22 Jan 2021
Coeliac disease is a lifelong autoimmune condition caused by an abnormal immune response to eating gluten. It is one of the most common gastrointestinal conditions that require dietetic support. If untreated, coeliac disease leads to extensive intestinal villous atrophy that causes malabsorption of essential nutrients such as calcium, iron, vitamin B12 and folate. In the long term, gluten consumption in coeliac disease can lead to complications such as osteoporosis, lymphoma and small bowel cancer, depression and infertility. A gluten‐free (GF) diet is the sole treatment for coeliac disease and many patients find this extremely challenging. The provision of GF staple foods on prescription plays an essential role in supporting people with this condition to facilitate adherence to their treatment; a strict, life‐long GF diet. Excluding gluten from the diet requires removal of many staple food items such as breads and pasta, additionally gluten is found in many processed foods, requires people to develop skills and knowledge to navigate the numerous sources of gluten in and out of the home environment.
The BDA states that:
- Coeliac disease is a condition that warrants the continued availability of staple GF foods on prescription (such as breads, flour mixes and pasta). It is a lifelong autoimmune disease with serious complications associated with non-adherence to a GF diet. The ingestion of even small amounts of gluten causes damage to the lining of the small intestine leading to inflammation and malabsorption, and therefore subsequent nutritional deficiencies, in addition to an increased risk of osteoporosis, depression, infertility and malignancy.
and believes that:
- People diagnosed with coeliac disease require access to staple GF foods on prescription. National prescribing guidelines (1) recommend a monthly unit allowance that, ensures equality in treatment for all with the diagnosis of coeliac disease. Gluten free prescriptions:
- help ensure equitable access to staple GF foods.
- maximise adherence and facilitate the prevention of long-term medical consequences associated with gluten consumption.
- support individuals in meeting raised nutritional requirements, as many GF foods on prescription are fortified with calcium and B vitamins.
- reduce the financial burden of purchasing staple GF foods.
- Dietitians may make recommendations that deviate from the national prescribing guidance; these will be based on expert assessment, taking into account the individual’s clinical condition, overall nutritional requirements, and external influencers of, the only treatment, GF dietary adherence.
- In line with the NICE Quality Standard for Coeliac Disease (2), all patients diagnosed with Coeliac Disease should receive an annual review, preferably with a dietitian with expertise in coeliac disease. This will support GF dietary adherence and nutritional adequacy, allow symptoms to be reviewed and further appropriate information, advice and support to be provided.
- The NHS should take advantage of new and innovative models for the provision of GF foods using dietetic-led (e.g., dietitian prescribing in Rotherham) or pharmacy-led schemes (e.g., Gluten Free Food Service in Scotland), in Wales Hywel Dda University Health Board has successfully trialed a card payments scheme. These models have been found to be cost effective and convenient for patients and healthcare professionals.
- The cost to the NHS of supplying prescribed GF foods is complex involving manufacturers, pharmacies and wholesalers. In some cases, additional handling charges are placed by wholesalers. The BDA urges Clinical Commissioning Groups (CCGs) in England and other NHS providers to work with pharmacists and local healthcare professionals in getting the best price for providing GF food on prescription. It is possible to reduce the overall costs of supplying GF staple foods via new innovative schemes that save GP time and provide better cost control.
- Where provider organisations are reviewing the provision of GF staple foods on prescription, the BDA strongly advises that Coeliac UK, local dietitians, gastroenterologists, pharmacy prescribing leads, GPs and patient representatives are fully involved in the review process and monitoring any impact of changes. In England, the BDA would recommend that providers should, as a minimum, adhere to the outcomes of the national consultation that recommended GF bread and GF multipurpose mixes remain on prescription. Dietetic and patient representation is particularly important when considering rationalisation of the categories and brands of GF foods available so as to ensure the needs of the coeliac population in general, and the specific nutritional needs of each individual patient are understood and considered.