Jobsworth pharmacist at GP

[Izz82]

I’ve had a very stressful few calls in the last few weeks with the pharmacist at my GP surgery. I’m in surgical menopause following cancer surgery and treatment, and as I’m in my 30s and given my complicated medical history I have been seeing a lovely doctor at the Newson clinic and the HRT prescribed has changed my life. She wrote a letter to my GP asking if I could be prescribed meds (this was after the first 3 months, as I’m on UC as still recovering and get free prescriptions, but I paid for the first lot). My gp practice is amazing but for some reason the pharmacist there is useless. Long story short she prescribed a generic (she puts together the prescriptions and the gps just sign it off- they won’t have used the letter) and I got something that shouldn’t even be used for hrt from the local pharmacy. So I’ve gone back to request a named product as per the consultant letter and advice from the pharmacy and she’s kicked up a fuss. For another item (a patch) the consultant recommended two types, pharmacist put down generic, and I’ve got something different. She’s kicked up a fuss when I’ve asked to change it to Estradot as per the consultant, and for continuity (I don’t always use the same pharmacy and a generic could mean any of a number of brands). Does anyone know what I can do in this situation and what you are able to request on the nhs and what you are not? I’ve not been in this situation before as always been nhs. She questioned me on why I wasn’t getting the prescription privately if I’d seen someone privately, why I’d been changed from a gel to a patch etc, but I don’t think that’s any of her business is it?

Not sure I understand the difference. Does the generic have the same ingredients? If so, it's no different, just cheaper to dispense. Or is it a different format?

Pharmacists are often working within PCNs now to manage prescriptions and prescribing. Local prescribing policy may stipulate generic prescribing only unless necessary.

Pharmacists are also qualified to do medication reviews and ask the sorts of questions you’ve been asked. She’s also well within her rights to ask why the GP is now prescribing something originally prescribed privately.

What do you mean she prescribed something not even used for HRT?

Generic is the same ingredient just a different brand.
Bit like bags of sugar, silver spoon or Tesco, doesn't really matter!
Not sure what you mean by the GP signing off the pharmacists prescriptions as they aren't qualified to do so.
The GP prescribes an item (or consultant) and a pharmacist dispenses the item doing all the necessary checks and get it signed off by another dispenser/ technician.

I’m a pharmacist who works in community pharmacy, we can’t get hold of estradot at all at the moment. With the gp surgery pharmacist prescribing it generically, it means you’ll be able to get evorel, so they have probably made it easier for you. I’m a bit confused by your post though, are you saying the dispensing pharmacy gave you the wrong drugs because surely that’s not the gp pharmacists fault? Also if your seeing someone privately for hurt, it’s usually their responsibility to prescribe for you, unless you are completely back under the care of the surgery. Plus the pharmacist will be an independent prescriber, they will have full responsibility for what they prescribe, a GP won’t be signing it off for them. Of course it’s her business to ask, if she’s been given the responsibility to prescribe. The main advantage of the gel over a patch is, if your dose needs to be changed it can be done over the phone telling you to use more or less pumps, whereas with the patch you might get waste and would have to be prescribed a new strength. Plus a lot of women have problems with the patch keeping on. Just sounds like the pharmacist is doing her job.

I also thought generic meant that you got exactly the same (albeit unbranded) product and that it was cheaper.

I do have one medication that my specialist strongly advises not be filled with a generic. It’s because consistency matters too much on that particular med. tiny deviations in manufacturing or inactive ingredients can cause huge swings in absorption. So if you could consistently guarantee the same generic from the same manufacturer, it would be fine, but since you can’t, it has to be name brand.

I have another med that can only be filled with certain generics because of the inactive ingredients used by some manufacturers. This is actually a surprisingly common issue with patches, gels, and creams but it can be pills or injections too. The manufacturers only have to consistently deliver the same active ingredients. The inactive ingredients are allowed to differ.

so no, not all genetics are equal substitutes. Most of my meds are generic and it’s completely fine, but occasionally manufacturer does matter.

Hi OP. I would be frustrated too. I have had different patches and it bloody well does matter which you get! Of course in theory they are all the same but the reality is different.

The whole delivery mechanism of the drug is that it moves from the patch into your skin by being in constant connection with your skin. When you are given the crappy, huge, inferior patches they ripple, stop sticking, become loose and may peel right off. Clearly they are then not working as they should and can’t possibly be delivering the hormones into your body properly. I’m currently wading through a massive packet of huge HRT patches. They are so bad I have to put surgical tape all around them to stop them peeling off after a day. I shave, clean and thoroughly dry the area, carefully apply the patch to ensure no air bubbles. But still they come loose!
I hope you get yours sorted out.

Absolutely.

Swapping brands of levothyroxine, for example, can make patients become very unwell.

Sounds like she's just doing her job. And of course she's within her rights to ask why you want the NHS to reimburse you for what should be a private transaction

@SpindleInTheWind levothyroxine is not branded, they are all generic manufacturers.

This poster is likely referring to things like certain antiepileptics which must be prescribed by brand.

Can you say what you should get and what you did get?

It's usually the GP who prescribes and the pharmacist follows the script UNLESS the script says 'generic transdermal estrogen patch xmcgs.'

The position with seeing a private consultant then switching the prescribing to an NHS GP is that it's at the GP's discretion to continue. Most will, but I think it's their choice and you would then in theory be under their care as they'd be taking the responsibility. (happy to be corrected there.)

I see a private consultant, but I've stayed with them for a long time, as I want their expertise and I didn't want to hand over my menopause/HRT to a GP.

So I need to pay for my HRT at cost (not NHS prescription fees) but I am happy with that.

Maybe ask the pharmacist why they have not given you the branded version you asked for?

Are we at cross-purposes? I guess so. I thought the issues with switching brands of levo are well known. Lots of patients can't tolerate Teva brand, for example. So a GP would maybe specifically prescribe 'Levothyroxine 100 mcg Accord'.

Anyway this is about HRT and the OP's difficulties.

Ah, I've twigged. It's thought to be the excipients ^^

Reading with intrigue

GP here

Estradot not currently available from memory.

Also if my patients have a private consult for the most part I expect them to pay for their private script too.
Private healthcare is absolutely fine but can't chop and change between NHS and private and expect NHS to do what private doctor wants.
The private dr will know this, hence prescribing on a private script.

I worked in pharmacy for many years - we were always taught that generic was the same as the branded drug, but I've since learned via many pharmacists that this isn't necessarily the case.

Excipients indeed can be different, but the bioequivalence in different generics can be off and if you are sensitive to your meds, you will feel it. For example, I had a citalopram brand change and had a relapse in symptoms and side effects.

Bioequivalence can leave a 40% swing in strength - for example the FDA licenses generic drugs to be between 80-125% of the branded original once patent is over. I may have those percentages slightly off but I'm pretty sure it's that - meaning you could have one generic drug that is 80% of the original, use that constantly and then have a brand change that is 110% potency of the original - you will feel the difference. I hope I've explained that well enough.

Some people will be sensitive to this swing, some won't feel it, it's all down to you and how you work.

I always stick to the same brand as much as possible.

You are entitled to request any brand you want from the pharmacy as long as it is available from the manufacturer.

Also, you are exempt from prescription charge because you have had cancer, so even if you come off UC, you are still entitled to that exemption. (I've had cancer, too)

I Understand your perspectives, but can the private one actually do the transaction this way all above board so to speak, or is it still possible but more of them being cheeky sorta thing ?

I should add sorry, if your prescription is private your nhs exemption doesn't apply.

I have a named brand written in my prescription - it says “preferably”. It’s not for HRT but is for post-cancer medication. My treatment has all been NHS, though.

Meant to say, it’s a generic, but there are several different ones. People tolerate the different brands differently.

My G.P is more than happy to prescribe my HRT that is recommended by my menopause Dr, which I pay privately to see. We discuss which treatment is probably best for me, she writes a letter about what has been discussed with the recommendations, and my G.P has no problems with this. Where I live all the funding for the NHS menopause clinic has been withdrawn, which is disgusting.

I originally approached my Drs as I simply didn’t know what was happening to me, no libido, dry vagina etc. For the libido it was recommended to me to have a romantic meal with a bottle of wine, and after an internal examination no advice whatsoever ☹️. It’s no joke that a lot of G.Ps really don’t have sufficient knowledge about HRT, since going into menopause I’ve read many articles on official menopause sites to gem up on the subject, it’s not difficult, so why are we being let down so much?

That's not what the NHS says:

2.12 Patients who choose to be treated privately are entitled to NHS services on exactly the same basis of clinical need as any other patient.
2.13 Where a patient wishes to change from private to NHS status, consultants should help ensure that the following principles apply:

• any patient seen privately is entitled to subsequently change his or her status and seek treatment as a NHS patient;
• any patient changing their status after having been provided with private services should not be treated on a different basis to other NHS patients as a result of having previously held private status;
• patients referred for an NHS service following a private consultation or private treatment should join any NHS waiting list at the same point as if the consultation or treatment were an NHS service. Their priority on the waiting list should be determined by the same criteria applied to other NHS patients; and
• should a patient be admitted to an NHS hospital as a private inpatient, but subsequently decide to change to NHS status before having received treatment, there should be an assessment to determine the patient’s priority for NHS care.

www.nhsemployers.org/sites/default/files/2021-06/consultants-code-of-conduct-private-practice-guide.pdf

And:

"The NHS should continue to provide free of charge all care that the patient would have
been entitled to had he or she not chosen to have additional private care."

assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/404423/patients-add-priv-care.pdf

Have you also not heard of shared care? This sounds like what the OP is describing and is common practice. You can of course refuse a shared care agreement if you don't feel confident prescribing what the specialist has recommended but not because you object to people paying for private care and having medication prescribed via the NHS.

I currently see a private endocrinologist. He refers me to my GP for both testing and prescriptions. Thankfully as if I'd received adequate care by the NHS endo team, I wouldn't need to be paying to see a private endocrinologist, and it keeps the costs down a little.

It's at the discretion of the prescriber, period. So the pharmacist was within her rights to query it.

It's at the discretion of the prescriber, period. So the pharmacist was within her rights to query it.

That's not what the OP said though @GreenLunchBox She said the pharmacist made a change to the prescription and THEN checked with the GP.

Maybe it was about supply issues but the OP ought to ask.

No HRT is 'generic' by the way @Izz82 All of it has a brand name.

@sunnydaysmiles are you really a GP currently working? I know of many examples where people have an appt with a private consultant who then writes to their GP and recommends an ongoing NHS prescription for whatever they suggest as treatment. It's very rare for a GP to refuse, unless the drug is off-licence.