5. Gluten Free Prescribing Audit Prescribing Incentive Scheme 2011/12
Purpose of the Audit
The aim of the audit is to:
1. Ensure patients receiving Gluten Free foods on prescription have a diagnosis of coeliac from a
Consultant Gastroenterologist with documented evidence of a diagnosis on small bowel biopsy
with or without positive antibodies on blood test.
2. Proven Coeliacs are NOT exceeding the recommended monthly quantities of foods on
prescription as per table 2
3. Proven Coeliacs are NOT receiving cakes (mixes etc) and biscuits on prescription as per healthy
lifestyle advice endorsed by Coeliac Society
“We cannot make a special case of support for prescribing biscuits and cake mixes. They are not
staple foods and their use is not consistent with healthy eating recommendations”
Coeliac Disease (CD) is an autoimmune disorder that involves a heightened immunological
response to ingested gluten in genetically susceptible people. Patients who are diagnosed as
coeliac should follow a strict gluten free diet. Failure to do so may cause gastric symptoms. Long
term complications include various malabsorption states such as anaemia, osteoporosis and a slight
increased risk of bowel cancers.
The Department of Health, through the Advisory Committee on Borderline Substances (ACBS)
supports the prescribing of GF foods for patients with established CD or Dermatitis Herpetiformis
(DH). The intention is to promote compliance with a restricted diet and to ensure appropriate
nutritional requirements are met. The ACBS does not approve prescribing these foods for other
conditions such as IBS or wheat intolerance.
It is estimated that CD affects 1% of the UK population, although a recent study suggests that only 1
in 8 people with the condition are currently diagnosed. One reason for this is that the symptoms of
CD can sometimes be non-specific, and can often be confused with that of IBS or ‘wheat
intolerance’. It is therefore important to make a definitive diagnosis of coeliac disease. A small bowel
biopsy is still considered the gold standard for diagnosis of coeliac disease, so a referral to a
gastroenterologist should made in patients with positive antibodies and in those with negative
antibodies but in whom CD is still suspected.
NHS Brighton and Hove spent over £100k a year on Gluten free (GF) foods. This includes the basic
dispensing fee but does not include out of pocket expenses (OOP). OOP are claimed by
pharmacists to cover special delivery costs and are almost always incurred when fresh GF bread is
ordered. Whilst typically this is about £10 per order, anecdotally this can be up to £40. The price
paid by the NHS for gluten free foods on prescription is much higher than supermarket prices. When
dispensing fees and out of pocket expenses are included the cost to the NHS is significantly more.
Table 1 :Annual Spend on GF Sep 09 - Aug 10 by Brighton and Hove City PCT
Total Actual Cost Items
Breads £59,320 3693
Grains and Flour £210 37
Pasta £11,125 1216
Biscuits £10,441 1654
Mixes £19,204 906
Total Spend £100,300 7,506
Total spend inc dispensing fee £113,116
A wide range of gluten free foods are now available to purchase from all major supermarkets. They
are more expensive, as a general rule they cost about twice that of gluten containing foods – for an
adult wishing to continue to eat “normal” amounts of bread, pasta, cakes and biscuits this mean that
they would spend about £12 a month more on this food group than someone who was not coeliac.
Of course many coeliacs alter their diet and replace bread etc with other naturally GF foods such as
rice or potatoes rather than try to substitute with GF products, thus the incremental cost may be
To summarise for an average person the monthly costs to provide GF foods are
On NHS prescription - £40 + 4 x dispensing fees = £47
Purchased from the supermarket = £ 22.49
Equivalent gluten containing food = £10.40
Many coeliacs are exempt from prescription charges and those that are not will often purchase a
prepayment certificate which entitles them receive ALL their prescriptions free. In addition we should
note that many coeliacs do not request any foods on prescription at all, a small survey of 106
patients carried out in Surrey found 51 (48%) did not request any GF items at all on prescriptions. It
is also likely that many do not request the full volume recommended by the coeliac society.
The actual amount of Gluten free food a patient will need each month will depend on how much
carbohydrate they consume from other sources such as rice and potatoes. Table 2 is produced by
the coeliac society as a guide. These recommendations are based on units – units are
interchangeable eg bread may be replaced with pasta. Table 3 shows how these units convert into
Table 2. Recommended number of units of gluten free food per month
Age Group Suggested units per month
Child 1-3 years 10
Child 4-6 years 11
Child 7-10 years 13
Child 11-14 years 15
Child 15-18 years 18
Male 19-59 years 18
Male 60-74 years 16
Male 75+ years 14
Female 19-74 years 14
Female 75+ years 12
Breast feeding 4 extra units
3rd Trimester pregnancy 1 extra unit
High physical activity level 4 extra units
Table 3 – number of units contained in gluten free foods
Food No units
Bread 400g 1
Flour Bread / cake / pastry Mix 500g 2
Biscuits / crackers / crispbread 200g 1
Pasta 500g 2
1 NICE clinical guideline 86; Coeliac Disease: Recognition and assessment of Coeliac
Disease (May 2009)
2 Patient UK; Coeliac Disease (Updated 2010) www.patient.co.uk/doctor/Coeliac-Disease-(CD).htm
3 Coeliac UK (Accessed 2010) www.coeliac.org.uk/healthcare-professionals/prescriptions
4 Brighton and Hove Gluten Free Prescribing Guidelines August 2007
1: Conduct a search to identify those patients who are currently being prescribed gluten free products.
2: Check diagnosis in computer records or in notes (see above)
3: Compare product and quantities prescribed with recommended guidelines (see above) – i.e. review qty over last 3 months, total
up the units and divide by 3 for monthly usage
4. Populate the accompanying data collection sheet (examples given below)
Example of completed data collection form
NAME Age GF Item(s) on repeat Date Items rx in last 3 months Ave no. BMI Indication Biopsy? Issues identified?
incl qty started (incl. Qty) of units Blood Recommended action?
per test ?
Mr X 55 1. Glutafin fresh bread - 01/200 3 x 40 loafs in 3 months = 40 units 23 CD Yes – 1. High prescription quantity –
400gx10 7 120 units per 3 months both recommended
11/2006 minimum quantity of bread would be
18units/month +4units if highly active
person. Consider reducing.
Miss Y 25 1. Juvela sweet biscuits 6/2010 1. 3 items for 200g biscuits 16 units 30 Wheat No 1. Refer to Consultant
2. Il Pane di Anna white x5 (total of 15 units) intolerance gastroenterologist ? for diagnosis
cake mix 2. 3 items for Cake 2. Cakes & biscuits not recommended
3. Ener-G gluten free mix(500g) x 2 (total of – stop prescription – counsel on
cookies 12 units) healthy eating – high BMI
4. Dietary specials 3. 3 item Pizza bases x 7 3. quantities too high – recommended 14
pizza base (total of 21 units) units/month
Total of 48 units for 3 months
Review ofGluten Free foods – Data Collection Form
NAME Age GF Item(s) on repeat Date Items prescribed in last Ave no. BMI Indication Biopsy Issues identified?
incl qty starte 3 months (incl. Qty) of units ? Recommended action?
d per Blood
month test ?
Review ofGluten Free foods– Practice Action Plan
Clinical lead Date
Please give details of any learning points or actions taken by the practice
as a result of this review: