Digital HealthDistance Selling Pharmacy

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

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 NamePrescription ItemsActual CostCommonly Used For
Atorvastatin45,792,988£55,759,286Statins-high cholesterol
Levothyroxine32,934,807£62,757,734Low thyroid levels
Omeprazole31,791,795£50,092.650Indigestion or stomach ulcers
Amlodipine30,541,931£29,329,631High blood pressure – heart disease
Ramipril29,318,773£41,931,828High blood pressure – heart disease
Lansoprazole27,723,751£33,480,232Indigestion or stomach ulcers
Bisoprolol24,905,410£21,124,240High blood pressure – heart disease
Colecalciferol24,004,981£86,331,206Vitamin D deficiency
Metformin22,375,503£84,576,576Diabetes
Aspirin22,205,029£817,,516,108Reduce 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

RankDrug, class or BNF groupingMost commonly prescribed example(s)Prescribed in primary care (%)
1StatinsSimvastatin, atorvastatin, pravastatin6.50%
2Proton pump inhibitorsOmeprazole, lansoprazole5.50%
3Angiotensin-converting enzyme inhibitorsRamipril, lisinopril, perindopril4.30%
4Calcium-channel blockersAmlodipine, felodipine, diltiazem, nifedipine,3.70%
5Beta-blockersBisoprolol, atenolol, propranolol3.60%
6Anti-depressants, selective serotonin re-Citalopram, sertraline, fluoxetine3.20%
7Thyroid hormonesLevothyroxine2.90%
8 COX inhibitorAspirin2.80%
9Corticosteroids, topicalHydrocortisone2.40%
10Beta2 agonistsSalbutamol, salmeterol2.30%
11AnalgesiaParacetamol2.30%
12Calcium and vitamin D deficiencyCalcium and vitamin D2.10%
13Non-steroidal anti-inflammatory drugsNaproxen, ibuprofen2.10%
14Corticosteroids, inhaledBeclometasone, fluticasone, budesonide2.00%
15BiguanidesMetformin1.90%
16Angiotensin-II receptor antagonistsLosartan, candesartan, irbesartan1.80%
17Diuretics, thiazide and thiazide-likeBendroflumethiazide, indapamide1.70%
18H1 receptor antagonistsCyclizine, cetirizine, loratadine, fexofenadine, chlorphenamine1.60%
19Anti-depressants, tricyclic and related drugsAmitriptyline1.60%
20VitaminsFolic acid, thiamine hydrochloride, vitamin B1.50%
21Opioids: weak/moderateTramadol, codeine, dihydrocodeine1.40%
22Diuretics, loopFurosemide, bumetanide1.40%
23Penicillins, broad spectrumAmoxicillin, co-amoxiclav1.40%
24Alpha-adrenoceptor blocking drugsDoxazosin, tamsulosin1.30%
25Opioids: strongMorphine1.20%
26Vitamin K antagonistsWarfarin1.10%
27Neuropathic painGabapentin and pregabalin1.00%
28Anti-depressant drugs, otherVenlafaxine, mirtazapine1.00%
29EmollientsZerocream, 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 cream1.00%
30BenzodiazepinesDiazepam, temazepam, lorazepam1.00%
31Laxatives – osmoticMacrogol, lactulose0.90%
32Anti-platelet drugsClopidogrel0.90%
33SulfonylureasGliclazide0.80%
34BisphosphonatesAlendronic acid0.80%
35Anti-psychotics: 2nd generationQuetiapine, olanzapine, risperidone0.80%
36Corticosteroids, systemicPrednisolone0.80%
37Ocular lubricants (artificial tears)Hypromellose0.80%
38IronFerrous fumarate, ferrous sulfate0.70%
39Laxatives, stimulantSenna, docusate sodium0.70%
40NitratesIsosorbide mononitrate, glyceryl trinitrate0.70%
41InsulinNovorapid, Levemir, Lantus, Humalog, Actrapid, Humulin, Hypurin, Insuman, Insulatard0.70%
42Anti-muscarinics, genitourinary usesSolifenacin, tolterodine, oxybutynin0.60%
43Anti-fungal drugsClotrimazole, ketononazole0.60%
44Z drugsZopiclone0.60%
45Anti-muscarinics, bronchodilatorsTiotropium, ipratropium bromide0.60%
46Gout and hyperuricaemiaAllopurinol0.50%
47MacrolidesClarithromycin0.50%
48Alginates and antacidsGaviscon, Gaviscon Infant, Acidex Advance, Peptac0.50%
49Histamine (H2)-receptor antagonistsRanitidine0.50%
50TetracyclinesDoxycycline0.40%
51Prostaglandin analoguesLatanoprost0.40%
52Penicillins, penicillinase-resistantFlucloxacillin0.40%
53Urinary Tract InfectionsTrimethoprim0.40%
54Nocturnal leg crampsQuinine sulfate0.40%
55Dipeptidyl peptidase-4 inhibitorsSitagliptin, linagliptin0.40%
56Dopaminergic drugs used in parkinsonismCo-careldopa (carbidopa/levodopa)0.40%
57SeizuresLamotrigine0.40%
58Cardiac glycosidesDigoxin0.30%
595α-reductase inhibitorsFinasteride0.30%
60EpilepsyValproate0.30%
61Anti-muscarinics, cardiovascular andAtropine, hyoscine butylbromide0.50%
62Eye infectionsChloramphenicol0.30%
63Aldosterone antagonistsSpironolactone0.30%
64Direct oral anticoagulantsRivaroxaban, apixaban, dabigatran0.30%
65EpilepsyCarbamazepine0.20%
66Urinary Tract InfectionsNitrofurantoin0.20%
67PenicillinBenzylpenicillin, phenoxymethylpenicillin0.20%
68AminosalicylatesMesalazine0.20%
69MucolyticsCarbocisteine0.20%
70Rheumatoid arthritisMethotrexate0.20%
71Anaerobic infectionsMetronidazole0.20%
72Anti-motility drugsLoperamide0.20%
73Anti-emetics, dopamine (D2)-receptorMetoclopramide, domperidone0.20%
74Focal seizuresLevetiracetam0.20%
75Local anaestheticsLidocaine0.10%
76Anti-psychotics: 1st generationHaloperidol0.10%
77Drugs used in substance dependenceNicotine, methadone0.10%
78Anti-proliferative immunosuppressantsAzathioprine0.10%
79AntiviralsAciclovir0.10%
80CephalosporinsCeftriaxone, cefalexin0.10%
81ArrhythmiasAmiodarone0.10%

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

DrugFormStrengthQty
CodeineLinctus15mg/5ml5 x 200mls
CodeineTablets15mg56
CodeineTablets30mg56
CyclizineInjection50mg/1ml4 x 5
DexamethasoneInjection3.3mg/1ml1 x 5
DiazepamRectal Tubes5mg/2.5ml1 x 5
DiclofenacInjection75mg/3ml1 x 10
DiclofenacSuppositories100mg1 x 10
GlycopyrroniumInjection200mcg/1ml2 X 5
HaloperidolInjection5mg/1ml1 x 10
HaloperidolOral solution10mg/5ml2 x 100mls
Hyoscine Butylbromide (Buscopan)Injection20mg/1ml2X10
LevomepromazineInjection25mg/1ml2 x 10
LorazepamTablets1mg2 x 28
MetoclopramideTablets10mg1 x 28
MetoclopramideInjection10mg/2ml2 x 10
MidazolamInjection10mg/2ml4 x 5
Morphine sulphateConcentrated20mg/ml1 x 120ml
Morphine sulfate immediate releaseTab/caps10mg56 (or 60)
Morphine sulfate immediate releaseTab/caps5mg56 (or 60)
Morphine sulfateInjection10mg/ml8 x 5
Morphine sulfateInjection30mg/1ml8 x 5
Oxycodone (OxyNorm)Capsules5mg1 x 56
OxycodoneInjection10mg/1ml1 x 5
Morphine Sulphate (Oramorph)Solution10mg/5ml8 x 100mls
Water for injectionInjection10ml8 x 10
Sodium chloride solutionInjection0.0094 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.

³ https://openprescribing.net/