This policy guidance is issued as general guidance under section 14Z51 of the NHS Act 2006 to reduce unwarranted variation, improve patient outcomes and provide value for money for the NHS. It provides recommendations for items that are available over the counter (OTC) and should not be routinely prescribed in primary care because:

• there is limited evidence of clinical effectiveness for the item
• the item would be prescribed for a condition that is self-limiting and will clear up on its own without the need for treatment
• the item would be prescribed for a condition that is appropriate for self-care.

These items include medicines, devices, food supplements and other items that can be prescribed.

This guidance is for:

• prescribing healthcare professionals
• integrated care boards (ICBs)
• organisations that commission services.

The recommendations do not override the individual responsibility of healthcare professionals to support their patients in agreeing the most appropriate treatment options for them, through taking a shared decision-making approach.

Policy recommendations

All the recommendations in this policy guidance are ‘do not prescribe’ recommendations.

Items with limited evidence of clinical effectiveness

Recommendation

Do not prescribe.

This recommendation applies to:

• probiotics
• vitamins and minerals, except:
  • when the patient has a medically diagnosed deficiency, including for those patients who may have a lifelong or chronic condition, or have undergone surgery that results in malabsorption. Continuing need should however be reviewed on a regular basis. Maintenance or preventative treatment is not an exception
  • calcium and vitamin D for osteoporosis
  • prescription-only vitamin D analogues such as alfacalcidol
  • malnutrition including from alcoholism (see National Institute for Health and Care Excellence guidance)
  • patients suitable to receive Healthy Start vitamins, which are available to pregnant and breastfeeding people, people with a child under 1 year old, and children under the age of 4 (note: this is not on prescription but commissioned separately).

Self-limiting conditions

Recommendation

Do not prescribe unless the patient has:

• symptoms that suggest the condition is not minor
• ‘red flag’ symptoms (for example, indigestion with very bad pain).

Items to which the recommendation applies

The recommendation applies to over the counter (OTC) items used to treat the following:

• acute sore throat
• infrequent cold sores of the lip – the recommendation does not apply to immunocompromised patients
• conjunctivitis
• coughs, colds and nasal congestion
• cradle cap – the recommendation does not apply if the condition is not improving and is causing the infant distress
• haemorrhoids
• infant colic
• mild cystitis.

Minor conditions suitable for self-care

Recommendation

Do not prescribe unless for:

• managing a long-term condition (for example, regular pain relief for chronic arthritis or treatments for inflammatory bowel disease)
• treating more complex forms of minor illnesses (for example, severe migraines that are unresponsive to OTC medicines)
• managing presentations of symptoms that suggest the condition is not minor
• ‘red flag’ symptoms (for example, indigestion with very bad pain)
• patients with complex conditions (for example, immunosuppressed patients)
• treating an adverse effect or symptom of a more complex illness
• treating a minor condition suitable for self-care that has not responded sufficiently to an OTC item
• circumstances where the prescriber’s clinical judgement is that these are exceptional and warrant deviation from the recommendation to use self-care
• individual patients where the prescriber considers that the patient’s ability to self-care is compromised because of medical, mental health or significant social vulnerability to the extent that their health and/or wellbeing could be adversely affected if reliant on self-care
• circumstances where the product licence does not allow the item to be sold OTC to certain groups of patients. These may vary by medicine, but could include babies, children and/or women who are pregnant or breastfeeding. Community pharmacists will be aware of what these are and can advise accordingly.

Being exempt from paying a prescription charge does not automatically warrant an exception to the guidance. Consideration should also be given to safeguarding issues.

Items to which the recommendation applies

The recommendation applies to OTC items used to treat the following conditions:

• mild irritant dermatitis
• dandruff
• diarrhoea – the recommendation to not prescribe does not apply to children
• dry eyes or sore tired eyes
• earwax
• excessive sweating
• head lice
• indigestion and heartburn
• infrequent constipation
• infrequent migraine
• insect bites and stings
• mild acne
• mild dry skin
• mild to moderate hay fever or seasonal rhinitis
• minor burns and scalds
• minor conditions associated with pain, discomfort or fever
• mouth ulcers
• nappy rash
• oral thrush
• prevention of dental caries
• ringworm or athlete’s foot – the recommendation to not prescribe does not apply in cases of lymphoedema or history of lower limb cellulitis
• sunburn due to excessive sun exposure
• sun protection – the recommendation to not prescribe does not apply in cases of Advisory Committee on Borderline Substances approved indication of photodermatoses, where skin protection should be prescribed
• teething or mild toothache
• threadworms
• travel sickness
• warts and verrucae

Implementation

Integrated Care Boards (ICBs) will need to make implementation decisions locally, ensuring they consider their legal duties to advance equality and have regard to reducing health inequalities.

Prescribers should follow local policies in their prescribing practice.

Community pharmacy

Community pharmacists can play an important role in reducing prescribing of over the counter (OTC) items for minor and self-limiting conditions.

NHS England is committed to ensuring patients receive the right treatment at the right time. The NHS Pharmacy First Service builds on existing pharmacy services that support many patients who present directly to the pharmacy, by offering advice and OTC medicines for acute self-limiting symptoms. It utilises the skills of community pharmacists, who are able to manage minor conditions and advise on the appropriate treatment course. NHS patients in England who need access to prescription-only medicines and would previously have been directed to a general practice for a prescription, or who require a repeat clinical assessment or who may face a delay in accessing the right treatment, can use the Pharmacy First Service for the 7 clinical pathways the service covers and receive the appropriate treatment within the pharmacy.

The NHS Pharmacy First Service incorporates and builds on the previous Community Pharmacist Consultation Service (CPCS), to enable community pharmacy to complete episodes of care for 7 common conditions following specific clinical pathways. Patients contacting NHS111, 999, their GP practice, an urgent and emergency care setting or other primary care service about minor and self-limiting conditions should be routed in the first instance to a community pharmacy.

If the pharmacist thinks a patient needs treatment to help with symptoms, they can recommend an OTC item that can be purchased or they can provide information about self-care. In addition, the Pharmacy First Service will enable the management of common infections by community pharmacists through offering self-care, safety-netting advice and, only if appropriate, supplying certain OTC and prescription-only medicines via clinical protocol and patient group directions. This frees up GP appointments and emergency departments to focus on patients who need their help most, and ensures that patients are not inappropriately prescribed OTC items for minor and self-limiting conditions. If the pharmacist thinks a patient needs urgent care, they can refer to the appropriate service. This ensures patients get the right care at the right time for their condition.

Self-care

ICBs should consider how to ensure their population is able to self-care. There are many helpful resources available:

• NHS website
• Self Care Forum
• Successful Self Care Aware Consultations Programme – eLearning for healthcare
• PrescQIPP self-care resources

The appendix to this policy guidance includes more detailed information on how patients can self-care for the conditions it includes.

Health inequalities

Some patients may not be able to self-care due to significant medical, mental health or social vulnerability. ICBs should consider implementing services and pathways that mitigate potential negative effects on patients at risk of health inequalities from this guidance.

Data for improvement

To allow commissioners to identify areas of high prescribing of OTC items for self-limiting and minor conditions, dashboards showing current prescribing patterns for the items included in this guidance are available from NHS Business Services Authority in ePACT2 and PrescQIPP. Data on spend and volume is summarised by item and available at regional, integrated care system, primary care network and practice level. When monitoring, the clinical exceptions defined in this guidance should be considered and care taken to ensure that zero prescribing targets are not used inappropriately.

Appendix: Rationale and resources

Items of limited clinical effectiveness

Probiotics (updated 2023)

There is insufficient clinical evidence to support prescribing of probiotics within the NHS for the treatment or prevention of diarrhoea of any cause.

Following a review, the Advisory Committee on Borderline Substances concluded that the evidence did not sufficiently demonstrate that the items are clinically effective. These probiotics are no longer in part XV of the Drug tariff.

Both the UK Health Security Agency clostridioides difficile guidance and National Institute for Health and Care Excellence (NICE) guidance on gastroenteritis in under 5s do not recommend that probiotics; instead recommending that “good quality randomised controlled trials should be conducted in the UK to evaluate the effectiveness and safety of a specific probiotic using clearly defined treatment regimens and outcome measures before they are routinely prescribed”.

Vitamins and minerals (updated 2023)

NHS advice is that vitamins and minerals are essential nutrients which most people can and should get from eating a healthy, varied and balanced diet. In most cases, dietary supplementation is unnecessary.

Many vitamin and mineral supplements are classified as foods and not medicines. They therefore do not have to meet the strict criteria laid down by the Medicines and Health Regulatory Authority to confirm their quality, safety and efficacy before reaching the market.

NHS advice is that people at risk of vitamin D deficiency should consider taking daily supplements of vitamin D, which should be purchased from a pharmacy, supermarket or other retailer. No evidence supports taking vitamin D supplements to prevent or treat Covid-19. People with medically confirmed deficiency may be prescribed vitamin D in line with NICE guidance.

If prescribing for medically confirmed deficiency, choose the most cost-effective licensed product (for example, vitamin B compound strong is much more cost-effective than vitamin B compound [Future NHS log in required to access this information]).

Any prescribing that is not in line with listed exceptions should be discontinued.

Self-limiting conditions

Acute sore throat (updated 2023)

A sore throat with a viral or bacterial cause is a self-limiting condition. Symptoms resolve within 3 days in 40% of people, and within 1 week in 85% of people, regardless of whether the sore throat is due to a streptococcal infection.

Patients should be advised to try self-care measures such as drinking plenty of water, eating cool or soft foods or gargling with warm salty water. Patients may also want to ask a pharmacist about relieving the pain and discomfort of a sore throat by taking simple painkillers or using medicated lozenges containing either a local anaesthetic, antiseptic or a non-steroidal anti-inflammatory medicine.

Acute sore throat is 1 of the 7 clinical pathways included in the Pharmacy First Service.

Infrequent cold sores of the lip

Cold sores caused by the herpes simplex virus usually clear up without treatment within 7 to 10 days.

Antiviral creams can be purchased from a pharmacy without a prescription, and if used correctly can ease symptoms and speed up the healing time.

To be effective, these treatments should be applied as soon as the first signs of a cold sore appear. Using an antiviral cream after this initial period is unlikely to have much effect.

Conjunctivitis

Conjunctivitis is an eye condition caused by infection or allergy. Treatment is not usually needed as symptoms usually clear up within a week. Several self-care measures may help with symptoms.

Coughs, colds and nasal congestion (updated 2022)

Most colds start to improve in 7 to 10 days. Most coughs clear up within 2 to 3 weeks.

Both conditions can cause nasal congestion and this can be treated with self-care measures.

If a new continuous cough develops, advice on coronavirus symptoms should be followed.

Cradle cap (seborrhoeic dermatitis – infants)

Cradle cap is harmless and does not usually itch or cause discomfort. It usually appears in babies in the first 2 months of their lives, and clears up without treatment within weeks to a few months.

Haemorrhoids

In many cases, haemorrhoids do not cause symptoms and some people do not even realise they have them. Haemorrhoids often clear up by themselves after a few days. Making simple dietary changes and not straining on the toilet are often recommended first. 

However, many treatments (creams, ointments and suppositories) can reduce itching and discomfort, and these can be purchased from a pharmacy, supermarket or other retailer.

Infant colic

Colic eventually improves on its own; therefore, medical treatment is not usually recommended.

Over the counter (OTC) treatments are available and could be tried, but there is limited evidence for their effectiveness.

Mild cystitis

Mild cystitis is a common type of urinary tract inflammation, normally caused by an infection. It is usually more of a nuisance than a cause for serious concern.

Mild cases can be defined as those that are responsive to symptomatic treatment but will also clear up on their own. If symptoms do not improve in 3 days despite self-care measures, then the patient should be advised to see their GP.

Symptomatic treatment using OTC products that reduce the acidity of the urine are available, but evidence that they are effective is lacking.

Minor conditions suitable for self-care

Mild irritant dermatitis

Irritant dermatitis is a type of eczema triggered by contact with a particular substance. It is most commonly caused by irritants such as soaps, washing powders, detergents and solvents, or regular contact with water.

Once treated most people can expect their symptoms to improve and/or clear up completely if the irritant or allergen can be identified and removed or avoided.

Treatment normally involves avoiding the allergen or irritant and treating symptoms with emollients and topical corticosteroids purchased from a pharmacy.

Dandruff

Dandruff is a common skin condition. It can be defined as mild scaling of the scalp without itching. Dandruff is not contagious or harmful and can be treated with OTC antifungal shampoos. 

A GP appointment is unnecessary. Patients should be encouraged to manage mild dandruff with long-term treatments purchased from a pharmacy, supermarket or other retailer.

Diarrhoea (adults)

Diarrhoea affects most people from time to time and is usually nothing to worry about. However, it can take a few days to a week to clear up. 

Acute diarrhoea is usually caused by a bacterial or viral infection; other causes include drugs, anxiety or a food allergy.

Treatments available from a pharmacy, supermarket or other retailer can help replace lost fluids or reduce bowel motions.

Dry eyes or sore tired eyes (updated 2023)

Dry eye syndrome, or dry eye disease, is a common condition that occurs when the eyes do not make enough tears, or the tears evaporate too quickly.

Most cases of sore tired eyes resolve without treatment.

Patients should be encouraged to manage both dry eyes and sore eyes by implementing some self-care measures, such as good eyelid hygiene and avoidance of environmental factors, alongside treatment.

Mild to moderate cases of dry eye syndrome or sore tired eyes can usually be treated using lubricant eye treatments that consist of a range of drops, gels and ointments purchased from a pharmacy, supermarket or other retailer.

Earwax

Earwax is produced inside ears to keep them clean and free of germs. It usually passes out of the ears, but if too much builds up it can block the ears.

A build-up of earwax is a common problem that can often be treated using eardrops purchased from a pharmacy. These can soften the earwax so that it falls out naturally.

Excessive sweating (hyperhidrosis)

Hyperhidrosis is a common condition in which a person sweats excessively.

First-line treatment involves simple lifestyle changes. It can also be treated with high strength antiperspirants, usually one containing aluminium chloride, which can be purchased from a pharmacy.

Head lice

Head lice are a common problem, particularly in school children aged 4 to 11. They are largely harmless, but can live in the hair for a long time if not treated and can be irritating and frustrating to deal with.

Live head lice can be treated by wet combing. Chemical treatment is only recommended in exceptional circumstances and in these cases, medicines can be purchased from a pharmacy. If appropriate, everyone in the household needs to be treated at the same time – even if they do not have symptoms.

Indigestion and heartburn

Most people experience indigestion from time to time. Usually, it is not a sign of anything more serious and can be treated at home without the need for medical advice. As it is often mild and infrequent, specialist treatment is not required.

Most people can manage their indigestion and ease symptoms by making simple dietary and lifestyle changes, avoiding foods and drinks that make indigestion worse (eg rich, spicy or fatty foods, caffeinated drinks), or taking medication such as antacids, which can be purchased from a pharmacy, supermarket or other retailer.

Infrequent constipation

Constipation can affect people of all ages and can last just a short time.

It can be effectively treated with a change in diet or lifestyle.

Pharmacists can advise if diet and lifestyle changes are not helping. They can suggest a laxative for purchase. Most laxatives work within 3 days and they should only be used for a short time.

Laxatives are not recommended for children unless they are prescribed by a GP.

The recommendation in this guidance applies to short-term, infrequent constipation caused by changes in lifestyle or diet, such as lack of water or movement, or changes in diet.

Infrequent migraine

Migraine is a common health condition, affecting around 1 in every 5 women and around 1 in every 15 men. Mild infrequent migraines can be adequately treated with painkillers, and several combination painkiller and anti-sickness medicines for migraine can be purchased from a pharmacy.

Those with severe or recurrent migraines should continue to seek advice from their GP.

Insect bites and stings

Most insect bites and stings are not serious and will get better within a few hours or days.

Treatments available for purchase from pharmacies, supermarkets and other retailers can help ease symptoms, such as painkillers for pain and creams and antihistamines for itching.

Infected insect bites are 1 of the 7 clinical pathways in the Pharmacy First Service.

Mild acne

Acne is a common skin condition that affects most people at some point. Although acne cannot be cured, it can be controlled with treatment.

Several creams, lotions and gels for treating acne are available for purchase at pharmacies. Treatments can take up to 3 months to work.

Patients should be encouraged to manage mild acne with long-term use of OTC products.

Mild dry skin (updated 2023)

Emollients are often used to manage dry, itchy or scaly skin conditions. Patients with mild dry skin can be successfully managed using OTC products on a long-term basis.

The following are long-term conditions or circumstances where exceptions to the recommendation not to prescribe an item available OTC could apply:

• eczema, dermatitis or psoriasis which is in an active stage in need of treatment
• ichthyosis
• those who need emollients to compliment another treatment, such as phototherapy.

Mild to moderate hay fever or seasonal rhinitis

Hay fever is a common allergic condition that affects up to 1 in 5 people. There is no cure for hay fever, but most people with mild to moderate symptoms are able to relieve these with treatments available for purchase from pharmacies, supermarkets and other retailers.

Minor burns and scalds

Burns and scalds are damage to the skin caused by heat. Both are treated in the same way.

Depending on how serious a burn is, it is possible to treat burns at home.

Antiseptic creams and treatments for burns should be included among the products kept in a medicine cabinet at home.

However, more serious burns always require professional medical attention. Burns requiring hospital A&E treatment include but are not limited to:

• all chemical and electrical burns
• large or deep burns
• burns that cause white or charred skin
• burns on the face, hands, arms, feet, legs or genitals that cause blisters.

Minor conditions associated with pain, discomfort or fever (for example, aches and sprains, headache, period pain or back pain) (updated 2023)

In most cases, headaches, period pain, mild fever and back pain can be managed at home with OTC painkillers and lifestyle changes, such as getting more rest and drinking enough fluids.

Patients should be encouraged to keep a small supply of OTC analgesics in their medicine cabinet so they can manage minor conditions at home without the need for a GP appointment.

Examples of conditions for which patients should be encouraged to self-care include: headache, fever, earache, period pain, cuts, self-limiting musculoskeletal pain, sprains and strains, bruising, sinusitis or nasal congestion, recovery after a simple medical procedure, aches and pains.

Mouth ulcers

Mouth ulcers are common and usually harmless. They do not need to be treated because most clear up by themselves within 1 to 2 weeks. They can usually be managed at home, without seeing a dentist or GP. However, OTC treatment can reduce swelling and ease any discomfort.

Nappy rash

Up to a third of babies and toddlers in nappies have nappy rash at any one time. Nappy rash can usually be treated at home using barrier creams purchased at the supermarket or pharmacy.

Nappy rash usually clears up in about 3 to 7 days if recommended hygiene tips are followed.

Oral thrush

Oral thrush is a minor condition that can be treated without the need for a GP consultation or prescription in the first instance.

It is common in babies, older people with dentures, and those using steroid inhalers, and can be treated with gel purchased from a pharmacy, supermarket or other retailer.

Prevention of dental caries

Dentists may advise people at risk of tooth decay to use higher-strength fluoride toothpaste. Some higher fluoride toothpastes (~1,500ppm) and mouthwashes can be purchased from a pharmacy.

Ringworm or athlete’s foot

Ringworm is a common fungal infection that can cause a red or silvery ring-like rash on the skin. Despite its name, ringworm does not have anything to do with worms.

Athlete’s foot is a rash caused by a fungus that usually appears between the toes.

These fungal infections, medically known as ‘tinea’, are not serious and are usually treated with treatments purchased from a pharmacy, supermarket or other retailer. However, they are contagious and easily spread so it is important to practise good hygiene.

Sunburn due to excessive sun exposure (updated 2023)

Most people manage sunburn symptoms themselves or prevent symptoms developing by using sun protection and following advice for adults and children on sunscreen and sun safety in the UK and abroad. Products can be purchased from a pharmacy, supermarket or other retailer.

Sun protection (updated 2023)

Products can be purchased from a pharmacy, supermarket or other retailer.

Skin protection should be prescribed if for an Advisory Committee on Borderline Substances-approved indication of photodermatoses.

Teething or mild toothache

Teething can be distressing for some babies, but there are ways to make it easier for them.

Teething gels often contain a mild local anaesthetic, which may numb any pain or discomfort caused by teething in children aged 5 months and over. These products can be purchased from a pharmacy, but it is recommended to try non-medical options first, such as a teething ring.

If the baby is in pain or has a mild raised temperature (<38°C), then paracetamol or ibuprofen suspension can be given.

Toothache can come and go or be constant. Eating or drinking can make the pain worse, particularly if the food or drink is very hot or cold.

Mild toothache in adults can also be treated with OTC painkillers while awaiting a dental appointment for further investigation.

Threadworms

Threadworms (pinworms) are tiny worms seen in stools. They are common in children and can spread easily. They can be effectively treated without the need to visit a GP.

Treatment for threadworms can be purchased from pharmacies. This is usually a chewable tablet or liquid to be swallowed. Strict hygiene measures can also help clear up a threadworm infection and reduce the likelihood of re-infection.

Everyone in the household will require treatment, even if they do not have symptoms.

Travel sickness

Mild motion sickness can be treated with various self-care measures (for example, staring at a fixed object, getting fresh air, listening to music). More severe motion sickness can be treated with medicines purchased from a pharmacy, supermarket or other retailer. 

Warts and verrucae

Most people will have warts at some point in their life. They are generally harmless and tend to go away on their own eventually.

Several treatments can be purchased from a pharmacy to get rid of warts and verrucae more quickly, if required.

Publication reference: B0447