Medicine Shortages

After​ I finish my morning clinic as a GP there are a few tasks that I have to get done before heading out on home visits. The first is to check my inbox. There are always some messages from the government, public health alerts, emails from hospital consultants and district nurses with concerns about mutual patients, emails from the local medical school regarding students. Most GPs are independent contractors, not salaried to the NHS, a model which is cheaper for the taxpayer but means that doctors have to deal with a lot of the minutiae entailed in managing a small business. After the emails there will be hospital correspondence and test results to review, and after that there are prescriptions to sign.

Though digital prescriptions have been introduced in some parts of the UK, most GPs still sign a little slip of paper for every prescription they issue – 1.41 billion of them in the UK in the financial year 2022-23. The hope is that in time we can phase out the bits of paper altogether in favour of electronic barcodes. Pharmacists would then simply check a patient’s ID, see the prescription on their computer system and dispense it.

Recently there has been an additional strand of work for GPs to complete before they can get out on visits: amending prescriptions they have already issued. If a pharmacist doesn’t have a medication I have prescribed, they send the bit of paper back to me with a note saying ‘Can you prescribe an alternative?’ Pharmacists are highly trained professionals but they can’t legally issue a substitute for the intended prescription themselves. To find out what they have on their shelves, or what they can get hold of, I usually end up trying to get the pharmacist on the phone, adding further delay to my morning and theirs.

This used to be an occasional irritation, but it’s becoming routine. Between 2021 and 2023 there was a 67 per cent increase in the number of reports from pharmaceutical manufacturers that a medication was in short supply. In June I was helping to manage a community outbreak of whooping cough when the whole town ran out of clarithromycin suspension, the recommended antibiotic for the acute phase in children. None could be found, and I was reduced to asking the parents of affected children to get a pestle and mortar to grind up tablets and hide the powder in yoghurt. A few months ago we had an outbreak of scarlet fever and did the same with tablets of penicillin. The pestle and mortar is one of the oldest symbols of the pharmaceutical profession; it’s an unexpected twist in the spiralling problems of the health service that in 2024 we’re having to recommend returning to it.

Outbreaks of infectious disease are one thing, and it could be argued that, given the unpredictable nature of focal epidemics, it’s unreasonable to expect that the supply of antibiotics will always meet demand. But we are now seeing shortages of medicines that people take month in, month out. A House of Commons report in May listed a few of the reasons: geopolitical factors such as the war in Ukraine, the after-effects of the Covid pandemic and the disruption of supply chains in the wake of Brexit. It also pointed to manufacturing and distribution problems (the result of a lack of agility among pharmaceutical companies) and – more worrying – ‘severe’ financial pressures on pharmacies. Community pharmacies buy medicines with their own funds and are reimbursed for the ones they dispense under the auspices of the NHS according to the Drug Tariff, a list of prices set by the government. When global prices rise, the government can arrange a ‘price concession’, but may not do so straight away and won’t necessarily reimburse the full amount, so pharmacies stand to make a loss.

The report includes case studies on several drugs whose supply, as I know from my own experience, can be unreliable: the medicines to manage type 2 diabetes and Attention Deficit Hyperactivity Disorder, and the drugs comprising Hormone Replacement Therapy. The Royal College of GPs recently raised concerns that the diabetes drug Ozempic is in short supply because private clinics who use it ‘off-label’ as a slimming agent are buying up stocks to sell it at a premium. This is a global problem: a recent study from Denmark showed that between 2021 and 2023 the number of people prescribed Ozempic almost trebled, though a third of its users didn’t have a diagnosis of type 2 diabetes – they were being prescribed it as a dieting drug. Abuse by private clinics has been suggested as one of the reasons ADHD drugs are in such short supply, too, but in this case there have also been surges in diagnoses and prescriptions in recent years: 660,000 ADHD prescriptions were issued in NHS England in 2010, but more than 1.5 million in 2020. A recent study at UCL found that, between 2000 and 2018, there was a twenty-fold increase in ADHD diagnoses among young men and a near fifty-fold increase in prescriptions. There are a wealth of generic suppliers of most cardiac or diabetic medications, but only a limited number of manufacturers of ADHD drugs, which means that a hiccup in a single company’s supply chain can have protracted global effects. To take just one example, Takeda, a key supplier of Adderall, blamed recent glitches in supply on a packaging problem at one of its sites.

The UK isn’t alone in all this, but some factors peculiar to its situation have undoubtedly made things worse. In April the Nuffield Trust issued a report detailing what it described as ‘fragilities’ in the UK’s supply chains, with Brexit one of the chief causes (since it reduced the value of the pound and created new obstructions to trade across borders). The NHS has huge purchasing power and is able to drive the price of drugs down to levels so low that, if a medicine is in short supply globally, it can be more trouble than it’s worth for manufacturers to navigate the UK’s many barriers to trade. Earlier this year the EU offered incentives to Big Pharma to build more manufacturing plants and create a stockpile of commonly used medications to smooth out supply for member states – a stockpile to which the UK will have no access, and which won’t make it any easier for the UK to meet its own needs.

In March 2024 the Lord Bishop of St Albans submitted a written question to the government asking how many preventable hospitalisations had occurred because of Brexit-induced medicine shortages. Lord Markham, Tory under-secretary of state for health and social care, replied disingenuously: ‘The department has no evidence of the EU exit leading to sustained medicines shortages.’ But if you need a drug every day, you don’t care whether the shortage is ‘sustained’ or not – even one day’s delay is a problem. One of the medications affected is liquid salbutamol, which is delivered through a nebuliser to treat a severe asthma attack. If you are unfortunate enough to be in need of nebulised salbutamol, you need it right now. Another potential drag on supplies, as I mentioned already, is the sluggishness of government in making price concessions to pharmacies. In 2023 the surging price of atorvastatin, a cholesterol-lowering drug which is the most frequently prescribed medication in the UK (59 million prescriptions in 2022-23), meant that for several months, despite pleas from representatives of community pharmacies, the reimbursement offered by the government was lower than the price pharmacies had to pay for the drug.

Similar issues have beset the supply of HRT. Following a reduced emphasis on potential side-effects in medical guidelines, as well as increasing public awareness and requests for treatment, the number of prescriptions per month went from 238,000 in January 2017 to 538,000 in December 2021. The costs of HRT prescribed by GP practices over the same period increased from £3.2 million to £7 million. HRT drugs have repeatedly been in short supply since 2018. The NHS may have a lot of purchasing power, but it can’t ‘pull rank’ in the market for medications and has no legal right to jump the queue in meeting its own needs. In late 2019 the government was obliged to impose export restrictions on HRT drugs to stop wholesalers taking advantage of higher prices elsewhere.

The House of Commons report from May highlights the government’s introduction, also in 2019, of Serious Shortage Protocols, which give pharmacists some licence to be creative. Instead of sending the slip of paper back to the GP, for instance, they can offer the patient a liquid preparation in place of a capsule, or a greater quantity of tablets of a lower strength. In 2020, the National Supply Disruption Response was introduced to give clinical providers access to an ‘express freight’ mechanism, whereby the international logistics firm Kuehne and Nagel is used to help meet NHS demand for medicines. It’s strange that, in order to overcome trade barriers erected because of Brexit, the NHS is now obliged to pay a private company to circumvent those barriers, but then these are strange times. My own experience suggests that pharmacists somehow find a way to restock their shelves, and go to great lengths to serve those patients with the greatest need ahead of those who make the loudest demands. But until government support for their efforts improves, and drug supply chains become more robust, I imagine I’ll have to continue calling pharmacies to find out what they’re able to get hold of. Meanwhile, it may be a good idea for all of us to keep a pestle and mortar close to hand.