Achieving Value and Sustainability in Prescribing Medication

Published: 28/08/24

The Scottish Government are consulting on draft guidance on achieving value and sustainability in prescribing by reducing unwarranted variation across health boards.  

This includes items of low and limited clinical value, diabetic sundries, and antimicrobial stewardship. 

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There is variation in prescribing of medications across NHS Scotland. This can include items that may have low or limited effectiveness, safety concerns, or provide low value for money for NHS Scotland where there are more cost-effective items available. This can also include instances of antibiotics being prescribed unnecessarily or for longer than the recommended duration, increasing antimicrobial resistance. 

This guidance aims to promote the effective use of medicines and minimise unwarranted variation in prescribing practice across NHS Scotland. It supports the principles of Realistic Medicine through shared decision-making, encouraging medication review, and ensuring medicines are prescribed appropriately. 

Consultation Questions 

We have a total of 31 questions with some being multi-part, please answer as many as you feel able to. 

1. Co-proxamol 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 1a: Do you agree or disagree with the recommendation that prescribers should not initiate Co-proxamol for any new individuals?

  Agree

• Question 1b: Do you agree or disagree with the recommendation to deprescribe co-proxamol in all individuals?

  Agree

• Question 1c: Please provide any further comments on the recommendations for Co-proxamol.

  We would encourage close working between NHS boards and community pharmacies to ensure that any deprescribing or change to local formularies does not result in community pharmacies being left with surplus stock which cannot be dispensed and used up, resulting in medicines waste.  

  This statement is applicable to all items under scrutiny in this consultation. 

2. Glucosamine and Chondroitin 

• do not initiate in primary or secondary care

• deprescribe in individuals currently prescribed this item 

• Question 2a: Do you agree or disagree with the recommendation that prescribers should not initiate Glucosamine and Chondroitin for any new individuals?

  Agree

• Question 2b: Do you agree or disagree with the recommendation to deprescribe Glucosamine and Chondroitin in all individuals?

  Agree

3. Herbal Treatments 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 3a: Do you agree or disagree with the recommendation that prescribers should not initiate herbal treatments for any new individuals?

  Agree

• Question 3b: Do you agree or disagree with the recommendation to deprescribe herbal treatments in all individuals?

  Agree

4. Homeopathy 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 4a: Do you agree or disagree with the recommendation that prescribers should not initiate homeopathy for any new individuals?

  Agree

• Question 4b: Do you agree or disagree with the recommendation to deprescribe homeopathy in all individuals?

  Agree

5. Minocycline for acne 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 5a: Do you agree or disagree with the recommendation that prescribers should not initiate Minocycline for acne for any new individuals?

  Agree

• Question 5b: Do you agree or disagree with the recommendation to deprescribe Minocycline for acne in all individuals?

  Agree

6. Aliskiren 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 6a: Do you agree or disagree with the recommendation that prescribers should not initiate Aliskiren for any new individuals?

  Agree

• Question 6b: Do you agree or disagree with the recommendation to deprescribe Aliskiren in all individuals?

  Agree

7. Bath and Shower Emollients 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 7a: Do you agree or disagree with the recommendation that prescribers should not initiate bath and shower emollients for any new individuals?

  Agree

• Question 7b: Do you agree or disagree with the recommendation to deprescribe bath and shower emollients in all individuals?

  Agree

8. Dipipanone 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 8a: Do you agree or disagree with the recommendation that prescribers should not initiate Dipipanone for any new individuals?

  Agree

• Question 8b: Do you agree or disagree with the recommendation to deprescribe Dipipanone in all individuals?

  Agree

9. Doxazosin Modified Release preparation 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 9a: Do you agree or disagree with the recommendation that prescribers should not initiate Doxazosin modified release preparation for any new individuals?

  Agree

• Question 9b: Do you agree or disagree with the recommendation to deprescribe Doxazosin modified release preparation in all individuals?

  Agree

10. Lutein and Antioxidants 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item

• Question 10a: Do you agree or disagree with the recommendation that prescribers should not initiate lutein and antioxidants for any new individuals?

  Agree

• Question 10b: Do you agree or disagree with the recommendation to deprescribe lutein and antioxidants in all individuals?

  Agree

11. Nefopam 

• do not initiate in primary care or secondary care. 

• deprescribe in individuals currently prescribed this item. 

• Question 11a: Do you agree or disagree with the recommendation that prescribers should not initiate nefopam for any new individuals?

  Agree

• Question 11b: Do you agree or disagree with the recommendation to deprescribe nefopam in all individuals?

  Agree

12. Omega 3 Fatty Acids excluding icosapent ethyl [Vazkepa®] 

• do not initiate in primary care or secondary care. 

• deprescribe in individuals currently prescribed this item. 

• Question 12a: Do you agree or disagree with the recommendation that prescribers should not initiate omega 3 fatty acids for any new individuals?

  Agree

• Question 12b: Do you agree or disagree with the recommendation to deprescribe omega 3 fatty acids in all individuals?

  Agree

13. Oxycodone and Naloxone combination product 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 13a Do you agree or disagree with the recommendation that prescribers should not initiate oxycodone and naloxone for any new individuals?

  Agree

• Question 13b: Do you agree or disagree with the recommendation to deprescribe oxycodone and naloxone in all individuals?

  Agree

14. Paracetamol and Tramadol combination product

• do not initiate in primary or secondary care

• deprescribe in individuals currently prescribed this item

• Question 14a Do you agree or disagree with the recommendation that prescribers should not initiate paracetamol and tramadol for any new individuals?

  Agree

• Question 14b Do you agree or disagree with the recommendation to deprescribe paracetamol and tramadol in all individuals?

  Agree

15. Perindopril Arginine

• do not initiate in primary or secondary care

• deprescribe in individuals currently prescribed this item

• Question 15a Do you agree or disagree with the recommendation that prescribers should not initiate perindopril arginine for any new individuals?

  Agree

• Question 15b Do you agree or disagree with the recommendation to deprescribe perindopril arginine in all individuals?

  Agree

16. Probiotics 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 16a Do you agree or disagree with the recommendation that prescribers should not initiate probiotics for any new individuals?

  Agree

• Question 16b Do you agree or disagree with the recommendation to deprescribe probiotics in all individuals?

  Agree

17. Rubefacients and Poultices 

• do not initiate in primary or secondary care 

• deprescribe in individuals currently prescribed this item 

• Question 17a Do you agree or disagree with the recommendation that prescribers should not initiate rubefacients and poultices for any new individuals?

  Agree

• Question 17b Do you agree or disagree with the recommendation to deprescribe rubefacients and poultices in all individuals?

  Agree

18. Alimemazine 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 18a Do you agree or disagree with the recommendation that Alimemazine is only prescribed for an exception or indication named in this guidance?

  Agree

• Question 18b Do you agree or disagree with the recommendation to deprescribe alimemazine in individuals where appropriate?

  Agree

• Question 18c Do you agree or disagree with the recommendation to only prescribe alimemazine if no other item or intervention is clinically appropriate or available?

  Agree

19. Amiodarone 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 19a Do you agree or disagree with the recommendation that amiodarone is only prescribed for an exception or indication named in this guidance?

  Agree

• Question 19b Do you agree or disagree with the recommendation to deprescribe amiodarone in individuals where appropriate?

  Agree

• Question 19c Do you agree or disagree with the recommendation to only prescribe amiodarone if no other item or intervention is clinically appropriate or available?

  Agree

20. Ascorbic Acid 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 20a Do you agree or disagree with the recommendation that Ascorbic acid is only prescribed for an exception or indication named in this guidance?

  Agree

• Question 20b Do you agree or disagree with the recommendation to deprescribe ascorbic acid in individuals where appropriate?

  Agree

• Question 20c Do you agree with the recommendation to only prescribe ascorbic acid if no other item or intervention is clinically appropriate or available.

  Agree

21. Buprenorphine Patches 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 21a Do you agree or disagree with the recommendation that buprenorphine patches should only be prescribed for an exception or indication named in this guidance?

  Agree

• Question 21b Do you agree or disagree with the recommendation to deprescribe buprenorphine patches in individuals where appropriate?

  Agree

• Question 21c Do you agree or disagree with the recommendation to only prescribe buprenorphine patches if no other item or intervention is clinically appropriate or available?

  Agree

22. Chloral Hydrate 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 22a Do you agree or disagree with the recommendation that chloral hydrate should only be prescribed for an exception or indication named in this guidance?

  Agree

• Question 22b Do you agree or disagree with the recommendation to deprescribe chloral hydrate in individuals where appropriate?

  Agree

• Question 22c Do you agree or disagree with the recommendation to only prescribe chloral hydrate if no other item or intervention is clinically appropriate of available?

  Agree

23. Dosulepin 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 23a Do you agree or disagree with the recommendation that dosulepin should only be prescribed for an exception or indication named in this guidance?

  Agree

• Question 23b Do you agree or disagree with the recommendation to deprescribe dosulepin in individuals where appropriate?

  Agree

• Question 23c Do you agree or disagree with the recommendation to only prescribe dosulepin if no other item or intervention is clinically appropriate or available?

  Agree

24. Dronedarone 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 24a Do you agree or disagree with the recommendation that dronedarone should only be prescribed for an exception or indication named in this guidance?

  Agree

• Question 24b Do you agree or disagree with the recommendation to deprescribe dronedarone in individuals where appropriate?

  Agree

• Question 24c Do you agree or disagree with the recommendation to only prescribe dronedarone if no other item or intervention is clinically appropriate or available?

  Agree

25. Immediate Release Fentanyl 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 25a Do you agree or disagree with the recommendation that immediate release fentanyl should only be prescribed for an exception or indication named in this guidance?

  Agree

• Question 25b Do you agree or disagree with the recommendation to deprescribe immediate release fentanyl in individuals where appropriate?

  Agree

• Question 25c Do you agree or disagree with the recommendation to only prescribe immediate release fentanyl if no other item or intervention is clinically appropriate or available?

  Agree

26. Lidocaine 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 26a Do you agree or disagree with the recommendation that lidocaine should only be prescribed for an exception or indication named in this guidance?

  Agree

• Question 26b Do you agree or disagree with the recommendation to deprescribe lidocaine in individuals where appropriate?

  Agree

• Question 26c Do you agree or disagree with the recommendation to only prescribe lidocaine if no other item or intervention is clinically appropriate or available?

  Agree

27. Liothyronine 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 27a Do you agree or disagree with the recommendation that liothyronine should only be prescribed for an exception or indication named in this guidance?

  Agree

• Question 27b Do you agree or disagree with the recommendation to deprescribe liothyronine in individuals where appropriate?

  Agree

• Question 27c Do you agree or disagree with the recommendation to only prescribe liothyronine if no other item or intervention is clinically appropriate or available?

  Agree

28. Trimipramine 

• prescribe only if for an exception or indication named in this guidance. 

• consider deprescribing in individuals currently prescribed this item where appropriate. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 28a Do you agree or disagree with the recommendation that trimipramine should only be prescribed for an exception or indication named in this guidance?

  Agree

• Question 28b Do you agree or disagree with the recommendation to deprescribe trimipramine in individuals where appropriate?

  Agree

• Question 28c Do you agree or disagree with the recommendation to only prescribe trimipramine if no other item or intervention is clinically appropriate or available?

  Agree

29. Blood Glucose Monitoring Strips (costing more than £10 per 50 strips) 

• do not initiate strips that cost over £10 for 50 strips 

• deprescribe or change in individuals currently prescribed this item. 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 29a Do you agree or disagree with the recommendation that prescribers should not initiate blood glucose monitoring strips that cost over £10 for 50 strips?

  Agree

• Question 29b Do you agree or disagree with the recommendation to deprescribe or change blood glucose monitoring strips that cost over £10 for 50 strips?

  Agree

• Question 29c Do you agree or disagree with the recommendation to only prescribe blood glucose monitoring strips that cost over £10 for 50 strips if no other item or intervention is clinically appropriate or available?

  Agree

30. Insulin Pen Needles (costing more than £5 per 100 needles) 

• do not initiate needles that cost over £5 for 100 needles 

• deprescribe or change in individuals currently prescribed this item 

• prescribe only if no other item or intervention is clinically appropriate 

• prescribe only if no other item or intervention is available 

• Question 30a Do you agree or disagree with the recommendation that prescribers should not initiate insulin pen needles that cost over £5 for 100 needles?

  Agree

• Question 30b Do you agree or disagree with the recommendation to deprescribe or change insulin pen needles that cost over £5 for 100 needles?

  Agree

• Question 30c Do you agree or disagree with the recommendation to only prescribe insulin pen needles that cost over £5 for 100 needles if no other item or intervention is clinically appropriate or available?

  Agree

31. Antimicrobial Stewardship 

• Avoid prescriptions for antibiotics in self-limiting or viral infections to reduce the risk of antibiotic resistance. Promote self-management for these situations: e.g., rest, symptomatic relief and hydration. Encourage people to become antibiotic guardians. 

• Ensure that antibiotic courses are prescribed for the appropriate duration. (e.g., three days for uncomplicated UTI’s in women and five days for community acquired and hospital acquired pneumonia) 

• Reinforce advice that antibiotics are taken as directed to ensure effectiveness (Take at regular intervals, do not skip doses and check that the full course is taken). Advise that patients do not save antibiotics for later or share unused antibiotics with family or friends. 

• Ensure a management plan is documented within 72 hours when commencing IV antibiotics, including consideration of continuation and rationalisation of treatment with the potential for stopping, or switching IV to oral therapy. 

• Prescribe oral solid dosage forms where possible, minimising use of liquid preparations or IV to where they are necessary and appropriate. 

• Offer resources and advice to patients and families on learning how to swallow pills. 

• Encourage that any unused medicine is returned to community pharmacy for safe disposal. 

• Signpost and encourage healthcare staff to update education in antibiotic management using SAPG and NES materials on TURAS. 

• Question 31a Do you agree or disagree with the recommendation to avoid prescriptions for antibiotics in self-limiting or viral infections?

  Agree

• Question 31b Do you agree or disagree with the recommendation to prescribe antibiotics for the appropriate duration?

  Agree

• Question 31c Do you agree or disagree with the recommendation to ensure a management plan is documented within 72 hours when commencing IV antibiotics?

  Agree

• Question 31d Do you agree or disagree with the recommendation to prescribe oral solid dosage forms, minimising use of liquids?

  Agree

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