A practice in the Blaby area

4. Mrs B complains about the care and treatment she received from the Practice from November 2023 and January 2024 to August 2024. Specifically, she complains the Practice: • did not issue her HRT (a treatment that replaces or adds hormones like oestrogen and progesterone to help manage menopause) medication as instructed by her private consultant • failed to clearly communicate that she required a letter from her private consultant before the Practice would agree to increase her HRT medication dosage.

5. Mrs B says she had multiple conversations with her GP and involved her MP and it was several weeks before the Practice agreed to issue the medication. She says the process was stressful and distressing. She says the delay in not communicating what she needed to get her dosage changed led to her suffering from insomnia, low mood and flushes.

6. As an outcome she would like an apology, service improvement and financial compensation for the distressed caused.

7. In August 2022 Mrs B informed her GP she was struggling with managing her menopause symptoms. Due to Mrs B’s history of breast cancer, she was referred to the complex menopause clinic (the clinic).

8. In September 2022, the clinic informed the GP Practice that it had 16 months waiting time and recommended it submit its request using the advice and guidance triage service, which it did. In October the clinic responded with a list of treatment options available to Mrs B.

9. In November, the Practice discussed the response from the clinic with Mrs B and she was started on gabapentin (to treat nerve pain) and to be reviewed in four weeks.

10. In November 2023, Mrs B informed her GP that she wished to be given HRT.

11. The GP sought advice from the clinic using the advice and guidance triage service. In December 2023, the GP received a response from the clinic, but it did not clarify whether Mrs B could receive HRT. In January 2024, the GP went back to the clinic. In February they received a response to send a referral for Mrs B to be seen in person.

12. In January 2024, Mrs B was seen at a private menopause clinic. In February 2024, the Practice had an informal agreement with Mrs B’s private consultant to prescribe HRT.

The Practice did not issue HRT medication as instructed by her private consultant

15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. Having done so we have found the Practice has already done enough to put right the impact of these events.

16. Good Medical Practice, domain one, section 7 states ‘[doctors] to promptly provide (or arrange) suitable advice, investigation or treatment where necessary’.

17. Domain one, section 7 states ‘[doctors] must propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when [doctors] have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs’.

18. GMC guidance on prescribing medication, paragraph 26 states ‘[doctors] must only propose, prescribe or provide medicine, treatments or devices if it is safe to do so. It is not safe to propose, prescribe or provide medications, treatment or devices if you don’t have sufficient information about the patient’s health or if the mode of consultation is unsuitable to meet their needs’.

19. BMA guidelines states ‘if requested by a private consultant to initiate or continue prescribing medications, and if the GP agrees with this advice, then this could be appropriate. However, if the GP does not feel competent to prescribe the requested medication, or they do not know of the medication best serves the patient’s need, the GP should inform the private provider that the prescription should be provided by a specialist’.

20. In January 2024, Mrs B asked her GP if it could prescribe HRT as she felt this was the only medication to help manage her symptoms. The GP submitted a request to the clinic for advice on HRT and whether it was suitable to prescribe to Mrs B.

21. Mrs B told us she was seen in a private menopause clinic. On 1 February she emails a copy of the letter from the private clinic to her GP and asked that it prescribe HRT medication.

22. We reviewed the letter from the private clinic Mrs B attended on 23 January 2024. The letter is not addressed to the GP but to her breast surgeon asking for their opinion and discussion regarding prescribing HRT. As the letter did not require the GP Practice to do anything it opted to wait until it had received a response from Mrs B’s breast surgeon.

23. On 2 February Mrs B sent the GP Practice an email trail between herself and her private clinic. The menopause specialist nurse had suggested the Practice prescribe Mrs B a trial of lenzetto HRT, whilst it waited for a response from the breast surgeon.

24. Mrs B’s GP reviewed the email but was not happy to issue a trial of the HRT until information came back from the breast surgeon. It received a response to its follow up from the menopause clinic. The GP’s decision to not prescribe HRT based on the information Mrs B provided is in line with the GMC guidelines and BMA guidelines.

25. On 14 February, the GP received a response from the clinic to refer Mrs B to the clinic for further consideration, if she still wanted HRT. On 23 February, the GP had a discussion with Mrs B and her husband. It discussed the advice received from the clinic and Mrs B’s breast surgeon. The GP agreed to then prescribe HRT.

26. Having considered the guidelines, we cannot see any indication of failings on the part of the GP in relation to the prescribing of HRT.

27. We are sorry for how this experience has undeniably caused Mrs B distress.

Communication: she required a letter from her private consultant to agree to increase her HRT medication dosage

28. Mrs B says she spoke to the GP on several occasions to have her HRT medication increased but the GP told her it could not be done. She said the Practice failed to communicate to her that her private consultant needed to write to her GP, before it would agree to increase her HRT medication dosage.

29. GMC Good medical practice paragraph 29 states ‘[doctors] must make sure that the information they give patients is clear, accurate and up to date, and based on the best available evidence’.

30. The Practice policy states all communication from external providers regarding medication changes must be received in writing, clearly identifying the responsible clinician. The communication should include the rationale for the dose change, any necessary monitoring requirements, and potential side effects. On receiving the request, the Practice will review the recommendation, considering the patient’s medical history and current treatment plan. If the GP agrees with the recommendation they will proceed with the dose change.

31. We reviewed Mrs B’s medical records and note on 15 March 2024, Mrs B asked the GP to increase her medication dosage from one pump to two. The Practice agreed to this. It also advised it would get advice on the dosage increase and associated risk. On 18 March the Practice wrote to Mrs B’s consultant breast surgeon for advice.

32. The Practice received a response from Mrs B’s consultant breast surgeon which stated that Mrs B had been advised to stop HRT in six months from the date it was prescribed with gradual reducing dose.

33. We have seen evidence that Mrs B requested her GP change her prescription in October. On 14 October, the GP raised a task to inform Mrs B that dosage of repeat prescriptions could not be changed without a letter from the hospital or private nurse. On 16 October, the Practice left a message for Mrs B explaining that it required a letter from the hospital/private nurse to change the prescription.

34. On 25 October, the GP increased Mrs B medication from two pumps to three pumps.

35. From the evidence we have seen the Practice did communicate to Ms C the information it required from her before considering a change in prescription. This is in line with GMC and the Practice policy. Therefore, we find no indication of failing.

36. We thank Mrs B for bringing her concerns to us. We recognise our decision may be disappointing to her but we hope she found the explanation above helpful.

1. We have carefully considered Mrs B’s complaint and the care and treatment she received at the Practice. We are sorry to hear about Mrs B’s experience. We understand this would have been a very7 worrying and distressing time for you.

2. We have seen the Practice acted in line with the guidance when it considered Mrs B request to be prescribed hormone replacement therapy (HRT) and when she requested a dosage change.

3. We have explained the reason for our decision below.