Self Care

Self-care is widely acknowledged as an important solution to managing demand and keeping the NHS sustainable. Supporting people to self-manage common conditions such as coughs and colds could help bring down the 57 million GP consultations each year for minor ailments, a situation which costs the NHS approximately £2 billion and takes up to an hour a day on average for every GP.

Promoting the concept of self-care and increasing the awareness that there are alternatives to making GP appointments, or attendance at OOHs or A&E departments with minor conditions, will encourage patients to explore self-care in the future, so changing the culture of dependency on the NHS.

Derby and Derbyshire ICBs spent over £9.5 million in 2016/2017 on some of the medicines that are available to purchase over-the-counter (OTC). This amount reduced to around £9 million in 2017/2018 and approximately £8 million in 2018/2019.  It is recognised that much of this cost is attributable to long-term or complex conditions, but considerable spend is also for conditions that may be considered suitable for self-care.

By reducing spend on treating conditions that are self limiting or which lend themselves to self care, or on items for which there is little evidence of clinical effectiveness, these resources can be used for other higher priority areas that have a greater impact for patients, support improvements in services and/or deliver transformation that will ensure the long term sustainability of the NHS.

Medications no longer routinely prescribed are for conditions that:

• may be considered to be self-limiting, so they do not need treatment as they will get better of their own accord or
• are suitable for self-care, so that the person suffering does not normally need to seek medical advice and can manage the condition by purchasing OTC items directly (table 1 has examples of medicines that fall into these categories).

In addition

• some products prescribed at NHS expense have insufficient evidence of clinical effectiveness and should no longer be routinely prescribed (see table 2)

Exceptions can be found in the full Self Care policy here

Items which should not be routinely prescribed across Derbyshire can be found here

Joined Up Care Derbyshire condition specific patient information leaflets can be found here

Dental Factsheets for Healthcare Practitioners can be found here

The medicines referred to are all readily available from community pharmacies and in many cases from supermarkets and other outlets. The cost to the patient will vary depending on the condition being treated, treatment length and where the product is purchased. Paracetamol cost as little as 19p for 16 tablets whereas head lice treatments may cost around £5.00 for a single person treatment or as much as £12.00 for a family pack (although wet combing is inexpensive and is the preferred method of treatment).

Table 1. Examples of medicines that can be purchased over-the-counter for the treatment of self-limiting conditions and those conditions deemed suitable for self-care. (Note: this list and examples given is not exhaustive. For further detail please refer to Bulletin 227 GP guide to self care over the counter items PrescQIPP in reference/resources section).

Self-limiting Conditions
Condition	Example products (not exhaustive)	Specific Exceptions (for general exceptions full policy)
Acute sore throat	Sore throat lozenges and sprays
Infrequent cold sores of the lip	Aciclovir cream Zovirax cold sore cream	Immunocompromised patients
Conjunctivitis (also see hayfever below)	Chloramphenicol eye drops or ointment	Children patient under 2 years of age
	Sodium cromoglicate eye drops Otrivine-antistin eye drops
Coughs, colds and nasal congestion	Simple linctus, pholcodine linctus Pseudoephedrine nasal sprays and oral preparations Xylometazoline and ephedrine nasal spray and drops
Cradle cap	Olive oil, cradle cap shampoos	If causing distress to infant and not improving
Haemorrhoids	Anusol cream, ointment or suppositories
	Anusol HC cream, ointment or suppositories	Patient less than 18 years of age
Infant colic	Simeticone liquid  Dimeticone liquid
	Colief liquid	Confirmed lactose intolerance only
Mild cystitis	Potassium citrate mixture or sachets Cranberry products

Minor conditions suitable for self care
Condition	Example products (not exhaustive)	Specific Exceptions (for general exceptions see full policy)
Mild irritant dermatitis	Emollient creams and lotions
	Mild corticosteroid creams (e.g. hydrocortisone)	Exceptions for hydrocortisone cream: Children under 10 years Pregnant women When required for use on the face, anogential region, broken or infection skin (including cold sores, acne and athlete's foot)
Dandruff (mild scaling of the scalp)	Shampoos including antifungal, antiseptic, selenium and coal tar
Diarrhoea (adults)	Loperamide Oral rehydration sachets	Children
Dry eyes/ sore tired eyes	Hypromellose eye drops, carbomer 980 gel
Earwax	Olive oil, sodium bicarbonate ear drops
Excessive sweating (hyperhidrosis)	Aluminium chloride 20% solutions (e.g. Driclor, Anhydrol Forte)
Head lice	Dimeticone, malathion, cyclomethicone, permethrin shampoos and liquids	Children under 6 months of age
Indigestion and heartburn	Peptac, Gaviscon
Infrequent constipation	Senna, lactulose, macrogol sachets	Children where dietary and lifestyle changes have not been sufficient MHRA Drug Safety August 2020
Infrequent migraine	Analgesics, migraleve, triptans	Patients with severe or recurrent migraines
Insect bites and stings	Antihistamine oral and topical preparations, calamine lotion
	Topical corticosteroids	Exceptions for hydrocortisone cream: Children under 10 years Pregnant women When required for use on the face, anogenital region, broken or infected skin (including cold sores, acne and athlete's foot)
Mild acne	Benzoyl peroxide creams and gels
Mild dry skin	Emollient creams and lotions
Sunburn due to excessive sun exposure	Emollients, oral and topical antihistamines, analgesics
Sun protection	Sun creams such as Uvistat, Sunsense, etc.	ACBS approved indication of protection from UV radiation in abnormal cutaneous photosensitivity (i.e. where skin protection should be prescribed)
Mild to moderate hayfever/   seasonal rhinitis	Antihistamines, nasal sprays, eye drops
Minor burns and scalds	Antiseptic creams, analgesics	More serious burns always require professional medical attention. Burns requiring hospital A&E treatment include but are not limited to: all chemical and electrical burns large or deep burns burns that cause white or charred skin burns on the face, hands, arms, feet, legs or genitals that cause blisters
Minor conditions associated with pain, discomfort and/or fever (e.g. aches and sprains, headaches, period pain, back pain)	Analgesics, NSAIDs, topical anti-inflammatory preparations
Mouth ulcers	Local anaesthetic gels, hydrocortisone buccal tablets	Exceptions for hydrocortisone buccal tablets: Children under 12 years of age
Nappy rash	Barrier preparations such as Sudocrem, metanium
Oral thrush	Daktarin oral gel  Nystatin oral suspension	Infants less than 4 months old (Note that Daktarin oral gel is only licensed for 4 months and older)  Nystatin is POM so will need a prescription if required
Dental products	Mouthwashes Toothpaste
Ringworm/ athlete's foot	Topical preparations containing miconazole, clotrimazole etc.	Lymphoedema or history of lower limb cellutitis
Teething/ mild toothache	Teething gels, paracetamol, ibuprofen
Threadworms	Mebendzole	Children under 2 years of age. Not licensed for OTC sale
Travel sickness	Cinnarizine, hyoscine
Warts and verrucae	Salicyclic acid containing products, glutaraldehyde	Treatment of anogential warts

Table 2. Examples of medicines that have little evidence of benefit (Note: this list and examples given is not exhaustive)

Product category	Example of products (not exhaustive)	Specific Exceptions (for general exceptions see full policy)	Resources
Probiotics	VSL#3, lactobacillus,acidophilus	VSL#3 classified as a BLACK drug as not recommended or commissioned as the ACBS had withdrawn their approval. . No routine exceptions have been identified.
Vitamins and minerals	Pharmacy own brands of vitamins/ multivitamins (i.e. Boots, Lloyds, Superdrug, Valupak), Haliborange, Sanatogen, Fruitivits Sachets, Spatone, Seven Seas, Lamb, Vita E, Osteocaps, Osteocare, Redoxon, Centrum	Vitamin D (high strength) for proven vitamin D deficiency. Calcium and vitamin D for osteoporosis or osteopenia. Vitamin D for patients with hyperparathyroidism, hypercalcaemia and patients receiving parenteral osteoporosis treatment as per the JAPC position statement on self-care with vitamin D*. NB maintenance or preventative treatment is not an exception. See vitamin D management, position statement, and patient information leaflet Vitamin B - refeeding syndrome. For details please see traffic light classifications here Vitamin B12 deficiency. Post bariatric surgery – only as specified in the JAPC guideline on monitoring and medication after bariatric surgery - link Vitamin supplements for premature and low birth weight babies as advised by hospital. For details please see Infant feeding guideline Patients suitable to receive Healthy start vitamins for pregnancy or children between the ages 6 months to their fourth birthday. (NB this is not on prescription but commissioned separately)