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A GP's view: How I wish pharmacists could deal with stock shortages

"If the indemnity issue is sorted out, this shortage protocol seems like a very sensible idea"

Pharmacists should be able to dispense alternatives to cut unnecessary phone calls to practices, but questions remain over indemnity, GP Toni Hazell writes in her first C+D blog

“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

8 Comments

Paul Thomson, Community pharmacist

Pharmacists in Scotland already have a lot of ability to deal with shortages. We currently use a PGD to supply medication to patients who don't have a script. The same PGD allows us to supply alternatives to a lot of shortages. We can't change the actual drug but it saves a lot of phone calls in cases where alternative strengths or formulations can be used.  

jennifer Wright, Community pharmacist

Agree with all comments, sigma conference available through pharmacy magazine worth a look, Hement Patels piece on stress excellent, unfortunately many may chose the option he mentioned, leaving the profession. Many professional, dedicated, knowledgeable, caring people will be lost before long.

 

Leon The Apothecary, Student

A common sense solution. I personally have always wondered why it is such a big deal to make the infamous 2x250mg Naproxen instead of the 1x500mg Naproxen and similar switches; even witnessed it being done automatically with some pharmacies who have a close relationship with their surgeries knowing that their GP and Prescriptionist will complete the paperwork without fuss.

Some of the more complicated switches might need some collaboration beforehand certainly on the other hand and that will take up a bit more time, but would it be worth making those initial baby steps, those low-risk changes that allow "no-brainer" switches.

Good article, thank you for sharing Dr Toni.

Lucky Ex-Boots Slave, Primary care pharmacist

It's a big deal to the pharmacy companies on drug reimbursement prices hence why it is a big deal to get the script changed. It's never a clinical issue as everyone even a 3-year old knows 2x250mg = 500mg 

George Ibrahim, Community pharmacist

National plasters and paracetamol service

Roy Sinclair, Community pharmacist

I am now retired from pratice but yesterday chatted to my local pharmacist about the shortage of Migraleve pink. Not a prescription drug but a desperately needed item for a relative who relies on it. I listened to some of the tales of the kind of abuse the pharmacist had to go through trying to explain any shortages, the resulting loss of prescriptions from angry customers and the assumption that the pharmacist is the cause. Few patients felt that any substitution was anyting other than poor management by the pharmacist rather than an effort to help.  I suspect this is probably common to most pharmacies and wondered at how much of these difficulties are being absorbed by the good-will of the Pharmacist at the coal-face. I have read the reports of the shortages but was really horrified to hear how the shortages really were affecting patients and the blame being placed mostly on the pharmacist. When I was in practice, such a situation would have been a national scandal. The Three-day-week was a walk in the park compared to dealing with this problem. Where is the official government notice that can be displayed in pharmacies to at least help explain the problem.  That would be a start!

Lucky Ex-Boots Slave, Primary care pharmacist

An even easier solution may as well be leaving the sector completely like how I did. I'm literally completely fed up with the fact that pharmacists are the ones to take the blame whatever has gone wrong, whether it is out of stock, wrong drug/formulation/quantity prescribed, missing/lost scripts, refused requests by GPs for whatever reasons, missing drug orders especially the "automatic" orders (which are never automatic in the first place but pharmacists again always take the blame for it!) or sometimes when GPs decided to make some cost-effective brand/formulation switches and patients always think pharmacists are the ones doing it to get things done on the cheap. I will not be surprised to see more and more fellow pharmacists choose to leave the sector because enough is enough!

Seena R, Community pharmacist

With the proposed IR35 tax legislation that will soon be applied for locum pharmacists, the shortage of staff in branches and the extra workload of services I'm sure many will leave. Oh and the yearly pay cut that is implemented by the multiples!

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