Stock management

To ensure continuity of medication supply to patients, some participants pre-emptively engaged with their stock management:

We generally take a proactive approach to medicine stock holding. So, I suppose the phrase is we’d rather be looking at it than looking for it . . . we carry a significant range of controlled drug medicines and medicines that might be required in end-of-life situations . . .

CP10, independent

For others, a more traditional approach to stock management was taken, reducing pharmacy stock levels (and overall stock value) while maintaining enough stocks to meet anticipated local need (derived from prescribing data).

Anticipating and/or triaging of prescriptions

Some CPs discussed how, on occasion, they anticipated prescriptions being sent electronically (via EPS) to the pharmacy to facilitate supply at the weekend for patients, whereas others discussed how they triaged (and prioritised) prescriptions for patients they knew to be in the last year of their life:

It’s a very community-based pharmacy so we tend to know who is poorly and who is getting worse and we might look for scripts and certainly if I see their names, I will immediately pull them out . . . so you are triaging constantly . . .

CP09, large multiple

Patients and families

Often embedded in respective communities via well-established businesses, CPs sought to facilitate seamless care through the provision of medicines to their local EoL populations. Some CPs had developed relationships with patients and their families over numerous years:

I know all the patients by first name, I’ve been here for many years . . .

CP11, independent

Other health-care professionals

To provide care and medicines access, some CPs worked to develop and maintain relationships with a myriad of relevant HCPs (e.g. local GPs, palliative care CNSs, CNs and other pharmacists) with varying levels of success:

. . . specialist nurses, community nurses, community matrons . . . all call in to us, we supply them, we help them, we deliver, we call out. We do as much as we can to help them . . . There are strong relationships with those people . . .

CP16, independent

The lines of communication are nowhere near as good [as in the past]. But this again is because people are going around chasing their tails . . .

CP15 independent

Relationships with local general practices, and GPs, were unanimously viewed as crucial. This was particularly the case when prescriptions needed to be changed by the GP prescriber, with the pharmacist recommending available medicines options or requesting a review of the medicines:

We’d often contact the GP on their [patients’] behalf and just try and bridge communication gaps so that patients are not left frustrated without medication . . .

CP07, independent

Despite this need for relationships, contact with general practices and GPs could be problematic. For many, speaking to the GP directly was a lengthy process and so most either e-mailed or sent a note to the receptionists at the practice to pass to the GPs. This meant that messages were not received until GPs were out of surgeries. Relationship-building appeared easier for CPs co-located next door to a general practice, as staff within the pharmacy could physically take the prescription request to the practice.

Use of key wholesalers/distributors

All CPs spoke of using key WDs for supply into their pharmacies (usually one, occasionally two, as first-line options). The use of key WDs could also facilitate communication and relationships between the pharmacy and WD:

[Where] a medication has been out of stock and it comes back in stock and the suppliers tend to give us a call letting us know that this is back in stock ‘would you like to take an order before the stock runs out?’ Which is very helpful . . . You can only get this when you do have a good relationship with them . . .

CP03, independent

Decisions about which WDs were used hinged on cost, availability and speed of supply, and some CPs explicitly referred to using a protocol-based decision-making system.

Information technology systems

Supply was facilitated by pharmacy IT systems for stock management and/or for placing orders with WDs. The extent to which pharmacies used IT systems to manage their stocks varied, but all pharmacies placed orders with WDs via online systems. Only a few SLs did not provide any online ordering platform. In general, online ordering systems were perceived to facilitate supply:

The online ordering systems are very good. Send an order, instant reply, yes it’s in stock or no it’s not . . .

CP21, large multiple

Time to delivery

Community pharmacists were generally satisfied with the time to delivery offered by WDs. All FLs were able to provide twice-daily deliveries and SLs provided once-daily delivery (with some also able to provide twice-daily deliveries).

Community pharmacists emphasised that when orders needed to be placed to fill a prescription, if WDs had their own stocks then delivery could be that same day for orders placed before the respective cut-off time:

It just depends on whether we order it in time before our cut off. For one of the wholesalers I think it’s 11.30, one it’s 12.15. So, if you order it before then then it will come in a few hours . . .

CP24, small multiple

Once the cut-off time had been crossed, then delivery into the pharmacy would be for the following day. Ability of the WDs to provide same- or following-day delivery was perceived to be as good as possible, considering the need for supplies to be transported from distribution centres/warehouses. When third parties were used to place orders, then generally supply would be for the following day.

Sourcing stock from other pharmacies

When pharmacies did not hold stocks of the required medicines, or could not source them via WDs, most CPs contacted other pharmacies on behalf of patients. CPs spoke of contacting nearby pharmacies that were part of large multiples because of their likelihood of holding more extensive stocks and their ability to contact other chain branches. In addition, most CPs referred to the use of community pharmacy networks, often run via instant messaging applications:

If anything goes short . . . we now WhatsApp [Facebook, Inc., Menlo Park, CA, USA] . . . it’s a big group of 20 of us . . . somebody has got them in stock, and they [pharmacy staff with the product in stock] bring it to us. That way . . . we can help each other . . .

CP11, I

Medicine shortages

Medicine shortages were, generally, a universal challenge experienced by CPs, potentially exacerbated by Brexit (i.e. the UK’s exit from Europe). A lack of information surrounding medicines shortages was problematic, with CPs having to seek information via various sources, such as professional organisations, rather than from WDs and manufacturers. This contributed to the pharmacists’ workload and to further delays in accessing medicines:

If I give them, the wholesalers, a call . . . they just say, ‘we’re not getting it back until this date’ and that’s it. They don’t really tell you what’s going on. Really what I have to do is search online through the PSNC [Pharmaceutical Services Negotiating Committee] and obviously various pharmacy channels to see what’s happening, if it’s a manufacturing problem, if it’s a licensing problem or there’s another issue . . .

CP05, small multiple

In relation to palliative medicines specifically, CPs reported varying difficulties related to shortages, ‘which is more distressing . . .’ (CP07, independent), but ‘. . . we haven’t experienced the problems that we’ve seen in other parts of our business with non-availability of drugs generally . . .’ (CP12, small multiple). It appeared that some CPs had successfully weathered palliative medicines shortages because of the efforts they and their pharmacies put into sourcing medicines, sometimes from all over the world.

Medicine shortages led to quotas being imposed by the WDs and/or manufacturers. These quotas were perceived as a hurdle that the CPs had to navigate to gain supplies, and were often harshly viewed as creating additional work and causing a delay in supplying to patients:

Often we’re having to fax anonymised prescriptions to a quota team which has been set up by the mainline wholesalers who then ration out stocks . . . We’ve had a patient on phenytoin suspension, in the last year of her life . . . It’s been a challenge to get hold of that for her family. So, we’ve had to contact [named manufacturer] directly to get supplies issued . . .

CP07, independent

Community pharmacists highlighted that any shortage in the market would drive up the price of the respective medicine. This was a key issue because of professional obligations to supply the medicines, but prices frequently exceeded the monthly stated Drug Tariff price (i.e. purchase cost to the pharmacy exceeds reimbursement price). In addition, at the time of purchase, CPs did not know whether or not a price concession would be granted retrospectively and at what price. This led to profound consequences, with pharmacies dispensing such medicines at a loss, contributing to some pharmacies operating at a loss overall. Alternatively, medicines were returned to the WD because the purchase price was deemed too far in excess of the Drug Tariff price, leading to delays in patient access:

As soon as something becomes short in the market the prices go sky-high . . . Sometimes we’re getting reimbursed £1 for it and we paid £20 . . . you’ve got patients who need their medication, so you take a gamble and order it in and hand it out and just hope for the best . . .

CP19, independent

When medicine shortages occurred, CPs perceived placing a request for a prescription change via the prescriber as a ‘last resort’ once they had exhausted all avenues for supply. It was apparent that getting a prescription changed via the prescriber contributed to delay in medicines access for the patient.

Need to use multiple wholesalers/distributors

Although utilising key WDs was a facilitator to supply, conversely, the need to use multiple WDs (range 2–16, median 5) acted as a barrier, with CPs endlessly having to shop around ‘from one to another’ (CP14, independent). This precluded straightforward supply, adding complexity to supply chain routes into pharmacies and contributed to the onerous workload of CPs. The necessity to use multiple WDs was part of the context of medicine shortages:

. . . so, over the last year we’ve increased it by three wholesalers . . . short-liners, just to give us extra options if we can’t get hold of things . . .

CP19, independent

Community pharmacists also perceived that Solus agreements (i.e. when the manufacturer uses a sole/single WD to distribute their products) contributed to their need to use numerous WDs. They were often critical of such practices, describing them as monopolies or restrictive practices:

It annoys me intensely that something like midazolam we seem to only be able to get through one particular wholesaler . . . The fact that we have restrictive practices in what wholesalers can supply seems to fly in the face of all logic to me . . .

CP15, independent

For some CPs, mainly those in independents, it was only their pharmacies’ use of numerous WDs that enabled them to accommodate such Solus agreements and access the full range of medicines prescribed for patients during the last year of life.

Lack of communication and relationships with wholesalers/distributors and manufacturers

Another barrier to supply was the lack of meaningful communication (two-way information transfer underpinned by trust) with WDs and manufacturers, and the consequent lack of relationships. CPs highlighted that when they needed to speak to WDs, particularly regarding medicine shortages, they did so by telephoning the respective company’s customer services team. It was relatively rare (according to CPs) for WDs to contact CPs and so communication was generally pharmacist initiated. Telephoning service centres was time-consuming and like telephoning a ‘call centre’, not knowing who they were talking to:

It’s always the telesales consultants . . . There’s no clinical knowledge there at all . . . that’s just how it works, you just phone up, have you got so and so, and they’ll say yes or no . . .

CP17, large multiple

The lack of clinical insight held by those answering the telephones at WDs was an issue for some CPs because they did not appear to understand the urgency of palliative medicine supply:

It used to be quite some time ago that when you’d speak to someone, they’d have more of an awareness about the medication . . . Now there’s less . . . so, they may not understand how urgent it is . . .

CP23, large multiple

Furthermore, a lack of understanding could preclude the WDs’ sales staff searching for alternative options and a total reliance on their IT systems:

We look at the product and go right eight different manufacturers they all come with their own seven-digit PIP [Pharmacy Interface Product] code and we’ve been in situations where we’ve read each code out on the phone and they’ve gone ‘no, no, no, no, oh the fifth one is in’, brilliant. ‘Is your software not searching for it’ . . .?

CP06, independent

This lack of meaningful communication and information exchange precluded relationship development between CPs and WDs, and this was a fundamental barrier to supply:

I don’t think you do have a relationship with them, not like you used to. There are no reps that come round. I wouldn’t even know who my account managers were anymore with these big companies [FLs]. Never see them. Never ring up or anything . . .

CP14, independent

This appeared to be underpinned by mistrust on the part of the CPs towards WDs and manufacturers, triggered by conflicting cultures and priorities. The CPs argued that they were primarily focused on patient care and needs (and accountability to the patient), whereas CPs perceived the WDs and manufacturers to be focused entirely on commercial priorities:

[To get access to medicines] . . . I have to jump through hoops, spend time which equals money, takes me away from looking after patients and all of my staff away from looking after patients to try and source medication or products . . . they’re commercial operations looking to make the most that they can out of what they’re doing . . .

CP16, independent

Shortcomings of ordering systems

Despite IT ordering systems being a facilitator of supply, many CPs identified shortcomings of online systems:

A lot of times I’ve given [named FL] a call and I’ve said ‘oh yes I placed the order online’ and it said it went through and they were like ‘oh well yes we only had this reserve amount and you are number 40 something and you will be waiting for it’.

CP02, small multiple

Community pharmacists stated that the majority of orders could be dealt with solely online, but as soon as there was an issue (e.g. the product being identified as out of stock), then they would need to ring the WD (e.g. to find out if there was a date the product would be back in stock). Other reasons for needing to telephone the WDs were to find out about specific brand availability, expiration dates of the product, the price of the product (as prices altered daily), where a product was low in stock if they actually had it, if the product was a switch line (i.e. switched to supply from a different warehouse/distribution centre and, therefore, how long it would take to be delivered), and where a third-party order platform was used to ascertain availability (as in such cases availability of products was not stated on the platform system). The telephoning round WDs, although it did not occur for most ordering, was perceived as hugely time-consuming to gain ‘definitive answers’ and source product for the patient.

Disincentives to stocking palliative medicines

Pharmacies from which the CPs operated varied widely in the number of prescriptions dispensed per month (see Appendix 29, Table 41) and so, for some CPs, a lack of stock turnover of palliative medicines was a strong disincentive for stocking such medicines:

The hurdle is that the medication are usually high value, so pharmacists don’t tend to keep them in stock. They’re also not commonly prescribed, you don’t know which strength they’re going to be . . .

CP17, large multiple

Related to this were the associated costs of the medicines and the lack of a long shelf life for some medicines. CPs could also be concerned of the risk of the medicines not being collected by patients or their families:

Some of these medicines are not very long dated, like midazolam and stuff aren’t. And then you get some stuff that you are never going to use, like . . . glycopyrronium injections . . . if they’ve not collected it . . . one or two of these injections can be £70/£80 . . . a lot of small businesses they’re marginalised as it is at the moment and with small operating margins can they afford to do these medicines . . .

CP08, independent

Some CPs discussed disincentives specific to stocking CDs often used in palliative care, including legal requirement to store the medicines in locked cupboards, the inability to return CDs to the WD when the medicines were not collected by the patient/family and the requirements around the destruction of out-of-date Schedule 2 CDs (subject to full CD requirements). In the main, disincentives revolved around the implications (e.g. cost) of medicines not being collected.

Lack of weekend ordering and Sunday deliveries

Community pharmacists who worked at weekends and worked in stores with Sunday (or bank holiday) opening emphasised that supply into community pharmacies over weekends could be an issue for patients:

I’ve had occasions where you might get the prescription on the Saturday and obviously because wholesalers are closed weekends you can’t get a supply in until Monday . . .

CP04, small multiple

Although pharmacies usually had one delivery (per WD) on a Saturday, the inability to place orders over the weekend and the requirement to wait for Monday’s deliveries was a barrier to supply into pharmacies and, ultimately, medicines access over the weekend.

Issues with wholesaler/distributor deliveries

Some CPs referred to occasional issues with deliveries into their community pharmacies:

Traffic jams and snow. They’re very rare. Usually the wholesalers are decent enough to phone us and say look the M25 there’s been a crash your delivery won’t be there, or your delivery will be in at 17.00 today.

CP06, independent

However, for others, delivery issues appeared more frequent, particularly in relation to missing products from orders that that goes unnoticed until a delivery arrives.

Commercial and quality drivers

Most WDs discussed commercial and quality drivers as important in gaining community pharmacy business. Three large national wholesalers provided a FL service of all pharmaceuticals, including palliative medicines, in contrast to SLs that provided a limited range and usually at a competitive price. Competition in the branded medicines market was more limited, with three FLs mainly competing for manufacturers’ business. Competition was based on winning business from their competitors, as they all serviced the same customer group. Some participants discussed Solus or dual arrangements, which, according to interviewees, assured continuity of supply from the WD:

. . . If we’ve got one source of supply that goes through to one distributor and then to the end-user we can keep a much tighter rein on where that stock is, how is it supplied, control of that stock, control of purchasing . . . There’s a lot of benefits of having a very tight and secure supply chain, assured supply chain . . .

WD05, FL

Solus or dual arrangements were, therefore, perceived to generate more secure business:

Commercially it’s better for us to get all of the volume where you get 100% market share [Solus contract]. We’re in a volume-based business so this brings us volume.

WD03, FL

Despite this perception, the Solus contract could increase the risk of supply failure, as the product could not be accessed by pharmacies via other WDs.

Commercial drivers also dictated the discount awarded to pharmacies based on the volume of stock purchased from WDs. Within the Solus contract there was less of a need to be competitive, being the sole supplier, and so any discounts applied were based on commercial decisions.

Inability to secure sufficient stock levels was considered a commercial ‘faux pas’, as it had a negative impact for the business as a commercial enterprise (i.e. not having assets to sell) and also resulted in not being able to offer the expected service to patients. WDs struggled to differentiate within the market, offering very similar services:

I suppose we don’t really compete on availability we compete on other services for pharmacies so I suppose healthy competition between wholesalers will improve the availability of product if product is available in the market . . .

WD01, FL

Quality improvement of service, facilities and infrastructure was one of the key means to maintain a WD’s competitive position and increase the volume of stock sold.

Relationship-building

All WDs noted the importance of relationship-building in facilitating medicines access, whether through formal agreements or contracting arrangements with manufacturers, day-to-day relationships with community pharmacies (via sales and customer service teams) or informal communications and networks. Relationships were stated to support regular dialogue, with a two-way flow of information and feedback on problems and issues up and down the supply chain:

I think ultimately it’s about good communication and good dialogue between all of the people that sit in the supply chain . . .

WD04, FL

Upstream relationships with manufacturers/suppliers

Contracts or agreements with manufacturers/suppliers could provide assurance of inbound stock to WDs; however, formal contracts were not universally used because of manufacturers/suppliers not being able to guarantee to supply against an order (e.g. owing to adverse weather, shortage of raw materials or quality audit failure). When supply disruptions were envisaged, manufacturers were responsible for informing and communicating this information to the Department of Health and Social Care (DHSC):

What does work very well is when the manufacturers help us and let us know when they’ve got a [shortage] problem because that allows us to make alternative arrangements . . . from time to time it could be better and that’s always something we’d work together with.

WD03, FL

Downstream relationships with pharmacies

Wholesalers/distributors reported that community pharmacies accessed information on medicines shortages from online ordering systems and customer services teams. This was viewed as a two-way conversation through telesales or sales representatives providing feedback to WDs and manufacturers. WDs reported that they had a strategic role to put pressure on manufacturers when shortages were identified by pharmacies. WDs argued that they benefited from their role in this triad by transferring information (e.g. regarding changes in prescribing patterns) from pharmacies upstream to manufacturers. This could instigate proactive responses from manufacturers regarding production plans/stock level holding:

We will inform them [pharmacies] of supply chain issues from our side in terms of procurement from manufacturers and likewise they will communicate back if they have again noticed any changes in prescribing habit or difficulties that other suppliers in the UK supply chain are experiencing.

WD08, SL

Collaborative relationships

A few WDs discussed good practice in supply chain management when severe medicines shortages, such as with diamorphine injection, had been co-ordinated nationally via the DHSC Medicines Supply Team and NHS England and NHS Improvement (NHSE&I) Commercial Medicines Unit. There was a willingness to work collaboratively to get medicines to patients, setting aside competitive relations in response to the shortage:

I think that . . . where there has been a problem where we’ve seen collaboration across the commercial medicines unit the DHSC and the manufacturer and ourselves as wholesalers in the middle I think it’s probably when we see best practice.

WD03, FL

Relationships between WDs, manufacturers and community pharmacies were viewed as extremely important in supplying palliative medicines, and WDs reported acting as a point of mediation in the supply chain.

Investment in logistics infrastructure

All WDs identified logistical issues in the pharmaceutical supply chain as critical in ensuring medicines access at EoL. There was emphasis on the requirement for WDs to deliver on time and in full so that they could be responsive to community pharmacies’ and patients’ needs. This was facilitated by contracting with reputable haulage firms familiar with regulatory governance, investing in logistics infrastructure and by having a clear visibility of stock levels:

We’ve invested a lot into the logistics side of things to ensure that they get to the patient in every bit as good condition as they arrived into us . . .

WD08, SL

Wholesalers/distributors reported that high-quality logistics infrastructure ensured that stock could be delivered with increased certainty and that orders would be delivered on the same or next day, on time and complete.

Demand and stock management

Wholesalers/distributors sought to ensure supply continuity into community pharmacies, with a key element being access to stock within the UK market and, if there was a shortage, their ability to source an alternative product outside the UK. If the product was generic, then there tended to be a greater source of alternative suppliers. If a product could not be sourced, then it was because it could not be found (as opposed to no attempt made):

. . . majority of time that shortages occur are about not having the product available for supply and that’s down to maybe raw material, maybe choice and allocations to different countries, maybe production issues . . .

WD05, FL

If we can’t get hold of one drug, we’d probably work with another company that had got a competitor drug . . .

WD02, FL

Wholesalers/distributors advised that they shared their demand profile and activity with manufacturers to inform manufacturing capacity management. This information transfer aimed to ensure that stock levels were as needed and that medicines shortages did not develop.

The majority of WDs described complex systems for managing stock in response to forecasted demand.

Transparency regarding customer demand patterns, stock holding levels and locations of stock meant that WDs could adjust stock levels throughout the country in distribution centres to respond to spikes in demand.

Buffer stock availability

Most participants discussed how buffer stocks (i.e. stocks within the UK and Europe) had an important role in adding resilience into the supply chain to facilitate medicines access. Holding buffer stock could be recommended by the manufacturer to the pre-wholesaler if they expected a product shortage or it could involve the WD transferring stock between distribution centres (ensuring quicker response times for orders and equitable distribution):

They [pre-wholesaler] hold a buffer [stock] which normally means that there is strong supply into the market .

WD01, FL

Wholesalers/distributors reported that stock availability was always dependent on manufacturer production schedule and lead time for distribution. SLs were noted to fill a gap when FLs were devoid of stock to maintain supplies into community pharmacies.

Supply chain disruptions

Manufacturers’ commercial decisions on where to send their product worldwide (influenced by UK regulations, medicines pricing and the value of sterling) had an impact on supply. These commercial decisions, together with globalisation of manufacturing sites, meant that WDs could have limited supplies of medicines, leaving them unable to meet customer demand:

A manufacturer . . . producing products on a global basis has many choices to make . . . in terms of how many places around the world is that product manufactured . . . if that is only one or two units . . . and those units have problems then that has a worldwide implication of non-availability of stock.

WD05, FL

Many of the WDs referred to shortages that had an impact on their ability to supply customers, requiring WDs to source alternatives and increase stockholdings of other products. WDs expressed concern about supply assurance regarding palliative medicines:

We’re concerned . . . that manufacturers will . . . choose not to supply the drugs to the UK because they will be able to make more money supplying it elsewhere in the EU [European Union]. So . . . the supply chain . . . is a really big worry and for palliative care medicines that’s especially important. This isn’t something where you can order something in and wait 2 months . . . it’s being ordered because it is needed there and then and once you’ve missed that chance to support the patient at that crucial moment in their lives that moment has gone.

WD06, large multiple

Strategic drivers

Strategic supply influences that acted as barriers included generic medicines, quotas and storage capacity, all of which influenced WDs’ decision-making.

Downstream issues

Participants reported instances of downstream issues that affected the supply chain. These issues included export trading by pharmacies, product switches, geographical differences in palliative medicines lists, speculative stockholding by pharmacies, changes in prescribing habits and stockpiling by patients due to a lack of understanding about the supply chain.

Upstream issues

The inability of manufacturers to adequately predict operational issues or forecast demand led to production issues and shortages of manufactured stock. WDs considered the notice period and delay in release of information from manufacturers/DHSC problematic, reportedly due to commercial sensitivity of information. WDs considered that there was not always enough time to make alternative arrangements (e.g. ordering in alternative products) to maintain supplies into pharmacies, and worked closely with manufacturer account managers to try to assure product availability.