“It’s the pharmacist on the phone. There’s a shortage of naproxen, could you suggest an alternative?”
There are few things more likely to wind me up during a busy surgery than one of these phone calls. Ones about drug shortages seem to be getting more common. Sometimes it’s easy: “The 500mg tablets are out of stock, could I do a script for the 250mg?” But sometimes the issue is more complicated.
I gather from colleagues that some brands of hormone replacement therapy are the latest drug to be in short supply. Finding a suitable alternative that will keep the woman symptom free isn’t always straightforward. A no-deal Brexit, with the medicines supply chaos it might have caused, seems unlikely now, but no one can tell what will happen to drug supply chains in the future, whether or not we leave the EU.
On the face of it, a shortage protocol seems sensible. Pharmacists are highly trained professionals and it’s insulting to make them phone me for permission to dispense two 50mg tablets because the 100mg isn’t available. If there’s different bioavailability between a tablet and a capsule, then quite frankly a pharmacist is more likely to be aware of this risk than I am.
When a drug is completely unavailable, a qualified pharmacist could make an evidence-based decision on which other drug in the same category is the next most appropriate, using the same resources that I would, such as the British National Formulary or advice on the relevant National Institute for health and Care Excellence (Nice) clinical knowledge summary page. The ability to dispense a generic equivalent is surely a no-brainer – there are very few drugs for which the brand is important, with even some antiepileptics now being given as generics.
Who is responsible for patient harm?
What is the problem with this shortage protocol? And why don’t we use it all the time to save some of these unnecessary phone calls? As always, the devil is likely to be in the medicolegal detail. We live in an increasingly litigious society and the proliferation of ‘no-win, no-fee’ lawyers means that the most vexatious of complaints can get much further than they used to. If a patient is harmed by a switch – or, more likely, they think they have been harmed, possibly with no evidence to back it up – who is going to take responsibility?
As a GP, I indemnify myself against my own decisions and those of any staff for whom I hold vicarious responsibility. Will the organisations that indemnify pharmacists be happy to defend any complaints resulting from the use of this shortage protocol? Too often, allied healthcare professionals are introduced with no thought for the indemnity, with the eventual medicolegal responsibility being held by the GP. This mustn’t be the case for this issue.
If the indemnity issue is sorted out, this shortage protocol seems like a very sensible idea and something that could be applied long-term. I’m sure that neither pharmacists nor GPs will miss the ritual of the ‘please could you substitute’ phone calls. Perhaps this will herald a new era where trained non-doctor healthcare professionals are able to make, and take responsibility for, more of their own clinical decisions.
Toni Hazell is a GP based in a practice in London