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‘Pharmacies need a new way of tackling HRT medicine shortages’

“I feel that the SSPs are a half-measure, a drop in the ocean”

Time-consuming shortages of hormone replacement therapy (HRT) medicines and other drugs require better protocols, says PCN pharmacist Danny Bartlett

The increasing number of medicines going out of stock or being discontinued entirely is having a profound effect on the work the medicine teams are doing in the three surgeries I work in. We are having to combat the shortages with alternative protocols, and ensure patients don’t run out of their medications in the interim periods.

The shortages are predominantly HRT drugs but many other medicines have also been affected. I would estimate that 30-40% of my time working in medicine teams at surgeries is spent dealing with patients who need to be switched to alternative medicines as their current one is out of stock.

Not only is this an enormous portion of my time, but it increases the prescribers’ workload, too. I’m not able to switch a patient from one HRT treatment to a different drug combination or form without the sign-off from the prescriber, even if I’m confident of the same indication and therapeutic benefit of the drug. This means I have to create a ‘task’ on the surgery system to notify the doctor and ask for the go-ahead after suggesting an alternative. This can also mean that the patient is at risk of running out of their medication.

In terms of stock information, the data available is sparse. There isn’t one centralised system that both surgeries and pharmacies are able to access. With community pharmacies having direct lines to their wholesalers, they are generally the first to know of a shortage, but there can be a time delay between the pharmacy finding out and the surgery being notified.

Some nationwide shortages are announced via the Medicines and Healthcare products Regulatory Agency (MHRA) central alerting system, for example ranitidine, but this does not cover all of the shortages by a considerable amount.

With community pharmacies having to deal with shortages every day, I’ve found that different pharmacies have different protocols in place for shortages. Some pharmacies are reluctant to go to certain suppliers, despite the supplier having that item in stock, due to head office instructions favouring particular wholesalers.

This is another hurdle to overcome in getting medicines to patients, and another strain on my surgeries’ resources. Medicine teams being told an item is out of stock, when it is with one or two less favored suppliers, can put a strain on GP surgeries’ relationships with their local pharmacies as well as on their rapport with patients.

“SSPs are a half-measure”

Last year, serious shortage protocols (SSPs) were implemented to allow pharmacists to supply alternatives for particular medicines without having to contact surgeries to source an alternative prescription.

An SSP for fluoxetine 30mg capsules allowed community pharmacies to give patients 20mg and 10mg capsules of the drug as an alternative on the existing script. This is all well and good, but I’ve noticed that many pharmacies are reluctant to use SSPs due to a lack of training and information distributed about them, or a lack of awareness that they will be able to recoup the cost of dispensing the alternative.

I feel that the SSPs are a half-measure, a drop in the ocean in a situation where many items are out of stock across the country and there are few SSPs in place. The time spent dealing with shortages is at the forefront of medicines teams’ day-to-day work in GP surgeries across the UK.

Following Brexit, I believe there needs to be more defined protocols in place that grant pharmacists in GP surgeries more power to prescribe alternatives without having to seek prescriber approval. There should also be a centralised pathway approved by clinicians to guide into selecting the correct alternative.

A more accessible way of finding out what is out of stock across all clinical commissioning groups (CCGs), along with suggested alternatives, would help, too. I’ve found that my CCG may have different updates to the one next door, despite there being no notable change in supplier networks.

In all, a lot of time is being taken up by the drug shortages putting a strain on the relationship chain: GP surgery to community pharmacy to patients. Streamlining how we deal with shortages is paramount to the functionality of the system as a whole.

Danny Bartlett is a PCN pharmacist for the Coastal West Sussex Partnership


Tired Manager, Community pharmacist

I'm not sure of PCN rules but as a directly employed practice pharmacist, the GPs I work with are perfectly content to trust my judgement RE alternatives, as such, all requests for alternatives are passed to the pharmacist. I find the SPS website often has useful guidance/memos on shortages so they may be just as happy for you to print scripts and send for signing with note (e.g) "as per SPS shortage guidance, sign if happy" rather than creating another query. Depends on the practice I guess but most GPs are normally game for anything that reduces workload. Also I agree that "preferred" wholesalers etc.. is an unnecessary problem, I find it sad that some pharmacists at these companies don't feel confident enough to say "this patient needs this, I don't care if it's not from supplier X this month"... I certainly never had a problem telling the pen-pushers at head office where to go in my Community Pharmacy days.


Joan Richardson, Locum pharmacist

The lack of information about what is out of stock and why is a real problem.  We have no idea what the problem is or even if something is ever going to come back into stock.  We are fed up with being made to look stupid in front of both patients and staff at local surgeries.  One of my dispensers spent 25 minutes trying to get through to a surgery to request a prescription for an alternative only to find stock of the original item in the afternoon delivery.

Something that would save time would be if oestrogen only containing HRT was prescribed generically. This would save having to ask for changes such as evorel to estraderm or elleste solo to zumeron etc.

N O, Pharmaceutical Adviser

""Something that would save time would be if oestrogen only containing HRT was prescribed generically. This would save having to ask for changes such as evorel to estraderm or elleste solo to zumeron etc.""

Have you ever read the DT ?? Please check the price difference between brands + 8% to 10% automatic discount deduction from them. Now would you be willing to hand out any brand for a generically prescribed HRT ?? apart from the clinical reason given by ABC DEF

I am aware of the points ABCDEF makes, generic prescribing would still be possible in some cases. I'd hope the pharmacist would check with the patient before giving out.

I'll admit N O, I didn't consider the cost implications, I stand corrected. 

In hindsight, sticking to brand prescribing would better all round. I'll think harder before typing next time.

ABC DEF, Primary care pharmacist

You do realise the frequency of application and licensed dose range are different for each brand don't you? And that estradiol hemihydrate is not 1:1 to valerate? 

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