WE know the alternative – but we’re not allowed to give it

ABSTRACT:

A patient stands at the counter, frustrated and anxious. 
Their usual medicine is out of stock and they're down to their last tablet. 

The pharmacist has a safe, equivalent alternative two inches to their right. But their hands are tied.

The patient leaves with nothing, and a preventable problem is passed back to the GP. 
This happens every day and not because pharmacy professionals are evil, but because they don't have the authority.

METHODOLOGY: 

The Independent article on pharmacies issuing warning about shortages: 
https://www.independent.co.uk/news/health/pharmacy-prescription-changes-medication-nhs-b2826965.html

DISCUSSION AND RESULTS:

At a time when medicine shortages are exploding, pharamcists are still legally unable to change a prescription to an appropriate alternative. Not without going back to the original prescriber. 
This means turning patients away, more delays, more time wasted for healthcare professionals, and a lot more risk to patients. 
Pharmacies are usually the final point of contact for patients in healthcare as they turn in their prescription - and that means we're usually the ones that are expected to explain there's a problem, research and offer a solution, and still send people away empty-handed. 

The situation is absurd.

Prescribers call us every day asking 'what can we give instead?" So the professional trust is already there (mostly). 
Pharmacists are the experts with a masters degree in medicines. So the clinical expertise is there; but the legislation isn't. 
It's frustrating for the healthcare teams and it's the patients who pay. 



THE SSP ILLUSION. 
Arguably, there is already a system in place that allows pharmacists to change to an alternative - Serious Shortage Protocols (SSPs). 
They let phramacies make substitutions without going back to the prescriber. However, they are a rarity. 

SSPs only apply to a small number of medicines and are created when the government decides they are a 'serious shortage' - and I would love to know the criteria for this as there are buckets of medicines that never make it to the list. 

Even when SSPs are issued, they're inflexible. They list exactly which alternative can be given - even if that alternative is also unavailable. Pharmacists can't use their professional judgement outside of what has been predefined, even if it's a matter of branding. 

Not only are they hand picked, ignoring the dozens of other daily shortages we are managing behind the scenes, they have expiries. If the shortage persists for longer than the SSP is valid, then you can't make the switch next month when the patient comes with a new prescription. 

Worse maybe, is the public - and even some prescribers - aren't aware that an SSP is what allowed us to make a switch in the first place. I can't blame them though - why should they need to know why a substitute could be made, it should just be possible to make it.
So when it expires, we're back to telling people a medicine is unavailable, and it looks like the pharmacy is being inconsistent or unhelpful. 

So why aren't SSPs used as a framework for new legislation that allows pharmacists to switch to a clinically suitable alternative? 
Why aren't SSPs expanded to allow for all categories of medicines at all times? 
Why even use an SSP? Why not allow pharmacists to endorse a prescription to create an audit of the substitution, reason for the alternative, and the foundation for payment. 


WHAT NEEDS TO CHANGE. 
Pharmacy professionals are highly trained, highly regulated, and already make critical safety decisions every day. 
We are also one of the healthcare services that has the most frequent contact with patients who are  managing chronic conditions. We see them monthly - and we get to know them, their unique circumstances and sometimes even their family. Arguably, it's better insight into how medicines play a role in their lives than the GP has, and lends itself to making more suitable alternatives.  
Allowing us to make clinically appropriate substitutions should be a logical step, not a legislative leap. 

LOGICAL CONCLUSIONS:

Allowing pharmacies to make clinically suitable substitutions probably looks like a scary change to those who create legislation in this country. But as the shortages are getting worse, I only see benefits to safety at this point.
This wouldn't 'replace' a prescriber, it would relieve pressure on them.
This wouldn't cause more demoralising work for pharmacy staff, it allows them to help right away. 
And, most importantly, it wouldn't continue this cycle of patients who are being sent back and forth in a bureaucratic bukake party. 
It's not just convenience, it's safety. Every medicine shortage and referal delays or disrupts treatment; and it effects the patient's motivation to engage in that treatment.
Every incomplete prescription therefore poses a risk to their health declining, and it's a risk we could manage effectively - if we were allowed to.