We want your views on the prescribing of certain medications

Sutton Clinical Commissioning Group has been asked by NHS England to respond to national engagement on the prescribing of certain drugs. In order to inform our response we are asking local people for their views. Please read the information on each of the six medications we are looking at and then let us know what you think. 
The survey should take less than ten minutes to complete, so thank you in advance for taking part.

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* 1.
Liodcaine Plasters
Lidocaine plasters can be applied for pain relief and are licensed for symptomatic relief of neuropathic pain associated with previous herpes zoster infection (post-herpetic neuralgia, PHN) in adults.
Annual  National Spend  - £19,295,030 (NHS Digital)
Rationale for recommendation
NICE CG173 Neuropathic pain in adults: pharmacological management in non-specialist settings does not recommend lidocaine plasters for treating neuropathic pain. The group also considered a PrescQIPP CIC review, and due to its non-inclusion in NICE guidance the group considered lidocaine plasters suitable for inclusion in the proposed guidance.
Category
Item of low clinical effectiveness, there is a lack of robust evidence of clinical effectiveness or there are significant safety concerns
Recommendation
Advise CCGs that prescribers in primary care should not initiate Lidocaine plasters for any new patient. Advise CCGs to support prescribers in deprescribing lidocaine plasters in all patients &, where appropriate, ensure the availability  of relevant services to facilitate this change. Advise CCGs that if, in exceptional circumstances, there is a clinical need for lidocaine plasters to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional
Do you agree with the proposed recommendations for Lidocaine Plasters?

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* 2.
Liothyronine
Liothyronine (sometimes known as T3) is used to treat hypothyroidism. It has a similar action to levothyroxine but is more rapidly metabolised and has a more rapid effect;
Annual National Spend  - £34,802,312 (NHS Digital)
In addition £1,000,049 is spent on Liothyronine + Levothyroxine combination products e.g. armour thyroid
Rationale for recommendation
The price (NHS Drug Tariff) of liothyronine has risen significantly and there is limited evidence for efficacy above Levothyroxine. The British Thyroid Association, in their 2015 position statement, state "There is no convincing evidence to support routine use of thyroid extracts, L-T3 monotherapy, compounded thyroid hormones, iodine containing preparations, dietary supplementation and over the counter preparations in the management of hypothyroidism".
Liothyronine is used for patients with thyroid cancer, in preparation for radioiodine ablation, iodine scanning, or stimulated thyroglobulin test. In these situations it is appropriate for patients to obtain their prescriptions from the centre undertaking the treatment.
Due to the significant costs associated with Liothyronine and the limited evidence to support its routine prescribing in preference to levothyroxine, the group considered Liothyronine suitable for inclusion in this guidance.
Category
Items which are clinically effective but where more cost-effective products are available, including products that have been subject to excessive price inflation
Recommendation
Advise CCGs that prescribers in primary care should not initiate Liothyronine for any new patient. Advise CCGs to support prescribers in deprescribing Liothyronine in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change. Advise CCGs that if, in exceptional circumstances, there is a clinical need    for Liothyronine to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional 

Do you agree with the proposed recommendations for Liothyronine?

Question Title

* 3.
Oxycodone and Naloxone combination product
Oxycodone and Naloxone combination product is used to treat severe pain and can also be used second line in restless legs syndrome. The opioid antagonist naloxone is added to counteract opioid-induced constipation by blocking the action of oxycodone at opioid receptors locally in the gut.
Annual National Spend  - £5,062,928 (NHS Digital)
Rationale for recommendation
PrescQIPP CIC have issued a bulletin and did not identify a benefit of Oxycodone and Naloxone in a single product      over other analgesia (with laxatives if necessary). Due to the significant cost of the Oxycodone and Naloxone combination product and the unclear role of the combination product in therapy compared with individual products, the group considered Oxycodone and Naloxone suitable for inclusion in the proposed guidance.
Category
Items which are clinically effective but where more cost-effective products are available, including products that have been subject to excessive price inflation
Recommendation
Advise CCGs that prescribers in primary care should not initiate Oxycodone and Naloxone combination product for any new patient. Advise CCGs to support prescribers in deprescribing Oxycodone and Naloxone combination product  in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change.
Advise CCGs that if, in exceptional circumstances, there is a clinical need for Oxycodone and Naloxone combination product to be prescribed in primary care, this should be undertaken in a cooperation arrangement with a multi-disciplinary team and/or other healthcare professional
Do you agree with the proposed recommendations for oxycodone and naloxone?


Question Title

* 4.
Paracetamol and Tramadol Combination Product
Paracetamol and Tramadol are both commonly available painkillers. This recommendation relates to where both chemical ingredients are used together in a single combination product.
Annual National Spend  - £1,980,000 (NHS Digital)
Rationale for recommendation
Paracetamol and Tramadol combination products are more expensive than the products with the individual components (Drug Tariff).
PrescQIPP CIC also issued a bulletin which did not identify any significant advantages over individual products, however it does recognise that some people may prefer to take one product instead of two. There are also different     strengths of Tramadol (37.5mg) and Paracetamol (325mgmg) in the combination product compared to commonly available individual preparations of Tramadol (50mg) and Paracetamol (500mg), although the PrescQIPP CIC review    found no evidence that combination product is more effective or safer than the individual preparations. Due to the significant extra cost of a combination product, the group considered Paracetamol & Tramadol combination products suitable for inclusion in the proposed guidance.
Category
Items which are clinically effective but where more cost-effective products are available, including products that have been subject to excessive price inflation
Recommendation Advise CCGs that prescribers in primary care should not initiate Paracetamol and Tramadol combination product for any new patient. Advise CCGs to support prescribers in deprescribing Paracetamol and Tramadol combination product in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change.
Do you agree with the proposed recommendations for Paracetamol and Tramadol Combination product?


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* 5.
Immediate Release Fentanyl
Fentanyl is a strong opioid analgesic. It is available as an immediate release substance in various dosage forms; tablets, lozenges, films and nasal spray. Immediate release fentanyl is licensed for the treatment of breakthrough pain in adults with cancer who are already receiving at least 60mg oral morphine daily or equivalent.
This recommendation does not apply to longer sustained release versions of fentanyl which come in patch form.
Annual National Spend - £10, 952,130 (NHS Digital)
Rationale for recommendation
NICE CG140 Opioids in Palliative Care states Do not offer fast-acting fentanyl as first-line rescue medication.
Immediate release fentanyl products are licensed for treating adults with cancer who have breakthrough pain and are receiving opioid therapy, equivalent to at least 60mg of oral morphine. Consensus of the working group was that there was a small number of people who this would apply to and therefore does not justify current prescribing volumes.
Due to the recommendations from NICE and immediate release fentanyl being only licensed for use in cancer, the group considered immediate release fentanyl was suitable for inclusion in the proposed guidance.
Category
Items which are clinically effective but where more cost-effective products are available, including products that have been subject to excessive price inflation
Recommendation
Advise CCGs that prescribers in primary care should not initiate Immediate Release Fentanyl for any new patient
Advise CCGs to support prescribers in deprescribing Immediate Release Fentanyl in all patients &, where appropriate, ensure the availability of relevant services to facilitate this change.
Do you agree with the proposed recommendations for Immediate Release Fentanyl? 


Question Title

* 6.
Once Daily Tadalafil
Tadalafil is a phosphodiesterase-5-inhibitor and is available in strengths of 2.5mg, 5mg, 10mg and 20mg used to treat erectile dysfunction. In addition 2.5mg and 5mg can be used to treat benign prostatic hyperplasia. Only 2.5mg and 5mg should be used once daily. 10mg and 20mg* are used in a "when required fashion".
Tadalafil can be prescribed for erectile dysfunction in circumstances as set out in part XVIIIB of the Drug Tariff.
*There is also a 20mg once daily preparation, branded Adcirca, which is used to treat pulmonary hypertension. This recommendation does not apply to this product, however it should only be prescribed by specialist centres and not routinely prescribed in primary care.
Annual National Spend  - £11,474,221 (NHS Digital)
Rationale for recommendation
Benign Prostatic Hyperplasia: NICE terminated their technology appraisal (TA273) due to receiving no evidence from the manufacturer. In NICE CG97: Lower Urinary Tract Symptoms in Men NICE state that there is not enough evidence to recommend phosphodiesterase inhibitors in routine clinical practice.
Erectile Dysfunction: PrescQIPP CIC have reviewed the evidence for Tadalfil and although tadalafil is effective in treating erectile dysfunction, there is not enough evidence to routinely recommend once daily preparations in preference to "when required" preparations.
Due to recommendations from NICE and that alternative Tadalafil preparations are available, the group felt once daily Tadalafil was suitable for inclusion in the proposed guidance.
Category
Products which are clinically effective but where more cost-effective products are available this includes products that have been subject to excessive price inflation.
Recommendation
Advise CCGs that prescribers in primary care should not initiate once daily Tadalafil for any new patient
Advise CCGs to support prescribers in deprescribing once daily Tadalafil in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change.
Do you agree with the proposed recommendations for Once Daily Tadalafil?

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* 7. Another area of NHS prescribing that has been suggested for consideration are those products which can also be purchased    over the counter. We know that there is variation in prescribing practice across the country and so NHS England and NHS Clinical Commissioners propose as a next phase of this review to look at over 3,200 products which could otherwise be
purchased over the counter from a pharmacy and/or other outlets such as petrol stations or convenience stores. The NHS in   England spends approximately £645million p.a. on such medicines.

Please review the following list & tell us whether you agree or disagree with the suggestion that prescriptions no longer be issued for these conditions.

  Agree Disagree Unsure
Diarrhoea
Cold sores
Constipation
Teething
Acute Pain
Nappy rash
Athlete’s foot
Mouth ulcers
Fever
Haemorrhoids
Oral and vaginal thrush
Ear wax
Head lice
Warts and verrucae
Insect bites and stings
Conjunctivitis
Contact Dermatitis
Sore throat
Headache
Indigestion and heartburn (Dyspepsia)
Minor burns and scalds
Viral upper respiratory tract infections
Scabies
Ringworm
Mild acne

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* 8. Please tell us in what capacity you are responding

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* 9. Equality and Health Inequalities
NHS England has legal duties which require giving due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and having regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.  Further information on our duties can be read at https://www.england.nhs.uk/about/equality/
Do you feel there are any groups, protected by the Equality Act 2010, likely to be disproportionately affected by this work?

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* 10.
Do you feel there is evidence we should consider in our proposals on the potential impact on health inequalities experience by certain groups e.g. people on low incomes; people from BME communities?

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