One of the major costs associated with starting a new pharmacy in the UK is the initial cost of stock. It is a requirement of the NHS Pharmacy contract, that licensed pharmacies are required to dispense all medicines presented by patients on NHS prescriptions in a timely manner. If the pharmacy does not have the item, contingency arrangements need to be in place to source supply where stock is unobtainable from regular wholesalers, this may include having reciprocal arrangements with neighbouring pharmacies when required to meet urgent patient needs, and the use of manufacturers’ contingency order arrangements.
The good news for new licensees is that 90% of medicines prescribed via the NHS are regularly available to pharmacies, in this article we will look at how best to predict which lines should be initially prioritised to ensure patients rarely run out of medicines.
Fast mover / ‘next patient’ stock
Fast movers is the term associated with medicines that are dispensed most by pharmacies. What is included in a specific pharmacy’s as a fast mover category differs in regards to the local demographic served, however, if the pharmacy has a Distance Selling Pharmacy license where the remit is to serve patients nationally the following Top 10 most nationally prescribed medicines in primary care will be of relevance…
| BNF Paragraph Name | Prescription Items | Actual Cost | Commonly Used For |
| Atorvastatin | 45,792,988 | £55,759,286 | Statins-high cholesterol |
| Levothyroxine | 32,934,807 | £62,757,734 | Low thyroid levels |
| Omeprazole | 31,791,795 | £50,092.650 | Indigestion or stomach ulcers |
| Amlodipine | 30,541,931 | £29,329,631 | High blood pressure – heart disease |
| Ramipril | 29,318,773 | £41,931,828 | High blood pressure – heart disease |
| Lansoprazole | 27,723,751 | £33,480,232 | Indigestion or stomach ulcers |
| Bisoprolol | 24,905,410 | £21,124,240 | High blood pressure – heart disease |
| Colecalciferol | 24,004,981 | £86,331,206 | Vitamin D deficiency |
| Metformin | 22,375,503 | £84,576,576 | Diabetes |
| Aspirin | 22,205,029 | £817,,516,108 | Reduce the risk of heart attacks and stroke |
Figure 1. Top 10 most prescribed medicines in NHS primary care¹.
Dependent on the predicted prescription volumes, staffing levels and available space within the pharmacy the Top 10 fast movers might be the Top 20 or even Top 30. The size of the fast mover catergory is dependent on the ergonomic layout of the pharmacy, fast movers should be easily physically reached by staff or in a prime location within an automatic dispensing machine. The next level of stock catergory are the Medium Movers…
Medium Movers
| Rank | Drug, class or BNF grouping | Most commonly prescribed example(s) | Prescribed in primary care (%) |
| 1 | Statins | Simvastatin, atorvastatin, pravastatin | 6.50% |
| 2 | Proton pump inhibitors | Omeprazole, lansoprazole | 5.50% |
| 3 | Angiotensin-converting enzyme inhibitors | Ramipril, lisinopril, perindopril | 4.30% |
| 4 | Calcium-channel blockers | Amlodipine, felodipine, diltiazem, nifedipine, | 3.70% |
| 5 | Beta-blockers | Bisoprolol, atenolol, propranolol | 3.60% |
| 6 | Anti-depressants, selective serotonin re- | Citalopram, sertraline, fluoxetine | 3.20% |
| 7 | Thyroid hormones | Levothyroxine | 2.90% |
| 8 | COX inhibitor | Aspirin | 2.80% |
| 9 | Corticosteroids, topical | Hydrocortisone | 2.40% |
| 10 | Beta2 agonists | Salbutamol, salmeterol | 2.30% |
| 11 | Analgesia | Paracetamol | 2.30% |
| 12 | Calcium and vitamin D deficiency | Calcium and vitamin D | 2.10% |
| 13 | Non-steroidal anti-inflammatory drugs | Naproxen, ibuprofen | 2.10% |
| 14 | Corticosteroids, inhaled | Beclometasone, fluticasone, budesonide | 2.00% |
| 15 | Biguanides | Metformin | 1.90% |
| 16 | Angiotensin-II receptor antagonists | Losartan, candesartan, irbesartan | 1.80% |
| 17 | Diuretics, thiazide and thiazide-like | Bendroflumethiazide, indapamide | 1.70% |
| 18 | H1 receptor antagonists | Cyclizine, cetirizine, loratadine, fexofenadine, chlorphenamine | 1.60% |
| 19 | Anti-depressants, tricyclic and related drugs | Amitriptyline | 1.60% |
| 20 | Vitamins | Folic acid, thiamine hydrochloride, vitamin B | 1.50% |
| 21 | Opioids: weak/moderate | Tramadol, codeine, dihydrocodeine | 1.40% |
| 22 | Diuretics, loop | Furosemide, bumetanide | 1.40% |
| 23 | Penicillins, broad spectrum | Amoxicillin, co-amoxiclav | 1.40% |
| 24 | Alpha-adrenoceptor blocking drugs | Doxazosin, tamsulosin | 1.30% |
| 25 | Opioids: strong | Morphine | 1.20% |
| 26 | Vitamin K antagonists | Warfarin | 1.10% |
| 27 | Neuropathic pain | Gabapentin and pregabalin | 1.00% |
| 28 | Anti-depressant drugs, other | Venlafaxine, mirtazapine | 1.00% |
| 29 | Emollients | Zerocream, Zerobase Cream, Diprobase cream, Doublebase gel, Aveeno cream, Cetraben cream, Zeroderm ointment, Diprobase ointment, Emulsifying ointment, Hydromol ointment, White soft paraffin and liquid paraffin 50:50, Dermol 500 lotion, Dermol cream | 1.00% |
| 30 | Benzodiazepines | Diazepam, temazepam, lorazepam | 1.00% |
| 31 | Laxatives – osmotic | Macrogol, lactulose | 0.90% |
| 32 | Anti-platelet drugs | Clopidogrel | 0.90% |
| 33 | Sulfonylureas | Gliclazide | 0.80% |
| 34 | Bisphosphonates | Alendronic acid | 0.80% |
| 35 | Anti-psychotics: 2nd generation | Quetiapine, olanzapine, risperidone | 0.80% |
| 36 | Corticosteroids, systemic | Prednisolone | 0.80% |
| 37 | Ocular lubricants (artificial tears) | Hypromellose | 0.80% |
| 38 | Iron | Ferrous fumarate, ferrous sulfate | 0.70% |
| 39 | Laxatives, stimulant | Senna, docusate sodium | 0.70% |
| 40 | Nitrates | Isosorbide mononitrate, glyceryl trinitrate | 0.70% |
| 41 | Insulin | Novorapid, Levemir, Lantus, Humalog, Actrapid, Humulin, Hypurin, Insuman, Insulatard | 0.70% |
| 42 | Anti-muscarinics, genitourinary uses | Solifenacin, tolterodine, oxybutynin | 0.60% |
| 43 | Anti-fungal drugs | Clotrimazole, ketononazole | 0.60% |
| 44 | Z drugs | Zopiclone | 0.60% |
| 45 | Anti-muscarinics, bronchodilators | Tiotropium, ipratropium bromide | 0.60% |
| 46 | Gout and hyperuricaemia | Allopurinol | 0.50% |
| 47 | Macrolides | Clarithromycin | 0.50% |
| 48 | Alginates and antacids | Gaviscon, Gaviscon Infant, Acidex Advance, Peptac | 0.50% |
| 49 | Histamine (H2)-receptor antagonists | Ranitidine | 0.50% |
| 50 | Tetracyclines | Doxycycline | 0.40% |
| 51 | Prostaglandin analogues | Latanoprost | 0.40% |
| 52 | Penicillins, penicillinase-resistant | Flucloxacillin | 0.40% |
| 53 | Urinary Tract Infections | Trimethoprim | 0.40% |
| 54 | Nocturnal leg cramps | Quinine sulfate | 0.40% |
| 55 | Dipeptidyl peptidase-4 inhibitors | Sitagliptin, linagliptin | 0.40% |
| 56 | Dopaminergic drugs used in parkinsonism | Co-careldopa (carbidopa/levodopa) | 0.40% |
| 57 | Seizures | Lamotrigine | 0.40% |
| 58 | Cardiac glycosides | Digoxin | 0.30% |
| 59 | 5α-reductase inhibitors | Finasteride | 0.30% |
| 60 | Epilepsy | Valproate | 0.30% |
| 61 | Anti-muscarinics, cardiovascular and | Atropine, hyoscine butylbromide | 0.50% |
| 62 | Eye infections | Chloramphenicol | 0.30% |
| 63 | Aldosterone antagonists | Spironolactone | 0.30% |
| 64 | Direct oral anticoagulants | Rivaroxaban, apixaban, dabigatran | 0.30% |
| 65 | Epilepsy | Carbamazepine | 0.20% |
| 66 | Urinary Tract Infections | Nitrofurantoin | 0.20% |
| 67 | Penicillin | Benzylpenicillin, phenoxymethylpenicillin | 0.20% |
| 68 | Aminosalicylates | Mesalazine | 0.20% |
| 69 | Mucolytics | Carbocisteine | 0.20% |
| 70 | Rheumatoid arthritis | Methotrexate | 0.20% |
| 71 | Anaerobic infections | Metronidazole | 0.20% |
| 72 | Anti-motility drugs | Loperamide | 0.20% |
| 73 | Anti-emetics, dopamine (D2)-receptor | Metoclopramide, domperidone | 0.20% |
| 74 | Focal seizures | Levetiracetam | 0.20% |
| 75 | Local anaesthetics | Lidocaine | 0.10% |
| 76 | Anti-psychotics: 1st generation | Haloperidol | 0.10% |
| 77 | Drugs used in substance dependence | Nicotine, methadone | 0.10% |
| 78 | Anti-proliferative immunosuppressants | Azathioprine | 0.10% |
| 79 | Antivirals | Aciclovir | 0.10% |
| 80 | Cephalosporins | Ceftriaxone, cefalexin | 0.10% |
| 81 | Arrhythmias | Amiodarone | 0.10% |
Figure 2. Top prescribed medicines UK²
Figure 3. How we got here: Prescribing Trends³.
Medium movers, in traditional pharmacies, are often positioned a little further out from the centre of the dispensary as they are used relatively less than fast movers.
Whilst the medicines discussed thus far are a requirement of the NHS Pharmacy License there are some recommendations made by local authorities for minimum stock of “emergency medicines“. Whilst this list is not a requirement of the NHS contract it is worthy of attention as local authorities can commission Enhanced services that can provide additional revenues to the business.
Local emergency medicine expectations
| Drug | Form | Strength | Qty |
| Codeine | Linctus | 15mg/5ml | 5 x 200mls |
| Codeine | Tablets | 15mg | 56 |
| Codeine | Tablets | 30mg | 56 |
| Cyclizine | Injection | 50mg/1ml | 4 x 5 |
| Dexamethasone | Injection | 3.3mg/1ml | 1 x 5 |
| Diazepam | Rectal Tubes | 5mg/2.5ml | 1 x 5 |
| Diclofenac | Injection | 75mg/3ml | 1 x 10 |
| Diclofenac | Suppositories | 100mg | 1 x 10 |
| Glycopyrronium | Injection | 200mcg/1ml | 2 X 5 |
| Haloperidol | Injection | 5mg/1ml | 1 x 10 |
| Haloperidol | Oral solution | 10mg/5ml | 2 x 100mls |
| Hyoscine Butylbromide (Buscopan) | Injection | 20mg/1ml | 2X10 |
| Levomepromazine | Injection | 25mg/1ml | 2 x 10 |
| Lorazepam | Tablets | 1mg | 2 x 28 |
| Metoclopramide | Tablets | 10mg | 1 x 28 |
| Metoclopramide | Injection | 10mg/2ml | 2 x 10 |
| Midazolam | Injection | 10mg/2ml | 4 x 5 |
| Morphine sulphate | Concentrated | 20mg/ml | 1 x 120ml |
| Morphine sulfate immediate release | Tab/caps | 10mg | 56 (or 60) |
| Morphine sulfate immediate release | Tab/caps | 5mg | 56 (or 60) |
| Morphine sulfate | Injection | 10mg/ml | 8 x 5 |
| Morphine sulfate | Injection | 30mg/1ml | 8 x 5 |
| Oxycodone (OxyNorm) | Capsules | 5mg | 1 x 56 |
| Oxycodone | Injection | 10mg/1ml | 1 x 5 |
| Morphine Sulphate (Oramorph) | Solution | 10mg/5ml | 8 x 100mls |
| Water for injection | Injection | 10ml | 8 x 10 |
| Sodium chloride solution | Injection | 0.009 | 4 x 10ml |
Figure 4. Local emergency medicine expectation.
Pharmacy staff should advise patients to request their prescription in good time. This is particularly important for patients taking medicines with a significant clinical consequence where missing any doses (e.g. anti-psychotics, anti-epileptics, anti-cancer, etc) can cause harm.
Initial Volume
So, we know what percentage of stock should be proportioned to each medicine, however, what overall volume should be stocked? The answer to this is dependent on what the initial predicted prescription volumes will be. To get a ballpark of this figure keep in mind that the average amount of items dispensed monthly by UK pharmacies in 2019/20 was 6.6 thousand, however over 2,400 pharmacies dispensed an average of over ten thousand items a month.
References
² Audi, S., Burrage, D. R., Lonsdale, D. O., Pontefract, S., Coleman, J. J., Hitchings, A. W., and Baker, E. H. (2018) The ‘top 100’ drugs and classes in England: an updated ‘starter formulary’ for trainee prescribers. Br J Clin Pharmacol, 84: 2562– 2571. https://doi.org/10.1111/bcp.13709.
