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Is our medicines supply chain fit for purpose?

In the first of two articles on the medicines supply chain, Professor Liz Breen discusses some of the factors that can lead to stock shortages and their effect on prescribers and patients

It is as predictable as rain stopping play at Wimbledon: every year, medicines shortages hit the headlines.

What should alarm us is the increasing frequency of these reports, coupled with industry information suggesting shortages are growing, putting patients’ lives at risk, challenging prescribers and leaving pharmacists stressed and burnt out.

The NHS turned 75 in July. Reporting on this momentous occasion, The Lancet stated that “the founding principles of the NHS put into practice 75 years ago are at risk of being compromised”. Can the same be said of our pharmacy services, given the fragility of our pharmaceutical supply chain?

Read more: We must stop starting conversations with ‘I’m really sorry, but…’

The pharmaceutical supply chain is a core part of our healthcare ecosystem. It is a global phenomenon that has global impact. According to the World Health Organisation (WHO), “efficient medicines supply systems are integrally linked to strong health care systems”.

The WHO goes on to point out that several “key components” go into ensuring the “uninterrupted availability and accessibility of essential medicines”, including human resources and suitable funding.

With the continuing closure of community pharmacies in the UK, there may be concerns that demand managed by pharmacies will shift to others. Patients need to have their medications and trust their pharmacy teams to deliver this service. In times of product shortages, diminishing pharmacy numbers can place additional burden on those that remain.

 

Why is there a problem?

 

If someone asked you whether we have an efficient medicines supply chain in the UK, what would you say? From the evidence that we have and what practice is showing us, I think it would be fair to say we’re not doing so well.

The issues affecting medicines access are complex and cannot be attributed to a single factor. Brexit and the COVID-19 pandemic have heightened our awareness of medicines shortages, and while these factors have exacerbated supply issues across many sectors, it is undeniable that shortages existed before these global events.

Read more: Wholesalers' view: What caused the atorvastatin crisis?

Equally, like other areas of the NHS that are under increasing scrutiny and pressure, it would be easy to pigeon-hole this as another example of a lack of funding and resources. But dig into the issues more deeply and perhaps the real question is actually: is the medicines supply chain fit for purpose in the 21st century?

This article, the first of two, will discuss access to medicines in relation to two key stakeholders in the pharmaceutical supply chain: the patient and prescriber. It does not attempt to give full insight into the many burning issues that need to be addressed, but provides food for thought.

 

The patient

 

Since the NHS long term plan was published in 2019, providers have systemically improved practice to involve patients and carers in care decision-making, empowered them with choice and control, and promoted greater information transparency.

Patients are more aware than ever about their health and treatment options through greater access to information and social media channels, changing the traditional relationship between patient and prescriber.

Read more: Has the NHS long-term plan delivered for community pharmacy so far?

However, this increased awareness can lead to heightened expectations, promoting frustration if these expectations are not met. Our patients are not always privy to information that is timely and actionable. They may only know about issues such as medicines shortages when they need repeat medications prescribed. This is just one example where the system functions in a way that is not patient-centric.

Another practice alteration that can cause confusion and anxiety for patients is the switching of branded medicines to generic. Patients can assume this is a cost-saving exercise when it’s not; switching products can be an optimal solution when there are medicines shortages. The crux here is while we have examples of practices in the UK that do provide information about the nature of shortages and what to do next, we don’t collaborate enough with our patients to co-design educational materials that work for them.

Read more: Wholesalers: Media 'horror stories' cause 'self-fulfilling’ shortages

The same issue applies to sharing information regarding new services and new therapies. Do our patients always receive this, and, if not, do we know why? Particularly in the digital era when more and more interactions are going online, how do we ensure equality of access to pharmacy, health and social care services and medicines?

The equality guidance for pharmacies asks them to ensure equal opportunity for staff, patients and the wider public. Pharmacies as organisations and service providers aim to deliver to this agenda.

We shouldn’t forget that the patient as a consumer and user of medicines can also drive up the demand for products. This increase can contribute to medicines becoming limited in availability where supply does not match demand. In 2022, some hormone replacement therapy (HRT) product shortages were attributed to the “Davina effect” , with television presenter Davina McCall raising awareness of the value of these products and an uptick in demand occurring.

 

The prescriber

 

For prescribers, this expectation is also creating a dilemma. We have seen a sea change from prescribers being the sole actor in prescribing changes to pharmacists taking control via the launch of serious shortage protocols (SSPs). SSPs for products in short supply are actioned in real time by medicines experts, are safe and convenient for patients and take pressure off a pressured GP system.

We should remember that not all medicines shortages are caused by manufacturing issues and natural disasters. Some are made by prescribing patterns in our health system. The shortage of the product semaglutide is a recent example where demand and prescribing patterns have contributed to product shortages.

Read more: Pharmacies pioneer private Wegovy service as drug sees UK launch

This product used off-label for weight loss has adversely impacted on patients with type 2 diabetes accessing this medicine. Social media endorsement and advertising of this product led to a higher volume of online sales and prescriber requests, and GPs were advised to stop prescribing this product for off-label use.

But do GPs and primary care teams have enough insight into medicines shortages to inform patients and avoid issues such as this escalating? How do we arm doctors with the right information about availability of medicines to ensure they play their part in managing supply for certain treatments?

 

Shortages not always inevitable

 

When medicines are unavailable, patients suffer unnecessarily. Some shortages are unavoidable, caused by natural disasters, but many are not. What often happens in these highly complex situations with multiple stakeholders and demands is that finding solutions gets pushed down the road, or worse still left in the ‘too hard’ tray for someone else to deal with.

The UK, and its global counterparts, are all in the same boat. We are all trying to understand how to address the thorny issue of stopping shortages and most likely need to accept that we can’t.

Read more: DH and MHRA ban wholesalers from exporting or hoarding semaglutide

What we can do is make every effort to identify where we can strengthen our supply chains, root out the weaker elements that can lead to failure, and be realistic with what we can achieve. Digital solutions such as machine learning and artificial intelligence can inform planning of production schedule, inventory management, resource allocation and delivery of our services to meet patients’ needs.

The COVID-19 pandemic has shown us how the pharma industry and this supply chain can come together and respond with high levels of creativity and agility in times of crisis. Partnerships flourished where they didn’t before and competitors came together with a common bond, creating vaccines to save lives.

The same innovative thinking and quick action can be applied to reducing vulnerabilities in our pharmaceutical supply chain to improve access to medicines. We just need to make it happen.

Professor Liz Breen is director of the Digital Health Enterprise Zone and professor of health service operations at the University of Bradford School of Pharmacy and Medical Sciences

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