There are some things that most of us take for granted. If we go to the supermarket, we’ll be able to stock up on essentials, such as bread, Irn Bru and, of course, Monster Munch.

If we go to a café, we expect to choose and consume any item on the menu. And as we get to the end of our box of medication, we should be able to take our repeat prescriptions and get more of what we need to maintain health or control disease from our pharmacy. But what happens if we hear our pharmacist utter the dreaded words ‘sorry, this week we’re out of stock of this’? What could be causing this?

The effects of a possible no-deal Brexit are likely to have negative consequences on healthcare as pharmacies and hospitals will start to run out of certain drugs. There will be a problem of drug supply in the weeks and months following withdrawal from the EU, since around two-thirds of medicines used in Britain are imported from the EU, with 90% of those arriving via the Calais-Dover channel route.

When the UK becomes a ‘third country’ i.e. no longer part of the EU, the introduction of more stringent customs checks will not only increase costs but also delay the deliveries of medicines to pharmacies and hospitals. It is uncertain whether some medicines will simply be stopped as their cost will no longer be feasible.

And these delays described would be due solely to customs checks carried out on the UK side. If France decides to introduce further checks of outgoing goods, delays and shortages could be even more drastic. The UK exports 45 million packs of medicines to the EU each month. If the UK becomes a ‘third’ country’ following a ‘no deal’ withdrawal, medicines arriving in Malta, for example, would be subject to import fees and then released by a Qualified Person.

During this process, the medicines would need to be housed in a temperature-controlled facility, require Quality Assurance and regulatory affairs checks, perhaps a relabelling process before releasing for sale, depending on how far post-Brexit labelling regulations diverge from those in the EU and whether any mutual recognition agreement has been reached. If they are Prescription-Only Medicines (POMs), then there is the Falsified Medicines Directive aspect to take into consideration. For some products, all this might not be worth the hassle and we could see importers deciding to drop some UK medicinal products, rather than go through – and pay for – this process. This dropping of products from the UK could occur all over the EU.

Interruption of medication can have serious consequences, and it is not always easy or possible to substitute for another medication, assuming this is available. For example, patients who have tried several different medications before finding one that will stabilise their depression without serious adverse effects may soon find themselves desperate for next week’s doses. Anti-depressants should not be stopped abruptly, it should be tapered down under professional supervision, particularly if the patient has been taking the drug for several months, or even years. The sudden cessation will precipitate discontinuation (withdrawal) symptoms. The patient may have symptoms of the flu or a stomach bug, but more worrying are the disturbing or foggy thoughts.

This is just one example of many: take, for example, people stabilised on medication for high blood pressure, epilepsy, or diabetes, where the out of stock situation would also have detrimental effects very quickly. Patients have been known to drive for miles in a desperate attempt to buy an EpiPen containing epinephrine, a life-saving drug used during emergency treatment of serious allergic reactions such as anaphylaxis, when there were shortages of this. Delays would be devastating for treatments that require urgent delivery, such as radioisotope compounds, used in scans for the diagnosis of cancer and heart disease and in the treatment of cancer.

While shortages may already be happening within the UK, there are no reports directly linking these to Brexit. Could there be other reasons? And if so, are these about to be augmented?

Now the UK government has taken some measures in an attempt to avoid this shortage situation by encouraging firms to stockpile for an extra 6 weeks in the event of a no-deal Brexit. 7000 prescription drugs have already been identified for stockpiling, including, as many will be glad to hear, Viagra. However, some patients have already been observed taking the matter into their own hands as they turn up early to have their repeat prescription filled, resulting in an individual stockpiling situation as each patient gathers a bit of overflow each month. This contributes to a depletion in current stock.

Of a total of 2.1 billion British pounds available for a no-deal exit from the EU, 434 million have been dedicated to the continuity of medicines supply and focus on freight being redirected through other ports in southern England.

In view of supply shortages, the UK government has also issued Serious Shortage Protocols (SSPs) giving pharmacists additional powers to alter prescriptions and supply alternative medications in the event of a serious shortage of the specific drug.

When they receive their license to practice, pharmacists take an oath to always protect the patient’s well-being. In a no-deal scenario, pharmacists will be on the front line dealing with patients in worrying situations. It is no secret that pharmacists often suffer the wrath of political atmospheres, dealing with patients who arrive at dispensaries already angry, unfortunately looking for someone to blame.

Powers given to pharmacists to dispense alternate drugs can only go so far. Currently, many pharmacists already spend up to 15% of a typical working week chasing supplies. Aside from the added pressure on these healthcare professionals, this is time that could be better dedicated to patient care. This is in the context of a heavier burden placed on community pharmacists, where patients are being directed to visiting pharmacies for minor illnesses and injuries in order to take the pressure off GP and Accident & Emergency services.

All this is going on in the context of a health and social care agenda that has been gnawing at the UK for a while. Issues that were in dire need of addressing - of which the rise in poverty and homelessness are glaring symptoms - have been neglected due to austerity, on the one hand, and ongoing Brexit discussions and dilly-dallying, on the other. Poverty and social inequality by 2018 reached the same levels as in 1930. There has been a ten-fold increase in the use of food banks since 2011, typically used by families in full employment who cannot afford to feed themselves adequately or their children. Homelessness has increased by 165% since 2010. Last year, over 20 people died on the streets of Manchester. A similar figure was recorded across Yorkshire. These are figures more like the England of the 1880s, rather than the 21st century.

By Miriam Calleja, Pharmacist and Author, Malta

and Mark Gibson, Health Communication Specialist, United Kingdom

31st August 2019

Sources:

PSNC Briefing 023/19: Serious Shortage Protocols (SSPs) – a guide for community pharmacy teams. June 2019. Retrieved from: https://psnc.org.uk/wp-content/uploads/2019/08/PSNC-Briefing-023.19-Serious-Shortage-Protocols-FINAL-PUBLISHED-v2.0.pdf
Health risks of a Brexit no-deal. New Scientist. 19 January 2019.
Stephen, H. Chemist and Druggist. 40% of readers have seen evidence of patients stockpiling for Brexit. 19 March 2019.
Manchester, united. The Economist. 11 May 2019.
Dorling D, Peak Inequality, New Statesman, 6-12 July 2018.
Hungry for answers, The Economist, November 17th 2018.
An unhealthy situation, The Economist, April 16th 2016.

Brexit and Pharmacy Practice