Agenda item

Report of the Chief Transformation Officer and Deputy Chief Executive, ICB.

The Board received an update from The Integrated Care Board (ICB) regarding Prioritisation of NHS Services and the review on how gluten-free (GF) foods were prescribed for adults and children who had been diagnosed with coeliac disease or dermatitis herpetiformis.

The ICB was responsible for making sure NHS resources were used in the best possible way for local people. This meant making decisions based on evidence of what was working well, focusing on the greatest health needs, tackling inequalities, and ensuring money was spent in a way that delivered real benefits.

Coventry and Warwickshire faced serious financial pressures and the ICB must be more selective about what it funded, directing money to services that made the greatest difference. The work to reduce waste and be more efficient would continue however, some tough choices about which services could be maintained would be required.

In order to make these decisions fairly and in order to consider all aspects of a service before making decision on their future, the ICB worked with system partners to create a new approach to prioritisation, bringing together existing methods into one consistent and transparent methodology, so that decisions were fair and based on clear evidence. It would be used to consider the short- and long-term impacts of funding decisions on health outcomes, finances, and inequalities. It would guide a range of decisions, such as whether to stop or reduce funding for a service, restrict or expand access, invest in new technologies or review contracts.

When assessing a service or proposal, seven key areas were looked at:

1. How well it fits with NHS strategy
2. The level of population need
3. Its impact on health inequalities
4. Clinical effectiveness and risk
5. Value for money
6. How it connected with other services
7. How deliverable it was.

Four of these areas were scored and weighted, giving an overall rating from ‘Stop’ through to ‘Expand’. These ratings would help identify where investment should go and ensure decisions were consistent across the system. These ratings and the supporting evidence would be considered by the ICB Senior Leadership Team, who would make a recommendation for the next steps.

This new approach was about making sure that every pound spent delivered the best possible value for patients and communities. By using a fair and transparent process, the ICB and its partners aimed to protect essential services, address inequalities, and ensure the local NHS remained sustainable for the future.

As contracts came up for renewal, or new proposals for contracts were received, the prioritisation methodology was being applied to assessing whether, in the case of new contracts they would meet the needs of the population, or for current contracts, that they were delivering against the goals set out when the contract was first introduced. This led to four possible outcomes being recommended by the Senior Leadership Team:

• Invest and Expand
• Continue to commission, investing if funding is available
• Review service for value for money and access
• Decommission / Disinvest

For current contracts which had been through the prioritisation process and received a recommendation of decommissioning, the ICB would then enact its decommissioning policy. This policy outlined the steps needed to safely decommission a service. This included the production of an Equality and Quality Impact Assessment (EQIA) which aimed to identify, remove, or minimise negative impacts on disadvantaged groups which could be brought about by ending the contract. Through the decommissioning policy the ICB would involve stakeholders where appropriate, to ensure it understood the impacts of removing the service.

Once these steps had been undertaken, the ICB would take a final decision to decommission the service, considering both the value and any impacts on service users and patients outlined by the EQIA and other sources. If the decision to decommission was then taken the ICB would support the contract holders with wind down and service closure.

The ICB would continue to use the prioritisation process to determine the ongoing value for money and effectiveness of contracts, using the mechanisms described in this paper.

The ICB started the process of assessing services through the prioritisation process in March 2025. As this work was ongoing it was still too early to recognise the scale of savings achieved however, reporting would continue through the ICB’s designated structures going forward.

Where there was a potential impact identified through the EQIA, the ICB were committed to involving the Scrutiny Committee to both understand views and to enable the process to be scrutinised.

Gluten-free Prescribing

In 2017, the Department of Health & Social Care conducted a public consultation leading to legislative changes restricting GF prescribing to a limited list of items (bread and flour mixes) under the NHS Drug Tariff.  Across England, approximately one-third of ICB’s had decommissioned GF prescribing.  This shift reflected a growing consensus that GF prescribing was not clinically essential, given the wide availability of GF products in supermarkets and the existence of naturally GF alternatives ie. Rice, potatoes.

The C&W ICB had reviewed the case for continuing to provide GF foods on prescription.

The evidence base and impact assessment was carried out which investigated:

• population need of GF foods
• the health impacts of cessation of GF food prescribing
• health inequalities - the risks associated with decommissioning GF prescribing were largely mitigated by the availability of naturally occurring GF foods and retail access and prescribing data across C&W showed no correlation between deprivation and prescribing rates, suggesting prescribing was driven by clinical diagnoses rather than socio-economic factors.
• System financial impact – GF foods were more expensive for individuals to purchase when compared to gluten-containing equivalents however, the cost of GF products to the NHS via NHS prescription was even higher due to clinician time, dispensing fees and delivery charges.

As part of the engagement process, C&W ICB conducted a survey following approval from the Finance & Performance Committee.  The survey was widely promoted amongst people who were living with coeliac disease and a total of 232 responses were received. A full report detailing the responses had been included at Appendix A.

Following these findings, the ICB considered 4 possible options for GF prescribing:

Option1:  Retain the status quo

Option 2: Restrict to patients with financial hardship only

Option 3: Restrict to children only

Option 4: Decommission GF prescribing completely

The above options had been considered by the ICB’s Senior Leadership Team who agreed that the preferred option would be that GF prescribing was decommissioned completely.  This was the recommendation to the ICB’s Finance & Performance Committee.

The Cabinet Member for Sport, Health and Wellbeing, Councillor K Caan, welcomed the item, advising the frameworks would enable improved results for residents in the future and the consultation would ensure the concerns of residents would be considered with inequality the top priority.

The Cabinet Member for Adult Services, Councillor L Bigham, expressed concerns over the cost of gluten-free food for residents should prescriptions cease, suggesting a precedent was being set and that further investigation and a wider consultation was required prior to making a decision to decommission the service.

Members of the Board, having considered the report and presentation, asked questions and received information from officers on the following matters:

• As contracts came up for renewal, or new proposals for contracts were received, the prioritisation methodology for assessing whether new contracts were applied, ascertaining whether the needs of the population were being met and whether current contracts were delivering against their goals.
• AI was not being used as the technology was not in place for this.  Evidence was being gathered from clinicians.
• The ICB worked with partners looking at data in real time and forward projection data to ascertain future population requirements and officers worked closely with public health colleagues on joint strategic needs assessments.
• As £240k was being spent each year on gluten-free prescribing, this had prompted the ICB to review gluten-free prescribing for residents with coeliac disease.
• Approximately 1100 residents of Coventry received gluten-free prescriptions last year.
• Gluten-free prescriptions were not a treatment for coeliac disease.  Prescribing was introduced when gluten-free products were not widely available however, they were now widely available in supermarkets.
• Those ICB’s which had already decommissioned gluten-free prescribing had not reported any significant adverse outcomes and patients had not reported any long-term impacts.
• If, at the end of the prioritisation process, the outcome was to decommission, involvement and support would be undertaken with those residents affected including an EQIA.
• During the consultation process, ICB officers had contacted the Coeliac Society, spoken to dieticians and GP’s.  Advertising had been undertaken on social media and with specific coeliac community groups and it was felt that by engaging with coeliac groups and dieticians, the digitally enabled would be made fully aware.
• A full engagement report had been produced on gluten-free prescribing which had been considered by the ICB Finance and Performance Committee.  Their role it was to look at the impact of decommissioning and make a decision.
• Approximately 30 services had been through the decommissioning process to date however, they were mostly services which were coming to the end of their contracts and were not renewed or were pilots which had come to the end of their funding.
• Mitigations would be put in place should decommissioning of gluten-free prescribing go ahead which would signpost patients to alternative support.
• Wider consultation could include asking the opinion of people who don’t have coeliac disease or have gluten-free food on prescription however, this may not be completely reflective of patients impacted by the change.

Members of the Board expressed a broad range of views on the decommissioning of gluten-free prescribing and clarified that the Board was requested to support the validity of the engagement process.

The Board requested:

• Further data regarding demographic data arising out of the consultation.
• Feedback on whether the consultation was open to all gluten free patients, just specific groups and methods of gathering feedback.
• Details of services (non-commercial data) that have already gone through the decommissioning process.

RESOLVED that the Health and Social Care Scrutiny Board (5):

1. Notes the information regarding prioritisation in Appendix 1 in light of the paper regarding gluten-free prescribing.

2. Supports the decision of the C&W ICB that the information in the paper regarding the engagement undertaken, numbers of patients affected by the change and mitigations outlined are sufficient to go ahead with the proposed service change.

3. That the Boards concerns regarding affordability of gluten-free items if they are not prescribed, are provided to the ICB Finance & Performance Committee.