The Department is closely monitoring the Middle East conflict to assess any potential impact on United Kingdom medical supply chains through disruptions to manufacturing and logistics.

We have limited direct exposure to the Middle East for medical products, and we maintain well‑established contingency arrangements to manage medicine and medical device supply disruptions where these occur. These can include coordination of mutual aid, work to identify alternative products, alternative clinical practices, regulatory easements, and/or use of the Express Freight Service which can provide bespoke global logistics services in the event of critical supply disruption.

The Department is not aware of supply issues impacting codeine and co-codamol as a result of the conflict. The Department is aware of supply constraints affecting co-codamol 30 milligram/500 milligram tablets, which pre-date the conflict and which are due to manufacturing issues. These are in limited supply until early July 2026. We have engaged with National Health Service specialist clinicians and issued comprehensive guidance on how to manage patients during this time and advise on available alternative preparations.

The Medicines and Healthcare products Regulatory Agency (MHRA) is an executive agency of the Department, with responsibility for ensuring medicines meet appropriate standards of quality, efficacy, and safety.

Medicines authorised to treat pain fall with several different classes of medicine. Prescription medicines include opioids, gabapentinoids, namely pregabalin and gabapentin, and non-steroidal anti-inflammatories (NSAIDs). Other classes of medicine such as anti-epileptics or antidepressants may also be used for the treatment of neuropathic pain, a type of pain evolving from nerve damage, as recommended by the National Institute for Health and Care Excellence (NICE), with further information available at the following link:

https://www.nice.org.uk/guidance/cg173

New medicines are also available for the treatment of migraine. The MHRA monitors the safety of all these medicines and has issued warnings and updated product and patient information on the risk of addiction to opioids, with further information available at the following link:

https://www.gov.uk/drug-safety-update/opioids-risk-of-dependence-and-addiction

The MHRA is currently undertaking a review to improve the information supplied with dependency-forming medicines including gabapentinoids. If additional signals of risk arise, action will be taken to protect public health.

All medicines have side effects, although not everyone will experience them. The MHRA encourages anyone who suspects or experiences a side effect of their medicine to report it to the MHRA through the Yellow Card scheme.

NICE also provides clinical guidance called Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults, code NG 215. This guidance is available at the following link:

https://www.nice.org.uk/guidance/NG215

Additionally, NHS England has an initiative to reduce long-term opioid use, with further information available at the following link:

https://www.england.nhs.uk/long-read/reducing-long-term-opioid-use/

In March 2023, NHS England published Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and primary care, which is available at the following link:

https://www.england.nhs.uk/long-read/optimising-personalised-care-for-adults-prescribed-medicines-associated-with-dependence-or-withdrawal-symptoms/

The framework includes five actions, resources and case studies to help systems develop plans that can support people who are taking medicines associated with dependence and withdrawal symptoms by:

- optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms;

- informing ICB improvement and delivery plans, when commissioning services and developing local policies that offer alternatives to medicines in the first place and/or support patients experiencing prescribed drugs dependence or withdrawal; and

- ensuring a whole system approach and pathways involving multiple interventions, to improve care for people prescribed medicines associated with dependence and withdrawal symptoms.

The commissioning of services to support people to safely withdraw from prescribed medicines that may cause dependence and withdrawal lies with ICBs. NHS England expects ICBs to commission appropriate services to meet the needs of the population that the ICB geographically covers. This includes taking due regard to any national commissioning and clinical guidance.

The National Health Service Business Services Authority provides data dashboards relating to painkiller prescribing, to help systems develop plans and to monitor improvement in line with the published Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and primary care guidance.

The Department remains committed to exploring the extension of medicine responsibilities for non-medical professionals. This will support the aim that patients are cared for, and treated by, the most appropriate healthcare professional to meet their needs, where it is safe and appropriate to do so. Many regulated healthcare professionals have already received extended medicine responsibilities and the Department is committed to assessing the impact that these changes have had on patient care.

Regarding the extension of paramedics’ medicine responsibilities, there is a process in place for making changes to ensure proposals are safe and beneficial for patients. Officials are carefully considering proposals relating to a range of healthcare professionals, including paramedics, and the use of fentanyl as an analgesic agent, as part of wider work.

The Prescription Cost Analysis data release gives items and quantities of each medicine dispensed in the community in England. The following table shows the total number of items dispensed for analgesics in England, regardless of where prescribed, as well as the unique number of patients that were dispensed medicines listed in British National Formulary (BNF) Section 4.7 Analgesics, from December 2023 to November 2024:

For further information, BNF 4.7 includes:

- non-opioid analgesics and compound preparations;

- opioid analgesics;

- neuropathic pain medicines; and

- antimigraine medicines.

No data has been captured relating to the clinical indication a prescription is intended for. Some of these products can be used for a variety of clinical indications and therefore the figures provided may include items that were prescribed for a different condition, rather than for pain relief.

It is important to note that this data does not capture medicines classified elsewhere within the BNF, which are primarily used for other reasons, but may also be used for analgesic purposes. This includes, for example, non-steroidal anti-inflammatory drugs, which feature in 10.1 ‘Drugs used in rheumatic diseases and gout’, and antidepressants, used off-label in chronic primary pain, which feature in 4.3 ‘Antidepressant drugs’.

Treating clinicians use National Institute for Health and Care Excellence guidance, which helps practitioners and commissioners get the best care to patients, when assessing, signposting to, and prescribing pain relief medications.

It is a prescriber’s duty when providing clinical care for conditions, such as urinary tract infections, to prescribe medicines, including pain relief, when they have adequate knowledge of the patient’s health and are satisfied that the medicine is clinically suitable for the patient.

A wide variety of medicines are used for the purpose of pain-relief, and they have differing levels of regulation. Some items can be bought off-the-shelf without a prescription, whilst others require authorisation from a medical professional. The Human Medicines Regulations 2012 set out the responsibilities which certain medical professionals may undertake regarding the supply and administration of regulated medicines. The Misuse of Drugs Act 1971 sets out the legal framework for the prevention of misuse of controlled drugs.

Decisions about what medicines to prescribe and administer are made by the doctor or other qualified medical personnel responsible for that part of the patient’s care. They must always satisfy themselves that the medicines they consider appropriate for their patients can be safely prescribed and administered, and they must take account of appropriate national guidance on clinical effectiveness. Clinicians are responsible for the decisions they make regarding the administration of medicines, and they are regulated by the relevant regulatory body for their profession.

Professional regulators are responsible for setting and enforcing their own standards for the healthcare professionals that they regulate. The General Medical Council (GMC) is the regulator of all medical doctors practising in the United Kingdom, and the Nursing and Midwifery Council (NMC) is the regulator of nurses and midwives in the UK. Both the GMC and the NMC are independent of the Government, are directly accountable to Parliament, and are responsible for operational matters concerning the discharge of their statutory duties.

Following the Shipman Inquiry's Fourth Report, published on 14 July 2004, the Government introduced tighter controls on the procurement, storage, supply and prescribing of controlled drugs, and established national and regional monitoring by the Care Quality Commission (CQC) and a network of regional NHS Controlled Drug Accountable Officers. The CQC is responsible for making sure that health and care service providers, and other regulators, maintain a safe environment for the management and use of controlled drugs in England. The CQC does this under the Controlled Drugs (Supervision of Management and Use) Regulations 2013. These regulations strengthened system governance to monitor the safe use and prescribing of controlled drugs, and require greater co-ordination between the health system and police, to investigate and take action, to protect patients and the public against the misuse and diversion of controlled drugs. Further information on these regulations is available at the following link:

https://www.legislation.gov.uk/uksi/2013/373/contents/made

We are aware of a supply disruption affecting Zapain. The Department is working with the manufacturer to resolve this issue as soon as possible.

The Department works closely with the Home Office and relevant authorities on supply issues concerning drugs controlled under the Misuse of Drugs Act 1971. We, however, cannot comment on discussions relating to individual licence holders or prospective licensees about applications that may have been made to the Home Office.

We have well-established processes for managing and mitigating medicine supply issues, which involve working with the pharmaceutical industry, the Medicines and Healthcare products Regulatory Agency, NHS England, the devolved governments and others operating in the supply chain to help ensure patients have access to the treatments they need.

NHS England has been working with the trusts where gas and air supplies have been affected due to differing and localised issues. Guidance has been published to support Trusts in responding to issues raised in relation to gas and air usage and is available at the following link:

https://www.england.nhs.uk/long-read/guidance-on-minimising-time-weighted-exposure-to-nitrous-oxide-in-healthcare-settings-in-england/

Some trusts have taken a decision to temporarily suspend the use of gas and air within their maternity units due to concerns of over exposure of gas and air for staff. Once a trust takes the decision to suspend the use of gas and air it is expected that they implement locally agreed solutions that enable them to continue to provide safe and personalised care to women. Trusts are expected to undertake a full risk assessment in line with guidance to demonstrate the rationale for suspension of use and mitigations to address this.

No specific assessment has been made by the NHS England National Specialised Commissioning Team on the potential merits of simplifying the administration of pain relief for Sickle Cell patients or, of increasing funding and staffing levels for sickle cell services. However the National Sickle Pain Group, a sub-group of the Specialised Commissioning Haemoglobinopathies Clinical Reference Group, has produced guidance for hospitals to improve the care for sickle cell patients presenting with acute sickle pain and are working on an associated acute pain audit to measure the time to first analgesia universally across England.

NHS England has launched an end to end sickle cell clinical pathway review led by the Health Inequalities Improvement team. The end to end clinical pathway for patients with Sickle Cell Disease is being reviewed to identify opportunities for delivering improvements. The review is at an early stage but has highlighted a number of opportunities to improve current services, including in relation to workforce, the digitalisation of care plans and general education of the public about the condition.

In addition, NHS England is undertaking an exercise to assess compliance of Specialist Haemoglobinopathy Teams and Haemoglobinopathy Co-ordinating Centres with the respective service specifications which are published on the Haemoglobinopathies Clinical Reference Group webpage.

No specific assessment has been made.

Specialist haemoglobinopathy teams (SHTs) and haemoglobinopathy co-ordinating centres (HCCs) are required to submit data via the Specialised Services Quality Dashboard on the percentage of patients given pain relief within 30 minutes of presentation with a sickle cell crisis, as per the National Institute for Health and Care Excellence guidelines. The data does not include patients attending non-specialist haemoglobinopathy providers and further work is required to improve the accuracy of the data submission before it can be used to assess compliance.

No specific assessment has been made.

Specialist haemoglobinopathy teams (SHTs) and haemoglobinopathy co-ordinating centres (HCCs) are required to submit data via the Specialised Services Quality Dashboard on the percentage of patients given pain relief within 30 minutes of presentation with a sickle cell crisis, as per the National Institute for Health and Care Excellence guidelines. The data does not include patients attending non-specialist haemoglobinopathy providers and further work is required to improve the accuracy of the data submission before it can be used to assess compliance.

No specific assessment has been made. Specialist haemoglobinopathy teams and haemoglobinopathy co-ordinating centres are required to submit data via the Specialised Services Quality Dashboard on the percentage of patients given pain relief within 30 minutes of presentation with a sickle cell crisis, according to the National Institute for Health and Care Excellence’s guidelines. The data does not include patients attending non-specialist haemoglobinopathy providers and further work is required to improve the accuracy of the data submission before it can be used to assess compliance.

Sickle cell disease and thalassemia are now described as core competencies haematology medical curriculum. Health Education England (HEE) also provides e-learning which includes content on sickle cell disease. HEE, the Royal College of Pathology and the Royal College of Physicians have ensured this curriculum is deliverable to all four nations, in line with the General Medical Council’s standards. Haemoglobinopathy Coordinating Centres also provide network development, leadership, learning and education. Following the publication of ‘Our plan for patients”, the Department is reviewing its priorities on preventing ill-health and address health disparities.

The Department has not done so. The Royal College of Obstetricians and Gynaecologists is an independent organisation, responsible for producing clinical guidelines which set standards for high quality women’s healthcare.

The Department does not set or review clinical practice and no specific assessment has been made. The Royal College of Obstetricians and Gynaecologists has established a review group to consider the latest evidence on foetal pain and foetal awareness, which is expected to report on its findings by the end of 2022.

The Department does not set clinical practice. The Royal College of Obstetricians and Gynaecologists has considered the issue of fetal pain and awareness in its guidelines on ‘The Care of Women Requesting Induced Abortion’ and ‘Fetal Awareness: Review of Research and Recommendations for Practice’, which are available at the following links:

https://www.rcog.org.uk/globalassets/documents/guidelines/abortion-guideline_web_1.pdf

https://www.rcog.org.uk/globalassets/documents/guidelines/rcogfetalawarenesswpr0610.pdf

The Royal College has established a review group to consider the latest evidence on fetal pain and fetal awareness. It is expected to report on its findings by the end of 2022.

As part of this years’ World Sickle Cell Day, NHS England launched a new sickle cell disease awareness campaign on the signs and symptoms of sickle cell disease, aimed at urgent and emergency care staff and those living with the condition and their carers.

There have been recent improvements to the haematology medical curriculum, with understanding sickle cell disease and thalassemia now described in the curriculum as core competencies. Health Education England (HEE) provides e-learning which includes content on sickle cell disease. HEE has held discussions with the Royal Colleges of Pathology and Physicians to ensure this curriculum is deliverable to all four nations, in line with General Medical Council’s (GMC) standards. The Haemoglobinopathy Coordinating Centres also provide network development, leadership, learning and education.

The Sickle Cell Society and the All-Party Parliamentary Group on Sickle Cell and Thalassaemia report ‘No One’s Listening’ highlighted the lack of awareness of sickle cell disease among healthcare professionals. Officials are considering the report’s recommendations. NHS England estimates that awareness amongst accident and emergency medical and nursing staff, specifically of conditions such as sickle cell disease, is high across England and in areas where there is a higher prevalence of the condition. However, NHS England and other bodies continue with further awareness raising.

No specific assessment has been made regarding the extent of compliance to the National Institute for Health and Care Excellence’s (NICE) guidance on pain relief for sickle cell patients. The Care Quality Commission (CQC) considers evidence of how registered persons have met fundamental standards through its regulatory approach. The CQC will consider the processes providers have to ensure that best practice is implemented for quality standards, including NICE’s guidelines.

No specific assessment has been made as the Department does not set clinical practice.

The Royal College of Obstetricians and Gynaecologists is currently reviewing its report ‘Fetal Awareness: Review and Recommendations for Practice’. The College has established a review group to consider the latest evidence on fetal pain and fetal awareness which is expected to report on its findings by the end of 2022.

The Department does not set guidelines for clinical practice. The Royal College of Obstetricians and Gynaecologists considered the issue of fetal pain and awareness in its guidelines ‘Fetal Awareness: Review of Research and Recommendations for Practice’. The Royal College is currently reviewing this guidance.