HNY Policy and Pathway Repository - York

Coeliac disease, Gluten-sensitive enteropathies and Dermatitis Herpetiformis

Prescribing of GF products is only commissioned for people if:

• the prescribing clinician considers that a patient’s ability to self-manage their disease (or their parent's/carer's ability in the case of a child or an adult who is unable to manage independently) is compromised by a medical or mental health condition resulting in severe mental impairment AND
• prescribing is restricted to GF bread and bread mixes

In this context 'severe mental impairment' means a severe impairment of intelligence and social functioning (however caused) which appears to be permanent and would typically prevent a person being able to carry out required activities of daily life independently without additional support. Prescribing of low protein products (including ones that are GF) is commissioned if a patient has an illness for which the management includes following an extremely restricted diet for which specialist foods are not readily available on the high street, e.g. Phenylketonuria (PKU).

In the past GF foods were considered specialist food items, were not readily available to purchase and were extremely expensive compared to their equivalent gluten-containing products. However, GF foods are now widely available to purchase in supermarkets and other outlets and the price is more comparable to gluten-containing products.

Following the NHSE consultation in 2018, many GF products were removed from Part XV of the Drug Tariff and are no longer available on NHS prescription. Only certain GF breads and mixes are still available on NHS prescription.

Unlike other foodstuffs, gluten containing products are not essential for a healthy diet, Patients with gluten sensitivity can safely exclude it from their diet and still eat healthily without purchasing special foods. Patients can safely eat meat, fish, vegetables, fruit, rice and most dairy products, and there are a wide variety of readily available products e.g. rice cakes, crackers etc. to allow patients to complement their GF diets safely and obtain all their nutritional requirements.

Although GF products can be accessed via NHS prescription, this is not the case for other allergies and intolerances so creates an inequity in provision and a cost pressure for the NHS. Humber and North Yorkshire ICB spent over £396,000 in the last 12 months on the prescribing of GF products. By reducing prescribing of GF products, the saving can be re-invested into other treatments.

There are various uncertainties, including:

• there are associations between conditions managed with a GF diet and higher incidence of other conditions, including bowel cancer and osteoporosis, but uncertainty about whether there is direct causation
• uncertainty about whether and to what extent adherence to a GF diet reduces (if at all) the incidence of the above associated conditions
• the proportion of people who would reduce their dietary adherence following introduction of this policy

These uncertainties are acknowledged, so mitigating actions have been identified, including continued prescribing for people least able to control their diet, promoting access to dietetic advice on achieving a healthy GF diet without special GF products and annual reviews of people requiring a GF diet to monitor adherence.

NHS England » Prescribing Gluten-Free foods in Primary Care: Guidance for Clinical Commissioning Groups – frequently asked questions

Food and Drink Guide - Coeliac UK

Dermatitis herpetiformis - Coeliac UK

Phenylketonuria - NHS (www.nhs.uk)