What stock levels do I need as a new UK primary care community pharmacy?

Mike Bereza — Thu, 01 Jul 2021 23:24:44 +0000

How much stock will your new pharmacy need?

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 5: Prescribing trends.

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

¹https://www.thedatalab.org/blog/123/what-are-the-most-commonly-prescribed-medicines-top-10-prescribed-medicines-in-nhs-england-primary-care-for-2019/

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.