Overview
A quick reference tool summarising NHS England guidance on conditions for which over-the-counter (OTC) items should not routinely be prescribed in primary care.
General Exceptions to the OTC Guidance
- Patients prescribed an OTC treatment for a long term condition (e.g. regular pain relief for chronic arthritis or treatments for inflammatory bowel disease)
- For the treatment of more complex forms of minor illnesses (e.g. severe migraines that are unresponsive to OTC medicines)
- For those patients that have symptoms that suggest the condition is not minor (i.e. those with red flag symptoms, e.g. indigestion with very bad pain)
- Treatment for complex patients (e.g. immunosuppressed patients)
- Patients on prescription only treatments
- Patients prescribed OTC products to treat an adverse effect or symptom of a more complex illness and/or prescription only medications should continue to have these products prescribed on the NHS
- Circumstances where the product licence does not allow the product to be sold OTC to certain groups of patients
- Patients with a minor condition suitable for self-care that has not responded sufficiently to treatment with an OTC product
- Patients where the clinician considers that the presenting symptom is due to a condition that would not be considered a minor condition
- Circumstances where the prescriber believes that in their clinical judgement, exceptional circumstances exist that warrant deviation from the recommendation to self-care
- Individual patients where the clinician considers that their ability to self‑manage is compromised as a consequence of medical, mental health, or significant social vulnerability to the extent that their health and/or wellbeing could be adversely affected, if reliant on self-care. Being exempt from paying a prescription charge does not automatically warrant an exception. Consideration should also be given to safeguarding issues.
Table 1: Self-limiting Conditions
| Acute Sore Throat | |
| Annual spend | c. <£100,000 |
| Rationale for recommendation | A sore throat due to a viral or bacterial cause is a self-limiting condition. Symptoms resolve within 3 days in 40% of people, and within 1 week in 85% of people, irrespective of whether or not the sore throat is due to a streptococcal infection.There is little evidence to suggest that treatments such as lozenges or throat sprays help to treat the cause of sore throat and patients should be advised to take simple painkillers and implement some self-care measures such as gargling with warm salty water instead. |
| References |
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| Recommendation | Advise CCGs that a prescription for treatment of acute sore throat should not routinely be offered in primary care as the condition is self‑limiting and will clear up on its own without the need for treatment. |
| Exceptions | ‘Red flag’ symptoms. |
| Infrequent Cold Sores of the Lip | |
| Annual spend | c. <£100,000 |
| Rationale for recommendation | Cold sores caused by the herpes simplex virus usually clear up without treatment within 7–10 days.Antiviral creams are available OTC from pharmacies without a prescription and if used correctly, these can help ease symptoms and speed up the healing time. To be effective, these treatments should be applied as soon as the first signs of a cold sore appear. Using an antiviral cream after this initial period is unlikely to have much of an effect. |
| References |
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| Recommendation | Advise CCGs that a prescription for treatment of cold sores should not routinely be offered in primary care as the condition is self‑limiting and will clear up on its own without the need for treatment. |
| Exceptions | Immunocompromised patients.‘Red flag’ symptoms. |
| Conjunctivitis | |
| Annual spend | c. £500,000 |
| Rationale for recommendation | Treatment is not usually needed for conjunctivitis as the symptoms usually clear within a week. There are several self-care measures that may help with symptoms. If treatment is needed, then treatment is dependent on the cause:
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| Recommendation | Advise CCGs that a prescription for treatment of conjunctivitis should not routinely be offered in primary care as the condition is self-limiting and will clear up on its own without the need for treatment. |
| Exceptions | ‘Red flag’ symptoms. |
| Coughs and Colds and Nasal Congestion | |
| Annual spend | c. £1,300,000 |
| Rationale for recommendation | Most colds start to improve in 7–10 days. Most coughs clear up within 2–3 weeks. Both conditions can cause nasal congestion. Neither condition requires any treatment. |
| References |
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| Recommendation | Advise CCGs that a prescription for treatment of coughs, colds, and nasal congestion should not routinely be offered in primary care as the condition is self-limiting and will clear up on its own without the need for treatment. |
| Exceptions | ‘Red flag’ symptoms. |
| Cradle Cap (Seborrhoeic Dermatitis—Infants) | |
| Annual spend | c. £4,500,000 |
| Rationale for recommendation | Cradle cap is harmless and does not usually itch or cause discomfort. It usually appears in babies in the first two months of their lives, and clears up without treatment within weeks to a few months. |
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| Recommendation | Advise CCGs that a prescription for treatment of cradle cap should not routinely be offered in primary care as the condition is self-limiting and will clear up on its own without the need for treatment. |
| Exceptions | If causing distress to the infant and not improving. |
| Haemorrhoids | |
| Annual spend | c. £500,000 |
| Rationale for recommendation | In many cases, haemorrhoids do not cause symptoms and some people do not even realise they have them. Haemorrhoids often clear up by themselves after a few days. Making simple dietary changes and not straining on the toilet are often recommended first.However, there are many treatments (creams, ointments, and suppositories) that can reduce itching and discomfort and these are available OTC for purchase. |
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| Recommendation | Advise CCGs that a prescription for treatment of haemorrhoids should not routinely be offered in primary care as the condition is self-limiting and will clear up on its own without the need for treatment. |
| Exceptions | ‘Red flag’ symptoms. |
| Infant Colic | |
| Annual spend | c. <£100,000 |
| Rationale for recommendation | As colic eventually improves on its own, medical treatment is not usually recommended.There are some OTC treatments available that could be tried however; there is limited evidence for the effectiveness of these treatments. |
| References |
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| Recommendation | Advise CCGs that a prescription for treatment of infant colic should not routinely be offered in primary care as the condition is self-limiting and will clear up on its own without the need for treatment. |
| Exceptions | ‘Red flag’ symptoms. |
| Mild Cystitis | |
| Annual spend | c. £300,000 |
| Rationale for recommendation | Mild cystitis is a common type of urinary tract inflammation, normally caused by an infection; however it is usually more of a nuisance than a cause for serious concern.Mild cases can be defined as those that are responsive to symptomatic treatment but will also clear up on their own. If symptoms don’t improve in 3 days, despite self-care measures, then the patient should be advised to see their GP. Symptomatic treatment using products that reduce the acidity of the urine to reduce symptoms are available, but there’s a lack of evidence to suggest they’re effective. |
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| Recommendation | Advise CCGs that a prescription for treatment of mild cystitis should not routinely be offered in primary care as the condition is self-limiting and will clear up on its own without the need for treatment. |
| Exceptions | ‘Red flag’ symptoms. |
Table 2: Minor Conditions Suitable for Self-care
| Mild Irritant Dermatitis | |
| Annual spend | c. £14,500,000 |
| Rationale for recommendation | Irritant dermatitis is a type of eczema triggered by contact with a particular substance. Once treated most people can expect their symptoms to improve and/or clear up completely if the irritant or allergen can be identified and removed or avoidedIt is most commonly caused by irritants such as soaps, washing powders, detergents, and solvents, or regular contact with water. Treatment normally involves avoiding the allergen or irritant and treating symptoms with OTC emollients and topical corticosteroids. |
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| Recommendation | Advise CCGs that a prescription for treatment of contact dermatitis should not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Dandruff | |
| Annual spend | c. £4,500,000 |
| Rationale for recommendation | Dandruff is a common skin condition. It can be defined as mild scaling of the scalp without itching. Dandruff isn’t contagious or harmful and can be easily treated with OTC anti-fungal shampoos.A GP appointment is unnecessary. Patients should be encouraged to manage mild dandruff with long term OTC treatments. |
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| Recommendation | Advise CCGs that a prescription for treatment for dandruff should not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Diarrhoea (Adults) | |
| Annual spend | c. £2,800,000 |
| Rationale for recommendation | Diarrhoea normally affects most people from time to time and is usually nothing to worry about. However it can take a few days to a week to clear up.Acute diarrhoea is usually caused by a bacterial or viral infection and other causes include drugs, anxiety or a food allergy. OTC treatments can help replace lost fluids or reduce bowel motions. This recommendation does not apply to children. |
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| Recommendation | Advise CCGs that a prescription for treatment for acute diarrhoea should not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Dry Eyes/Sore Tired Eyes | |
| Annual spend | c. £14,800,000 |
| Rationale for recommendation | Dry eye syndrome, or dry eye disease, is a common condition that occurs when the eyes don’t make enough tears, or the tears evaporate too quickly.Most cases of sore tired eyes resolve themselves. Patients should be encouraged to manage both dry eyes and sore eyes by implementing some self-care measures such as good eyelid hygiene and avoidance of environmental factors alongside treatment. Mild to moderate cases of dry eye syndrome or sore tired eyes can usually be treated using lubricant eye treatments that consist of a range of drops, gels, and ointments that can be easily be purchased OTC. |
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| Recommendation | Advise CCGs that a prescription for treatment of dry or sore eyes should not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Earwax | |
| Annual spend | c. £300,000 |
| Rationale for recommendation | Earwax is produced inside ears to keep them clean and free of germs. It usually passes out of the ears harmlessly, but sometimes too much can build up and block the ears.A build-up of earwax is a common problem that can often be treated using eardrops bought from a pharmacy. These can help soften the earwax so that it falls out naturally. |
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| Recommendation | Advise CCGs that a prescription for the removal of earwax should not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Excessive Sweating (Hyperhidrosis) | |
| Annual spend | c. £200,000 |
| Rationale for recommendation | Hyperhidrosis is a common condition in which a person sweats excessively.First line treatment involves simple lifestyle changes. It can also be treated with OTC high strength antiperspirants. An antiperspirant containing aluminium chloride is usually the first line of treatment and is sold in most pharmacies. |
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| Recommendation | Advise CCGs that a prescription for high‑strength antiperspirants for the treatment of mild to moderate hyperhidrosis should not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Head Lice | |
| Annual spend | c. £600,000 |
| Rationale for recommendation | Head lice are a common problem, particularly in school children aged 4–11 years. They are largely harmless, but can live in the hair for a long time if not treated and can be irritating and frustrating to deal with.Live head lice can be treated by wet combing; chemical treatment is only recommended in exceptional circumstances and in these cases OTC medicines can be purchased from a pharmacy. If appropriate everyone in the household needs to be treated at the same time—even if they do not have symptoms. Further information on how to treat head lice without medication can be found on NHS Choices. |
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| Recommendation | Advise CCGs that a prescription for treatment of head lice will not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Indigestion and Heartburn | |
| Annual spend | c. £7,500,000 |
| Rationale for recommendation | Most people have indigestion at some point. Usually, it is not a sign of anything more serious and can be treated at home without the need for medical advice, as it is often mild and infrequent and specialist treatment is not required.Most people are able to manage their indigestion by making simple diet and lifestyle changes, or taking medication such as antacids. Most people can ease symptoms by simple changes to diet and lifestyle and avoiding foods that make indigestion worse (e.g. rich spicy or fatty foods, caffeinated drinks). |
| References |
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| Recommendation | Advise CCGs that a prescription for treatment of indigestion and heartburn will not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Infrequent Constipation | |
| Annual spend | c. £22,800,000 |
| Rationale for recommendation | Constipation can affect people of all ages and can be just for a short period of time.It can be effectively managed with a change in diet or lifestyle. Pharmacists can help if diet and lifestyle changes are not helping. They can suggest an OTC laxative. Most laxatives work within 3 days. They should only be used for a short time only. Laxatives are not recommended for children unless they are prescribed by a GP. This guidance applies to short term, infrequent constipation caused by changes in lifestyle or diet such as lack of water or movement or changes in diet. |
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| Recommendation | Advise CCGs that a prescription for treatment of simple constipation will not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Infrequent Migraine | |
| Annual spend | c. £700,000 |
| Rationale for recommendation | Migraine is a common health condition, affecting around one in every five women and around one in every 15 men. Mild infrequent migraines can be adequately treated with OTC pain killers and a number of combination medicines for migraine are available that contain both painkillers and anti-sickness medicines.Those with severe or recurrent migraines should continue to seek advice from their GP. |
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| Recommendation | Advise CCGs that a prescription for the treatment of mild migraine should not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Insect Bites and Stings | |
| Annual spend | c. £5,300,000 |
| Rationale for recommendation | Most insect bites and stings are not serious and will get better within a few hours or days.OTC treatments can help ease symptoms, such as painkillers, creams for itching, and antihistamines. |
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| Recommendation | Advise CCGs that a prescription for treatment for insect bites and stings will not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Mild Acne | |
| Annual spend | c. £800,000 |
| Rationale for recommendation | Acne is a common skin condition that affects most people at some point. Although acne cannot be cured, it can be controlled with treatment.Several creams, lotions, and gels for treating acne are available at pharmacies. Treatments can take up to 3 months to work. Patients should be encouraged to manage mild acne with long term use of OTC products. |
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| Recommendation | Advise CCGs that a prescription for treatment of mild acne will not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Mild Dry Skin | |
| Annual spend | c. £33,000 |
| Rationale for recommendation | Emollients are often used to help manage dry, itchy, or scaly skin conditions. Patients with mild dry skin can be successfully managed using OTC products on a long-term basis. |
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| Recommendation | Advise CCGs that a prescription for treatment of dry skin should not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | See earlier for general exceptions. |
| Sunburn Due to Excessive Sun Exposure | |
| Annual spend | c. £33,000 |
| Rationale for recommendation | Most people manage sunburn symptoms themselves or prevent symptoms developing using sun protection products that can easily be bought in a pharmacy or supermarket. |
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| Recommendation | Advise CCGs that a prescription for treatment of sunburn should not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | See earlier for general exceptions. |
| Sun Protection | |
| Annual spend | c. £33,000 |
| Rationale for recommendation | Most people manage sunburn symptoms themselves or prevent symptoms developing using sun protection products that can easily be bought in a pharmacy or supermarket. |
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| Recommendation | Advise CCGs that a prescription for sun protection should not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | The Advisory Committee on Borderline Substances approved indication of photodermatoses (i.e. where skin protection should be prescribed). See earlier for general exceptions. |
| Mild to Moderate Hay Fever/Seasonal Rhinitis | |
| Annual spend | c. £1,100,000 |
| Rationale for recommendation | Hay fever is a common allergic condition that affects up to one in five people. There is currently no cure for hay fever, but most people with mild to moderate symptoms are able to relieve symptoms with OTC treatments recommended by a pharmacist. |
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| Recommendation | Advise CCGs that a prescription for treatment of mild to moderate hay fever will not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Minor Burns and Scalds | |
| Annual spend | c. £200,000 |
| Rationale for recommendation | Burns and scalds are damage to the skin caused by heat. Both are treated in the same way.Depending on how serious a burn is, it is possible to treat burns at home. Antiseptic creams and treatments for burns should be included in any products kept in a medicine cabinet at home. |
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| Recommendation | Advise CCGs that a prescription for minor burns and scalds should not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | See earlier for general exceptions.No routine exceptions have been identified. However, more serious burns always require professional medical attention. Burns requiring hospital A&E treatment include but are not limited to:
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| Minor Conditions Associated with Pain, Discomfort, and/or Fever (e.g. Aches and Sprains, Headache, Period Pain, Back Pain) | |
| Annual spend | c. £38,200,000 |
| Rationale for recommendation | In most cases, headaches, period pain, mild fever, and back pain can be treated at home with OTC painkillers and lifestyle changes, such as getting more rest and drinking enough fluids.Patients should be encouraged to keep a small supply of OTC analgesics in their medicines cabinets at home so they are able to manage minor conditions at home without the need for a GP appointment. Examples of conditions where patients should be encouraged to self‑care include: headache, colds, fever, earache, teething, period pain, cuts, self-limiting musculoskeletal pain, sprains and strains, bruising, toothache, sinusitis/nasal congestion, recovery after a simple medical procedure, aches and pains, and sore throat. |
| References |
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| Recommendation | Advise CCGs that a prescription for treatment of conditions associated with pain, discomfort, and mild fever will not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Mouth Ulcers | |
| Annual spend | c. £5,500,000 |
| Rationale for recommendation | Mouth ulcers are usually harmless and do not need to be treated because most clear up by themselves within a week or two. Mouth ulcers are common and can usually be managed at home, without seeing your dentist or GP. However, OTC treatment can help to reduce swelling and ease any discomfort. |
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| Recommendation | Advise CCGs that a prescription for treatment of mouth ulcers will not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Nappy Rash | |
| Annual spend | c. £500,000 |
| Rationale for recommendation | Up to one third of babies and toddlers in nappies have nappy rash at any one time. Nappy rash can usually be treated at home using barrier creams purchased at the supermarket or pharmacy.Nappy rash usually clears up after about 3–7 days if recommended hygiene tips are followed. |
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| Recommendation | Advise CCGs that a prescription for treatment for nappy rash will not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Oral Thrush | |
| Annual spend | c. £4,500,000 |
| Rationale for recommendation | Oral thrush is a minor condition that can be treated without the need for a GP consultation or prescription in the first instance.It is common in babies and older people with dentures or those using steroid inhalers. It can easily be treated with OTC gel. |
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| Recommendation | Advise CCGs that a prescription for treatment for oral thrush will not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Prevention of Dental Caries | |
| Annual spend | c. <£100,000 |
| Rationale for recommendation | The dentist may advise on using higher-strength fluoride toothpaste if you are particularly at risk of tooth decay. Some higher fluoride toothpastes (~1500 ppm) and mouthwashes can be purchased OTC. |
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| Recommendation | Advise CCGs that a prescription for high-fluoride OTC toothpaste should not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Ringworm/Athlete’s Foot | |
| Annual spend | c. £3,000,000 |
| Rationale for recommendation | Ringworm is a common fungal infection that can cause a red or silvery ring‑like rash on the skin. Despite its name, ringworm doesn’t have anything to do with worms.Athlete’s foot is a rash caused by a fungus that usually appears between the toes. These fungal infections, medically known as ‘tinea’, are not serious and are usually easily treated with OTC treatments. However, they are contagious and easily spread so it is important to practice good foot hygiene. |
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| Recommendation | Advise CCGs that a prescription for treatment of ringworm or athlete’s foot will not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | Lymphoedema or history of lower limb cellulitis. See earlier for general exceptions. |
| Teething/Mild Toothache | |
| Annual spend | c. £5,500,000 |
| Rationale for recommendation | Teething can be distressing for some babies, but there are ways to make it easier for them.Teething gels often contain a mild local anaesthetic, which helps to numb any pain or discomfort caused by teething and these can be purchased from a pharmacy. If baby is in pain or has a mild raised temperature (less than 38°C) then paracetamol or ibuprofen suspension can be given. Toothache can come and go or be constant. Eating or drinking can make the pain worse, particularly if the food or drink is hot or cold. Mild toothache in adults can also be treated with OTC painkillers whilst awaiting a dental appointment for further investigation. |
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| Recommendation | Advise CCGs that a prescription for teething in babies or toothache in children and adults will not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Threadworms | |
| Annual spend | c. £200,000 |
| Rationale for recommendation | Threadworms (pinworms) are tiny worms in your stools. They are common in children and can be spread easily. They can be effectively treated without the need to visit the GP.Treatment for threadworms can easily be bought from pharmacies. This is usually a chewable tablet or liquid you swallow. Strict hygiene measures can also help clear up a threadworm infection and reduce the likelihood of reinfection. Everyone in the household will require treatment, even if they don’t have symptoms. |
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| Recommendation | Advise CCGs that a prescription for treatment of threadworm should not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Travel Sickness | |
| Annual spend | c. £4,500,000 |
| Rationale for recommendation | Mild motion sickness can be treated by various self-care measures (e.g. stare at a fixed object, fresh air, listen to music etc.); more severe motion sickness can be treated with OTC medicines. |
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| Recommendation | Advise CCGs that a prescription for treatment for motion sickness will not routinely be offered in primary care as the condition is appropriate for self‑care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
| Warts and Verrucae | |
| Annual spend | c. £900,000 |
| Rationale for recommendation | Most people will have warts at some point in their life. They are generally harmless and tend to go away on their own eventually. Several treatments can be purchased from a pharmacy to get rid of warts and verrucae more quickly if patients require treatment. |
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| Recommendation | Advise CCGs that a prescription for treatment of warts and verrucae will not routinely be offered in primary care as the condition is appropriate for self-care. |
| Exceptions | No routine exceptions have been identified. See earlier for general exceptions. |
References
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