These frequently asked questions have been developed to support Clinical Commissioning Groups (CCGs) to implement the NHS England guidance for people living in care homes.
In the year up to June 2017, the NHS spent approximately £569 million on prescriptions for medicines which could otherwise be purchased over the counter (OTC) from a pharmacy and/or other outlets such as petrol stations or supermarkets, sometimes at a lower cost than that which would be incurred by the NHS.
These prescriptions include items for a minor condition:
- That is considered to be self-limiting and so does not need treatment as it will heal or be cured of its own accord (although a patient a may still want to obtain symptomatic relief with an over the counter (OTC) medicine until the condition has resolved);
- Which lends itself to self-care, i.e. that the person suffering does not normally need to seek medical advice but may decide to seek help from a local pharmacy for symptom relief and use an OTC medicine.
- For which there is limited evidence of clinical effectiveness.
By reducing spend on treating minor conditions that are self-limiting or which lend themselves to self-care, these resources can be used for other higher priority areas that have a greater impact for patients, support improvements in services and help deliver the long-term sustainability of the NHS.
Therefore, the guidance was developed to direct CCGs when formulating their local polices, and for prescribers to reflect local policies in their prescribing practice.
The National Institute for Health and Care Excellence (NICE) published Managing medicines in care homes which advises on processes for prescribing, handling and administering medicines in care homes. It also recommends how care and services relating to medicines should be provided to people living in care homes including advice on provision of OTC medicines for care home residents. Recommendation 1.16 details a homely remedies process which should be considered when treating care home residents for minor ailments.
The Care Quality Commission (CQC) also published Treating minor ailments and promoting self-care in adult social care which explains homely remedies and provides information on supporting residents in care homes to self-care where appropriate. It also covers how the administration of the OTC medicines to residents should be documented.
The implementation of the CCG guidance has been identified as a priority for the Regional Medicines Optimisation Committees (RMOCs). RMOCs are committees within England that make recommendations, pursue actions, and co-ordinate activities related to any aspect of Medicines Optimisation (MO). There are four committees, one for each NHS England region; however they produce national recommendations and resources to support and guide Area Prescribing Committees (APCs) and CCGs on a range of MO topic areas. In August 2018 the Midlands & East RMOC reviewed issues pertaining to homely remedies in care homes. The RMOC programme has now issued guidance on this subject, which includes a template policy which can be adapted for local use.
Stopping prescribing for the conditions in the CCG guidance should be considered for care home residents on an individual basis. The CCG guidance has identified certain scenarios where patients should continue to have their treatments prescribed (general exceptions) and these are outlined below:
- Patients prescribed an OTC treatment for a long term condition (e.g. regular pain relief for chronic arthritis or treatments for inflammatory bowel disease).
- For the treatment of more complex forms of minor illnesses (e.g. severe migraines that are unresponsive to over the counter medicines).
- For those patients that have symptoms that suggest the condition is not minor (i.e. those with red flag symptoms for example indigestion with very bad pain.)
- Treatment for complex patients (e.g. immunosuppressed patients).
- Patients on prescription only treatments.
- Patients prescribed OTC products to treat an adverse effect or symptom of a more complex illness and/or prescription only medications should continue to have these products prescribed on the NHS.
- Circumstances where the product licence doesn’t allow the product to be sold over the counter to certain groups of patients. This may vary by medicine, but could include babies, children and/or women who are pregnant or breast-feeding. Community Pharmacists will be aware of what these are and can advise accordingly.
- Patients with a minor condition suitable for self-care that has not responded sufficiently to treatment with an OTC product.
- Patients where the clinician considers that the presenting symptom is due to a condition that would not be considered a minor condition.
- Circumstances where the prescriber believes that in their clinical judgement, exceptional circumstances exist that warrant deviation from the recommendation to self-care.
- Individual patients where the clinician considers that their ability to self-manage is compromised as a consequence 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. To note that being exempt from paying a prescription charge does not automatically warrant an exception to the guidance. Consideration should also be given to safeguarding issues.
A wide range of information is available to the public on the subjects of health promotion and the management of minor self- treatable illnesses. Advice from organisations such as the Self Care Forum and NHS Choices is readily available on the internet. Many community pharmacies are also open extended hours including weekends and are ideally placed to offer advice on the management of minor ailments and lifestyle interventions. The Royal Pharmaceutical Society offers advice on over the counter products that should be kept in a medicine cabinet at home to help patients treat a range of self-treatable illnesses.
The GP contracts state that GP practices must have due regard to relevant guidance issued by NHS England. The CCG guidance includes specific reference to prescribers, and requires prescribers to reflect local policies in prescribing practice. GP practices are therefore able to follow the CCG guidance and exercise judgement about when it is (and is not) appropriate to prescribe OTC items, without any risk that they will be in breach of their contract. It does not remove the clinical discretion of the prescriber, in accordance with their professional duties. GPs are also able to inform patients they must have due regard for the CCG guidance when communicating any decision not to prescribe an OTC item for treatment of one of the conditions identified.
The intention of the CCG guidance is to produce a consistent, national framework for CCGs to use, while taking account of local circumstances and their own impact assessment and legal duties to advance equality and have regard to reduce health inequalities.
If the resident is able to self-care then they are clinically accountable as is the case for people living in their own home. However, if the condition is not responding to treatment or the condition is getting worse then a referral to the GP or pharmacist is required. If a GP or pharmacist is prescribing a medication then they would be clinically accountable.
It is up to the individual care home; some care homes will already have infrastructure in place to do those assessments. The care home may seek advice from a GP or pharmacist should they have concerns or need further advice. We encourage that residents and their families should be involved in decisions about self-medication and what medicines they take.
People who are not able to self-care fall under the general exceptions in the CCG guidance (see Question 4). The ability to self-care should be assessed by a healthcare professional on an individual basis.
An assessment would need to take place to determine whether a resident has the ability to self-care and they should be supported to do so. If they do lack capacity then a best interest’s judgement can be made by consulting with their family or GP about what to do. The general exceptions in the CCG guidance may apply in some circumstances.
An Easy Read ‘over the counter’ leaflet has also been developed to support conversations with people with learning disabilities.
All medicines taken by a resident including those they self-administer should be documented by the care home. In cases where care homes have received advice from a health professional (e.g. GP or pharmacist) they should document the advice in the resident’s care plan or similar document.
Local pharmacies provide NHS services in the same way as GP practices. Pharmacists and pharmacy staff are trained to identify red flags for OTC medicine and assure that all medicines being prescribed are patient-appropriate. If care homes are struggling with the CCG guidance, pharmacists will be there to advise them, in a medicine advisory and optimisation capacity.
NHS England’s Medicines Optimisation in Care Homes (MOCH) programme works closely with care homes and pharmacy teams. There is ongoing work to reduce the variation in implementing the CCG guidance across all care homes.