Medicines shortages: minimising the impact on patients (a blog by Catherine Picton)

Summary

Catherine Picton is a health and policy consultant who has worked for over 25 years for the NHS, professional bodies, health think tanks and patient charities. A pharmacist by professional background, her policy work is often connected to medicines.

In this blog, Catherine talks about the recent report she co-authored for the Royal Pharmaceutical Society; Medicines Shortages Policy: Solutions for empty shelves, and minimising the risk to patient safety. 

Content

At the end of 2023 I was contacted by The Royal Pharmaceutical Society (RPS), the professional leadership body for pharmacists and pharmaceutical scientists. As an organisation they were increasingly hearing from their members about the number and extent of medicines shortages and the impact that was having on teams managing the shortages and the corresponding impact on patient care. The RPS decided that addressing medicines shortages was a priority for them and so commissioned me to ’hold the pen’ on a thought leadership report. 

A complex issue

It soon became apparent that medicines shortages are a problem that touch all parts of the system from the regulation, manufacture and distribution of medicines through to the clinical teams prescribing and the pharmacy teams supplying those medicines. Not to mention the direct impact on patients.

We wanted to produce a report that showed how all these parts of the system fit together and  where problems arise. Ultimately, we wanted to highlight the need for collaboration across the system, to enable the UK to prevent and mitigate medicines shortages and to minimise the impact on patients when shortages do occur. 

Collaboration was key

We engaged with many people and worked with an expert advisory group of stakeholders from across the medicines supply chain.

Our engagement activity involved:

• Manufacturers
• Wholesalers.
• The Department of Health and Social Care.
• Think tanks.
• Academics.
• NHS teams managing medicines shortages nationally.
• NHS staff with expertise of procurement and managing shortages locally in both hospitals and in primary care.

Most importantly, with the help of National Voices and their members, we worked with patients. and this gave us insight into the impact that medicines shortages are having on patients and their families.

The impact on patient safety

Patient safety concerns are multifactorial with medicines shortages. In the report we saw that different shortages can have different levels of safety risks, and therefore need to have different measures in place.

Deterioration - At a fundamental level, if a patient is rationing or missing doses of their medicines because they are unable to obtain a supply, as has been reported with the current shortage of Pancreatic Enzyme Replacement Therapy, there is a significant risk of deterioration in the patient’s clinical condition.

Dosing errors - In other cases, there may be a risk of dosing errors. For example, where one medicine is being substituted for another or a different route of administration is being used and healthcare professionals are less familiar with the guidelines for using these medicines.

Delays - At another level, where professional staff are diverted from front line care to manage medicines shortages, access to healthcare professionals is delayed. This can subsequently cause delays to necessary treatment.

Case study: medication for schizophrenia

There has been a recent shortage of olanzapine which is given as a slow release injection monthly. It is typically used to manage symptoms of schizophrenia such as hallucinations, delusions, and disordered thinking. It is used in forensic settings to help people recover and return to the community. Slow release injections of olanzapine are also essential for patients once in the community, to help them remain stable.

National medicines supply teams cascaded a Medicines Supply Notification about the shortage with management recommendations. Local pharmacy teams, working with their clinical colleagues, introduced a range of these solutions to manage the shortage. These included moving stock around the country and delaying starting olanzapine for new patients to conserve supplies for those already on established treatment.

As a last resort when shortages were severe, vials of olanzapine were split so that two patients could be treated with one vial. A process that added an increased risk of error in medicine dosing as nursing teams were unfamiliar with the process.

Pharmacy and clinical teams spent significant amounts of time looking for supplies of olanzapine and managing patients unable to be effectively treated. As well as pulling them away from seeing other patients, this took a toll on clinical teams who were aware that their decisions could lead to deteriorations in their patient’s mental state. The impact of deteriorations could, for example, lead to:

• readmission to forensic settings
• assaults on other patients or staff
• general decline in function which would likely delay their discharge.

Reducing risk and improving communication

Medicines shortages present a real risk to patient safety. On a national level we need to look across the supply chain to see how we can put systems into place that enable the UK to protect against these risks.

It also means making sure that we have systems in place locally to manage medicines and communicate better with individual patients. When a medicine is in shortage patients need to know what steps to take and when their medicines will be available. We can work more closely with patient charities and the voluntary sector to ensure that accurate and reliable messages get out to patients and head off misinformation.

For teams managing increases in medicines shortages the impact on their workloads has been substantial. This is coming on top of already busy stressed working environments. Anything we can do to help teams manage this new level of shortages and help to take away some of that load will benefit patient safety.

The report recommendations include:

• Reducing unnecessary duplication of effort.
• Providing easily accessible, trusted information about the causes and expected duration of shortages.
• Facilitating easier communication between healthcare teams.

Final reflections

The causes of medicines shortages are complex and the current increase we are seeing is driven by a range of different factors. There is a lot of work already going on nationally to help local NHS organisations manage medicines shortages, but we do need to do more.

From my perspective, I don’t see medicines shortages reducing any time soon. We need to be better at communicating with healthcare teams and patients about the causes of shortages, and what we all have to do to help ensure that the impact on patients is minimised.

Now the report has been published RPS are continuing to raise the profile of medicines shortages within parliament and working collaboratively with stakeholders to take forward recommendations. The RPS also committed to review the implementation of the recommendations in the report in twelve months to establish the extent of progress made.

Related reading

• Medication supply issues: A pharmacist’s perspective
• Medicines shortages: House of Commons Research Briefing
• Medication supply issues: Mast cell activation syndrome (MCAS)