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Remedy quest

Still practising

Chris Preece

Tuesday, 29 January 2019

Before we begin properly, here’s a quick story.

mountain_AdobeStock_194793291.jpgOnce upon a time, in a land not all that far from here there was a man on a mighty quest. He had travelled great distances in search of a substance that would cure all his ills. He had visited many wise men, but had been turned away, until finally he came to seek the assistance of The Great Sage of The Mountain. He dragged his tired broken body up the mountainside, through wind and rain, ignoring the sighs of his aching joints. For days he lived on moss and rainwater, his mind focussed on nothing but his goal until, finally, he arrived at the feet of the Wisest of All Mankind.

Our hero was speechless on finally encountering this revered individual, and simply threw himself prostrate at his feet. The sage reached down, and placed a hand on his shoulder. “You are here now,” he said. “Your journey may have been long, but you have found what you were looking for. There is no knowledge I cannot bestow, no quest I cannot aid. Tell me, what do you seek?”

The man still could not find the words, and simply raised his right hand, which had remained clenched tightly around its contents throughout his journey. Slowly he opened his arthritic fingers, as if his hand were a flower suddenly blossoming on that barren mountainside. The sage reached down, and took the contents – a crumpled piece of green paper. He slowly flattened the creases with his hand, then bent to study the words, his eyes small and shrewd at first, then gradually widening with horror and realisation. The man stared up at him with a look of desperation, but the sage simply shook his head sadly.

“This is a prescription for naproxen”, he said sighing, “I’m a wise man, but I’m not a bloody magician.”

 

AdobeStock_180072866_remedyquest.jpgOK. It’s not quite that bad, but it certainly feels like it’s getting there. For any readers wondering what I’m talking about, Britain has a drug problem. No, not the vertiginous rise in opioid prescribing, but more with the simple provision of medicines in the first place.

As was widely reported earlier this month, the number of medicines in such short supply that the Department of Health and Social Care (DHSC) has agreed to pay price concessions has risen to 80. (In other words, drugs that are so hard to get hold of that pharmacists are having to pay significantly above their list price in order to obtain them. Once recognised by the DHSC, pharmacists can reimburse these increased costs from the NHS.) The number was 45 back in October.

Even more worrying is the nature of the drugs in question. Doctors and patients are perhaps used to occasional shortages of rare and unusual medications, but these are nothing of the sort. The list includes ramipril, furosemide, allopurinol, propranolol and, yes, naproxen. There are a lot of people taking these drugs.

The effects of such shortages shouldn’t be underestimated either. The most obvious risk is that patients won’t get the medicines that they need, which is an awful lot of people potentially in pain or at risk. Of course, in many cases either the medication will be found, or a suitable alternative provided in the interim, but that’s little consolation for those where that isn’t the case. Besides there are a whole host of other, less obvious risks as well. Stock shortages tend to result in increased adverse incidents – as preparations are swapped and changed, and patients lose track of, what, exactly, they’re taking this month. Equally the constant back and forth to try and obtain medication X leads to a reduction in compliance, as people simply opt to stop taking their treatments, rather than go through the ridiculous convolutions required to obtain them.

If it’s bad for patients, then it’s also a problem for pharmacies and dispensers. Shortages result in large quantities of time being spent trying to source medications, or negotiating with GPs to arrange an alternative prescription (a decision they may be able to make themselves in the future, under the slightly scary Serious Shortage Protocol proposals). The increased costs of procuring these medicines is also prohibitive for pharmacies, particularly small local chemists. Whilst most of these deficits can be reclaimed once the DHSC recognises the problem, and adds the relevant drug to the short supply list, this can create incredibly difficult cash flow issues for small businesses. Meanwhile whilst some increases are reimbursed (after application, every month), some are not, meaning that pharmacies are dispensing drugs at a loss – which is not a terribly sustainable position.

In addition, there’s the cost to the NHS as a whole - every drug on that list is, by definition, a drug that is costing the NHS significantly more than it usually would. The price concessions alone have cost an estimated £144,560,000 in the last 12 months.

In reality there have been issues with drug shortages in the UK since 2017. There’s considerable debate as to why this might be, with a number of factors being pointed out. Some point to the closures of plants manufacturing generic drugs, and the increasing global demand for medicines, particularly as we all live longer. Others point to the UK’s low prices for generics, which are great for the NHS, but make us a not terribly attractive market for global pharmaceutical companies who prioritise those places that offer the best financial return.

Of course, none of those things explain why the problem is only hitting the news now. For that we have to look at something that the Royal Pharmaceutical Society has been keen to stress has absolutely no link to drug shortages. Definitely none. No way. Namely, Brexit.

I wouldn’t dream of contradicting the RPS, so let’s just stress that the change in exchange rate that they do identify as a potential cause, was in no way triggered by Brexit negotiations either. Equally, there is absolutely no possibility that the Government’s instructions to drug companies to stockpile an extra six weeks of medication in preparation for Brexitgeddon could, in any way, be contributing to this mess.

Despite the clear message that it’s Not Brexit Stupid, it does seem to be this that has captured the imagination of the public and the media, and irrespective of the truth, perhaps it’s to be welcomed that we are at least discussing this problem and, as a result, looking for some long-term solutions. After all, previously when there was a shortage so severe that there were safety concerns we would seek help from the European Medicines Agency, but sadly they’ve just packed up and left us. So, here’s hoping a solution is found soon, lest obtaining your monthly prescription becomes the stuff of legends.

Author's Image

Chris Preece

Chris has worked as a GP Partner in North Yorkshire since 2004, and still relishes the peculiar challenge of never quite knowing what the next person through the door is going to present with. He was the chair of his local Practice Based Commissioning Group, and when this evolved into a CCG he joined the Governing Body, ultimately leaving in April 2015. He continues to work with the CCG in an advisory capacity. When not being consumed by all things medical, Chris occupies himself by writing, gaming, and indulging the whims of his children. He has previously written and performed in a number of pantomimes and occupied the fourth plinth in Trafalgar Square. Tragically, his patients no longer tell him he looks too young to be a doctor.
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