Review of the Gluten-free Food Additional Pharmaceutical Service

4 Chapter 4: Views of Stakeholder Organisations

Summary

• All stakeholder organisations and individual respondents were in favour of the trial GFFS and for the service to become embedded in NHS Scotland.
• The unanimous view was that GFFS should be continued with a general agreement that the service improved patient care and facilitated better use of clinician skills.
• There was general agreement that all the service aims were met.
• The annual health check due to the short time since the introduction of the service requires further assessment to confirm success.
• A number of improvements were suggested and particularly the urgent need for an IT solution to the current paper based ordering system within community pharmacy.
• The GFF manufacturers who responded suggested a number of criteria for consideration when reviewing prescription ACBS approved GFF for local Health Board formulary inclusion.

Introduction

To gain the views of the major stakeholders involved in the trial service, Scottish Health Boards, gluten-free food manufacturers and a number of stakeholders who would be affected by the GFFS were asked for their views. The questions asked mainly focussed on their opinion of the GFFS attaining the aims outlined in Appendix B of the NHS Scotland Circular: PCA (P) (2013) 295. We were also interested in their thoughts on retaining the GFFS, possible service improvements as well as any other issues the stakeholder group considered relevant.

Health Board responses were received from 7 of the 14 Health Boards and included NHS Ayrshire and Arran, NHS Fife, NHS Tayside, NHS Greater Glasgow and Clyde, NHS Highland, NHS Dumfries and Galloway and NHS Shetland. A response was also provided from NHS National Services Scotland (NSS).

Other stakeholders who responded included the National Pharmacy Association, British Dietetic Association, Coeliac UK, British Medical Association (BMA), National Services Scotland (NSS) and Community Pharmacy Scotland (CPS). We also had 5 responses from interested individuals.

Responses were also received from three gluten-free food manufacturers from the nineteen who were contacted by letter.

In order to obtain some further views from a cross section of the main stakeholders meetings were arranged with the Scottish General Practitioners' Committee (SGPC) of BMA Scotland, Coeliac UK, CPS, NSS and the Scottish Dietetic Network which represents dietitians across the Scottish Health Boards.

4.1 NHS Organisations

a. Support the provision of direct NHS pharmaceutical care to patients with coeliac disease or dermatitis herpetiformis by providing a pharmacy led nationally consistent service;

All Health Boards which responded indicated that the provision of direct NHS pharmaceutical care has been improved to this patient group. The service supporting patient care by the provision of a pharmaceutical care record, a patient assessment as part of the electronic registration process and an annual pharmacy health check. The responses indicated three specific issues which affected the consistency of the service provision:

• GFF formulary choices available across the different Health Boards vary significantly. This was illustrated by one Health Board where the geographic location created issues as neighbouring Health Boards have either a wider or narrower range of formulary products. The general consensus indicated a need for reduced variation in gluten-free food (GFF) formularies between Health Boards to improve consistency of the service across Scotland.
• Requirement for an electronic solution to handwriting CPUS to save valuable community pharmacy time, increase accuracy of prescriptions and improve CHI capture for monitoring and payment verification purposes.
• Inequity of service in rural areas where for example a sizeable proportion of NHS Highland's patients have their prescriptions supplied to them by dispensing GP practices due to geographic location as there is no local community pharmacy.

b. Make optimum use of clinicians' skills and empower the patients to actively manage their own condition;

There was unanimous agreement that improved patient empowerment had been achieved. The service empowering patients to take more control of their diet and manage their condition better. A stakeholder in one Health Board found the service had resulted in reduced dietetic appointment times and length of clinic letters.

All except one response agreed that the service allowed clinicians from different professions to use their skills better. Another positive noted was improved multidisciplinary working relationships between dietetics and pharmacy in developing the service to improve patient care.

c. Improve the patient experience of obtaining GFFs on prescription by reducing the number of visits needed to GP surgeries;

Experience within all Health Boards indicated there was a reduction in GP surgery visits where the service was used. The access and flexibility of the service provided through community pharmacies had definitely improved the patient experience. Responses indicated that the majority of patients appear satisfied with the service, particularly the opportunity to try different products more easily. One Health Board pointed out that where the service was not available the prescription burden on dispensing practices and their patients' experiences were unaltered.

One issue raised in a number of responses reflected on why some patients would not participate in GFFS. The reasons generally were certain patients were unhappy with the maximum number of units allocated as per national guidelines or the range of GFF on their local Health Board formulary. Two examples given were number of packets of biscuits a month or loaves of bread a week.

The recommendation from Health Boards to support resolution of this issue would be that no matter the prescribing point the maximum number of units was standard across all prescribers (GP and community pharmacist) and all Health Boards. A caveat would be that dietitians had the discretion to request additional units to support underweight patients especially children. The other was to have closer alignment of GFF Health Board formularies

d. Provide appropriate clinical monitoring for patients directly affected including dietetic intervention and annual pharmacy health check;

The Health Board experience to date suggests that although the service provides an annual pharmacy health check this has not yet been generally evidenced. One Health Board noted that the clinical monitoring through the annual health check had been useful for compliance with diet and identification of clinical signs of complications. It was also highlighted that the effectiveness of the previous system of GP annual reviews was never assessed.

The majority view was that the new GFFS provides every adult coeliac disease patient registered with the opportunity of an annual health check and therefore an improvement. NHS Tayside where this service has been available for a number of years noted that the annual pharmacy health check was valued by community pharmacists as a useful and effective tool. Another response noted that patients were reassured that they were to have an annual health check from the Community Pharmacist. Issues highlighted in responses included:

• Potential additional workload for undertaking annual blood tests as recommended by guidance from the British Society of Gastroenterology for patients recruited to the scheme.
• Request to add a generally accepted measure of bone health such as FRAX or Qfracture as part of the annual health check to distinguish patients who may benefit from DEXA scanning as these services have limited capacity.
• Lack of awareness in medical practices, that community pharmacists were providing a health check and should receive a standard letter back on the outcome.
• Further work nationally was required to ascertain if the annual health check is effective.

e. Provide more systematic nationally consistent management of patient needs;

The majority of responses were in agreement that the service improved consistency across Scotland but that there was more to be achieved. The main inconsistencies highlighted were some patients opting to stay with the GP prescribing due to ability to receive different quantities and items than from the GFFS. The other was the differences in Health Board GFF formularies. Each Health Board presently devises their own formulary from the National GFF List of prescribable items. The differences can present practical problems for cross-boundary patients who are registered with GPs and pharmacies in different Health Boards.

The possible resolution if appropriate would be a Scotland wide formulary and consistency in approach to GFF unit allocation no matter where the prescribing took place. Another point noted was to have a more systematic approach to the management of the entire coeliac disease / dermatitis herpetiformis (CD/DH) patient pathway. There was a suggestion that an NHS HIS CD/DH clinical standard may be required but that is far wider than the remit of the GFFS evaluation.

f. Allow eligible and qualifying patients access to staple Gluten-free Food to access a convenient service customised to their needs which is also cost effective for NHS Scotland

There was general agreement that this allowed patients who could access a pharmacy a customised service for their GFF needs. The Health Boards generally noted that although the number and range of prescribed items have increased overall, prescribing costs have not risen sharply. This appears to reflect the greater flexibility now available to patients to change the products on request at the pharmacy each month. One request from a number of Health Boards was to have a pathway to allow a patient to change community pharmacy for reasons other than moving home so that they do not need to re-register via the GP unless moving GP surgery. A possible solution would be to mimic the pathway used in the minor ailment service (MAS) to change community pharmacy.

It was observed that it was as yet too soon to determine the cost effectiveness as this would require knowledge of the service clinical effectiveness e.g. episodes of illness and associated costs averted that can be attributed to the service.

g. Assist through collaborative working the better management of the demand on the time of all members of the primary care team involved in providing this service to patients

There was general agreement that this has supported better demand management on members of the healthcare team. It was recognised that the majority of the work shifted from GP practice to community pharmacy staff. The main issue reported was the excessive time pharmacists spent in the manual completion of CPUS forms when recording patient orders. It was universally stated that in order for the service to progress electronic prescribing was essential.

Potential opportunities, to expand the existing system, to other nutrition areas such as low protein foods were noted. Another avenue of collaborative working between dietetics, GPs and community pharmacy was provision of oral nutritional supplements. Provided robust nutritional screening and pathways were in place community pharmacy prescribing of oral nutritional supplements could reduce patient journey and improve patient care as well as cost effectiveness.

h. Remove the need for a GP to be involved in issuing multiple gluten-free prescriptions once he/she has determined the unit allocation and the patient has registered with a pharmacy

There was a unanimous response that this service had freed up GP time. One service proposal for the future was for dietitians and not GPs to decide on unit allocation and commence patients on the GFFS with direct referral to the community pharmacist. This move to remove GP from the GFFS has been done in collaboration with GPs in NHS Tayside.

i. Reduce the incidence of out of pocket expenses incurred as a consequence of community pharmacy dispensing of individual prescriptions for gluten-free foods written by GPs.

Health Boards observed that the out of pocket expenses (OOPE) reduced significantly when the four main manufacturers stopped charging in the year before the GFFS trial started. During the trial there has been little change in OOPE. One contributor suggested that this was likely due to local GFF formularies that in general do not include items with OOPE. This would be a general ongoing recommendation to ensure best value formularies are provided along with maximum choice for patients.

j. Should the new GFFS be retained on an ongoing basis?

There was unanimous agreement that this trial service should be retained and expanded to improve patient access and care where appropriate.

k. Are there improvements or changes required to the trial GFFS should the service be retained?

A number of areas for improvement were raised by Health Boards for consideration:

• A regularly updated national GFF ACBS approved food list for prescribing applicable across all primary care clinicians. This would inform and improve consistency across Health Board formularies.
• Increased utilisation of dietitians when initiating treatment to provide a recommendation of the required number of GFF units directly to community pharmacy with a copy to the GP for their records.
• Clarity of the medical monitoring role and annual blood tests including which parameters should be monitored.
• An electronic means of generating CPUS forms was essential rather than the current paper copy when recording products for patients. The development would help address the current issues regarding CHI completion / accuracy and consistency in item selection and description.
• Influence manufacturers to supply smaller minimum quantities e.g. 'outers' of fresh bread etc. This limits some patients' options with their unit allocations while there was awareness that currently the majority of the fresh bread companies bake the bread to order.
• Access to a GFF Online Service across Scotland which will improve access to people with health literacy issues.

l. Are there any specific issues you would like to raise relevant to the evaluation of the trial GFFS?

One Heath Board questioned the requirement of GFFS as a pharmacy service as GFF products are not medicines, although as Borderline Substances they are regarded as having the characteristics of drugs in certain circumstances.

Certain issues were raised concerning prescription processing including

• A lack of standardisation of prescribing items, with often no standardised dm+d code.
• Payment Verification is significantly affected by incomplete or missing CHI mainly as a result of the handwriting of GFF prescriptions on the CPUS forms. A number of stakeholders recognised that with around 19% of the CPUS forms paid do not have a complete/accurate CHI which significantly impacts on the ability to undertake any patient level analysis.
• Health analysis using a low CHI capture rate means using patient numbers produces inaccurate results. It was also noted that the assignment of patient to the host GP may at this time also be not 100% successful.
• Patients receiving GFF prescriptions from their GP were highlighted. Although small numbers anecdotally, the perception is that the patient choice to stay with the GP was due to ineligibility as had effectively "self-diagnosed" or may not have had formal diagnosis to be eligible for the GFFS scheme. Another perception was some patients may have remained with their GP to receive non formulary GFF items on prescription.

4.2 Other Stakeholder Organisations

Stakeholder organisations external to the NHS that provided views on the trial included the British Medical Association (BMA), British Dietetic Association (BDA), Coeliac UK, Community Pharmacy Scotland (CPS) and National Pharmacy Association (NPA).

All respondents supported the trial service with one respondent stating it had been very well received by general practice and was consistent with the aims of both the Scottish GP Committee and the Scottish Government to ensure GP practices are focused on appropriate activity. Another respondent noted that their membership appreciated the opportunity the service provided to significantly contribute to the care of this patient group.

a. Support the provision of direct NHS pharmaceutical care to patients with coeliac disease or dermatitis herpetiformis by providing a pharmacy led nationally consistent service

All stakeholders agreed that this aim was met while also noting inconsistencies between NHS Health Boards in the interpretation on some aspects of the guidance. A consistent message from the stakeholders was that the GFFS provides a service with the potential to improve patient experience and adherence to a GFF diet.

One stakeholder highlighted that the service builds upon the fundamental strengths of prescribing in Scotland enabling GFF to be available, accessible and affordable for people with coeliac disease. Another stakeholder noting the service meant pharmaceutical care was provided when necessary.

b. Make optimum use of clinicians' skills and empower the patients to actively manage their own condition

The consensus was that this aim was met with patients now able to self- manage their diet and condition better as can change their prescription without going through a GP. There was also the perception that the calculation of food allowance should lie with the professionals who diagnose or initiate treatment rather than the GP.

One respondent noted that previously many patients had unchanging prescriptions which may suggest inappropriate dietary management of their condition. They also often missed appropriate clinical monitoring and professional dietetic advice. Another stakeholder noted that patients through the service recognised the pharmacist as a useful source of clinical advice and also observed that a strong clinician-patient relationship was built through the registration process and the frequent patient pharmacist encounters due to ordering GFF products. This enables the pharmacist to monitor the patient's wellbeing and refer where appropriate. The annual adult pharmacy coeliac disease health check empowered pharmacists to have significant patient care interventions, collate patient data and formalised the ability to refer patients directly. The PCR information was considered useful to support developing improvements in patient care.

c. Improve the patient experience of obtaining GFFs on prescription by reducing the number of visits needed to GP surgeries

The experience across all the stakeholders was that there had been a reduction in the number of visits to GP surgeries which by inference indicated an improvement in the patient experience.

d. Provide appropriate clinical monitoring for patients directly affected including dietetic intervention and annual pharmacy health check

The view of the stakeholders was that the introduction of the annual check in principle, was supported but they were not yet able to comment if the annual health check has provided any positive impact. One reason was it may be too early in the programme to determine the impact with GPs, as not yet routinely receiving information on the annual pharmacy checks.

e. Provide more systematic nationally consistent management of patient needs;

All the respondents agreed this was a positive development in the provision of a national standardised service from pharmacies available to patients across Scotland. It was noted was this service improvement was only for patients diagnosed with Coeliac Disease or DH but not patients ineligible by living in care homes or patients previously prescribed GFF but with no formal diagnosis.

The service also only provides a more nationally consistent management for patients registered with a pharmacy for the service. Patients who are unaware of the service, in dispensing GP practices or decide to remain receiving GFF prescriptions from their GP do not receive the benefits of the service.

f. Allow eligible and qualifying patients access to staple Gluten-free Food to access a convenient service customised to their needs which is also cost effective for NHS Scotland

There was a general recognition in the value of the service provision to patients with an acknowledgement of possible variation across Scotland in the definition of eligible and qualifying patients. The additional work undertaken to provide the service by community pharmacy was also highlighted.

The service was perceived as cost effective to the NHS by reducing GP practice appointments, prescription waste and maintaining clinical monitoring which according to one stakeholder decreases acute hospital and clinic referral admissions. The service potential was for a more customised service resulting in a more varied diet using fresher products, increased promptness of supply resulting in a reduction in wasted foods.

Another stakeholder noted, the experience of similar schemes in individual Clinical Commissioning Groups in England, showed that a pharmacy led scheme offers improved product control. Pharmacists are in a better position than GPs to identify and source products without incurring out of pocket expenses. In addition, the service enables pharmacists and people with coeliac disease the opportunity to work together to ensure only those items and quantities that are required are ordered, leading to further product control over supply and costs.

g. Assist through collaborative working the better management of the demand on the time of all members of the primary care team involved in providing this service to patients

The consensus was that collaborative working was supported as improves efficiency and provides for a much greater patient experience. One example provided was the ability for direct referral from the pharmacist to the patient's GP which provided the assurance that the clinical issue would be followed up. One stakeholder noting that the introduction of this guidance followed the production of the evidenced-based Coeliac Disease pathway which was designed by a wide range of practitioners in primary care.

h. Remove the need for a GP to be involved in issuing multiple gluten-free prescriptions once he/she has determined the unit allocation and the patient has registered with a pharmacy

There was general agreement that this aim had been achieved with GP time overall reduced. Issues raised which require review included why the need for a signed pharmacy referral form from their GP as a repeated GP appointment was required, if the correct paperwork was unsigned. The second issue was the need for a patient to return to the GP if they decide to change their registered community pharmacy.

i. Reduce the incidence of out of pocket expenses incurred as a consequence of community pharmacy dispensing of individual prescriptions for gluten-free foods written by GPs.

Overall there was agreement that these expenses appear to be reduced but required evaluation. One stakeholder noted that owing to some distribution companies altering practices, there has been evidence of an increase. There was agreement that ongoing work was needed to ensure that best value is possible for NHS boards while maintaining sufficient GFF variety for patients.

j. Should the GFFS be retained on an ongoing basis?

All respondents supported the retention of GFFS and its establishment on a permanent basis for the benefits to patient care and NHS Scotland efficiencies.

One stakeholder response stated 'Feedback indicates that everyone involved with the service likes it'. Another from a stakeholder constituent summed it up in the comment:

"Yes, it's a very easy Service to use. Simply fill in the form with the items and codes, take to your pharmacy and pick up when ready. There is now no putting in prescriptions, no waiting days, no taking it to the pharmacy, and also no GP appointments just to change items. It has better flexibility when working nine to five as you do not need to visit the GP."

k. Are there improvements or changes required to the trial GFFS should the service be retained?

A number of possible improvements were suggested:

• Minimise GP involvement

One stakeholder indicated in their view, there was no need for GP practice involvement after a patient's referral to gastroenterology with dietitians rather than GPs determining the amounts of GFF required. The patient could take a copy of the completed form to the community pharmacist with the practice separately electronically receiving this information. A copy of the annual health checks report should go to GP practice and if a pharmacist believes a patient requires further investigations then the GP practice should be contacted.

• Service provision

• Consideration to extend the service to care home patients
• Ensure all CD/DH patients are referred to the pharmacy service

• GFF prescribing
• Provide a national GFF formulary, to improve consistency of service provision particularly where a patient's pharmacy and their GP practice reside in different Health Boards
• NHS Scotland to work with GFF manufacturers to develop patient convenient pack sizes of products

• Electronic enhancements
• Provide electronic solutions to prescription provision, claims and reporting
• Linking the Patient Care Record electronic system to the pharmacy Patient Medication Record with appropriate authorisation safeguards
• Providing an electronic solution to registration that can be transferred with the patient, for example in the case of patient relocation
• Develop a national electronic online service
• Provide an NHS public awareness campaign of the GFFS
• Specify regular audit and review of the service
• Analyse patient and prescription data with regard to improved patient outcomes, sustained community pharmacy workload and NHS efficiencies. Suggestion was these factors should influence future service settlements within the Scottish Pharmacy Contract.

l. Are there any specific issues you would like to raise relevant to the evaluation of the trial GFFS?

The specific issues mentioned by the respondents are a reiteration of some specific concerns highlighted earlier. These included:

• GPs are not best placed to determine the unit allocation.
• Support for the National Prescribing Guidelines and for Health Boards to continue making decisions on prescribed items based on these Guidelines noting restrictions on items prescribed would impact most on vulnerable patients due to low income and/or poor mobility.
• A request for a national formulary, to support the aim to 'provide more systematic nationally consistent management of patient needs'. This would avoid regional variations between local formularies and therefore patient choice and an issue consistently coming in feedback from one Stakeholder.
• Requirement for better communication between Health Boards and in Health Boards around their prescribing policies. This includes consultation of those using the service should be undertaken prior to changes in items prescribed.
• Two stakeholders emphasized the high priority need for an electronic solution to writing and claiming GFF prescription.
• Request that all patients have ability to choose to access the pharmacy service rather than retain prescription ordering with GPs.
• The GFFS provides improved patient management and efficiency for NHS Scotland. It necessitates however increased pharmacist time for patient care and electronic and paper bureaucracy which should be remunerated appropriately.

4.3 Gluten-free Food Manufacturers

Three of the 19 gluten-free food prescription manufacturers contacted to ask their views on the trial service responded. Below are the views of these three manufacturers:

Two expressed a welcome of the service however the third did not. This manufacturer expressed specific concern about the lack of direct communication about the GFFS prior to launch. The same manufacturer considered there was restrictive practices in terms of the inclusion on National GFF ACBS approved list due to non inclusion of their products. In their opinion this was detrimental to patient care, well-being and choices. However, the National GFF ACBS approved list contains all GFF approved by ACBS for prescribing.

Another of the other manufacturers noted anecdotally they had received positive support from patients regarding the trial service. They also welcomed the collaborative approach from the implementation team in checking with manufacturers in order to finalise overall national GFF list. All three manufacturers expressed their preparedness to move forward positively with the national GFF list reviews. They all expressed criteria for consideration when reviewing a product for inclusion into the national GFF prescribable list:

• Differences in ingredients e.g. sugar content between different pasta.
• Ensure any key new lines can be considered for incorporation within reasonable time periods.
• Price review should compare the cost of any item based on 100g including carriage and handling costs to allow accurate comparison. The need to be aware of price maintenance variation between manufacturers was also highlighted.
• Minimum pack sizes require attention due to potential for waste. It was noted that mixed outers are potentially available to maximise cost effectiveness and minimise waste.
• Shelf Life of Products was an issue as a long shelf life provides a longer period for consumption helping to eliminate potential waste and supporting cost effectiveness.
• Delivery times required noting particularly timescales in remote areas.

4.4 Individual Responses

There were responses from two GPs as individuals, one dietitian and one pharmacist. All four were positive about the trial and favoured continuation in the longer term. The positives highlighted by one or more of the respondents included the quote, 'positive change in service for patients with coeliac disease'. Another observed an improved consistency in the amount prescribed to individual patients and that the single access point prevented duplication of work including the 'unnecessary inconvenience of a prescription for both patient and GP surgery'. A question on GFF prescribable units, their calculation and the value of an electronic ordering system was also noted.

One respondent had a query about the necessity of a tissue diagnosis particularly for those with a diagnosis for a long time but where they lacked tissue diagnosis as some patients were infirm. The respondent proposed there should be exceptions to the eligibility criteria if for medical reasons a return to a gluten containing diet for a period followed by endoscopy was contraindicated.

Another issue was the need for clarity on responsibilities and funding around the annual review requirement with blood tests and consideration of DXA scan. More national guidance on when and why review should be offered may assist and prevent or reduce variations in care was suggested.

The dietitian also raised concerns that to date localised referral/review pathways were being established which might lead to variations in care offered to adult coeliac patients throughout Scotland.

4.5 Stakeholder Meetings

4.5.1 Coeliac UK

As a key stakeholder representing patients with coeliac disease a meeting was convened to provide an opportunity to communicate directly into the review. This was additional to the response Coeliac UK provided to the survey.

The following is a list of points which Coeliac UK were interested to find answers for within the evaluation:

• Improved ease to order and change GFF orders due to the importance of identifying if patients were changing and varying their diet.
• Adherence to a GFF diet is important and analysis on adherence before and after the GFFS trial would support the evaluation.
• Analysis to indicate whether GP time was saved as a result of the scheme.
• Consider any clinical benefits of the scheme in terms of nutrition, by looking at the consistency and variation between the Health Board formularies and their relationship with the national food list from which local formularies are taken Review of delivery charges and identify any distribution issues particularly in relation to more rural areas.
• Analyse the costs and volume including changes since GFFS was introduced, looking at per patient cost.
• Consider improving awareness amongst users and explore what further analysis can be undertaken on trends in GFF dispensed.
• Identify why there is variation in GFFS uptake across different Health Boards.

Additionally Coeliac UK asked to be given reassurance that the annual health check element of GFFS is equivalent in standard and quality to that already offered by dietitians, plus assurance that pharmacists had appropriate skills and knowledge to know when, and who, to refer a patient for follow-up.

4.5.2 Community Pharmacy Scotland (CPS)

The positive meeting provided CPS a direct opportunity to feed into the review specific points, concerns and issues raised by community pharmacists. Overall CPS was encouraging about the GFFS and its continuation with issues centred on three main aspects:

• No electronic system for generating prescriptions which significantly increased community pharmacy contractor workload which was in addition to increased number of prescriptions generated.
• GFF formulary aspects contributed significant concerns. This ranged from formulary variation across Health Boards, concerns about distribution, ordering quantities and availability of the formulary items particularly in relation to fresh bread. Other formulary issues included out-of-pocket expenses if contractors were not ordering from the same supplier
• Administration issues such as need to refer patients back to their GP if moving community pharmacy. CPS also highlighted that some contractors and pharmacists found it easier to navigate and populate the PCR than others. It was noted that generating reports at individual patient level was easier than generating management information.

4.5.3 Scottish General Practitioners' Committee (SGPC) of BMA Scotland

The SGPC welcomed the GFFS particularly as in their opinion it had reduced GP workloads. The discussion ranged on a number of issues noted below.

The SGPC discussed the current process and queried if the GP was the correct person to determine the number of units for a patient rather than a dietitian and noted that more complex patients tend to stay with gastroenterologist. In general the preference would be that dietitians would determine patients' needs in terms of number of units they are entitled to rather than GPs. For instance, the gastroenterologist confirms the diagnosis and writes to the GP while the dietitian determines patient's needs and gives them the referral form to take to their pharmacy of choice. The discussion then led on to the GFFS annual re-registration. The SGPC view is that this is unnecessary as once diagnosed with coeliac disease it is a lifelong condition. It was also noted that the pharmacy health check had not resulted in concerns about requests for investigations.

SGPC raised their concerns that anecdotally GPs were being asked to prescribe 'around' a gluten-free food local Health Board formulary due to the restrictive choices available within the Health Board formulary.

In terms of future developments the SGPC raised the possibility of other oral nutritional prescribing following a similar service was mentioned e.g. low protein foods as the GP is only mandating for a condition that patient is not going to recover from. The ineligibility of care home patients was raised and SGPC enquired if this would be reconsidered. Other developments would be around process such as information transfer electronically rather than paper e.g. information from a pharmacy annual health check.

4.5.4 Scottish Dietetic Leadership Network

The meeting with this network was very supportive of the trial service and strongly supported its continuation. The discussion covered a range of the GFFS aspects and future development suggestions.

• GFFS Trial Points

It had been expected that referrals to dietetics as a result of pharmacy service would have increased but this had not occurred suggesting no large increase in diagnosis. NHS Tayside, however, had seen a doubling of diagnosis of new patients over last year in part due to a local awareness campaign and improvement in the patient pathway which ensured that dietitians always treated newly diagnosed patients.

• It was noted that the new service had identified patients not diagnosed or those wrongly receiving GFF.
• The dietitians were looking forward to a GFF online service. It was highlighted that patients would like to add product reviews and also information regarding storage instructions on the online service.
• Communication between dietitian and community pharmacist was an area where electronic connection would be very helpful.

• Gatekeeping Role

There was a discussion on the possibility of dietitians rather than GPs taking on the gatekeeping role due to their skills and knowledge in this area of practice which had already occurred in NHS Tayside. This would however have resource implications for the dietetic service as further roles would be introduced such as communication with other healthcare professionals etc. Questions such as would the pharmacy annual health check still send issues back to GP or to dietitian instead if they became the gatekeeper would require to be thought through. The introduction of supplementary prescribing for dietitians will fit with the gate keeping role allowing dietitians to work at the top of their competency. Overall agreement was that dietitians would welcome this development.

• Dietetic Pathways.

The group all agreed that there was a need for Health Boards to facilitate the establishment of clear, appropriate pathways for all patients to follow as currently not evident in all Health Board areas with appropriate stakeholder involvement e.g. gastroenterologist. The need for standard operating procedures was noted and an acknowledgement that the autumn publication of NICE guidelines would inform pathways.

• Formulary

The variation between Health Board formularies was raised due to resultant issues for patients on the border between Health Boards. Stock delivery issues were also highlighted. For consideration, was the suggestion of national criteria to help Health Boards prepare their local formulary.

4.5.6 National Services Scotland (NSS)

The discussion focussed principally on specific prescription processing and payment issues with one positive concerning the observation of reduced "on-cost". The issues were due to the lack of standardisation of prescribing items as what is written on a prescription can be tricky to track in dm+d (unique code for the prescribed item) and eVADIS.

• This was the result of the handwritten prescription forms, no dm+d code support plus incomplete or missing CHI (patient identifier). The effect of handwriting the CPUS forms (pharmacy prescription forms) had resulted in governance issues within payment verification, as a fifth of the CPUS forms paid did not have a complete/accurate CHI which affected ability of patient level reporting.
• The low CHI capture rate also added to imperfect assignment of patient to the host GP and impacted on ability to undertake health analysis.
• Another observation was the retention of some prescribing by GPs other than care home patients who were ineligible. The probable reasons were considered to include non formulary prescribing, as well as patients who had not been formally diagnosed which allowed patients eligibility for the GFFS.

NSS highlighted two developments which would resolve most of the above issues

• Electronic support for pharmacy-led services is being actively progressed which would help address the current issues in GFFS regarding CHI completion / accuracy and consistency in item selection and description.
• Changes have also been raised to allow report on patient use of the service for those managed through this service although this reporting is impacted by the CHI completion and item selection as noted above.