Communication fundamental to avoid medicines shortages
In the second of two articles on the medicines supply chain, Professor Liz Breen discusses the impact that the pharmacy, pharmaceutical supplier, and government could have on the situation.
In my last blog, I discussed how vulnerabilities in the pharmaceutical supply chain affected drug shortages. In this second part, I will discuss how the pharmacist, policy maker, and pharmaceutical supplier can have a direct impact on this situation, and what is stopping us from using every weapon in our armamentarium to keep drug shortages out of the headlines and bring medicines into our pharmacies.
There is much discussion about the pharmacist taking on a bigger role in patient care, most recently in the NHS Mandate.
Pharmacies are recognised for their expertise in medicines optimisation, equally supporting patients and conducting clinical duties in hospitals and working within primary care. Broader technological developments such as the Discharge Medicines Services have also demonstrated the value of pharmacies in the patient journey and supporting the wider health and social care eco-system.
Medicines are a vital input in patient treatment and pharmacy teams work diligently to secure these, at times going above and beyond in their endeavours. The reports of excessive time spent by these teams searching for medicines with limited availability continue with staff stressed and overwhelmed.
Compounding this issue is the fluid movement of pharmacists out of community pharmacy into primary care, which offers excellent career progression, but can lead to gaps in the community pharmacy workforce. Both hospital and community pharmacies are struggling to fulfil their existing mandate, and additional stressors such as medicines shortages distracts from time better spent supporting patients. While pharmacy teams can educate, empower, and support patients to self-manage their conditions, this is not a long-term solution to address medicines shortages, this is an essential prop in a fragile system.
Within the UK the pharmacy purview differs with roles extended in one part of the country and not others. There needs to be more discussion about giving pharmacists greater flexibility to source, procure, and redistribute medicines.
Why is it that community pharmacists cannot action simple prescription switches like hospital pharmacies and Scottish community pharmacies? They can perform this task in response to SSPs, so why not on a normal basis? The COVID-19 pandemic has shown us the level of resilience and flexibility of our front-line staff in responding to patient needs. We should look at how to build upon this success.
The pharmaceutical supplier
In 2019, pharmaceutical supply chain stakeholders reported that the pharmaceutical supplier should have clear and regular communications with NHS bodies regarding stock issues to avoid problems occurring and escalating.
Pharmaceutical manufacturers and distributors can be labelled as the “bad guy” when shortages are reported as being attributed to ‘manufacturing issues’. How accurate is this? Most manufacturers plan their schedules many months in advance. This creates inflexibility to respond if there are changes in demand, which manufacturers do not have clear sight of once the medicine moves into distribution. Manufacturers have also been impacted by inflation and raw materials costs which challenges the production sustainability of important but inexpensive medicines.
Stock availability and ‘misallocation’ of stock, where some locations are over-supplied with medicines and others have limited stock, are contributing factors to shortages within the supply pipeline. Transparency and communication of stock availability by suppliers can equip government and pharmacies with greater responsiveness to pull stock through the supply chain to the patient.
The biggest long-term issue, though, is around pricing. Manufacturers invest heavily in drug discovery, but without predictable contracts from the NHS they will be reluctant to commit to larger production cycles or provide access to innovative treatments. Generic manufacturers operate on much smaller margins to deliver huge cost savings for the NHS, but as the recent challenges over the Voluntary Scheme for Branded Medicines Pricing and Access (VPAS) tax demonstrate, this has led to frustrations about the impact on their business model.
Pharmaceutical companies are required to be more transparent about issues and pricing but that raises questions about the viability of the economic model which is heavily dependent on the NHS subsidising medicines for patients. Without those incentives it will be difficult to encourage them to bring treatments to the UK. How do we incentivise manufacturers to produce more medicines (including surplus stock) than they can sell just to avoid shortages?
The policy maker
As with any challenging situation in a highly regulated industry, the government and its policy makers are often accused of not moving fast enough to respond to demands from industry, the NHS and patients.
Pharmacy representatives have spoken out about the impact of shortages on our patients and the need for the government to do more, to plan better, have better contracts, and to be more responsive when shortages occur.
The government wants pharmacists to take a more active role in patient care. The role of the pharmacy team has expanded over recent years, but it is no secret that they have the skills and expertise to do more. The NHS Long Term Workforce Plan (2023) has three priority areas: train, retain and reform with education and training places for pharmacists set to grow by nearly 50% up to 2031/32.
These developments are very welcome, but will the rest of the system be ready to accommodate this surge in activity with university places, placements, and other training routes such as apprenticeships? An increase in pharmacists and pharmacy technicians will not reduce the frequency of medicines shortages but will provide more hands to search for alternative products when shortages happen. Staff doing this activity are not recompensed for this additional activity which can lead to frustration with the system which fails to adequately address the frequency and scale of these shortages.
Addressing the huge operational and financial burden of shortages on pharmacies is key. Would a more systematic approach to sharing information about medicine stocks enable pharmacies to avoid shortages and help to create more predictability for manufacturers and wholesalers?
From a public perspective, people want to know more about the nature and timing of shortages, so visibility is desirable. Whilst the UK government does have a medicines shortages reporting system, it does not offer the same transparency as others, for example the Australian government Therapeutic Goods Agency system.
There is no doubt that there are many moving parts to the medicines shortage issue in England. Discussion, incentivisation and communication is needed by all parties. Joined up thinking between the manufacturers, government and representative organisations is fundamental in changing a situation that does not have to be inevitable every year.