Review of the Gluten-free Food Additional Pharmaceutical Service

7 Chapter 7: Recommendations

The evaluation of the GFFS trial using questionnaires, surveys and meetings of stakeholders produced results from which the following recommendations were produced:

7.1 The GFFS should be continued and embedded into NHS Pharmaceutical Services

Stakeholder groups were unanimous in their agreement that the GFFS should be continued as had generally delivered the objectives which had been set out to achieve.

7.2 Improved alignment of Health Board gluten-free food formulary choices, while still accounting for variations in local population need

At present, there is up to a ten-fold variation in the number of GFF product choices available for patients across the 14 Health Board GFF formularies. Stakeholders highlighted this variation, as an equity of access issue. Although local Health Board formularies differ to allow for local population needs, the reasons why the degree of present variation requires review. Patient participation in formulary development is recommended.

7.3 Establish regular updates to the National Gluten-free Food NHS Prescribable List which include sufficient information to support Health Boards in local formulary development minimising resource duplication

The regular update of the National Gluten-free Food NHS Prescribable List was highlighted as important by patients, GFF manufacturer respondents and dietitians. The list supports and informs the regular updating of all Health Board formularies. The inclusion of a range of information on the GFF products would assist standardisation of variables to be considered by a Health Board in deciding on formulary GFF product choices. There is also a need for a clear central point of contact for maintaining the list so that manufacturers know who to notify regarding new products. Suggested information for inclusion from stakeholders to support patient choice and cost effectiveness includes:

• Number of GFF units per item
• Shelf life of products to support minimisation of waste
• Minimum orders required particularly for fresh items with short expiry dates
• Delivery times required noting particularly timescales in remote areas.
• Cost of item based on 100g plus any carriage costs and handling charges
• Availability of mixed 'outers' to maximise cost effectiveness and minimise waste
• Differences in ingredients e.g. some GFF are fortified with vitamins/ minerals where others are not

7.4 Completion of the development and rollout of electronic prescribing forms for community pharmacy to undertake the service

The GFFS service use of the CPUS forms which require to be handwritten was highlighted as a significant problem. The prescribing of the various GFF choices takes considerable time and causes frustration for community pharmacists and patients. A further outcome has been the significant reduction in the patient CHI capture rate to 81% which impacts on payment verification and the need to manually process some prescriptions.

Practitioner Services Division of NHS National Services Scotland has a single electronic form in development for community pharmacy services. This is considered an important priority for completion and implementation in GFFS.

7.5 Rollout of Pre-printed GFF Order Forms with standardised data set and Gluten-free Online Service for patients

Patients highlighted frustration in the need to write out their GFF choices and then go to their community pharmacy to order their GFF. Some community pharmacies already provide an email service option. One suggested improvement is a standardised pre-printed order form with all relevant GFF ordering information criteria already provided and aligned with the local Health Board formulary. In at least two Health Boards a standardised pre-printed order form with check boxes has been introduced with patients and pharmacists declaring benefit. A lack of knowledge on the GFF available was also noted as a problem. To support greater access to information and help with the ordering process a gluten-free food online service has been in development within NHS Tayside and could be rolled out across Scotland.

7.6 Monitoring and further evaluation of the annual pharmacy coeliac health check to assess value to the patient

The evaluation highlighted a number of issues. These included concerns from a range of stakeholders on the value of the pharmacy annual health check. The results of the questionnaires also indicated that only 23% of the patient respondents had received an annual health check although 44% had been offered an annual health check which was similar to the offer rate prior to the introduction of the service.

GFFS has only been implemented since April 2014 with few patients transferred to GFFS for 12 months or more. A review of this aspect of the GFFS in one to two years would be of value to appropriately assess the benefits of the annual pharmacy adult coeliac disease health check and if any further refinement was required.

7.7 Annual re-registration for the service should be discontinued as coeliac disease is life long

Once a patient is assessed as having coeliac disease or DH, as a life-long condition, no annual re-registration is necessary to assess need for continued inclusion in the service. GPs will continue to be notified of new diagnosis or GFF unit changes through the dietetic services and provided with a record of the annual health check undertaken by the pharmacist at the designated community pharmacy.

7.8 Consider inclusion of patients resident in care homes within the GFFS

Stakeholders generally agreed that care home patients should be able to participate in the service as not to do so sanctioned inequity of service provision for care home patients. Non participation means GP have to continue to prescribe for care home patients which reduces the GFFS benefits. One service offered by community pharmacy makes monitoring and review of prescribing more efficient.

7.9 Further develop the pharmacy and dietetic processes and communication links to optimise use of professional skills including their prescribing roles

Views from the various stakeholders indicated that aspects of the service required development and improvement. Specific aspects highlighted varied between stakeholders but included:

• The formation of a standardised dietetic led patient pathway to support health Boards
• Improved communication pathways between community pharmacists and dietitians. Improved communication links would potentially allow dietitians to directly refer the patient to the community pharmacy of their choice. A copy of the dietetic assessment of the patient's GFF allowance requirements would also be sent to the GP practice. This would reduce the patient journey and GP workload plus increase dietitian and pharmacy communication which has not changed significantly since introduction of the GFFS in some areas
• Improve the Pharmacy Care Record (PCR) operational use as stakeholders highlighted problems in its functional capability and requested its linkage to the PMR
• When changing to another community pharmacy for any reason a system similar to the Minor Ailment Service (MAS) registration should be considered instead of the patient needing to return to the GP.

7.10 Consideration of other potential areas of prescribing where a similar service could improve patient access, improve skill utilisation reduce GP workload and improve cost effectiveness.

The prescribing areas identified for consideration were foods for special diets such as patients with phenylketonuria (PKU) and patients with metabolic conditions on low protein diets or patients requiring oral nutrition support. Also suggested for consideration were other areas of non-drug prescribing.