How are pharmacy teams coping with the “new normal” of medicines shortages, and what more can be done to address the issue? By Saša Janković 

In the last few months, a plethora of reports have pored over the causes of medicines shortages and their impact on patients and clinicians, as well as presenting calls to action for solutions to the escalating problem.

In the middle of April, a report by the Nuffield Trust pointed to diverse causes, including NHS efforts to curb its drugs spend, global market factors and the fallout from Brexit that resulted in “companies removing the UK from their supply chains”. This dire picture was reinforced by the publication of a Healthwatch report showing that 24 per cent of patients had experienced their pharmacy being out of stock of their medicine in the previous 12 months.

Then in early May, the results of Community Pharmacy England (CPE)’s 2024 pharmacy pressures survey showed that medicines supply problems have become a “daily occurrence” in pharmacies across England. Some 97 per cent of respondents said patients were being inconvenienced as a result, and 79 per cent said patient health is being put at risk.

Specific shortages

CPE says medicines across a range of clinical and therapeutic areas are being affected by supply disruptions at different times. Issues this year have affected medicines used for the treatment of diabetes, ADHD, and epilepsy; last year saw problems with HRT, adrenalines and antibiotics.

Pharmacy consultant Michael Stewart says other recent examples include worrying shortages of some brands of standard and modified-release carbamazepine.

“I have personal experience of a teenage patient with epilepsy having to switch carbamazepine formulations and subsequently experiencing an increase in seizures,” he says. Issues with various glutide injections, such as Ozempic, Wegovy and Trulicity, “represent a unique problem where supply could not meet demand for the drugs, exacerbated by social media and unprecedented private prescribing,”he adds.

The current biggest issue for Stewart is isosorbide mononitrate 60mg MR tablets, where there are “numerous branded generics”, some of which have been out of stock for several weeks. “The inexorable rise of branded generic prescribing, to pinch a few pennies here and there, now leads to other costs in terms of workload for both pharmacy and GP surgeries when these ‘brands’ go out of stock,” says Stewart.

As well as the immediate risks to patient health and wellbeing, the CPE report says medicines supply issues are ranked by pharmacy owners as one of the most severe pressures on their businesses. Almost three-quarters of pharmacy staff estimate they are spending one to two hours a day or more trying to obtain medicine stock or alternatives, with 97 per cent experiencing extra workload, and 96 per cent reporting additional stress for staff.

“I know in my own pharmacy it’s a daily occurrence of managing expectations of patients who quite rightly assume that medicines should be in stock or available, managing multiple wholesaler orders to try to ensure a supply is delivered to the pharmacy, managing daily owings of prescriptions, managing calls from patients playing ‘pharmacy bingo’ by calling round every pharmacy to see if we have their medication in stock, and managing constant emails to GP practice colleagues asking for alternative prescriptions for products we can get hold of,” says Reena Barai, community pharmacist and owner of SG Barai Pharmacy in Sutton.

Fin McCaul, managing director of Prestwich Pharmacy near Manchester, says: “Fundamentally, the Government is not paying any of primary care for the job they need to do, but especially the pharmacists. This is what we live with, day in and day out, and it’s horrible for contractors. So many are having to put cash into their own businesses to pay wages and bills, and the risks of people becoming personally bankrupt are now significant and increasing every day.”

“This situation with pharmacy is like the Post Office scandal,” says Anil Sharma, pharmacist and director of Alconbury Pharmacy in Huntingdon, “except we don’t have a computer that’s glitching – we’ve got MPs, Treasury and Government glitching. We are trying to make the Government listen and we are not striking like other healthcare professionals, but we can only solve the NHS crisis with proper and core funding. The people it’s really hurting are the vulnerable, and this is a matter of life and death for many patients.”

At a recent Westminster Health Forum conference on medicines access, pharmacist and clinical advisor at The Menopause Charity, Bushra Effendi, mentioned that inequalities with reimbursement are also putting a financial squeeze on pharmacy businesses. “Often, community pharmacies are having to pay more for the medication than they are getting reimbursed for it, and that is adding to access issues because it’s pricing some of these community pharmacies out of the market because it’s not sustainable for them to continue working at a loss,” she said.

She also noted concerns around vertically integrated wholesalers that have involvement in medicines manufacturing, distribution and retail. “What they have is a little bit of a monopoly in terms of where those drugs are being directed to,” she said. “If they can see a shortage come in, they will redirect some of those to their own retailers, and so there’s a shortfall within the system for other people to be able to use them.”

Martin Sawer, executive director of the Healthcare Distribution Association (HDA UK), says that while using a buying platform helps, pharmacists now have to deal with phoning around a lot of wholesalers to get product: “I do sympathise with them”.

However, he sees a bigger problem: “Because the supply chain is global, and medicines volumes are going up because of growing population health issues, decisions are made on a global scale, but historic demand is not a useful predictor. As a result, all countries are experiencing shortages to some degree or another.”

Government steps

The Nuffield report focuses on rebuilding bridges with the EU to address some of the supply chain issues, but are there other steps the Government needs to take?

McCaul says: “The solution is in the Government’s hands in terms of increasing the price of drugs and increasing resources to pharmacies, practices and wholesalers to make sure we get the stuff available back in the country again.”

Stewart says there are now so many medicines and patients affected that it is “impossible” for the Government to ignore the problem any longer. “Personally, I think a public enquiry is long overdue into how medicines are manufactured, procured and distributed in this country currently and how this can be improved to safeguard our medicine supplies into the future,” he says.

Indeed, the Independent Pharmacies Association (IPA), together with the Epilepsy Society, Epilepsy Action, SUDEP Action and Parkinson’s UK, are calling for a complete review of the medicines supply chain. Leyla Hannbeck, IPA chief executive, says: “The UK has a smaller medicines budget than anywhere else in Europe or the US. The NHS is continually driving down the price of medications, which means that manufacturers prefer to sell outside of the UK where they can make a better profit. The medicines supply chain is broken at every level and unless the Department of Health reviews its processes and procedures, we will never achieve the stability that will guarantee patients their prescription when they need it.”

Immediate fixes

In the interim, industry insiders suggest a raft of measures that could address some of the challenges.

“We know that there will always be medicines that go out of stock from time to time,” says Stewart, “but what we can change is how stock shortages are managed in the community. Perhaps wider use of more flexible serious shortage protocols would be a start, or a direction to prescribe generically when possible or specifically when a stock issue comes to light.”

Effendi suggests “capping the buying power of larger multiples, which is pricing smaller wholesalers and manufacturers out of the market” and “making sure that reimbursement of medication is fair and appropriate”.

Sawer says the solution is distributing medicines in a way that better matches demand. “That might be about better transparency or partnership between manufacturers, distributors and those they are distributing to, or improved technology,” he says.

Barai says her ask is simple and echoed by all of the pharmacy bodies: “A short term solution is to allow us to amend prescriptions when there is a shortage,” she says. “SSPs were a start to this, but now these need evolving as the problem is too great and fluid. It seems like a no-brainer solution to me.”