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The new Royal Pharmaceutical Society (RPS) Greener Pharmacy Toolkit is easy to use and provides prompts to introduce more sustainable practices to reduce emissions, improve patient care, prevent ill health, tackle medicines waste and achieve efficiency savings. The Greener Pharmacy Toolkit is a pioneering digital self-assessment tool designed to help community and hospital pharmacy teams take practical action to reduce the environmental impact of pharmacy services, pharmaceutical care and medicines, while supporting patient care. The toolkit outlines three levels of accreditation—bronze, silver, and gold—based on various actions that pharmacy staff can voluntarily take to make their pharmacies more sustainable. Achieving the target accreditation triggers a certificate, which can be displayed to demonstrate the pharmacy’s commitment to environmental sustainability. Commissioned by NHS England and supported by Greener NHS, the toolkit is free and open access, available for use by hospital and community pharmacy teams throughout Great Britain. The digital toolkit and accompanying guidance aligns closely with RPS’ work on sustainability which recognises the impact of climate change on health.

Despite various initiatives to tackle the problem, safety incidents linked to the late administration of medicines, or medicines that have been omitted entirely, have remained stubbornly high for decades. In this article (link at bottom of page) for the Pharmaceutical Journal, David Lipanovic says a national focus may finally deliver a solution. Related reading: HSSIB investigation report: Medication not given: administration of time critical medication in the emergency department (5 December 2024)

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.  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)

The three national pharmacy boards at the Royal Pharmaceutical Society (RPS) identified medicines shortages as a key policy area that is impacting patients, pharmacy teams, clinicians and wider groups throughout the NHS. As a result, in January 2024, RPS commissioned a report into medicines shortages. This report is the culmination of extensive engagement and collaboration with patients, the pharmacy profession, wider healthcare professionals and the key local, regional and national stakeholders integral to ensure the continuity of medicines supply. The report concludes by setting out 19 recommendations. Recommendations UK National Policy Recommendation 1: Publish a UK-wide strategy for shortages The UK government should develop a cohesive cross-government and NHS strategy to improve medicines supply chain resilience and medicines security in the context of changing pharmaceutical market dynamics and the ongoing increases in medicines shortages globally. The strategy should incorporate current national policy, ongoing work and existing measures, and create greater alignment in managing shortages across primary and secondary care. Recommendation 2: Recommendation 2. Support UK manufacturing infrastructure for medicines The Government should boost UK medicines manufacturing infrastructure, in both commercial and NHS manufacturing units –particularly generic manufacturing, which accounts for 80% of medicines prescribed in the NHS. UK manufacturing infrastructure offers the potential for a more rapid response from manufacturers to help mitigate acute national medicines shortages. Recommendation 3: Flexibility in existing medicines regulations to speed up access Building on the learning applied during the COVID-19 pandemic, existing and potential regulatory flexibilities should be explored with the MHRA. Recognising that nothing should be done to undermine the purpose of regulation, timely opportunities to flexibly use existing regulations in acute supply challenges associated with national shortages should be identified. For example, enabling medicines manufacturers to reactivate dormant market authorisations more rapidly so they could potentially supply medicines in acute shortage. Recommendation 4: Make better use of pharmacists’ skills The Government should enact legislation to enable community pharmacists to make minor amendments to prescriptions in line with existing hospital practice, RPS policy and the recommendation of the Health and Social Care Select Committee report into pharmacy. Organisations, professional bodies and regulators should identify where pharmacist prescribers can use their prescribing qualification to help manage the impact of medicines shortages on patients and develop pathways to enable this role. Recommendation 5: Reiterate the legal and ethical responsibilities of the supply chain Organisations and professionals in all parts of the supply chain, from manufacturers to wholesalers, pharmacists and prescribers, should understand their responsibilities to patients to enable appropriate, equitable and ethical access to medicines. The 2013 guidance published by the Department of Health Supply Chain Forum – Best practice for ensuring the efficient supply and distribution of medicines across the supply chain (2013) – should be refreshed (or an equivalent developed) and re-promoted to reinforce the behaviours expected in all parts of the supply chain. Recommendation 6: Review the community pharmacy contractual framework The community pharmacy contract in each of the UK nations should be reviewed to ensure that, while acknowledging a pharmacists professional and contractual responsibilities, it minimises the risk of individual contractors incurring a potential loss on the purchase of medicines and supports a stable supply of medicines to patients. Predicting, reporting and responding to shortages Recommendation 7: Earlier reporting of shortages by Marketing Authorisation Holders Timely and accurate information on supply disruptions and shortages should be provided by medicines manufacturers. Marketing Authorisation Holders should work with DHSC to find ways to improve the reporting of medicines shortages and the provision of ongoing information to help mitigate shortages, with a focus on early and consistent information sharing. Developing a more meaningful performance management approach to reporting that promotes good practice, distinguishes between planned and unexpected shortages and actively penalises repeated poor performance would facilitate this. Recommendation 8: Enable greater data sharing to support planning and predict demand The NHS and manufacturers/wholesalers should proactively collaborate to share data, for example, NHS data that enable manufacturers/wholesalers to better predict demand for their products and manufacturer/wholesaler supply chain data that enable the NHS/DHSC to proactively manage the medicines supply chain to minimise disruption and increase resilience of supply. Information flows Recommendation 9: Expand and develop information cascades Information cascades about medicines shortages from DHSC and relevant NHS national medicines supply teams to the wider healthcare system should be reviewed to ensure that they are reaching the right people at the right time. All organisations that cascade or need to act upon information about national shortages should review and develop systems to ensure that information is cascaded to and accessed by those that need it. Equally, healthcare professionals should be aware of their responsibility to access this information and act promptly. Recommendation 10: Further Involve patient groups to support information sharing Patient groups should be a fundamental part of information cascades to facilitate the appropriate sharing of consistent and accurate information to patients. This will enable patient groups to provide support for patients experiencing acute national shortages of their medicines. Recommendation 11: Fund, promote and develop the DHSC/NHS Medicines Supply Tool The DHSC/NHS medicines supply tool hosted on the SPS website (sps.nhs.uk). should be the single source of accessible, consistent, accurate and rapidly updated information about medicines shortages for healthcare teams across the UK. As well as promoting the current tool more widely to healthcare teams, its utility should be increased. There should be funding for the integration of the tool into prescribing systems to alert prescribers to shortages and enable alternatives to be prescribed in real time to provide proactive updates, for example, when medicines are no longer in shortage, and to developing an app-based format to enable easier access to the information. Recommendation 12: Improve systems that provide timely information at the point of dispensing Wholesaler and community pharmacy IT systems should be developed to provide resupply dates for medicines out of stock to enable more meaningful communication with patients and help pharmacists to more rapidly distinguish short-term supply disruptions from national shortages. This is only possible with the provision of accurate and timely information from medicines manufacturers. Local systems Recommendation 13: Develop patient-centred pathways to manage shortages in local systems Continuity planning in local systems should account for the resources required for healthcare teams to manage medicines shortages. Local systems should have protocols for the management of a medicines shortage that works across a locality, particularly between GP surgeries and community pharmacies, to ensure that they continue to minimise the impact of shortages on patients and do not exacerbate health inequalities. Recommendation 14: Invest in the resources needed to manage medicines shortages NHS organisations should review whether they have sufficient resources in pharmacy teams to mitigate and manage medicines shortages. Any investment required needs to be weighed against the opportunity costs of healthcare teams managing a shortage and the impact on patients’ health outcomes and quality of life, not just the cost of alternative medicines. Recommendation 15: Develop cross-sector protocols for shortages of life-critical medicines Cross-sector emergency protocols for life-critical medicines where patients have no alternative treatment should be developed. This will require collaborative working across local systems and the use of regulatory flexibility to allow medicines to flow between primary and secondary care. There should be national/regional oversight to ensure this happens. Recommendation 16: Fund and recruit regional procurement specialists to work across sectors In England, NHS specialist pharmacy services’ regional network of procurement specialists should be funded to work with ICBs to facilitate the development of cross-sector approaches to acute medicines shortages. In Wales, Scotland and Northern Ireland, equivalent arrangement should be established. Recommendation 17: Prioritise supply chain resilience within secondary care contracts Supply chain resilience measures and management of lead times should be further developed and incentivised in awarding secondary care and homecare contracts, which should be proactively managed with suppliers to minimise avoidable causes of supply disruptions. Education, training and research Recommendation 18: Educate healthcare professionals, patients and the public on shortages Joint education programmes for healthcare professionals should be developed to support wider understanding of how UK systems operate end-to-end to mitigate and manage medicines shortages, and highlight common misconceptions about their causes and how to manage them. This will improve transparency and understanding across the supply chain and improve opportunities for shared education and training. All pharmacy teams and students should be trained in where to find accurate information about medicines shortages, and in how to have proactive, informed and supportive conversations with individual patients and the wider public regarding medicines shortages. Recommendation 19: Understand the economic cost of shortages to healthcare organisations and systems The research base on the costs of medicines shortages should be developed to inform resourcing decisions and underpin investment in resources and the implementation of quality improvement programmes. This should include not just the cost of alternative medicines but the wider costs to the healthcare systems and the clinical impact on patients in terms of their health outcomes and quality of life. Recommendation 20: Understand the impact of speculation and digital purchasing systems on the supply chain Further work needs to be done to understand the extent to which speculation exists within wholesale and medicines brokering activities and the extent to which the use of automated purchasing platforms is disrupting demand prediction and purchasing patterns. These factors have the potential to confuse the issue of medicines shortages locally. Read the full report on the Royal Pharmaceutical Society's website via the link below.

This webinar hosted by the Patients Association provides an opportunity to hear about the new Pharmacy First Service. Speakers include: David Webb, Chief Pharmaceutical Officer for England Pallavi Dawda, Head of Delivery, Clinical Strategy Community Pharmacy, NHS England Leighton Colegrave, member of Hertfordshire and West Essex ICB's Patient Engagement Forum Tunde Sokoya, community pharmacist, Essex Lindsey Fairbrother, community pharmacist, Derbyshire. The Patients Association Chief Executive Rachel Power will chair the webinar. Register for free.