Pharmacy teams need timely, accurate and concise information on medicines shortages. This was the main message of a roundtable meeting hosted by The Pharmaceutical Journal on 19 April 2023 at the Royal Pharmaceutical Society’s (RPS’s) London headquarters.
The event was convened to bring together a panel, including hospital chief pharmacists (see Box), to discuss medicines supply and shortages in UK hospitals.
Opening the meeting, co-chair Nigel Praities, executive editor of The Pharmaceutical Journal, highlighted the pressing nature of the current issues around medicine shortages and explained that the aim of the meeting was to “look at the factors behind medicine shortages in the UK”, before discussing “mitigation strategies and potential solutions” for the problem.
The meeting was co-chaired by Michael Dowdall, executive editor for research and learning at The Pharmaceutical Journal.
The roundtable was supported by iEthico, a start-up software company that is developing technology to match medicines demand with supply and provide real-time information on medicines shortages.
Scale and impact of the medicines shortages issue
Praities started the discussion by highlighting the growing problem of medicine shortages in the UK. Data collected by think tank the Nuffield Trust show that, since late 2017, there has been an increase in the number of price concessions granted by the UK government for medicines that cannot be purchased at their usual drug tariff price.
“We have seen — definitely last year — an increase in the number of shortages, and shortages that are impacting directly on patients as well. But I also think there’s more of an awareness generally in the country about shortages,” said Praities, noting that medicine shortages “has started to hit front pages of newspapers”.
This problem is not limited to the UK: a 2018 survey of 1,666 pharmacists in 38 countries by the European Association of Hospital Pharmacists revealed that 91.8% said that medicines shortages were a “current problem”, compared with 86.2% in 2014. Antimicrobials, vaccinations and oncology medicines were most frequently reported as having shortage problems, with pharmacists spending five hours per week dealing with supply issues. Just 56% of respondents reported that their country has an effective system to deal with shortages.
To present a more up-to-date picture of the issue facing hospital pharmacists in the UK, Dowdall reported on findings of a survey of hospital pharmacists, conducted by The Pharmaceutical Journal in March and April 2023. The survey had 56 respondents, 66% of whom were chief pharmacists.
Nearly 9 in 10 (89%) respondents thought that the number of medicine shortages had increased over the past year, with 40% aware of more than 90 product shortages and 25% aware of more than 150 shortages. Almost half of respondents (46%) said they were unable to supply medicines to more than 10 patients per week because of shortages (see Figure 1). However, Dowdall said that there were “very few people who were actively tracking this number”. Some 45% of respondents estimated that they spent more than 15 hours per week trying to source alternatives to unavailable medicines (see Figure 2).
“There was one response saying that they spend between 25% and 35% of procurement time [on managing shortages],” said Dowdall, adding that another response said they spend 75 hours per week, which is the same as an additional two whole-time equivalent pharmacy team members.
Mark Francis, assistant director of medicines procurement and optimisation in Wales and chair of the All-Wales Drug Contracting Committee at NHS Wales, highlighted that most NHS organisations have “got big workforce issues, so using people in this way is not sustainable.
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“When there’s a shortage, everyone is chasing the same thing. So, all our teams are ringing the same suppliers and the same wholesalers. The duplication is absolutely huge. You could reduce that duplication through much better transparency and honesty from everyone around what the spread of stock is [and] what’s available.”
Alison Tennant, chief pharmacist at Birmingham Women’s and Children’s NHS Foundation Trust, said that other elements of the impact should be measured, such as the “impact on the drug budget, impact on the suppliers, the logistics groups … what are they not doing as a result of working to manage medicine shortages?”
The Pharmaceutical Journal’s survey also asked respondents for the main problems and barriers pharmacy teams come across when trying to source alternatives. “Very much it was the availability of alternative medicines and formulations, which 91% of respondents highlighted,” said Dowdall, adding that a high proportion of pharmacists also said the increased cost of alternatives to patients (87%) and the lack of accurate and timely information (81%) were seen as significant barriers.
Ruckie Kahlon, associate director of medicines optimisation and chief pharmacist at The Dudley Group NHS Foundation Trust, summarised the impact of managing shortages as “demoralising, because it’s just relentless; that treadmill of just not getting anywhere”.
The survey results also prompted the attendees to discuss their impression of what is currently contributing to medicines shortages. According to the results, a large proportion of chief pharmacists suggested geopolitical factors, contracting prices and COVID-19 were significant factors. Other reasons included procurement practice and process, energy costs and inflation, logistics issues and the availability of raw ingredients.
Ross Maclagan, distribution and supply chain policy manager at the Association of the British Pharmaceutical Industry (ABPI), said he was “not surprised” that so many respondents mentioned geopolitics as a factor. However, he noted that he has “not personally seen significant issues of Brexit” in the supply chain, adding that “this is a global issue, not just a UK issue”.
Tennant noted that one of the contributing factors in the shortages of medicines for children is wider use in developing nations. “One of the things we’ve learned is that paediatric medicines are being used more frequently and therefore are going to other countries,” she said.
She added that, following the Carter report in 2016, trusts were asked to reduce their stock holdings of medicines. “The focus ten years ago was about reducing stock holding; it was about ‘just in time’. And the sustainability agenda for us now is about how to balance that reduced stockholding and the capacity [to store medicines].”
Kahlon said the reasons behind shortages are “multifactorial — you can’t pin it on one thing”. However, she added that one of the “key catalysts is that there is a raw ingredient or a QA issue … or the other catalyst we are seeing more and more now is social media”.
“Either of those two tends to send [supply] into a spiral,” she said.
Berwyn Owen, chief pharmacist at Betsi Cadwaladr University Health Board, said one of the issues is the value the NHS puts on medicines. “The bottom of the market has been reached and what we’re now finding is that the risk to my own community pharmacy and the region as a whole is probably the 50 medicines [that] we are currently buying [for] under 50p a box. That’s not sustainable for manufacturers,” he said.
“What’s the hidden factor here is manufacturers, in particular for [those medicines that] are non-branded, which are finding it extremely challenging to sustain the manufacturing of these medicines with raw material costs and inflation.”
Current activities to manage shortages
With all these factors at play, the attendees offered their anecdotes for how they are managing shortages, including sharing medicines at an NHS-organisational level.
“I could describe a situation where I was going to run out of renal replacement fluids within three hours,” said Kahlon. “So, I picked up my phone and I called my colleagues and we made it happen, trucks went out … that’s mutual aid.”
“But to have it facilitated by somebody who could see the backend of your datasets, and moving it according to your usage patterns, would be just brilliant.”
However, Raliat Onatade, chief pharmacist and director of medicines and pharmacy at NHS North East London, said the legislation around mutual aid does not allow hospitals to support community pharmacies, describing it as a “disabler” to some sectors.
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Francis said that the NHS in Wales has created resilience by building “a central storage facility that has continued since the pandemic”.
“So when we had the Strep A crisis, we were able to procure short-dated Pen B [phenoxymethylpenicillin]. The wholesalers didn’t want to put it into the supply chain because it only had eight weeks expiry on it but we were able to procure it for Wales and we were able to supply community pharmacies.”
Kahlon added that, during the Strep A antibiotic shortage in December 2022, chief pharmacists in the Black Country convened to find out who had stock of the necessary antibiotics to avoid “an avalanche” of patients into emergency departments.
Liz Breen, director of the digital health enterprise zone and professor of health service operations at the University of Bradford, noted that “amazing stuff is happening in hospitals” to mitigate shortages, “but it doesn’t go any further than four walls”.
During the meeting, Breen presented findings from a symposium held at the University of Bradford in 2019 to discuss solutions to the shortages problem. The symposium of 32 people working across the supply chain made 22 recommendations to the pharmaceutical industry, government, health organisations and patient advisory bodies.
These included recommendations for medicines to be sourced through multiple suppliers, for industry and healthcare organisations to set up non-adversarial partnerships and for accurate information to be clearly communicated in a timely manner across the supply chain.
“Information is key,” said Breen, “and this was mentioned so many times: accurate, timely, relevant, accessible and actionable. There is nothing worse than being given information and you can do nothing with it.”
“One of the things that I remember from that session was, somebody said that we send out alerts all the time to the hospital and the community, telling people about shortages, and we’re using NHS email. But people in the room were saying ‘I don’t access that, way too much hassle’,” she said.
“So, we had this impasse where information was being sent out, but it wasn’t being picked up by the professionals.”
Ways to improve shortages management
1. Professional information
Box: Summary of actions
- Information on shortages should be timely, accurate and accessible from a secure system that acts as “one source of truth”, providing all the information needed in one place;
- It was suggested that this system could look like an ‘Specialist Pharmacy Service +’ offering, which would provide a central repository of guidance and risk assessments for clinicians as they deal with medicine shortages;
- The experts also called for a system, such as Rx Info, that will allow trusts to share information on stock holding to assist with mutual aid agreements;
- The system should use intelligence from regional procurement leads, who can provide early warning of upcoming supply issues and understand local medicines usage;
- The system providing this information should enable it to be filtered and digestible so that hospital pharmacists can see applicable information on shortages;
- This would also enable prescribers and community pharmacists to access the information on shortages that they require;
- The system should also offer a standard pathway for managing large-scale issues, which could be facilitated through a “command and control” approach by the UK-wide Medicine Shortages Reference Group.
The need for clear and accessible information was a prominent theme raised by the experts at the meeting as a way for medicines shortages to be managed going forward.
“One of the things that is clear is that people just don’t have much information and it’s moving all the time,” said Tennant. “There is no way to truly quantify a medicine shortage because … when you think it’s resolved, it’s come back again, so that information is just not at our fingertips.”
Penny Daynes, lead pharmacist in operations medicines management and procurement at Calderdale and Huddersfield NHS Trust, added that the information needs to be accessible and updated seven days per week.
“We can have visibility of other hospitals’ stock Monday to Friday because the regional procurement team office is open Monday to Friday… but on a weekend when we run out of something or suddenly there’s a big supply problem, we have to ring around other hospitals in our region to try and find stock,” she said.
The attendees described the need for a secure system where all information on medicines availability and future availability can be accessed at once by people across the supply chain.
“I think there’s a lot of misinformation around medicine shortages from pharmaceutical companies,” said Daynes. “I was in contact with one company recently and I spoke to a few different representatives and they all gave me different information on why these shortages were happening.”
Onatade said she does not have time to search for information when faced with a shortage. “We need that information so that we can put plans in place. We need one source of information,” she said.
Onatade also noted that procurement teams “need to know ahead of time” if a medicine shortage is expected because they currently do not know that an order “isn’t going to come in until it doesn’t arrive”.
The source of information should include advice for how to respond to the shortages, as well as reasons behind them and how long they will last.
2. Managing supply and production
Box: Summary of actions
- Greater transparency and responsiveness around government contracts with suppliers to provide medicines, including offering parity to suppliers providing medicines;
- The contracting process should reflect the suppliers’ reliability in supplying medicines through a rating system;
- Better management of contracts across their lifecycle, with resources pooled nationally to help with this;
- Centralisation of medicines stock, similar to the system in Wales, to help manage demand and forecasting, particularly for critical medicines that could be stockpiled by the government
- Forecasting could be improved by gathering more comprehensive data on demand in trusts;
- The experts suggested relaxing regulations that require hospitals to have a wholesale dealers licence to provide medicines to another trust that is facing supply issues;
- Community pharmacists should be given more flexibility beyond the use of serious shortage protocols to make changes to prescriptions when the prescribed medicine is out of stock;
- The experts also suggested the government reconsider how manufacturers are incentivised for manufacturing supply as the price of generic medicines to the NHS is now lower than is sustainable for manufacturers to produce.
Attendees also noted that contracting structures between suppliers and NHS organisations could be improved to shore up supply.
Having “duplicity of supply comes with complexity for the suppliers”, said Francis.
“If it’s a framework contract, ‘Company A’ — who might have the lowest acquisition costs and has scored the highest on all the elements of the tender — will be used as the primary supply [while the product is available].
“[But] the other suppliers on the contract will have no idea what demand they’ll have. So then forecasting ‘how much do we need for Wales or the UK demand?’ — that is really difficult to do.”
Kahlon noted that there is little data on the demand of medicines from secondary care. “Primary care consumption is really well evidenced,” she said, but in secondary care “it’s really quite fragmented and historic, the way contracting happens, and hospital trusts own their own data and are almost handcuffed not to be able to provide anything”.
“So, I think there is a bit of work there with the CMU [commercial medicines unit] to enable secondary care to provide datasets,” she said.
Tennant added that she has participated in discussions around changing the way tender evaluations are conducted for medicine suppliers to consider past issues with supply, instead of just on a company’s evaluation.
“There is work going on through the commercial medicines unit at NHS England to look at how they can legally assess supplier performance and use that to inform future contracts,” said Francis.
3. Public-facing communication
Box: Summary of actions
- Explore potential to use the NHS App to offer patients accurate and accessible information on shortages that pharmacists can signpost to;
- Implement a public facing ‘shortages tsar’ to tackle issues in the supply chain;
- Develop an app, similar to the Argos model, that shows availability of medicines in community pharmacy.
Onatade highlighted the need for information telling the public where they can go to get the medicines they require. “Where can I get this medicine? Or if it’s not available and you can’t find it anywhere, what happens next?” she said.
The attendees also stressed the importance of making sure that there was equity across different patient groups and clinical areas. “We’ve all been in the position of choosing to direct supply towards one group of patients and away from [another] group of patients,” said Tennant, who highlighted the importance of discussing decisions with patients to switch patients to alternative medicines in times of shortage.
Kahlon added that an FAQ document is needed for each shortage for patients, but said: “The other part to all of this is actually the patients’ need to take responsibility and not leave it to a bank holiday to collect their medicines and then panic.”
Praities concluded the meeting by thanking everyone for attending, particularly to Breen for sharing her research with the group.
Box: Expert panel members
Liz Breen, director of the digital health enterprise zone and professor of health service operations at the University of Bradford
Penny Daynes, lead pharmacist in operations medicines management and procurement at Calderdale and Huddersfield NHS Trust
Mark Francis, assistant director of medicines procurement and optimisation in Wales and chair of the All Wales Drug Contracting Committee
Ruckie Kahlon, associate director of medicines optimisation and chief pharmacist at The Dudley Group NHS Foundation Trust
Ross Maclagan, distribution and supply chain policy manager at the Association of the British Pharmaceutical Industry (ABPI)
Raliat Onatade, chief pharmacist and director of medicines and pharmacy at NHS North East London
Berwyn Owen, chief pharmacist at Betsi Cadwaladr University Health Board
Alison Tennant, chief pharmacist at Birmingham Women’s and Children’s NHS Foundation Trust
Canice Ward, senior principal pharmaceutical officer and head of medicines regulatory group in Northern Ireland.
Representatives from the Department of Health and Social Care, British Generics Manufacturing Association, Healthcare Distribution Association and Alliance Healthcare were invited to attend.
iEthico announced its first customer, Remedi Solutions — a digital NHS prescription service dedicated to improving care home medicines management — on 12 May 2023. Implementation of iEthico’s procurement tool has enabled Remedi to work with new suppliers to receive quotes for medicines in a convenient, easy-to-use online environment, reducing the risks of “out of stocks” and quotas, while providing visibility of a wider network of suppliers.
This announcement follows the launch of iEthico’s cutting-edge solution that connects pharmacists to essential medicines via an innovative digital platform at the Clinical Pharmacy Congress, at ExCel London.