Off licence dosage and GP surgery

[backinthebox]

Last year I was prescribed an off licence dose of oestradiol after blood tests showed I was a poor absorber. I saw a private menopause doctor for advice, and she wrote to my GP suggesting 125mg of patches. She also suggested I would benefit from testosterone gel. She stipulated that I would need follow up blood tests to check on this if I was to continue on the higher dose of oestradiol and the testosterone. On the basis of this consultation, my GP agreed and prescribed me 125mg of Evorel. I found I had allergic reactions to the adhesive in these so was switched to Estrodot, but the shortage of this means that for the last 2 times I have been given Estraderm. These are big and crinkly, but they seem to work and on this regime I finally feel like HRT is working for me. The GP continues to prescribe Estrodot, in case it comes back in stock, but says the SSP procedure should see me given Estraderm if the pharmacy doesn’t have Estrodot in stock.

The last 2 times I’ve been to pick up my prescription, the pharmacy have refused to give me estroderm, as the prescription says Estrodot and they don’t have that and can’t get it. They have Estraderm on the shelf but they insist they cannot give me it. I’ve driven to a different pharmacy and been given it no problem as an allowable substitute. This time I insisted, they took my prescription back to see a GP (it is a dispensing surgery as we are very rural, hence my reluctance to drive elsewhere as the next nearest pharmacy is a long way away) and the questioned GP, who has never met me or read my notes, said I could not be prescribed the dose on the prescription, it is a new NHS rule, and actually told the pharmacy to not dispense it. I asked to see my doctor to clarify this, and was told there is a 3 week wait.

Has anyone come across a new NHS rule that a GP who does not know me can overrule a prescription that has been written for me by a GP who does know me on the advice of a specialist who has seen me and taken blood tests? I am beyond raging. I’ve complained to the practice manager, but she was useless. I’m really not sure where to go next, but cannot just sit here with no HRT prescription.

The GP is within his rights to not prescribe , no GP has to prescribe anything that has been recommended by a private doctor and they also shouldn’t prescribe anything that they are not happy with ie very high dosages etc as they are responsible for what they prescribe . Go back to the private dr , get him to write you a private prescription and pay or get a GP appointment and see what they will do for you .

'fraid I agree with the poster above.

Your GP is not obliged to follow 'instructions' from a private doctor.
There was also some directive from the BMS a while back which was about too high estrogen doses being prescribed and how they thought they were unnecessary.

You have a couple of options -
swap to gel, which you may find works better than patches and you can use up to 4 pumps which is a 100mcg patch dose.

Go back to the private dr, get a private prescription and the pharmacy will dispense that.

I switched to patches because I was not absorbing enough from the gel. I also have another issue with gel which I don’t need to discuss here, but which makes patches the better option for me. I made the switch on recommendation from the private doctor with agreement from my GP. The private doctor wrote to my GP about the higher dose and the GP was in agreement. I think the thing neither poster who has taken the time to reply has quite understood is that my GP has prescribed the off licence dosage - I have the paper prescription here in my hand, with my GP’s signature on it and only had an appointment with her (all the doctors involved are her, not him!) about it in March, after my most recent blood test. I understand that a doctor does not have to prescribe something off licence, however my GP has prescribed it, but the dispensary will not dispense it and when I questioned this they asked a GP who is not my GP and without ever even meeting me or reading my notes this GP altered my prescription.

But they couldnt have given you what was on your prescription anyway be cause they didnt have it? You said they wouldnt give you the substitute before so you went to another pharmacy. So it doesnt really matter what that gp said they wouldn't have given you anything anyway?

I did read what you wrote and will reiterate what I said , the GP that the pharmacist asked is not obliged to prescribe anything so you have options - private dr and pay for the script and meds or see your own GP who has agreed and get them to re prescribe it . The fact remains that the GP who was asked is not happy to do so and you can complain to whomever you like but the GP is still within his rights to say no .

This time I insisted, they took my prescription back to see a GP (it is a dispensing surgery as we are very rural, hence my reluctance to drive elsewhere as the next nearest pharmacy is a long way away) and the questioned GP, who has never met me or read my notes,

So the pharmacist physically took your prescription to the GP surgery and asked that GP? (Who is not your usual GP.) What were they asking and why?

There seem to be two different issues going on here-

1 The pharmacy won't substitute the out of stock patch with another (which they are obliged to do.)

2 Why would the pharmacy take your prescription to a GP anyway? It's not their role to oversee a dose- their role is to dispense.

Have you tried contacting your GP yourself and explaining the problem?
This isn't a GP problem it's a pharmacy problem.
Why would the pharmacy query the dose anyway? If it's on your records at the pharmacy that you've already had that dose, why question it with a GP?

@tinyspiny My understanding is that one GP authorised the high dose but they weren't available at the time when the pharmacy queried it.

@JinglingSpringbells yes I get that but what I’m saying is that the GP a that was on duty and was asked is not obliged to prescribe the non licensed dose even if it’s on the OPs notes as they are responsible for what they prescribe and can decline to do so . Re the pharmacy asking the GP I’m assuming that it is like our GP where there is a pharmacy onsite as it’s a village practice so they are all coworkers . Totally agree with you that the pharmacy should only give out what is on the prescription not do substitutions off their own back as again they are responsible for what they dispense .

OP the issue I think is with the pharmacy. If I were you I would print off the SSP which states that community pharmacies can/must substitute Estradot for Evorel or Estraderm MX. Actually point to it on the SSP! Or go to another pharmacy. Annoying!
https://cpe.org.uk/our-news/three-new-ssps-issued-for-estradot-patches/

Seem not to be getting anywhere here, but I’ll try and explain again @tinyspiny.

1. My GP is happy to prescribe a higher, off licence dose of Oestradiol patch for me. She (not he! I find the ‘default male’ assumption irritating here) wrote the prescription for me last week, and asked me to collect it from the rural practice pharmacy attached to the surgery once I got a message to say it was ready. This is the way it normally works.
2. The GP (after discussing this at my recent appointment with her) said she would prescribe Estrodot in case it unexpectedly came back into stock, but that I was unlikely to get it as nowhere can get it, but the pharmacy can subsitute Estraderm for this under the current nationwide Serious Shortage Protocol (SSP.) This does not need the GP to be involved - it is a government approved substitute with a published protocol available for anyone to read, and any pharmacy to act on. All of this has been discussed with my GP when I had an appointment with HER a couple of months ago. She did not require me to see her each time I need a repeat prescription, as long as I have regular blood tests (which I do, I had one today) so she can keep an eye on things.
3. The pharmacy decided not to carry out the substitute (the substitute that has been recommended by my GP and agreed by me at an appointment, and that is recommended as the approved substitute under the SSP protocol.)
4. I asked the pharmacy why they were not acting on government guidelines and my GP’s prescription instructions.
5. The pharmacy staff went next door with my prescription to the first GP they could find, who was in the same practice as but not my GP, to check if it was allowed to substitute Estraderm for Estrodot.
6. The GP (who is in the same practice as mine, but who has never met or treated me) said this was an off licence dose and could not be dispensed.
7. On the basis of this discussion between a dispensary assistant and a GP with no working relationship to me I am now left without a HRT prescription, and the recommendation that I need to make an appointment to see my GP, despite the fact that I got this prescription as a direct result of a recent appointment with my GP.

If you have got this far, well done. If you’ve got this far and still cannot see the problem, then I think that perhaps you are someone I probably wouldn’t be taking any advice from anyway.

My original question was - is another GP able to overrule my prescription that I have received from my own GP, who has been happily prescribing this dosage after reviewing my quarterly blood test results in conjunction with advice from a menopause specialist, without any input from the prescribing GP? Because that is what I have been told today, and I thing this is not correct. However the pharmacy staff insist that a very recent rule change says that it is correct.

@JinglingSpringbells
^So the pharmacist physically took your prescription to the GP surgery and asked that GP? (Who is not your usual GP.) What were they asking and why?
There seem to be two different issues going on here-
1 The pharmacy won't substitute the out of stock patch with another (which they are obliged to do.)
2 Why would the pharmacy take your prescription to a GP anyway? It's not their role to oversee a dose- their role is to dispense.
Have you tried contacting your GP yourself and explaining the problem?^

Yes, the dispensary assistant took my prescription to the GP surgery (they are in the same building.) The GP she spoke to is not my usual GP, it was one I have never met before. They were asking if they should substitute the brand of patch, and that is when the GP said she should not dispense it because it was a higher than licensed dose. I asked to see my GP immediately after this and was told the next appointment with her is in 3 weeks time. I will be out of the country by then, and cannot see her after that until the end of June, by which time I will have run out of HRT. The only other step available to me after that was to speak with the practice manager to explain the problems I was having. I am seeing my private doctor next week though, and will pay for a private prescription if necessary, but it seems pointless when my GP has already declared that she is happy to work with my specialist and prescribe what they recommend in order to save me the cost and inconvenience of a private prescription.

And if we are on the subject of not dispensing off license pharmaceuticals, I am very concerned for my testosterone prescription next time I go to collect that, because it is not licensed for women at all in this country, yet still I am able to get it thanks to my GP working in cooperation with the advice from the specialist.

So complain about the pharmacy and stop bringing the other GP into it as they have done nothing wrong .

What you're describing is quite easy to grasp although it's unusual what has occurred.

Yes, the dispensary assistant took my prescription to the GP surgery (they are in the same building.) The GP she spoke to is not my usual GP, it was one I have never met before. They were asking if they should substitute the brand of patch, and that is when the GP said she should not dispense it because it was a higher than licensed dose.

Maybe the fault lies partly with the dispensary asst- the pharmacist should have done this, not an asst. The pharmacy should KNOW which drugs can be substituted without having to ask a GP! They get weekly and monthly updates of shortage drugs and the subs listed.

It's not clear that you are sure who did what- an asst or the pharmacist.

A pharmacist should have queried why a GP (not yours who licensed this high dose) was able to overrule the prescription.

I think you need to speak to the pharmacy /manager (Often the same person) and ask them. Pharmacists have a lot of authority whereas a dispensing asst has not.

I know you say the pharmacy has told you that another GP can overrule an absent GP which may be the case. From what you say this may all have been communicated by an asst, not the pharmacist.

It may be that the law has been changed and a 'stand in' GP can overrule an off-licence script, although if you have a physical script in your hand it's SIGNED by the absent GP this is hard to understand.

Can't you insist on a phone call with the GP who authorised your patches?

Re the testosterone, I have it prescribed for HRT. Whilst getting this far was a pain in the arse, I’ve never once had an issue with any pharmacist issuing it.

The issue @backinthebox is with the pharmacy.
There was no need for the pharmacy asst ask a GP.

This is in the Community Pharmacy England info (website)

UPDATE: 03/04/2025
Update to communications issued on 19 December 2024. Material updates are shown in bold

• Estradiol (Estradot®) 25micrograms/24 hours and 50micrograms/24 hours transdermal patches will be out of stock until late April 2025

• Limited supplies of estradiol (Estradot®) 75micrograms/24hours and 100micrograms/24hours transdermal patches are available until late April 2025.

• Estradiol (Estradot®) 37.5micrograms/24 hours patches will be out of stock from late-April until July 2025.

• Alternative brands of estradiol patches (Evorel® and Estraderm MX®) across these strengths are available and can support a full uplift in demand.

The new GP is probably more up to date with guidelines which state that if your Oestrogen prescription is 100mcg or above, you need to increase your progesterone (unless it’s a Mirena)

I have no idea if the GP is new or not. However, I have a Mirena thanks. Thanks to the comprehensive consultations I’ve had with both specialist and my own GP.

I work in a GP surgery (although am not a doctor). It’s not uncommon for pharmacies to query prescriptions. Some are much better at issuing alternatives under the SSP than others.

Secondly, GPs can & will cancel a prescription issued by a colleague at the practice if they feel a mistake has been made. At my practice, any enquiry like this would go to Duty Dr for the day - not to a patient’s own GP who may or may not be in surgery.

Just to add, it is practice policy for our GPs not to prescribe off licence doses of HRT, under guidance from the local ICB.

Are you missing something OP said?

She has the paper prescription - it's not as if the other GP had to re-issue one.

The prescription was handed to the pharmacy who queried the substitution, not the dose. It was then that the 'new' GP picked up on the dose.

Cancel it even when the patient has the prescription in their hand and it's on their notes as being issued?

@backinthebox Given the patch is out of stock until at least July, your GP should issue you with an alternative which is easily available.
It's a bit pointless re-issuing it for Estradot when it's not available.

Your other option meanwhile is to go back to the private consultant and get them to write your 2 prescriptions, for a month or two each, one for Estradot and the other for a patch that's available.

You can then pick up either at any pharmacy that has them.

You can also submit these private prescriptions to online independent pharmacies who do 'mail order' and they will post them to you.

Obviously they will charge the RRP and not the NHS cost but it may be better that all this to-ing and fro-ing.

@JinglingSpringbells this is where I am at I think. Although it will be hugely frustrating when the whole reason I went to a private doctor to begin with was because my GP told me she thought I needed a higher dose, referred me to the local NHS menopause clinic as she said she could not initiate a higher dose under the practice guidelines but could continue to prescribe it if a specialist recommended it, and then (on discovering this NHS clinic had a waiting time of 22 months) she told me I should use a private specialist if my health insurance covered it. So I have followed my GP’s advice every step of the way here. It’s just really frustrating that despite doing this, the practice pharmacy staff and the other GP between them have decided that my GPs considered approach should be overruled.

I can't understand why the 'new' GP would refuse when you have (if I'm right?) the prescription in your hand! It doesn't seem ethical to overrule another GP when they are not there to talk to.

Maybe you would consider using the private doctor for your HRT and not involving your GP?

My HRT is private and has been for years. (Initially I saw my gynaecologist for something else- not meno- but stayed with them.)
I have to pay for my HRT as it's private prescription but I feel it's worth it.

If you do it privately, you can usually have a review every 6 months and get 6 months of HRT on one prescription and can take the prescription to any pharmacy, anywhere.

Your health insurance won't usually cover menopause - maybe the 1st appt for symptoms but not long term.

Yes. The only way you couldn’t cancel it is if it’s handwritten, but most are computer issued & printed these days and can be cancelled up until the point of the pharmacy dispensing them.

You’re lucky the GP has agreed to prescribe something on the day so of a private doctor.

and yes - they’re within their rights to refuse to prescribe something on the day so of the pharmacy or in fact anyone. And the pharmacist can refuse to dispense an alternative preparation from what’s on the prescription which is why prescribers will often put the generic drug rather than a brand name