutive years.
• Analysis suggests patients are ordering a wider variation within their GFF allocation across the food categories compared to the previous year.
• Prescribing cost per item decreased overall by 20% with cereals the main GFF category where cost per item increased.
• CHI capture rate has reduced from 99% to 81% since the introduction of the GFFS due to handwriting of prescription orders. The implementation of an electronic prescription form for the service would resolve this issue.
• Patient care records were created in 87% of pharmacies.

5.1 NHS Health Board GFF Formularies

All Health Boards across Scotland use the National Gluten-free Food Prescribable Product List as the starting point to develop a local GFF product formulary. The national list is the collation of all gluten-free foods which are ACBS approved, from all manufacturers for prescribable GFF on a NHS prescription and aids standardised practice in unit allocation across Scotland.

The range of GFF products in each food category for the Health Board formularies is noted in Table 1 overleaf. All GFF Health Board formularies are available on NHS Inform^[13].

Table 1 indicates the GFF formulary product range between Health Boards with NHS Lothian having the narrowest product range and NHS Grampian the widest product range. All except one Health Board have a single formulary that covers all coeliac patients, children and adults. In each Health Board, the formulary product choices are greatest for bread and rolls with the range of pasta choices second. External to the GFFS some patients require a low protein diet and these are usually gluten-free as well however these prescriptions are completed by the GP at present.

Seven of the 14 Health Boards have sweet biscuits currently on their formulary. ACBS however, no longer approve any sweet biscuits for prescription and all of these products are historic. It is understood that in many of those Health Boards, there is prescribing guidance on a maximum quantity limit for sweet biscuits as part of the GFF allowance.

It is notable that each Health Board formulary although derived from the one national food list is very different in the number of GFF products available. The questionnaire responses and stakeholder responses highlight the equity of access and concerns from patients and community pharmacists due to the variation. It is recommended that although some variation may reflect differences in local population demographics, the reasons for the variation should be assessed and greater alignment between Health Board formularies achieved.

Table 1: Number of GFF products within the main GFF categories listed in Health Board Formularies

NHS Health Board	Bread & Rolls	Home Baking	Pizza Bases	Pasta	Crackers & Crispbread	Baking Aids	Breakfast Cereal	Sweet Biscuits	Total
Ayrshire & Arran	51	12	4	18	6	1	4	0	96
Borders	52	13	4	22	9	1	4	0	105
Dumfries & Galloway	49	11	2	12	5	2	6	0	87
Fife	36	7	3	10	5	1	3	0	65
Forth Valley	45	14	2	19	9	1	7	9	106
Greater Glasgow and Clyde	50	37	2	43	8	2	7	8	157
Grampian	87	37	7	46	12	2	7	11	209
Highland	71	18	3	18	9	2	5	2	128
Lanarkshire	52	14	3	12	4	2	5	0	92
Lothian	10	3	2	2	2	0	2	0	21
Lothian Children	10	3	2	3	2	0	2	0	22
Orkney	60	22	4	15	8	2	6	8	125
Shetland	60	22	4	15	8	2	6	8	125
Tayside	72	24	5	43	12	1	9	10	176
Average	50	17	3	20	7	1	5	4	108.1
Minimum	10	3	2	2	2	0	2	0
Maximum	87	37	7	46	12	2	9	11

5.2 GFFS Implementation

Since the introduction of the GFFS there has been a switch in number of GFF prescribing through GP10 prescriptions written by the GP to the community pharmacy prescribed items via CPUS form. The implementation of the trial service has resulted in a change from 82% of prescribing by GPs in January to March 2014 to 82% by community pharmacy in January to March 2015 (Graph 1). NHS Tayside started supplying GFF through community pharmacy in 2010 with other Health Boards starting to implement GFFS from March 2014. Graph 2 shows the high rate of transfer from GP to community pharmacy prescribing particularly over the first six months of the GFFS implementation.

Graph 1: Change in percentage GFF items prescribed via GP prescribing (GP) and by Community Pharmacy since introduction of GFFS

*Information supplied by iSD special request

Graph 2: Change over the four quarters as the GFFS was implemented is seen in the graph below

*Information supplied by iSD special request

Graph 3 below shows the different percentage uptake of the GFF service across the different Health Boards. The graph indicates the percentage of GFF prescribed in the January to March 2015 for GP prescribing (GP10) and community pharmacy prescribing.

NHS Tayside has the highest implementation with 96% and the lowest is the Western Isles with 25%. Rurality was a factor in the uptake of GFFS as seen by the island Health Boards and NHS Highland. The lowest uptake across all the mainland Health Boards however was NHS Lothian. The figures do indicate a successful implementation of the GFFS.

Graph 3: Variation between Health Boards in implementation of GFFS

*Information supplied by iSD special request

5.3 GFF Prescribing Volume and Costs

Over the last year there has been a significant change in the prescribing of GFF costs and volume. Information Services Division (iSD) publish in June each year the prescribing statistics for the last financial year^[14]. The tables and graphs below utilise the information provided.

Prescribing Cost and Volume change for the first 12 months of the trial service

A review of the prescribing information indicates that the number of dispensed GFF items in the year prior to the new service to March 2014 was 2.2% with a small cost reduction of 2.1% compared to the previous year. In the year since the introduction of GFFS trial from April 2014 there has been a 31.6% increase in the number of dispensed GFF items. In terms of total GFF prescribing costs (GIC), however, only an increase of 4.6% has been observed since the introduction of the GFFS.

Table 2: Prescribing costs, number of GFF items dispensed and the average GFF item cost over the last three years

Total GFF Prescribing for Scotland	Total Dispensed Items	Total Gross Ingredient Cost (GIC)	Cost per Item (£)
April 2012 to March 2013	243,416	£3,969,770	£16.31
April 2013 to March 2014	248,811	£3,885,110	£15.61
April 2014 to March 2015	327,474	£4,062,863	£12.41
Prescribing change between the financial years 2014/15 and 2013/14	78,663	£177,753	-£3.21
Percentage of Prescribing Change between 2013/14 and 2012/13	2.22%	-2.13%	-4.25%
Percentage of Prescribing Change between 2014/15 and 2013/14	31.6%	4.6%	-20.5%

The prescribing information since the introduction of the trial service indicates that despite the total number of prescription items increasing significantly, the overall costs did not. A more technical economic analysis confirmed that changes in the number of items dispensed and the quantity prescribed per patient were statistically significant, but that there was no statistically significant change in the cost per patient. However, the analysis also flagged up that one year of data since the start of the new service might not be enough to give an adequate picture and that more data over a longer time-span is needed to make a final assessment.

Another observation was that the average cost of a GFF prescription item declined in the year prior to the GFFS trial. The cost per prescription item however has declined by 20.5% since implementation of GFFS. The cost of individual GFF products from manufacturers has not declined significantly over this period. This suggests patients were choosing to order smaller quantities of individual items per prescription, plus increasing the variety of products chosen within their allocated GFF allowance. The effect of this would be a reduced cost per prescription and an increase in the number of prescription items. This also corresponds with the information provided by patients and pharmacists in the questionnaire responses. Compliance with Health Board formularies which promote cost effective prescribing is also likely to be a factor in minimising any cost increases. This finding indicates achievement in part of the GFFS aim to allow eligible and qualifying patients' access to staple GFF through a convenient service customised to their needs which is also cost effective for NHS Scotland.

5.4 Gluten-free Food Prescribing Choices

The number of prescribed GFF items has increased across all food categories (Graph 4). The largest change in the prescribed GFF categories was a doubling in the cereals. Grains / flour prescribed along with the cooking aids also increased as necessary to utilise the flour. Both food categories had also seen a large increase in the financial year to March 2014 in comparison with other GFF categories. This particular GFF category increase also reflects the significant increase in the choices of gluten-free cereal available over the last 2 years.

Graph 4: Number of GFF items Dispensed per food category in the year before and after the GFFS Trial Service was introduced

Graph 5 overleaf shows the percentage increase in the number of dispensed items across all the GFF food categories from April 2014 to March 2015 compared to the year prior to the implementation of the GFFS trial. All GFF food categories had increased prescribed items with the lowest increase biscuits which were only on the formularies of half the Health Boards. Bread increased by 21% but is already by far the highest prescribed category.

The highest increase is in cooking aids which were previously prescribed minimally but are required for the mixes and flour which has increased by 30%. Cereals as a category had next highest growth of 133% but this is from a low prescribed volume previously. A 59% increase for crackers and crispbreads was also observed. The graph generally illustrates the increase in variety of GFF choices made by patients.

Graph 5: Percentage change in number of dispensed items in the year 2013/ 2014 and the year 2014 /2015 after the introduction of the GFFS Trial for the range of GFF categories

5.5 Prescribing Cost for Gluten-free Food Choices

The prescribing cost change in each category (Graph 6) reflects the increase in number of dispensed items. The largest effect was observed in cereals, unsurprising due to doubling of the prescribing volume. Although GFF cereals volume prescribed has doubled the largest dispensing cost category is bread at a gross ingredient cost of £2.4 million per annum. Local Health Board formulary choices reflect the variation in prescribing cost of gluten-free bread available with cost effective formulary choices made. The prescribing cost, manufacturer dependent, can be significantly higher than supermarket retail price. One supermarket 'own' brand of gluten-free bread costs £1.50 with another well known brand £2.50 with some others significantly higher.

The individual cost of other GFF categories is less than one fifth of the total cost of bread. The prescribing cost per item in general indicated a cost reduction (Graph 7).

Graph 6: Total prescribing cost (GIC) of GFF categories before and after the introduction of the GFFS Trial

Graph 7: Comparison of the cost per prescription item before and after the introduction of the GFFS Service

5.6 GFF Allowance Distribution across Food Categories

Graph 8: Percentage of the total prescribing for each GFF category before and since implementation of GFFS

The changes observed in Graph 8 illustrate the change in GFF allocation use by patients. The variation in food choices made by patients in using their GFF allocations is of interest. The significant change was a switch to more cereals and crackers /crispbread dispensed. As previously mentioned, the effect of an improved range of cereals available will be one factor in the growth. The only other category to have an increased share was crackers and crispbreads. Biscuits accounted for approximately 6.5% of the total GFF prescribed items a reduction from 7.5% previously.

5.7 Gluten-free food service (GFFS) support

Pharmacy Care Record (PCR) information

The Practitioner Services Division (PSD) of NSS provided information for the purposes of the review on the open and closed records created in support of the GFFS. It identified that 87.5% of the community pharmacies across Scotland had created at least one PCR with a maximum of 39 records in one pharmacy. It would be expected that Health Boards would seek to identify if a community pharmacy had not used the PCR that the pharmacy also did not have any patients receiving the GFFS. Graph 9 indicates the number of community pharmacies who opened at least one PCR record.

Graph 9: Total number of Community Pharmacies and the number of PCRs opened or closed for patients prescribed GFF as part of the trial service

5.8 GFFS Prescription Form information

PSD also provided for the review the number of GFF prescription forms submitted for March 2015 (Graph 10). There were 24,428 GFF prescription items in Scotland with 4719 patients identified using their CHI number, however as the average CHI completion for the submission was only 81% the patient numbers as an accurate reflection of number of patients within the GFFS require to be treated with great caution.

Graph 10: Number of GFF prescription items submitted per Health Board for March 2015

The number of contractors in each Health Board where no patient CHI number was captured is shown below in Table 3. The average percentage of community pharmacy contractors with no patient CHI number recorded is 4.7% presented in Graph 11. The effect is a current inability to accurately determine the number of patients receiving GFF prescriptions through community pharmacies including linking prescribing to GP practice for prescribing governance and cost allocation. This is also important from a payment verification perspective. The solution is electronic prescribing for the GFFS.

Table 3: Number of Pharmacy Contractors where no Patient has been recorded for GFFS

NHS Board	Total	NHS Board	Total
NHS Ayrshire & Arran	3	NHS Highland	3
NHS Dumfries & Galloway	2	NHS Lanarkshire	11
NHS Fife	4	NHS Lothian	7
NHS Forth Valley	1	NHS Tayside	5
NHS Grampian	3	NHS Western Isles	1
NHS Greater Glasgow and Clyde	19	NHS Scotland Total	59

Graph 11: Percentage of Health Board Community Pharmacies where no CHI was captured for the GFFS