Lost revenue, hours spent sourcing drugs and patient safety fears – this is now the daily reality for many pharmacists due to ever-increasing stock shortages. So what is being done to end this crisis? Léa Legraien reports

It is a situation every pharmacist will know: that sinking feeling in the pit of their stomach as a patient presents them with a prescription for a drug that’s not in stock.

What follows will be equally familiar. The apologies to the patient that their prescription isn’t available, the phone call to their GP in a futile attempt to get the prescription changed, the knowledge that the patient may suspect the pharmacist of being lax when ordering adequate stock and the fear that they will take their business elsewhere in the future.

Stock shortages are nothing new to pharmacists, but their prevalence has grown exponentially over the past year. Not only do they waste pharmacists’ time but also result in cashflow issues and loss of customer loyalty, not to mention patient safety concerns.

Since shortages reached a peak in September 2017, the Pharmaceutical Services Negotiating Committee (PSNC) has been fighting with the Government, always, it seems, pushing for endless lists of price concessions month after month. The crisis hit fever pitch several times in 2017, when almost one in 10 medicines were affected by shortages, according to PSNC.

In February, the Department of Health and Social Care (DHSC) amended its approach to setting concessionary prices – money paid back to contractors for certain drugs when their wholesale price exceeds that listed in the Drug Tariff. These are now based on ‘timely data’ from manufacturers rather
than wholesalers.

But is this enough to save pharmacists the immense stress caused by shortages?


The true price of stock shortages

Patients are those most obviously affected by stock shortages, suffering stress when they cannot get hold of much-needed medication as well as any side effects of going without. For example in May, one contractor revealed to The Pharmacist that he has had patients in his pharmacy ‘gasping for breath’ waiting for inhalers that he had no way of supplying.

But evidence suggests that patients are not the only casualties of this growing problem. In April, one London contractor told The Pharmacist he had lost around £20,000 in a three-month period due to the lack of availability of certain medicines.

Among the responses to our recent survey of 100 pharmacists, 95% say the shortages have increased their workload over the past year, while 35% say these problems have meant they have lost between £501 and £1,000 a month since summer 2017.

Among the 33% of pharmacists who say they have to contact more than six wholesalers a week to fill prescriptions, one respondent says they have to phone five different suppliers every day just to track down the medicines their patients need.

Similarly, 32% of respondents say they spend between two and three hours a week sourcing drugs. Another respondent comments: ‘On the top of category M, the funding cuts and branded generic prescribing, it’s not feasible for pharmacy to continue allocating already reduced hours to sourcing drugs [that are] most often at prices higher than the reimbursement price.’

Responding to the survey results, Sandra Gidley, English pharmacy board chair of the Royal Pharmaceutical Society (RPS), says that spending time sourcing medicines and being unsure of the price that will be repaid for them is ‘adding substantially to the daily working pressures pharmacists experience’.

She tells The Pharmacist: ‘Many pharmacists are spending hours ringing round manufacturers for urgent supplies of medicines when that time should be focused on advising and helping patients.

‘Many pharmacies are losing money when purchasing medicines in short supply, and these losses come on top of the reduction in funding from the community pharmacy contract.

‘The supply chain needs to be sensitive to the needs to both patients and pharmacists and flexible enough to cope with rapid changes in demand.’


Buying ‘in the dark’

In June, Government auditors the National Audit Office (NAO) found that there were more than 1,500 concessionary price requests made by contractors between August and December 2017 – reaching a peak of more than 3,000 in November compared with less than 150 before May.

A National Pharmacy Association (NPA) spokesperson tells The Pharmacist that pharmacies have to ‘buy in the dark’ as they purchase medicines at inflated prices without knowing whether they will be adequately reimbursed.

They say: ‘Pharmacies have had a torrid time due to medicine shortages and this situation has had an adverse impact on businesses.

‘Pharmacies went above and beyond what is normally required of them. In addition to the considerable increases in workload, this situation has put immense financial pressure on pharmacies as these figures demonstrate.

‘Furthermore, many price concessions are set at prices lower than what is reported by pharmacies, therefore they are often forced to purchase medicines at prices higher than the set price concessions, which results in pharmacies dispensing at a loss.

‘This intolerable situation impacts pharmacists’ opportunities to deliver clinical care to patients.’


Need for urgent action

It’s all too clear to see that the extent of shortages has some pharmacists near breaking point.

One survey respondent says: ‘Something needs to be done about this situation urgently.

‘Stock shortages – and the quota system – is bad for patient care, with vulnerable patients who will make errors with medicines they are unfamiliar with or take the wrong dose [when] supplied with a different strength than usual.’

Pharmacists are unsurprisingly showing the strain over shortages. But what are those in power doing to fix the problem?

Over the past few months, The Pharmacist has been questioning the DHSC on what measures it has put in place to tackle the ongoing problems as part of our #WarOnShortages campaign – a mission to increase Government transparency over shortages.

In response, a DHSC spokesperson tells The Pharmacist: ‘Our number one priority is to ensure that patients have access to safe and effective medicines.

‘Where we are aware of a generic drug shortage, we work closely with the Medicines and Healthcare products Regulatory Agency (MHRA), the pharmaceutical industry, NHS England, clinical experts, and others operating in the supply chain to ensure that the impact on patients is minimised.’

If some can praise the DHSC’s commitment to put patients safety first and foremost, others might wonder what is actually being done to help pharmacies overcome the financial blow caused by shortages.

Uncovering any new or tangible information about the state of the supply chain in the UK has proven difficult. According to the DHSC, there is a medicine team – made of pharmacists who solely look at supply issues – within the department whose top priority is to ensure patients have access to safe and effective medicines.

A Freedom of Information (FOI) sent to the DHSC by The Pharmacist in May to obtain the transcripts of the team’s meetings, among other information, revealed that no ‘formal minutes are recorded’.

The response reads: ‘There is a team within the DHSC that holds the responsibility for the supply of medicines and works on the management of medicine shortages in both primary and secondary care.

‘The team engages with all stakeholders on a daily basis, including the MHRA, NHS England’s commercial medicine unit, pharmaceutical trade bodies, individual pharmaceutical companies as well as
NHS colleagues.

‘These meetings take place over a variety of formats (such as phone calls, teleconferences and face-to-face meetings) and are not normally minuted.

‘As well as this, the team catch up on a daily basis to discuss the current work plan and active shortages cases. These meetings form part of the day-to-day operational work of this team and no formal minutes are recorded.’

With such apparently important work going on behind closed doors, it seems inconceivable that there are no formal minutes recording what the medicine team is actually doing to tackle stock shortages.

With so little information to go on, it is impossible to judge whether the DHSC is doing enough to manage the supply chain. That it is so difficult to squeeze any new information from the department suggests it is failing to be open with pharmacists about supply issues.


What’s to be done?

The lack of information from the DHSC is particularly unhelpful right now. Due to the unpredictable nature of the supply chain and other factors, such as the forthcoming Falsified Medicines Directive (FMD) and Brexit, it’s impossible to tell for how much longer these severe shortages will pose
a problem for contractors and patients alike.

While we at The Pharmacist will march on with our #WarOnShortages campaign to bring you all the latest information, it’s important for pharmacists to take action as well to inform patients and local GPs about the extent of the problem and how they can tackle it.

To help with this, The Pharmacist has put together a shortages toolkit with all the tools you need – including a patient information leaflet and a template email to local GPs informing them of the latest shortages and suggesting alternatives. Click here for the full toolkit and tips on how to use it.

In the meantime, it’s time for the Government to prove to pharmacists that they are giving the crisis the attention it deserves.

While it’s all very well for the DHSC to repeat its insistences that it regularly receives updates from supply chain stakeholders and Government bodies on the state of shortages, what is needed is proof of the work it is doing behind the scenes.

The Pharmacist will continue to push the DHSC for more information to give pharmacists the clarity they desperately need.

As one respondent to The Pharmacist’s shortages survey put it: ‘Nobody in authority seems to care. We are banging our heads against a brick wall.

‘Pharmacy is yet again dismissed as not being an important healthcare resource to be properly remunerated.’