"Should gluten-free foods be available on prescription?"

Continuing the theme of blogging outside of the core material typically included on this site, I couldn't resist a mention of the 'head-to-head' debate talked about in the article by Matthew Kurien and colleagues [1] published in the British Medical Journal (BMJ).

As per the title of this post, the name of the game was gluten-free products being available on prescription here in Blighty, and in particular, the prescribing of gluten-free products to patients diagnosed with coeliac disease. The head-to-headers were Matthew Kurien, Sarah Sleet & David Sanders* (*a name not unfamiliar to this blog) all in favour of keeping the status quo and James Cave presenting the opposing view and why prescriptions of gluten-free products to those with coeliac disease might not be the only way.

OK, first things first. A gluten-free diet is not some dietary 'fad' for people living with coeliac disease (CD); it is a clinically-indicated treatment tool for this autoimmune condition. As I've said a few times on this blog, not only are there are physiological effects linked to CD mostly 'solved' by use of a gluten-free diet, but there may be psychological effects too (see here). Gluten is most definitely the 'baddie' when it comes to CD and should not be in the diet of those with CD.

The head-to-head piece makes for interesting reading in terms of how in these days of focus on the finances of the National Health Service (NHS), the idea that removing food prescriptions as one way to "reduce costs in the short term" might have some important repercussions in the longer-term. Indeed I was taken by one quote in the 'keep gluten-free food prescriptions' camp: "Would clinical commissioning groups consider this if the treatment for coeliac disease was an immunosuppressive drug and not food?" Food as medicine? I like that sentiment (see here).

I have to say however that I did find the viewpoint from James Cave rather appealing in some aspects. Within his various facts and figures he shows how perverse it is that one can go into a supermarket and buy a gluten-free loaf of bread for one price and yet the same loaf is bought by the NHS for prescription for quite a bit more. Sorry to focus on cost and finances but this is salient point in these days of continued austerity and financial/political uncertainty. Cave also adds that gluten-free food prescriptions tend to be restricted to set items, come in bulk and generally need to be collected from a pharmacy. There are additional costs added to the supply of such goods.

The two viewpoints do however agree that slight changes could be made to the system to make it both run more efficiently and provide those with coeliac disease a little more 'opportunity' in what they select. As Cave notes: "A national voucher scheme or a personalised health budget could be provided to ensure that patients receive recompense for the extra expense of gluten-free products." As Kurien and colleagues note: "Alternative strategies to prescriptions, such as direct supply schemes from community pharmacies, or voucher allowances, may be a more efficient way of delivering NHS support." A voucher scheme for gluten-free products? Interesting.

In these days where areas of England are already seeing changes to gluten-free prescriptions (see here for example) I'm wondering if a voucher scheme might be the [inevitable] way forward, at least for the majority of patients. Not only does this offer more choice to the consumer in terms of what products they buy (and indeed, what they might prefer) but the whole process of the NHS ordering, buying and dispensing such products is also reduced. For those who perhaps do not have access to a full-range of gluten-free products as their local supermarket for example or have mobility issues, exceptions could be made but for the most part, patients are handed choice and a lot more buying power and freedom. A voucher scheme might also 'normalise' the idea of gluten-free products when it comes to CD. By 'normalise' I mean that a young adult diagnosed with CD for example, no longer has to go to their local pharmacy for their 'months supply' but rather can shop - pick and choose - from the growing range of gluten-free products that adorn supermarket shelves these days. Compliance to the gluten-free diet will no doubt benefit when there is more choice and a voucher scheme will bring choice.

Change is often difficult when it comes to the NHS and it's been over 50 years since gluten-free products were put on prescription for those with CD so this would be a big change. But gluten-free is everywhere these days and there is seemingly little to hold the NHS back from further empowering those diagnosed with CD in terms of their dietary choices...

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[1] Kurien M. et al. Should gluten-free foods be available on prescription? BMJ 2017: 356.

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Kurien M, Sleet S, Sanders DS, & Cave J (2017). Should gluten-free foods be available on prescription? BMJ (Clinical research ed.), 356 PMID: 28073799