If Brexit brings medicine shortages, how will nurses allay patients’ fears?
What you can do to reassure patients who are concerned about their prescriptions
What you can do to reassure patients who are concerned about their prescriptions
- Pharmacists are already reporting shortages in items including morphine products, antidepressants and diabetes medications
- Nurses likely to encounter issues such as drug or product substitutions and stockpiling by patients
- Experts advise on how to handle difficult conversations with patients
Three quarters of the UK’s medicines come from the European Union, yet even with the projected Brexit date of 31 October looming, it is still unclear what the effect will be on supply.
Health experts say one thing is certain: if shortages occur, nurses will face extra work and potentially difficult conversations with patients.
Nurse prescribers may have to find safe alternatives if medications become unavailable, and explain these prescriptions to patients. All nurses will have a role in reassuring and advising people.
Reports of difficulties
Pharmacies have been reporting increasing problems with the supply of a number of medicines in recent months. Items that appear on the UK's most up-to-date medicines shortage list include:
- Morphine products for patients with cancer.
- Antipsychotic medication used to treat schizophrenia.
- A range of antidepressants.
- Diabetes drugs.
- Medications for Parkinson’s disease and epilepsy seizures.
‘Shortages are happening more and more’
RCN project lead for medicines management and non-medical prescribing Heather Randle has seen an increase in medicine shortages in recent months.
‘We have noticed there has definitely been an increase in supply issues,’ says Ms Randle, an advanced nurse practitioner in general practice and an independent prescribing nurse.
‘Shortages are happening more and more – we didn’t used to see them as much.’
‘Patients may be more inclined to try to stockpile medication if they are worried about the supply and nurses should be aware of this effect’
Queen's Nursing Institute spokesperson
This has a knock-on effect on nurses' workloads, Ms Randle explains.
‘If a prescribed medication isn’t supplied or available, you have to find an alternative or search for it somewhere else. Particularly in general practice, that prescription then has to come back to the prescriber and that creates a lot of extra workload.’
She recalls upheaval last year when the supply of EpiPens for people with severe and life-threatening allergies temporarily dried up.
Although not Brexit-related, the shortage of the adrenaline auto-injectors meant patients were prescribed different devices and had to be taught how to use them in an emergency.
‘New prescriptions can create a lot of anxiety for the patient, especially if their condition is life-threatening,' adds Ms Randle.
She adds that patients can become anxious when changes are made to their prescriptions and, in some cases, won’t accept that generic versions are equal to branded medication. ‘Understandably, this all creates extra work for nurses.’
What can nurses do?
The Queen’s Nursing Institute (QNI) says nurses have a central role to play in medicines management for patients.
‘Managing patient anxiety, advocating for them and following up their concerns appropriately is a key skill of nurses and an important part of patient-centred care,’ says a QNI spokesperson.
of medicines in the UK are imported from or arrive via the EU
(Source: NHS Confederation)
He adds that patients living with long-term conditions that are managed in the community, such as diabetes or HIV, may worry about threats to the regular supply of medication.
‘Patients may be more inclined to try to stockpile medication if they are worried about the supply and nurses should be aware of this effect.
‘Patients are prescribed medication for varying lengths of time, so a patient with one month’s supply is likely to feel less secure than someone who is given medication for four or six months.’
My patients are worried about their prescriptions – what do I do?
RCN project lead for medicines management and non-medical prescribing Heather Randle says:
- Seek advice from the pharmacy It's a good source of information on what medicines are available and what would be a suitable alternative
- Do your homework Gain an understanding of the new medication and any differences, for example, does it require a device, or a timing or quantity change? Will the patient need support to take the medication, for example, a change in adrenaline pen device or inhaler?
- Communicate Provide written information to patients on the change in medication, if available, and direct them to good sources of information
- Be honest Explain why there is a medication change and any potential side effects; this is important to ensure patients' continued adherence with their medication
- Give reassurance Reassure the patient that their best interests are the priority. Make it clear that if they have any concerns they can come back to you or the pharmacist for advice
of NHS staff are from elsewhere in the EU
(Source: NHS Confederation)
‘Brexit uncertainty may be a factor’
Mike Dent is director of pharmacy funding for the pharmaceutical services negotiating committee, which represents all NHS pharmacy directors in England.
While medicine supply problems are nothing new, he says, Brexit uncertainty could help explain current difficulties.
'Community pharmacies are increasingly reporting struggles to source certain medicines so we are not surprised to see other healthcare professionals becoming more aware of the situation,' he says.
‘These shortages are due to a combination of factors, such as manufacturing issues, availability of raw ingredients, increased demand and product recalls.
‘Uncertainty around Brexit and contingency planning may be exacerbating these issues.’
Mr Dent says pharmacy teams sometimes have to contact up to seven or eight wholesalers to obtain medicines, or go back to the prescriber to find alternative medicine.
‘We recognise the additional workload medicine shortages bring to prescribers and dispensers and collaborative working at a local level is essential.’
The potential for harmful impact on patients
Patient groups, charities and healthcare organisations have expressed concerns about the effect of Brexit on the medicines supply.
The Epilepsy Society has reported a rise in calls to its helpline relating to potential drug shortages.
A spokesperson told Nursing Standard: 'Anxiety can be a trigger for seizures in people with epilepsy so the worry around continuing medication shortages is a concern.'
Parkinson’s UK says it has seen an increase in calls to its helpline from people who are struggling to obtain the drugs Sinemet and Madopar, but that there is no evidence this is Brexit-related.
Parkinson's UK service improvement programme manager Katherine French says: 'If people with Parkinson’s are unable to access the medication they rely on, this can have a serious impact on their quality of life and their ability to take control of their condition. In some cases, this could lead to avoidable hospital admissions due to poor medication management.'
There have been reports in the media of patients stockpiling medicines in case of a no deal Brexit.
Rachel Power, chief executive of charity the Patients' Association, says uncertainty about how and when Brexit will happen is creating a difficult situation for patients. ‘The end result could mean no change to patients’ medicine supply at all, or potentially serious disruption. In the latter event, it is impossible to say whether the government’s contingency planning will prove adequate.
‘This also puts healthcare professionals in a tricky position, with little certainty about the future provision of medicines.’
Planning at a national level
At an organisational level, the Department of Health and Social Care, which is responsible for the supply of medicines and medical devices UK-wide, has warned against stockpiling.
In February, health minister Stephen Hammond said: ‘Local stockpiling is unnecessary and could cause shortages in other areas, which could put patient care at risk.
‘It is important patients order their repeat prescriptions as normal and keep taking their medicines as normal.’
So what if there's a no-deal Brexit?
The government insists it has contingency plans in place, including national stockpiling of around 7,000 medicines and new ferry arrangements to transport medicines between the Netherlands and France and Britain.
A DH spokesperson says: ‘Our number one priority is for patients to continue to have access to medicines whatever the EU exit outcome and we have robust contingency plans in place.
‘We are confident that, if everyone does what they need to do, the supply of medicines and medical products should be uninterrupted when we exit the EU.’
Plan for the worst
NHS Confederation director of international relations Layla McCay agrees that while the contingency plans for medicines and medical supplies should ensure supply after Brexit, some patients were still anxious.
‘Nurses may need to reassure patients and help make sure people have accurate information about their medicines.’
Ms McCay also says that because preparations for a possible no-deal Brexit are now on hold, the risk is complacency.
‘The health service needs to work on the basis that we could still crash out of the EU without a deal – and do everything we can to make sure patients are protected if that happens.’
Preparations around the UK
The impact of Brexit on the NHS in the devolved healthcare systems of Scotland, Wales and Northern Ireland was examined in a research report, funded by the Economic and Social Research Council and published last December.
This report found the main issues with medicines shortages were the likelihood of multiple shortages taking place simultaneously and that, normally, responses to shortages were centrally run.
The authors wrote: ‘The size of NHS England compared to that of the devolved [nations] leads to concerns about how professionals in Northern Ireland, Scotland and Wales will access consumables they need to treat patients, especially in the event of a no-deal Brexit.’
Recently, Scotland’s health secretary Jeane Freeman announced that preparation for medicine shortages and stockpiling of medical devices was under way. Preparations include the creation of a medicine shortage response group and support for health boards.
A Welsh Government spokesperson said: 'Preparations are in place to ensure the NHS in Wales can operate as normal in the event of a no-deal Brexit. We have acquired an additional storage facility to ensure supplies of medical equipment and other essential items for hospitals are not disrupted.
Stockpiling is unnecessary and could reduce the availability of medicines for patients in other areas of Wales or the UK
Welsh Government spokesperson
‘For the supply of medicines we are working with the UK government, which has lead responsibility for this. This includes working with the manufacturers and suppliers of medicines to ensure they have more stock in the UK and securing new storage facilities for medicines.
‘It is important patients continue to order their medicines in the usual way and not to stockpile their medicines. Stockpiling is unnecessary and could compromise the plans being implemented by the UK government, reducing the availability of medicines for patients in other areas of Wales or the UK.
‘If patients have any concerns about their medicines or regular prescription, they should talk to their local pharmacist in the first instance.'
In Northern Ireland, where government is suspended, the Department of Health says it is working closely with other UK governments to ensure patients have continued access to medicines and medical supplies.
31 October 2019
The date the UK must choose to ratify the exit treaty, opt for a no-deal Brexit, or cancel Brexit
Brexit planning at a local level
Anti-Brexit campaign group Best for Britain recently published details of hospitals’ Brexit planning, after gathering the information under freedom of information laws.
Concerns about medicines’ supply featured prominently in Brexit planning by providers in England.
Most of the 35 trusts that responded to the information request reported concerns about the supply of medicines. These concerns included:
- Dudley Group NHS Foundation Trust reported ‘critical shortages’, with around 100 drugs at risk.
- Royal Orthopaedic Hospital NHS Foundation Trust identified 10% of its suppliers as being at high or medium risk.
- Tees, Esk and Wear Valleys NHS Foundation Trust gave the issue the highest possible risk rating and warned that supply disruption could mean inpatient units are put under ‘extreme pressure’.
Risk assessments and incident plans
Northern Devon Healthcare NHS Trust says its business continuity arrangements to prepare for Brexit and the possibility of ‘no deal’ include risk assessments and incident plans.
Chief operating officer Pete Adey says: ‘The trust is part of a national and regional network of EU “exit teams’” and we have been working closely with our partners to prepare.
‘Key members of staff have been developing plans that follow the national guidance issued to us.
‘We have carried out risk assessments and tested our well-rehearsed incident plans, which will help us to ensure we continue to provide safe and high quality care to our patients and service users.’
The RCN's Heather Randle says the difficulty for organisations and nurses in Brexit planning is there are so many unknowns, but being as prepared as possible will be key.
‘We don’t know what we don’t know,’ she says. ‘But, we need to realise there is going to be an impact on our time in order to sort this out.’