It's quite a long time since I looked at the full list of gluten-free foods available on prescription to people with coeliac disease. That's because in my area, as in many other parts of the UK, GPs have been advised that they should only give bread or flour on prescription. It's one of those compromises the NHS seems to be making so often these days in its attempts to save money.
Today saw further news of possible cost-saving measures. NHS England has identified a review of 'low value medicines' after local health bodies identified a possible £400 million in savings if GPs stopped prescribing some indigestion remedies, cough and cold treatments, gluten-free foods and travel immunisations.
Every GP has sighed regularly at the patient who phones for an 'urgent' prescription for paracetamol tablets. I've lost count of how often I've explained they can be bought over the counter for about a penny a piece - and had the response that 'I pay my taxes'. Yet 32 paracetamol tablets, which would cost 40p from a supermarket, cost the NHS several pounds after pharmacist's dispensing charges etc. are taken into account.
Should people have to pay for paracetamol for colds or aches and pains? In my opinion, absolutely. But should we ban them from prescription completely? That's much harder. For safety reasons, you can only buy 32 at a time - and for a housebound patient on maximum dose paracetamol for severe osteoarthritis, getting out to the shops every three days is not an option.
If paracetamol is available at all, some people will abuse their 'right' to get it. If it's banned, some vulnerable patients will suffer. Not as easy a choice as you might think.
Sometimes we've tried to move the NHS forward, adapting it to be more cost effective, and the result is, quite frankly, a mess. Take travel health. Travel immunisations used to be available free on the NHS for all. Then someone suggested that if people could pay to travel to exotic locations, they should be able to afford to protect themselves from infectious disease while they were there.
Aha, came the reply. But what about those people who don't have a choice - say, those called home to Africa or India urgently for a family emergency? And if the NHS doesn't pay, surely lots of people will risk foreign travel unprotected rather than paying for immunisations. Back and forth went the debate until we came up with the following:
- If you're travelling to a country which needs infectious disease immunisation which have always been available on the NHS, they're mostly free
- If you need protection against Yellow Fever, you have to pay for that
- If you're going to the same country but the advice is that you need malaria tablets as well, you have to get a private prescription for them
- If we develop immunisations against new diseases in the future, you'll have to pay for them
- If you're an essential health worker (like a nurse or doctor in General Practice) you aren't automatically eligible for immunisation against infectious diseases such as hepatitis B.
I get that not everyone who travels abroad is rich. I understand that if people do economise by not paying for travel immunisations, the NHS would have to pick up the pieces if they became ill on their return. But in my view, if the NHS makes some healthcare workers pay for their own immunisations, it should make travellers pay too.
The great gluten free debate
When gluten-free foods were first made available on the NHS in the 1970s, it was nigh on impossible to find them in the shops. By the time I became a GP in the 1990s, they were slowly filtering in to bigger supermarkets, but were still pretty eye-wateringly expensive. Today, courtesy of the thousands of unqualified 'nutritionists' who seem to diagnose everyone they see with 'gluten intolerance', shops have seen an opportunity and seized it. Gluten-free foods are everywhere, and as they become ever-more popular, their price has plummeted. You can buy 500g of gluten-free pasta for £1.20 - exactly the same as a branded packet which contains gluten in the same store. Gluten-free bread costs from £1.50.
Yet I regularly get requests for multiple prescriptions of gluten-free food from people who smoke - £8 a day on cigarettes they can afford, but £1.20 for gluten free pasta is the NHS's responsibility. Obviously that's an extreme example, and it's not the patient's fault they have coeliac and need to avoid every trace of gluten for ever. But people with life-threatening nut allergies can't get nut-free food on prescription.
Should there be a compromise? Should we be able to prescribe gluten-free products for children, people at risk of malnutrition and those on income support? Possibly - although that system might be desperately complicated to maintain, and would lead to a postcode lottery unless it was nationally monitored. Are people with coeliac right to say that the foods they get on prescription are 'staple foods', meaning they are the mainstay of the average diet? I get plenty of complex carbohydrates in my diet through lentils, beans, brown rice and potatoes, but I virtually never touch gluten-containing foods. And looking through the list of foods I can prescribe, I spot shortcake biscuits. A staple food? Really?
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