NHS England » Items which should not routinely be prescribed in primary care: policy guidance

How was the guidance developed?

We have worked with a multidisciplinary, clinical working group and NHS Confederation, and consulted widely with stakeholders to develop the guidance which has been reviewed several times since first publication in November 2017.

The first version included recommendations on 18 items (see consultation report of findings). In 2018 the guidance was reviewed; one of the 18 items was updated and 7 new items were added (see consultation on updated guidance).

In 2022, the guidance was reviewed again. The joint clinical working group responsible for developing the commissioning guidance considered:

the impact of guidance including prescribing activity and feedback from patients, professionals and organisations;
Updates to evidence or policy; and,
Impact on equalities and health inequalities.

Groups of people who could be impacted by the recommendations in the guidance were engaged with the review process and had the opportunity to provide feedback on the draft recommendations. The final recommendations set out in this guidance document reflect the outcome of the 2017 and 2019 consultations and the 2022 engagement. They were approved through NHS England’s medicines optimisation governance structures and publication approval process.

What has been updated in 2023?

The guidance is now aimed at integrated care boards and other organisations that commission NHS services, along with prescribing healthcare professionals.

The guidance is now in an accessible format.

The following items or conditions have been updated:

Aliskiren – updated background and rationale
Amiodarone – updated guidance links, added information about patent expiration, and clarified recommendation around shared-care arrangements.
Co-proxamol – updated the background and rationale
Immediate-release fentanyl – updated the background and rationale
Herbal treatments – changed name to include “and other natural products” and updated the background and rationale.
Liothyronine – updated background and rationale to link to the recently published British Thyroid Association (BTA) and Society for Endocrinology (SoE) joint consensus statement, and NHS England Liothyronine – advice for prescribers.
Omega-3 fatty acid compounds – updated background and rationale
Paracetamol and tramadol combination products – change of category and updated background and rationale
Rubefacients – updated to include other similar products, background and rationale
Once daily tadalafil – the item is removed from the guidance due to its price now being comparable with the “as required” treatment.

How will the guidance be updated in future?

NHS England will review the guidance every 3 years or more frequently if new evidence emerges that could lead to a change in the recommendations. The review process will consider:

Impact of the guidance implementation including prescribing activity and feedback from patients, professionals and organisations;
Updates to evidence or policy; and
Impact on equalities and health inequalities.
potential conditions to be retained, retired or added to the current guidance.

All relevant stakeholders will be engaged with when there are proposed changes to the guidance.

Have you considered the affect on health inequalities?

The potential impact of these recommendations on equality and health inequalities has been considered and is outlined in the Equality and Health Inequalities Impact Assessment documents (Nov 2017, June 2019) published alongside this guidance.

What is the aim of this guidance?

The NHS is here to help people to get the best results from their medicines – and to ensure we get the best possible value for the taxpayer at the same time. The guidance aims to support ensuring the best use of precious NHS resources. We cannot afford to:

Take medicines when there is no benefit, or when they can cause harm; or
Use medicines which are not cost-effective.

We are asking everyone who works in or uses the NHS to support the decision on items included in the guidance – so that we improve people’s health and increase safety. Every unnecessary item that is prescribed means fewer funds are available to help someone else when they need it.

Why has once daily tadalafil been removed from the guidance?

Once daily tadalafil was included in the 2017 and 2019 versions of the guidance. At that time it was much more expensive than the equally clinically effective “as required” formulation. Once daily tadalafil is a safe, effective medicine and its price is now comparable with the “as required” formulation.