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Can I insist patients get vitamin D over the counter?

Three experts advise a GP unsure of their obligations towards prescribing vitamin D

If a patient comes to me and asks to get vitamin D on the NHS, can you insist they get it over the counter?

Helen cotton 330x330

Dr Helen Cotton: Yes you can insist

There is a simple answer to this and it’s that yes you can insist that patients obtain this over the counter.

The recent PHE advice recommends that everyone considers taking a 10mcg vitamin D supplement in autumn and winter, and high risk groups take 10mcg all year round. The recommendation makes clear that this is not the same as treating vitamin D deficiency.

Whilst the GMS contract stipulates that medicines are supplied on an FP10 where treatment is required, this is not a treatment area. Vitamin D for treatment of vitamin D deficiency requires an FP10, vitamin D to prevent deficiency does not.

Current NICE guidance, although looking at high risk patients not total population prevention, is clear in not recommending that vitamin D be issued on an FP10. NICE recommends that health professionals issue the advice (akin to recommending reducing alcohol, taking folic acid, stopping smoking) and local authorities ensure vitamin D is available. It suggests improving uptake of healthy start vitamins, encouraging pharmacies and supermarkets to stock low cost vitamin D supplements and a widespread education programme.

Whether with current workload pressures you wish to spend time explaining the intricacies of why you aren’t issuing a prescription, making sure that all local GPs are doing the same and lobbying for vitamin D supplements to be available is a another matter. Until resources are in place to support you to decline the prescription you may opt to save time and issue a prescription.

Dr Helen Cotton is a GP in Yeovil, Somerset

Dr Natasha Usher

Dr Natasha Usher: Don’t prescribe on the NHS unless the patient is deficient

Recent recommendations from Public Health England state that everyone should take vitamin D supplements of 10mcg (400IU) in the winter months, although the evidence base for this is weak. Previous guidance[4] advised this for those at high risk; however, it advised doing this by making such supplements more readily available at cheap price via pharmacies - there is no mention of being prescribable on the NHS.

SMC guidance on vitamin D available on prescription (higher dose 800IU) is that it should be used for the prevention and treatment of vitamin D deficiency and as an adjunct to specific therapy for osteoporosis in patients with vitamin D deficiency or at risk of vitamin D insufficiency. It does state that this is too high a dose for general use (the only licensed preparations are at this dose), and that it requires monitoring as a prescription-only drug to prevent hypercalcaemia, especially with renal impairment.

Therefore it follows that should you decide to prescribe vitamin D on the NHS to this patient, the only available dose is higher than recommended and requires some form of monitoring, increasing workload to the practice.

This may be something that could change, should an appropriate preparation be made available for prescribing. However, at present, I would not prescribe to this patient on the NHS unless proved to be deficient. It would be worth discussing this with your partners, and the practice pharmacist if there is one, to ensure a consistent approach.

Dr Natasha Usher is a GP in Montifieth, near Dundee, Scotland

Dr Katie Grant

Dr Katie Grant: There is no obligation to prescribe

Updated public health guidance, such as the recent change in Vitamin D recommendations, may result in an increase in patients requesting prescription of products already available over the counter.

GMC prescribing guidance outlines that you should prescribe medications ‘only if you have adequate knowledge of the patient’s health and you are satisfied that they serve the patient’s needs’. You will also have to consider any local formulary or prescribing guidance. If your CCG or practice has a policy regarding such requests, you can discuss this with the patient.

When the patient presents to you with a diagnosis that requires treatment with vitamin D then you should provide the appropriate prescription. If your patient is eligible to receive free vitamin supplementation through schemes such as Healthy Start, you should encourage them to do so.

Otherwise, you may want to encourage the patient to take ownership of their health and self-care. If a patient asks you to prescribe vitamin supplementation you should explore their request, including advice relating to relevant lifestyle factors. You may also want to discuss the wide availability of low cost preparations from supermarkets and pharmacies, and encourage them to purchase supplements over the counter.

If a patient is adamant about being prescribed vitamin D, absolute refusal to do so may see you enter in to unnecessary conflict or attract a complaint. In this situation, you should consider the specific reasoning behind the request, the individual’s health and needs, and work together to reach a mutually agreeable outcome. This, of course, does not include an obligation to prescribe medication that you consider would not be of overall benefit to the patient.

Ultimately each request should be considered on an individual basis, seeking advice from colleagues as necessary.

Dr Katie Grant is a medicolegal adviser at Medical Protection

 

 

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Readers' comments (12)

  • Scam by the pharmaceutical industry. The entire population does not need vitamin d tablets.

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  • The entire population does not need half the drugs promoted by the pharmaceutical industry, most of them far more harmful than vitamin D. Why don't more GPs prescribe alternative treatments rather than dishing out what the pharmaceutical industry tells them to?

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  • I thought this might provide some clarity, but I was mistaken. It seems that any patient who insists, we should give in to, but others should be treated differently if they are less of a threat to us. This seems to incite a more demanding attitude from patients, which will untimately not help anyone.
    According to my cornflakes packet, a number of other vitamins have recommended daily amounts:- should all of these be available free on prescription to those who demand them, but not those who just need them to avoid risk of malnourishment?
    There is an added risk of overburdening the GP system with wholly unbeneficial workload, to the detriment of those who need our attention too.

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  • Wooly advice as usual from the defence organisation.... .... Not sure why we all have to pay such massive indemnity fees when the advice given to any dilemma is always so vague

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  • I have enormous respect for the medical defence organisations and their clinical advisors, but I find their complaints averse and risk averse culture extremely frustrating.

    So an entitled patient demanding a prescription for vitamin D deficiency prevention might make a complaint? Who cares? It's completely unjustified in the absence of deficiency. Why can't the MDOs be more assertive about inappropriate demands?

    Meanwhile.....we wonder why GPs are drowning in workload. Surely the increased activity this brings is a far bigger risk factor to making mistakes and needing the MPS again?

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  • Depends on the deficiency and patient.
    In line with NOS Guidance, high dose vitamin D3 supplements should be prescribed for treatment of high risk adults with proven deficiency or those about to be initiated on potent anti-resorptives.
    High Risk Groups for deficiency:
    • All pregnant and breastfeeding women, especially teenagers and young women are particularly at risk
    • Patients under 5 or aged 65 years and over
    • Patients not exposed to much sun, for example those who cover their skin for cultural reasons, who are housebound or confined indoors for long periods
    • Ethnic minorities who have darker skin, because their bodies are less able to produce vitamin D
    • Obese people (BMI30)
    • Medical risk factors such as renal and hepatic disease, malabsorption
    • Other risk factors such as alcoholics, vegetarians or vegans
    • Medication - patients taking rifampicin, anticonvulsants or Highly Active Antiretroviral Treatment (HAART)

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  • Great that Franka is here to tell us what to do.
    How often would Franka monitor the impact of this prescribed medication?

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  • Totally agree with Shaba about the defence bodies' kowtowing attitude and the 'do anything possible to avoid a complaint or escalation of one'. Sometimes you don't have to say sorry because you're not wrong, and sometimes you don't have to get bogged down in arguments over why you're not prescribing. I encourage all my patients to get OTC medications OTC, and have never failed to attract venom, criticism and outright aggression. Does that influence my prescribing? No, otherwise I'd just be turning into a cardie! Of course the point about getting everybody on board for consistency is very important, orherwise they'll try gaming the system and play us off against each other when they detect weaknesses there. I must sat that I am increasingly ashamed of the MDOs' stance of encouraging meek and self-flagellating responses when the case is clear-cut.

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  • More pathetic expert advice. It always follows the same trend - give in or you might get a complaint.

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  • If you get a complaint on a reading of 30 and you refusing to treat who defends you?
    Here in Dorset you need a mate on the CCG to help you
    They don't even tell you what is going on in the many corridors

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