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GP: Why we need pharmacists to suggest alternatives during shortages

"Perhaps the unforeseen benefit of shortages will be GPs and pharmacists talking more"

Community pharmacists can save GPs time spent dealing with medicines shortages by suggesting appropriate alternatives, says GP Toni Hazell

“Hi, it’s the pharmacist. We can’t get hold of Mrs Smith’s HRT, could you suggest an alternative?”

This used to be an occasional event that was generally straightforward to sort out. Maybe a brand name had changed, or a device was listed slightly differently on our computer systems.

But of late, drug shortages have been an absolute nightmare that take up a significant amount of GP time, with hormone replacement therapy (HRT) being the current worst culprit. Other recently unavailable drugs include nifedipine, adrenaline auto-injectors and methadone, with shortages affecting both branded and generic medicines.

So, why is this happening? It's easy to jump to the conclusion that it’s all about Brexit. Indeed, if we leave the EU without a deal and there are massive delays at Dover, then we may look back to now as a golden age when only some drugs were out of stock rather than most of them.

But there are other reasons, including shortages of raw ingredients and manufacturing issues. For example, when Bayer had a problem at their factory in Germany in May, it led to a six-week gap in the supply of Microgynon 30 tablets.

I have already written about plans to allow pharmacists to dispense alternatives without consulting the GP, which, if the indemnity and clinical responsibility is sorted, seem eminently sensible. However, this will only happen if a serious shortage protocol is activated by the government.

Other ways around the problem largely involve GPs trying to find an evidence-based way to replace the missing prescription with a similar one. This takes up a lot of our time and causes patient harm. Time spent doing this is time I can’t spend with a patient who needs to see me.

Community pharmacists can really help by suggesting an alternative medicine. Useful resources to aid with HRT shortages are on the websites of the British Menopause Society and MIMS. To access the latter, pharmacists will need a subscription.

I massively appreciate a phone call saying: “We can’t get hold of Mrs Smith’s HRT, but we do have (an alternative) in stock – which would be appropriate.” Or: “We can’t get immediate-release nifedipine, but the modified-release version is in stock.” Even though I'll take responsibility for prescribing the new script, it saves me loads of time, while using the pharmacist’s skills and training to their best effect.

The general trend in primary care is definitely for professionals in different areas to work together, rather than in silos. Medicines shortages are a dangerous nuisance, but perhaps an unforeseen benefit will be that GPs and pharmacists start talking to each other more than we have in the past.

Toni Hazell is a GP based in a practice in London

C+D is exploring the impact of medicine shortages on community pharmacy staff all week. Read the coverage so far and join the conversation by tweeting #MedicineShortagesWeek

14 Comments

Hanbal Chaudry, Community pharmacist

Firstly, I don’t want to imply any particular of my GP practices is better than the other. They are not. They are under the dare I same or similar pressures we are. The idea that I call the GP surgery is not as easy as suggested by the article. More often than not “you are in que position 12” message that I get on the phone. After waiting a considerable amount of time and manopolising the sole telephone line you don’t get to speak to a GP but a receptionist (say a messenger). Then you don’t hear back! 

John Higgins, Community pharmacist

I have worked in General Practice now for over three years, and I am disappointed at the poor standards in community pharmacy. Whether a superintendent pharmacist or a locum pharmacist in my past, it was such a basic to always offer an alternative if there were supply issues - it's in the patient’s best interest as pharmacist are meant to the be medicine 'experts' so should be best placed to suggest option. Also you have access to the SCR. It is also in the business interest as you're likely to keep the business. I find it unprofessional the comments above where the so call medicines experts are not suggesting alternatives where possible, and complaining about getting past receptionists.     

Firstly, your wholesalers give you up to date lists of medicines that are out of stock and you can look online to see what your wholesales have in stock - so stop making the excuse of not having access to Mims.   

Secondly you are expected to supply the product in a timely manner - surely suggesting an alternative speeds up the process allowing the patient to get a product in a timely manner.

And thirdly, get in the 21st century with the NHS - you have all been offered the chance to get secure NHS secure email addresses ... - use it to contact practices - no need to spent time on the phone and try to 'get past the receptionist' ........

 

 

 

Paul Knapton, Community pharmacist

I work with my local prescribing practice Pharmacist, we talk to each other and then she sends me a replacement prescription via EPS. Depending on the change one of us will let the patient know what is going on; patients leave happy and neither of us get into a war of post-it notes!

Asma Aroun, Community pharmacist

 "MIMS. To access the latter, pharmacists will need a subscription." may be it is about time to give pharmacists free access to such kind of resources (just checked it is £225+VAT per year)

Adam Hall, Community pharmacist

I happily suggest alterantives if one is available, and it does lead to closer working relationships with GPs..... However, you still get GPs whose view is 'That is what the patient wants, that is what I want - Get it!' and will suggest to patients they go to an alternative pharmacy 8, 9, 10 miles away because 'they can get it' (read: "Got one pack on the shelf they haven't used in 4 years and they won't be getting any more") so patient gets the impression, fuelled by Lord-God-GP that we are useless and, when the 'alternative supplier' is found out to not be able to supply the whole amount, the patient has to go back to the GP for an alternative, and a new script. Cue "I don't see why I have to pay again just because you can't supply it" conversation, despite the obvious fact we weren't the ones who only partly supplied the product in the first place!! GRRR!!!!!!!

Lucky Ex-Locum, Superintendent Pharmacist

It's all well and good recommending alternatives which we all do and always have done, but when you get that prescription for the same OOS item you told them about and recommended the alternative to 20 minutes ago, THAT'S when it gets annoying and I'm not wasting my day contacting the surgery for every single OOS script I receive every day. I quite simply don't have the time or energy. GPs are not 4 year olds. We should only have to tell them once.

A LOCUM, Community pharmacist

I get regular phone calls from surgeries to suggest alternatives which i'm happy to answer , my question is 'why don't they ask their practice pharmacist '?

Alexander The Great, Community pharmacist

So. Most pharmacists who work in large multiples do not have access to information of what is in stock. They even get told not to ring up to ask, as it blocks their lines. As an independent, I can log into alliance, AAH and colorama accounts online to see what is available.

So the patient wants, ellest solo. OOS. Zumenon OOS. I cannot recommend an alternative. There isnt any?

Evorel conti OOS, femseven conti OOS. I cannot recommend an alternative. There isnt any?

I wont subscribe to MIMS. I cannot afford it.

Farmer Cyst, Community pharmacist

I was pretty shocked to find out that this isn't common practice. Both at uni and during my pre-reg I had it drilled into my head 'Have an alternative suggestion you've checked out before hand before you speak to the surgery'

 

This is how I always did it, even when I was a locum - now I'm out of community I was really shocked at the attitude of lots of community pharmacists. Sending scritps back to GPs with 'OOS' on a post it note.

 

Don't get me started on requests for alternative products to be prescribed when it turns out the patient has 6 weeks of drugs built up in their cupboard and it's expected back in the wholesaler in 3 days....

Michael Mustoe, Community pharmacist

Grow up guys
Of course we should always be suggesting alternatives to GP's. You MUST consider this to be one of your tasks, and not just pass the problem back to the surgery
Act as part of the primary healthcare team and things will change for the better
Problem solving is a key part of being a good Community Pharmacist

V K P, Community pharmacist

so accessing the MIMS at no cost to the practice is a cumbersome task for which the practice is resourced handsomely, however the poor community pharmacist has to pay for a subscription and then find the alernative and present it on a plate for the doctor to prescribe. fat chance. do some work for the hoards of money that you get. pharmcists can do everything but not for free anymore. take the SSP to amazon and P2U. 

Tired Manager, Community pharmacist

I would hope any decent pharmacist does this for the majority of shortages anyway (although waiting 15+ mins on hold is not an option - you're getting a written note/fax from me which I hope gets to your desk eventually). Worth noting that there are times when some of us may not feel comfortable suggesting alternatives as we do not have access to their medical records. As community pharmacists is it really our place to suggest switching HRT from Evorel Conti patches to an oral preparation without first discusing the altered risk vs benefit with the patient? Food for thought, but I'd have thought given the lack of "close" alternatives that kind of thing should be referred back to you for a proper reassessment

Ben Merriman, Community pharmacist

Without access to fully records, I wouldn't expect that, no. I would however expect "we can't get any continuous transdermal HRT, or any combined for that matter, you might need to consider something orally" as opposed to "something else please" and then getting cross when you get a Rx for Femseven Conti.

I've tried to champion community pharmacy as much as I can despite having joined "the dark side" but a Post-It saying "can't get it, Doc" reduces the sector to nothing more than a supply function. There's difference between advising on possible similar alternatives and formally recommending/prescribing one.

Tas Bhatti, Community pharmacist

Getting past the receptionists would be a good start....

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