A practice in the York area

4. Mrs R complains that the Surgery stopped providing her hayfever medication, Dymista, without discussing this with her first.

5. She says this meant her hayfever was poorly managed for around two months because of this, making it difficult for her to leave her house.

6. Mrs R would like the Surgery to recognise that it got its handling of her medication change wrong and to make changes so that patients are reviewed before any withdrawn medication runs out.

7. For several years Mrs R had been prescribed Dymista, which is a nasal spray to treat hay fever. It consists of fluticasone (steroid) and azelastine (an antihistamine). A consultant instigated the prescription. Both her previous and current GP surgeries went on to prescribe this subsequently.

8. She asked for a repeat prescription from the Surgery in July 2024. A GP rejected this and sent her a text message. This said ‘Unfortunately Dymista is blacklisted and not prescribable. Please discuss an alternative OTC (over the counter) medication with your pharmacist.’

9. Three days later, a GP prescribed a fluticasone furoate nasal spray, which is the steroid component of Dymista. Mrs R added over the counter fexofenadine (an antihistamine) to use alongside this.

10. In early August, Mrs R complained to the Surgery about it not discussing the withdrawal of Dymista with her. She asked it to arrange a review of her hay fever medication. It sent her a text message the next day to explain it had reviewed her request and would book a routine appointment in three to six weeks’ time.

11. Upon attending the Surgery in late August for a blood test, Mrs R was seen by a GP. The GP prescribed azelastine hydrochloride, which is the antihistamine component of Dymista. This is not available to buy over the counter. Mrs R reports this working well alongside the fluticasone.

15. Mrs R complains that the Surgery stopped providing her hay fever medication, Dymista, without discussing this with her first

16. The Surgery’s responses confirm it rejected Mrs R’s prescription request for Dymista, as it was no longer commissioned to be prescribed in the NHS.

17. The Surgery acknowledged Mrs R would have preferred to have a telephone or face-toface consultation to discuss the medication change. It stated the GP had reviewed her medical records before prescribing the new nasal spray. Furthermore, it said ICB guidance does not specify the need to contact a patient to conduct such a review. The Surgery therefore stated it had handled the medication change appropriately.

18. Section 33 of GMC ‘Deciding if it is safe to propose, prescribe or provide medicines, treatment and devices’ guidance states doctors must establish a dialogue with patients to help them consider information about their options so they can decide whether to have care or treatment.

19. Furthermore, section 39 states clinicians should reach agreement with patients on the proposed treatment, explaining things like the likely benefits and risks and any follow-up arrangements.

20. Our adviser confirmed Dymista is comprised of fluticasone and azelastine. They said only fluticasone nasal sprays are available to buy over the counter, whereas azelastine nasal sprays are not. However, both can be prescribed separately.

21. Our adviser said the Surgery should have discussed the withdrawal of Dymista with Mrs R or prescribed the components as two separate nasal sprays with an explanatory note.

22. We acknowledge the Surgery did prescribe Mrs R with a fluticasone nasal spray. However, as per GMC guidance it should have discussed treatment options with her and agreed on the proposed treatment. It is clear from the evidence available that the Surgery did not do this. Moreover, the Surgery continues to deny that it needed to do this.

23. With the above in mind, we have found that the Surgery did not act appropriately when it stopped providing Mrs R with her regularly prescribed Dymista. We have gone on to consider the impact of this.

24. Mrs R says that due to the Surgery rejecting her prescription request, her hay fever was poorly managed for around two months. She says because of this, she found it difficult to leave her house.

25. Mrs R explains that she bought over the counter fexofenadine to use alongside the prescribed fluticasone nasal spray. She says that even with the added antihistamine, she needed to use her Ventolin inhaler for her asthma as her worsened hay fever symptoms impacted her breathing. Furthermore, she says she has tried numerous over the counter antihistamines which did not help manage her hay fever, hence why she was referred to a consultant several years ago. Mrs R states she could have provided this information to a GP had one contacted her to discuss the withdrawal of Dymista.

26. Mrs R contacted the Surgery on three separate occasions from early to mid August 2024. Firstly, she requested a prescription for Ventolin. She noted on the request that she required this as the replacement medication she was using for her hay fever was not effectively managing her symptoms.

27. Secondly, Mrs R requested a review of her hay fever medication as she explained that the alternatives to Dymista were not as effective, and she was therefore struggling to manage her symptoms. Lastly, Mrs R reiterated that the alternative medications to Dymista were not working effectively and again stated she was struggling to manage her hay fever symptoms. There is clear evidence, therefore, that the medication change had an almost immediate impact on Mrs R’s health.

28. Upon attending the Surgery for a blood test in late August 2024, a GP reviewed Mrs R. The GP prescribed her with an azelastine nasal spray to use alongside the already prescribed fluticasone nasal spray.

29. The Surgery sent Mrs R a follow up text message in mid-September 2024 asking how she was managing with the azelastine nasal spray. She responded the following day stating that the two sprays together were fantastic, and she was no longer struggling with her hay fever symptoms so she could now leave her house when she needs to.

30. Considering all the evidence available, it is our view that had the GP discussed the prescription change with Mrs R at the relevant time, they would have quickly realised that the OTC medication they had recommended was probably going to be ineffective. It is more likely than not that knowing this, they would have prescribed her the medication she needed either immediately or shortly after, and she would most likely have been virtually unimpacted by the change. She would not have suffered the five weeks of worsening symptoms, and she would have been better able to get out and about and enjoy her life.

1. We have decided to uphold Mrs R’s complaint. We are sorry to learn that Mrs R experienced worsening hayfever symptoms. We appreciate this must have been an upsetting time for her.

2. Our investigation has found that the Surgery did not act in line with guidance when it stopped providing Mrs R with her prescribed hay fever medication. This left her without the medication she needed, which meant her symptoms worsened and her ability to go about her life as usual was impacted for around five weeks.

3. We have made recommendations of an acknowledgement of the failing identified, an apology for the impact experienced and service improvements.