Running short: Why are pharmacies struggling to source medicines?

As medicines shortages continue to escalate, who is really to blame – and what can be done to reverse the crisis? By Saša Janković

Medicines shortages are nothing new in pharmacy, often consuming huge amounts of pharmacists’ time. This has reached crisis proportions in recent months; December saw the Government agree to a record-breaking 198 product price concessions as severe shortages and related price increases hit UK pharmacies and their patients. Widely prescribed products like gabapentin, levetiracetam, mebeverine and nitrofurantoin were among the lines affected.

That same month saw a panic over commonly prescribed antibiotic solutions for children hit the headlines, resulting in the introduction of Serious Shortage Protocols (SSPs) and calls from The National Pharmacy Association (NPA) for the health secretary to convene a ‘medicines supply taskforce’ following weeks of problems.

NPA chief Mark Lyonette wrote to Steve Barclay citing the precedent of the HRT Taskforce – which last summer brought together supply chain representatives after months of supply problems – saying: “It is imperative that we resolve this supply situation urgently and therefore we request that you convene a medicines supply taskforce, with all the relevant stakeholders in the supply chain, to urgently discuss and agree practical solutions to address the disruptions to the supply of medicines.”

As the new year began, January saw community pharmacists experiencing shortages of OTC cold and flu medicines such as Lemsip, and children’s medicine Calpol, as rates of flu and RSV soared. 

Stakeholder discussions 

Blaming “a lack of planning by officials [at the Department of Health and Social Care] in terms of foreseeing the problem and trying to plan in advance to sort it”, Leyla Hannbeck, chief executive officer at the Association of Independent Multiple Pharmacies, said publicly at the time that her organisation had been asking the DHSC for months “to hold stakeholder discussions to suggest solutions and plan better”.

This resulted in a conversation with health minister Will Quince, which Ms Hannbeck says was “a very constructive discussion around the causes and consequences to pharmacy and patients of the escalating problems around medicines supply and their cost”.

Ms Hannbeck continues: “In addition, we discussed the fact that our sector is underfunded and under-resourced, and I also highlighted the bureaucratic burden around the SSP process, which could be eliminated to make the process easier for pharmacists. 

“I called for the DHSC to involve community pharmacy as a key stakeholder in discussions around the medicines supply chain and asked for roundtable meetings involving manufacturers, wholesalers and pharmacies to discuss how we can introduce reforms to the current system.”

OTC shortages

PAGB refuted OTC shortage claims, saying it “can confirm that the suppliers of cough and cold medicines are not reporting widespread shortages in product availability”. Chief executive Michelle Riddalls commented: “Suggestions that the Government bring together manufacturers, wholesalers and pharmacists to ‘fix’ a problem in over-the-counter medicines supply shows a serious misunderstanding and is a complete misrepresentation of the issues at hand.

“Firstly, whilst the DHSC can play a significant role in helping secure the supply of prescription medicines when there are shortages, including activating shortage protocols, this is not the case with over-the-counter medicines.

“Secondly, the way over-the-counter medicines are supplied in the UK is different to that of prescription medicines. Most over-the-counter medicines, unlike prescription medicines, are supplied directly from the manufacturer’s designated warehouse straight to the retailers and large pharmacy chains. Wholesalers play a smaller role in supplying over-the-counter medicines.

“And thirdly, there are no reports of widespread over-the-counter medicine shortages – while some cough or cold products may be less readily available at some stores, this is likely to be local and very sporadic as there are no reports of widespread shortages." 

Pharmacy experience

Despite these reassurances, pharmacies across the nation continue to say that they, their teams and their patients are suffering the effects of shortages of all kinds of products.

“Medicines shortages are a huge problem for us and really started to get out of hand in June 2021,” says Neil Gathani, superintendent pharmacist and owner of Caledonian Pharmacy in North London.

“Pricing is ridiculous, the NHS is way out of kilter and on the wrong side when it comes to remunerating pharmacies, and the level of rudeness from the public has gone up exponentially.

“With POMs, we make a significant loss from the NHS on a monthly basis. GPs are not helpful by writing prescriptions for things which are not available, and when we speak to the GP to get it sorted, they are slow to react so patients will go without medicines for a couple of weeks.

“When it comes to OTC winter flu products, AAH, Sigma and Alliance wholesalers all had no stock available for us to order Lemsip, etc, so whether that’s a bottleneck at the manufacturer or wholesaler, we are simply not getting it.”

These concerns are echoed by Ali Sparkes, superintendent pharmacist and director of The Health Dispensary in Neath, South Wales. “If PAGB is saying there is no OTC problem at all, then why aren’t we getting these products?” she asks.

“We use six or so wholesalers and short liners, but they don’t tell us anything about why, just that ‘it’s out of stock’. It’s getting a bit ridiculous if you don’t have Lemsip or paracetamol on your shelves, and you can see the public thinking ‘what sort of pharmacy are you?’”

Antibiotic concerns 

Nathan Wiltshire, group chief executive of the Cambrian Alliance buying group, which supports over 1,200 members across the UK – one in four of the nation’s independent community pharmacies – says the most urgent need is for antibiotics following an increase in Strep A infections.

“With the unusually high level of infections, the public’s awareness of the presenting features of Strep A is high,” he says. “That means the demand for amoxicillin is extremely high and we’re seeing that reflected in our e-CASS system.” 

Describing December 2022 as “by far the most difficult in my seven-year career so far,” Ioannis Klappas, pharmacist manager in Preston Grove pharmacy in Yeovil, Somerset, says: “Almost all antibiotics, especially the penicillin ones, disappeared from our pharmacies, and parents were left upset and angry trying to find the antibiotic that their children were prescribed from pharmacy to pharmacy.

“Now there is some limited stock available but with a price higher than the price concession, making it difficult for independent pharmacies to dispense without a loss.” 

Time and money pressures

While it is common for medications that go out of stock for a while to come back with increased prices, Mr Klappas says that since the price concession list follows after these increases, he has been dispensing at a loss “for several medications, even common lines such as omeprazole”.

“Sometimes, even when medications are in the price concession list, we still dispense them at a loss as the actual prices from the suppliers are even higher – and a prime example of this again were and still are the antibiotics from December onwards,” he adds.

Mr Gathani posits that there may be an unfavourable skew at work when it comes to supplies. “I wonder if there is any favouritism for the multiples? For example, if you look at Boots’ Instagram, there is no mention of medicines, just plugging their new No7 product,” he says. “They can take a loss on items as they are making so much on OTC sales, but I think independents should be viewed differently from multiples as we don’t have this to top us up. I think we run mostly 90 per cent on NHS and 10 per cent on other products, so it’s a huge problem for us.”

There is also the time cost of managing shortages, which can cause other areas of the business to suffer. “Getting through to suppliers is so time consuming,” says Ms Sparkes.

“We can’t even phone another pharmacy to find out if they have something we need and we don’t have special lines to surgeries to ask for alternatives. All the time we spend on that means we miss out doing a consultation or catching up on claims.”

Patient experience

Former pharmacy technician Rachael Lemon has more than 30 years’ experience in the pharmacy sector, but from her perspective as a pharmacy customer, she says the issue of shortages is still not being properly communicated to patients.

“I’ve been using Pharmacy2U and three times now they have not been able to get my medicine,” she says. “The last time they emailed to let me know it was out of stock and they had cancelled my prescription, simply saying ‘sorry for the inconvenience’ – but inconvenience is missing the last bus.

“Common sense would have been to ring my doctor and ask for a prescription for a different strength, but no one communicated the situation with me before it was too late.”

Local solutions

Those with the will – and time – have come up with some local solutions to try to fill the gaps.

“We have created a WhatsApp group in our PCN, and as a PCN lead, I have managed to engage with all the pharmacies and surgeries in my area, in order to be on that group and exchange information about stock”, says Mr Klappas.

“Most of the pharmacies are very active on the group and we manage to exchange stock almost every day to support our patients. It’s also useful to have our local GP surgeries on the group in order to inform them about shortages and potential out of stock items in real time, to avoid having patients going around pharmacies to find medications that are not available.”

In the meantime, PSNC says it is seeking improvements to the current price concessions system, following significant concerns raised by pharmacy contractors about the unsustainable level of prices imposed by the DHSC in the past few months for certain medicines. It says it has sent “a strong and clear message” back to Government that pharmacies “cannot subsidise the NHS medicines bill”, escalating this within the DHSC and insisting that they find urgent solutions.

Possible solutions

Ms Riddalls admits that when it comes to OTC shortages, consumers may assume that all pharmacies get their medicines supplies in the same way. “Of course, it’s much more complex than that,” she says, “so pharmacists need to be able to signpost alternative products, or where they can get it somewhere else.”

Ms Sparkes suggests there is room for an even stronger messaging approach. “The Government should put out a statement as the public needs information about this and so do we,” she says. “But we need more information about supply. If the Government is saying there are supplies there, who is holding them and where are they?

“In 1992, I was told by a medical director that there was a policy of attrition to put community pharmacies out of business. At the time I thought ‘not on your nelly’, but now I’m not sure.”Mr Wiltshire says the issue is “hugely complicated” and suggests more joined-up working would help. “From Brexit to global manufacturing to the fallout of post-lockdown, the challenges are multiple and it’s impossible to pinpoint one,” he says.

“For sure, people working together and pharmacies being treated seriously as part of the healthcare mix with primary care would help. Being siloed from primary care doesn’t help us or doctors work together to make our communities healthier.”

For Mr Gathani, the lion’s share of the responsibility rests with the negotiator. “PSNC needs to act quicker on price concessions, it needs to negotiate way better with the NHS on a daily basis, up its game and let them know pharmacy is making big losses,” he says. “We think PSNC is not fit for purpose and it is failing to protect independent pharmacies for sure – but this could all be solved if they just listen to what we say.

“We need to see a clear separation between independents, multiples and supermarkets as it’s not a fair game. We need a concerted campaign to put pharmacy in the forefront of everyone’s mind in the country as the best place to go to get healthcare advice and help." 

Further information

If you have problems obtaining a Part VIII product at the stated Drug Tariff price, you can report the issue using the online feedback form on the PSNC website.