The Pharmaceutical Journal Vol 267 No 7160 p187
11 August 2001

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Managing drug shortages in the NHS

So far, the National Health Service has been able to deal with drug supply problems reasonably effectively. But, with the changing environment surrounding the pharmaceutical industry, this might not always be the case. Harriet Adcock examines why the shortage situation is getting worse

Drug shortages within the National Health Service are on the increase. So far, the NHS has been able to manage supply problems by conserving stock and prioritising needs. But is the NHS having to sail too close to the wind?

In the hospital pharmacy sector the combination of centralised procurement and formularies means that hospitals are using their buying power to secure lower prices. A downside to this is that prices can be driven too low with the result that suppliers are squeezed out of the market. In situations where only one supplier remains, hospitals are left in a vulnerable position.

Manufacturers and suppliers are increasingly maintaining only limited stock as a way to reduce costs. This could also be a contributing factor in what some see as an increasing shortages problem.

Howard Stokoe, of the NHS Purchasing and Supply Agency, told The Journal that because of the changing environment of the pharmaceutical industry, with companies merging and relocating, there has been a loss of flexibility in the supply chain. This loss was an effect of globalisation, he said.

The NHS has dealt with supply problems effectively at short notice. For example, the shortage of dexamethasone 2mg tablets in 2000 was resolved by the NHS buying the tablets in bulk and then using hospital production units to repack them. The NHS Purchasing and Supply Agency was able to establish and facilitate a dialogue between the Department of Health, the Medicines Control Agency, the suppliers and the production units.

A recent shortage of noradrenaline was also effectively managed by the NHS. Existing supplies were conserved and the supply prioritised for patients in intensive therapy units while other products could be sourced.

The fact that the NHS is able to manage supply problems effectively should be welcomed, but questions need to be asked about why such situations arise.

OXERA report

In a recent review of the generic drugs market by OXERA (see PJ, 28 July), commissioned by the Department of Health, the issue of drugs shortages was touched upon. OXERA found that most pharmacists reported that there were few true shortages and that a product could always be purchased, although often at higher prices. This may reflect the effective management of drug shortages by the NHS.

The OXERA report suggests reasons why manufacturers do not invest in more capacity and why there are not more manufacturers entering into the market, which would help alleviate shortage problems. These reasons are that returns may be too low, the required investment might be large leading to long periods of lowered profitability, and that licence requirements make entry into the manufacturing sector difficult.

The report’s authors comment that the financial benefits of trading in a drug that is in short supply can encourage speculative behaviour, but they suggest that it is unlikely that drug shortages can be created through stockpiling.

Hospital production units

Hospital production units can be effective at resolving supply problems, especially for low-volume niche products. However, some units are being closed down, thus adding to the problem of drug shortages.

Phil Bendell, unit manager at Torbay pharmacy manufacturing unit, South Devon Healthcare NHS Trust, explained that over the past year a number of smaller hospital production units had closed because of increased legislative requirements, and because hospitals were having difficulties staffing the units.

The fact that the MCA requirements for production units are becoming tighter and more specific has cost implications for hospitals. Tighter legislation means that some manufacturing units need to be refurbished, putting them out of action for what can be long periods. Not being able to fund the required upgrades means that units have to close and hospitals have to source the products that came from these units from other suppliers, such as larger units and commercial specials manufacturers.

Mr Bendell said that the closure of Manor Park manufacturing unit, which was part of the North Bristol NHS Trust, had caused problems for the trust. The unit had manufactured flexible bag products and hospitals had experienced difficulties in sourcing alternative supplies. “It is always difficult for every unit to respond to every requirement,” said Mr Bendell. Manufacturing units try to be flexible but tend to concentrate on certain fields. Because Manor Park was local and had been able to supply hospitals with their requirements for flexible bag products, the unit at Torbay had not attempted to compete.

At present, manufacturers are not obliged to inform the NHS of forthcoming shortages. However, a spokesman for the Association of the British Pharmaceutical Industry told The Journal that the ABPI had been invited to discuss the issue of managing drug shortages with the Department of Health. Previous talks between the ABPI and the department on the topic of withdrawal of medicines from the marketplace had been successful and were likely to be used as a blueprint for the discussions regarding drug shortages, he said.

For drug withdrawals, the ABPI has agreed that manufacturers alert the department to an agreed protocol and time scale. A similar arrangement for drug shortages might reduce the impact that shortages have on the provision of health care services.

The current shortage of bupivacaine highlights some of the issues that hospitals have to deal with. Using alternative products, if there are any, is not always straightforward, and can involve changes to drug administration protocols. The alternative product might only be available at a higher or lower strength, or as a different formulation. And the fact that drug shortages like this are a regular occurrence means pharmacists have to address these issues frequently.

It is important that manufacturers and suppliers liase with the department as soon as they are aware of a potential supply problem. The NHS is coping with drug shortages and there is no evidence to suggest that patients have suffered. However, with more pharmaceutical companies merging and more production units being closed, a new strategy for dealing with problems of supply would be sensible.

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Harriet Adcock is on the staff of The Pharmaceutical Journal