Medication/communication
14. Ms P says the Surgery refused to prescribe her required dose of HRT between February and September 2024. She also says it reduced her HRT prescription in June without any notice. Understandably, Ms P is concerned as she told us she has experienced severe symptoms in the past and is worried she would experience them again if there was a reduction in her prescription.
15. It is important to explain NICE says you should apply Estradot, one patch twice weekly. The BMS says the maximum dose should be 100mcg patches. Based on her records from April 2023 Ms P’s Estradot prescription was 350mcg. Which is three and half patches twice per week. This is more than three times the recommended dose. This high dose is referred to as an ‘unlicensed’ dose of medication.
16. GMC guidance says you should usually prescribe licensed medicines in accordance with the terms of their licence. However, you may prescribe unlicensed medicines where, on the basis of an assessment of the individual patient, you conclude, for medical reasons, that it is necessary to do so to meet the specific needs of the patient.
17. It also says you should reach agreement with the patient on the proposed treatment, explaining any relevant processes for adjusting the type or dose of medicine and for issuing repeat prescriptions.
18. Ms P’s private clinic was prescribing a higher dose of her HRT medication. When her care transferred to the NHS at the Surgery in April 2023 it continued this high dose prescription. It told us it did this on the recommendation from the private clinic. The Surgery explained to us that in January 2024 it became aware of a safety alert released by BMS which stated that the upper limits of HRT should not regularly be exceeded to ensure patient safety. It said this caused it concern about the high dose it was prescribing for Ms P without any specialist NHS input. In February 2024 it discussed its concerns with Ms P and explained it would seek advice from an NHS specialist about her prescription.
19. The records show it prescribed the higher dose of HRT for Ms P on 22 March. It sent her a text on 8 May explaining it had received advice from the specialist and booked a telephone call with her for 29 May to explain what they said. On 13 May the Surgery reduced Ms P’s HRT prescription to the licenced dose of 100mcg in line with the BMS guidance.
20. From the records we can see Ms P rearranged the phone call it booked with her to 12 June. She attended the Surgery on 4 June to raise concerns about her reduced HRT prescription. It explained to her that the advice it had received, was her prescription should be initiated by a menopause specialist because of the high dose. We can see it told her it had referred her to the local community gynaecology clinic for an urgent appointment to discuss her prescription.
21. Ms P attended an appointment with the local community gynaecology clinic on 5 June and it wrote to the Surgery the following day to request that it continue to prescribe Ms P with 350mcg patches of Estradot as due commissioning restrictions it could not fulfil her prescription.
22. Ms P attended an appointment with the Surgery on 20 June and it agreed to prescribe the higher dose whilst it found a specialist gynaecology clinic to facilitate her prescription permanently. It explained this is because it was reluctant to provide the prescription long term based on the concerns raised by the BMS’s safety alert.
23. Based on the records, there is no indication the Surgery stopped prescribing Ms P’s HRT. However, we can see the Practice reduced Ms P’s prescription in May in line with the BMS guidance but without notifying her. We are sorry to hear Ms P feels she has had to continuously fight to receive the care she needs. It is clear she has experienced symptoms for several years and the reduction of her prescription was extremely concerning for her.
24. Our adviser says GMC guidance allows for clinical judgement. Therefore, they explain it is difficult to say what the Surgery should have done in Ms P’s case. They explain the Surgery’s approach was inconsistent as it initially agreed to prescribe the higher dose of HRT. However, it was then made aware of new evidence about concerns over prescribing higher doses long-term and sought to find another service to provide Ms P with her required prescription who had specialist knowledge.
25. Based on the evidence we have seen, we cannot see that the Surgery stopped Ms P’s prescription for HRT between February and September 2024. There is evidence which shows it continued to prescribe her with HRT throughout this period. We can see the Surgery reduced Ms P’s prescription in May 2024 in line with BMS guidance, after it received new evidence which caused it concern and advice that a specialist should prescribe the higher dose. However, it did this without discussing this with her first or explaining the change.
26. Therefore, we cannot say it got anything wrong by making the decision to change her prescription because this is in line with BMS guidance, it got new evidence which caused concern, and it needed specialist advice. GMC guidelines also allow for clinical judgement. However, it does not appear to have explained any processes in relation to reducing the dose of a medication to Ms P or come to an agreement about how it would do this in advance, which is not in line with GMC guidelines.
27. It is understandable that Ms P is concerned about her long-term care plan in relation to her HRT medication as the Surgery reduced it in May and agreed to increase it on a short-term basis whilst it sought a more permanent prescription method. It is clear from what she told us that she was worried she would not be able to return to work and she would lose her job, if she did not continue on 350mcg of HRT.
28. We discussed this with the Surgery. It explained following her complaint it has reflected on Ms P’s experience and is willing to acknowledge and apologise for what it got wrong with its communication with Ms P. It told us it has already taken action by ensuring shorter waits for routine appointments to share information with patients. It also explains it would be happy to put further improvements in place to prevent the same thing from happening again and would be happy to discuss what improvements it could make with Ms P.
29. Our Principles for Remedy says that to put things right organisations provide an apology and try to offer a remedy that returns the complainant to the position they would have been in otherwise.
30. Having considered all information, we can see how the Surgery’s lack of communication about it reducing her prescription would have caused her the concern she told us about. From what she has told us it appears Ms P was distressed that she would experience the same symptoms she had in past, and this is why she was more concerned, which we are sorry to hear about. We can see the Surgery explained it reasons for the reduction to her on 4 June. Which appears to be around the time she found out.
31. Overall, we did see indications of some failings with communication. We saw no evidence of these leading to a more severe or prolonged impact. Therefore, we are satisfied the Surgery has taken this complaint, and what happened seriously, and has taken action to address these mistakes, and this is enough to put right those mistakes. We will therefore not take further action on this complaint.
32. We understand Ms P’s experience has caused her great distress, which we are sorry to hear about. We hope this statement clearly explains our decision not to consider her complaint further and gives her some reassurance the Surgery has taken her complaint seriously and addressed the failings identified.
Communication with other organisations
33. Ms P says the Surgery did not communicate with other organisations to support her prescription requirement between February and September 2024. From what she has told us this led to her feel like she was left to struggle and manage her own condition, which we are sorry to hear about.
34. There are no specific guidelines in relation to communicating with third parties about prescriptions. However, we can refer to GMC guidelines which says you must work collaboratively with colleagues and be willing to lead or follow as the circumstances require.
35. Ms P’s records show the Surgery requested advice from a menopause specialist on 23 January. The Surgery sent Ms P at text on 8 May to explain it had received advice and planned to discuss it with her in a routine appointment on 29 May. In the meantime, on 10 May the Surgery referred Ms P urgently to the local community gynaecology clinic. The Surgery did this on the local community gynaecology clinic’s behalf as it had explained it had issues with the referral.
36. Ms P attended an appointment with the local community gynaecology clinic on 5 June. It wrote to the Surgery the following day to ask it to continue to prescribe Ms P’s unlicensed dose of HRT. The Surgery agreed to prescribe Ms P’s unlicensed dose of HRT on 20 June, for a short-term period whilst it sought a more long-term solution. The local community gynaecology clinic planned to see her again in October to discuss a more long-term solution for HRT.
37. Her records show the Surgery attempted to discuss Ms P with the local community gynaecology clinic several times in July. However, it appears they were unable to make contact due to issues with availability.
38. Based on the information we have seen, it appears the Surgery did follow GMC guidelines and worked in collaboration with the local community gynaecology clinic to support Ms P with her prescription. We can see it did this through advice requests and referrals. We can also see the Surgery did make several attempts to discuss Ms P by phone with it. Whilst it appears it did not successfully make contact, we cannot say it got anything wrong here as the guidelines do not specifically say how or when it should communicate with third parties.
39. It is clear from what Ms P has told us, that this was a difficult time for her, and she felt like she was fighting to get the treatment she needed. We do not wish to underestimate how difficult it must have been to relive these events and explain her complaint to us. We are grateful for the time and effort she has taken to do this.
40. Overall, based on the evidence we have seen, we are satisfied the Surgery did not get anything wrong and followed guidance when it collaborated with third parties to support Ms P’s prescription. We will therefore not take further action on this complaint.
41. Understandably, Ms P’s experience has caused her great distress, and we are sorry to hear about this this. We hope this statement clearly explains our decision not to consider her complaint further and gives her some reassurance the Surgery has taken her complaint seriously.