Instituto Nacional de Seguros

The focus group participants understood and were acquainted with the different response actions of buffering and bridging. The reasons why they made those decisions was also evident in some of their responses. Information and change were key factors mentioned, as highlighted in the Word Cloud, and one contributor mentioned:

“We do use information and data to base a lot of our decisions on but it does carry a risk in that the changing environment in which medicines are moved around the supply chain does put that at risk to some extent. Certainly, it is recognised that there has to be some sort of consistency in terms of the IT systems which are used, but the difficulty is you have got so many different stakeholders in the system. You have got the DH, you have got CMU, you have got the NHS, you have got individual suppliers, you have got third party outsource providers all having different IT systems to somehow bring and consolidate all of this together to allow information to flow more freely, which is what everybody is wanting, but it is just a matter of getting everybody around the table, therein lies the biggest challenge of all.” (Participant A1)

So, although decisions were based on information, that information was not uniform or consistent, with stakeholder dynamics being an influence. The changing environment leading to communication difficulties hampering decisions was also highlighted:

“Communication issues with a supplier, so you will be told one thing by one part of the company and another by another. The other thing that we find, because of the way the market works at the moment, is that suppliers are constantly changing names or they are merging their divesting products. There seems to be a lot of changes within companies, you lost the sort of corporate knowledge and contacts, and it is only when there is an issue that you re-establish those relationships then it's almost too late.” (Participant A3)

It was pointed out by the focus groups that there was a commercial and cost element to the supply decision dynamic to add to the regulatory and organisational challenges for the purchasing units:

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“For those medicines which have a framework agreement within England, if a hospital cannot procure a medicine within 14 days sitting on their shelves, they have recourse to source that product from elsewhere from an alternative supplier, potentially at list price and then the awarded supplier will have to reimburse the difference between the contracted price and the list price of the competitor products. So, an individual supplier can stand to lose a substantial amount of product within a given amount of time. Now that punitive measure can vary from one market to another, but it is the case in the UK that if a contracted supplier cannot supply within 14 days of a hospital placing an order, they can seek compensation if they have to source an alternative supplier, so it can be both a carrot and a stick.” (Participant A1)

Buffering actions were well used, however, there was not a straightforward rationale:

“We all have strategies to build up extra products.” (Participant B4)

However, even if a buffering response was put in place, some hospitals have limited physical space. Participant B1 gave one example of the consequences:

“You had difficulties at St. Thomas’ [Hospital], you had some stock at which you had built up, but the problem is people don’t understand the number of lines a hospital pharmacy can hold, so it’s much higher; it's typically 2,000, 3,000 lines, so if you run down one of those it can become critical as soon as you can’t get it.” (Participant B1)

So there exists a restriction to the response action on buffering in the pharmaceutical supply chain, which has an effect on the decision post disruption, and as such to an extent, the interplay potentially between the buffering and bridging decision. However, the bridging decision itself also has restrictions at the local level:

“Bridging is difficult because the personnel within the organisation changes so rapidly, so there is a little bit of that, the Department of Health have asked that there be somebody in each company [supplier] who is responsible for shortages, and they have that named person, and really that’s it and that just shows how ridiculous it was before.” (Participant B1)

So, neither the buffering nor the bridging options for a response decision is an easy one, it was evident from the focus groups, and there are restrictions and challenges with both. However, all groups recognised, as stated previously, that both of these actions were taken, whether that was separately, together, or in changing combinations.

There was also a conflict between which choice to take from a macro policy perspective, for example, the Carter Report. There were also seasonal elements to take into consideration:

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“So, what’s happening is this dichotomy situation where we are taught to manage our stocks to a minimum but that doesn’t support having extra stock just in case.” (Participant B3)

“There is a bit of an artificial effect at Christmas when we buffer, when we tend to hold more.” (Participant B10)

“And if you use French [suppliers], August.” (Participant B10)

Buffering actions were used in both a hedging response to buy time to see if the medicine in shortage would come back into supply but also as an emergency response reflex, as Participant C2 commented regarding drawing back stock from wards:

“Particularly where there’s more than one indication for a medication, there’s a critical indication that you keep the medication for that indication, so it does get used so you don’t lose a patient or if you were desperate.” (Participant C2)

The dynamic nature of decision-making post disruption in shortage management was evident throughout the focus groups with regards to buffering and bridging, as the below extract highlights:

“They do change their actions depending on how long it goes on for. Only so much that, I mean quite often we would look to specialist pharmaceutical industries to supply an unlicensed version of the product [that] can be sourced from abroad, where there is no other licensed alternative available in the country, and feedback from them is that in many shortage situations they won’t get any queries from trusts, or get any interest in using the unlicensed product. Which suggests trusts are managing with stocks they have, whether that be from a stockpile or from across the region; they are sharing but then every shortage sort of goes on. If it is prolonged, they then try to dip into the unlicensed source, yes. We then hear we are getting a lot of demand for finished stock. That is the type of action which is dynamic, which is anecdotal from the suppliers.” (Participant A3)

Unlicensed products are only allowed to be used in secondary acute care when the licensed product is not available, both actions are buffering by either stockpiling or by reaching out for alternatives, but the decisions are taken at different times subject to the circumstances that are changing over time.

Having both the technical expertise but also the awareness of the urgency of the situation is crucial:

“Each hospital will have different degrees of resilience in how they deal with disruptions and supply issues, just to supply a bit of context to all of this. It certainly is important that whoever deals in shortages has some appreciation for medicines as a commodity and the criticality of what the medicine does.”

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Again, there was an acknowledgement of the variation of performance and attributes of each hospital and trust throughout the focus groups. Considering the effects that performance has and the time element in the dynamic action process, the next topic looks at Feedback and Dynamics.