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Out of drugs and out of options

I’m fed up and frustrated this week. If you talk to my staff they’ll say I’m like this all the time, but I feel especially annoyed this week.

Mainly it’s due to the ongoing fiasco of both branded and generic drug shortages. This is a problem throughout the country and the bottom line is GPs are having to spend unnecessary time on fixing dispensing problems when our job is simply to prescribe.

Two particularly annoying things have happened in only the past week, involving both a  generic and a branded drug.

Firstly, there was announcement there was a supply problem with 100mg tablets of allopurinol. If a patient is on a small dose of perhaps only 100mg due to reduced renal function, and the next strength of tablet is 300mg, then you’re in a pickle. 

What is the patient to do? Stop it altogether and run the risk of getting an attack of gout? Try and break the tablets into thirds? Increase the dose and run the risk of toxicity or, as my NHS England local area team suggested, change over to allopurinol liquid preparation at £82 for 150ml (compared to 98p for 28 tablets)? Their advice just shows how out of touch with reality they are.

And after all the local pharmacies returned prescriptions to be altered, patients were advised on dose changes and GPs amended records, suddenly the ‘shortage’ was over and all the changes had to be reversed. 

Secondly, three days ago when ‘suddenly’ there was a supply problem with isosorbide mononitrate and prescriptions were being sent back requesting an alternative. 

This wouldn’t be a big problem, apart from the fact that few years ago my CCG had made us all change from the standard twice-daily formulation of a branded form of isosorbide mononitrate to once-daily, to save money. Despite the annoyance of contacting patients and changing their repeat prescriptions, all was fine. That is, until 

I contacted the CCG prescribing advisor and they confirmed that there were issues with this branded product and an alternative had to be found. 

By the by, in the struggle to save the CCG money by encouraging GPs to prescribe cost-effectively we have installed software that seamlessly suggests a cheaper alternative when you try and exercise some clinical individuality by prescribing something different for a particular patient you are treating. 

So when I tried to prescribe an alternative to the branded drug that is currently unavailable, a smart-arse message pops up telling me that, if I continue writing this prescription, it will cost £23 more per month than if I prescribe the preferred drug. By this point I couldn’t care less how much it cost so I hit the ignore button and carried on.

I also banged off an email to the CCG, the LMC and NHS England, venting my frustration. 

The reply was really helpful. Aparently, the drug is now apparently back in stock.  

Lack of generic and branded stock (for whatever reason) is increasing GP workload and I’m afraid from now on I will be taking the line of least resistance to accommodate the change, irrespective of the cost implications. I am officially putting this problem into the ‘too difficult for a GP to fix’ box.

Dr Hadrian Moss is a GP in Kettering, Northamptonshire. You can tweet him at @DrHMoss.