Medication supply issues: A pharmacist’s perspective

Summary

In this interview, we talk to Darren Powell, Clinical Lead for NHS England and Community Pharmacist, about medication supply issues. Darren shares his experiences of how medication shortages and tariffs are affecting patients and staff and offers insights into the complexity of the situation. 

He tells us his thoughts on potential causes and barriers, as well as suggesting three actions for wider system safety. 

Content

Can you introduce yourself and your role and your interest in patient safety?

I am a pharmacist by professional background, but I work across a number of roles, which include being a Clinical Safety Officer/Clinical Lead for NHS England. I maintain my clinical practice as a community pharmacist at least one day a week, on the frontline, supporting patients with their medications.

The care and safety of the patient is the focus of my work, from ensuring that digital technologies are "safe" to use in clinical practice, to the safe supply of medication to patients attending the pharmacy.  

What is the role of the pharmacist when it comes to providing medications and prescriptions to patients? 

The prescribing of medication is the most common patient level intervention and is the second largest cost after staffing in the NHS. The role of the community pharmacist is important in maintaining the safety and wellbeing of patients who visit the pharmacy. 

As pharmacists, we work alongside pharmacy technicians and support staff to:

• monitor the quality, safety and use of medicines
• interact with patients to provide support and information about the use of their medicines, alongside general healthy lifestyle advice
• provide over the counter medicines, often in response to patient's presenting with minor ailments of self-limiting conditions
• order and purchase pharmaceutical supplies, medical supplies, or drugs and ensure these are stored and handled correctly
• try and maintain stock levels appropriate to demands. 

How much are you able to control supply?

Pharmacies order their medications from pharmaceutical wholesalers. Generally, they receive a daily delivery of the medications they require.

People might not realise that pharmacies don't get paid for any stock they hold, the NHS only pay once a medicine has been supplied to a patient - and it normally takes 3 months for the NHS to pay. The NHS has a "fixed price" for some medicines regardless of what they might cost from the wholesaler, so pharmacies have to balance the need of their patients against the risk of holding an excess of stock - with the risk of it going out of date before it is supplied. This isn't normally an issue, and as long as the wholesaler has the stock in their warehouse - we can quickly obtain supplies.

When we receive our delivery, the pharmacy team will check if all the required items have arrived. If they haven’t, it is at this point we realise we need to take action. Some pharmacies use multiple wholesalers (sometimes termed first line and second line) so we can try and source the medication from another supplier.

Have medication supply issues got worse? 

Over the last year, and more significantly in recent months, the supply issue has worsened. 

Having to chase around for stock to supply to patients has now become part of daily life for pharmacy teams. We try different suppliers and wholesalers to obtain medicines - but sometimes it can be "national supply" problem, in which all wholesalers appear out of stock. Sometimes we are offered stock, but the price we have to pay is much higher than the NHS will cover, and some pharmacies have accepted that loss just to support their patients - but that isn't sustainable over the longer term.  

If the pharmacy is part of a larger chain, we can try and contact the branch network to see if a branch has the stock on their shelf and it isn't being used. I've personally contacted other pharmacy chains to try and get antibiotics for children, when there was a shortage. It means patients having to travel further afield, but it was important that the medicines were obtained. 

Do you know the reasons behind supply issues?

Often, unless it is a national issue, we don't get detailed information on what the cause of the shortage is. 

Medicines manufacturing is an international business, and a large proportion of our medicines are sourced from outside of the UK. So international issues can affect supply, for example: 

• issues at the manufacturing site
• quality control issues 
• demand for the medicines outside of the UK.

The NHS has been very effective at driving down the price it pays for the medicines supplied on prescription, maximising the value for money for the taxpayer. The consequences can be that a manufacturer can sell its products outside of the UK at a higher price point, so we might not be a priority for its limited supplies.

Ultimately, the supply problem is multifaceted, and not an easy problem to solve.  

Are there certain medications or conditions that are particularly impacted?

Recently there have been supply issues with products used in the treatment of diabetes affecting a number of products. But as I said, the reasons behind the shortages can be varied, so can affect a wide range of products.

The demand for a medication can also increase, and it isn't a simple task to produce more. Often it takes months of planning for a manufacturer to increase capacity, and in some cases whole new manufacturing sites have to be built to address the shortages.

How are patients affected?

One example is the shortage of medicines used to treat attention deficit hyperactivity disorder (ADHD). Patients, both adults and children, living with ADHD rely on these medicines to help them with their day-to-day activities. Without the medication, there can be significant impacts on their ability to remain in education or be as productive in their workplace.

My own daughter relies on such treatment, and she admits she would have great difficulty functioning and working in the role she currently holds without them. The thought of not being able to get medication brings a great deal of stress and concern to patients.

The shortage of certain diabetic medications meant patients had to be switched to alternative drugs. Potentially that could mean loss of the control of their condition, whilst they become accustomed to new medicines, or new ways of administering the medication. 

Frequent changes to someone’s prescription can understandably cause confusion about treatment and how to take a medication. There is also a loss in confidence that their treatment will work for them, and a general concern and anxiety around keeping well.

The added worry about supply is not helpful for patients trying to manage a chronic condition or illness.

What are GP surgeries and pharmacies doing to mitigate risk? 

GP surgeries and pharmacy teams try and lessen the impact on patients by working closely. 

We try and alert the surgery to the current shortages, so that they don't prescribe items that are out of stock, but it is difficult where medicines are a regular repeat medication. So if we get a prescription for medication we know can't be supplied, we have to call the surgery, and suggest alternatives (where that is possible) and the GP has to issue a replacement prescription. This all takes time both for the surgery and pharmacy teams. Where there are no alternatives, the issue is more complex as the GP has to consider switching therapies, and the suitability and impact of such changes on their patient. 

Internally as a pharmacy company we send emails asking branches if they have stock available, and we either send the patient to the branch, or transfer via our internal systems for the next day or so. All of this extra work, to source, and change and transfer medication is time away from caring for patients.

What needs to happen to make the wider system safer?

I believe the following is needed:

• A review of the reimbursement mechanisms for medicines, to make the UK a market where suppliers want to market their medication. 
• Encouraging manufacturing of medicines in the UK so we aren't so reliant on the international market.
• Data on supply issues being more available for primary care teams so a system approach to dealing with shortages can be taken.

Any final thoughts or reflections?

As much as patients are concerned about their supplies, please don't stockpile or order earlier than you need - remember what happened with the toilet paper supplies during Covid. Ordering 7 to 10 days in advance of running out of medication should be sufficient. 

Please give your GP and Pharmacy teams time to issue and process your prescriptions - they will be doing their best to ensure they get the supplies you need; And if you haven't already signup for the NHS App please do so. You can order your repeat medicines on there, and just recently it has been updated to give you information about your prescriptions.

Share your thoughts

What did you think of the issues raised in this interview? Have you been affected as a member of staff or patient or carer? Please comment below, or share your insights in our community forum on medication supply issues.

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