Testosterone prescribing in menopause

Testosterone prescribing in menopause has been an ongoing area of complexity across NHS Grampian, with variation in practice and uncertainty about referral, prescribing and monitoring responsibilities. 

A referral pathway had previously been developed, but had not progressed to implementation, reflecting wider system uncertainty and the challenges of defining a workable model across primary and secondary care. 

Clinical Interface Group (CIG) discussions highlighted a number of barriers:

• Unclear ownership of prescribing and monitoring
• Limited secondary care capacity to manage ongoing treatment
• Variation in confidence and approach within general practice
• No agreed service model or funding route for prescribing or monitoring
• Risk of inconsistent access for patients 

A significant number of patients were already receiving testosterone, but without a consistent approach across the system to support safe and equitable care.

The CIG supported a structured, staged approach to move the work forward. This included:

• Starting with clear referral criteria and pre-referral checks
• Developing practical tools to support consistent GP assessment
• Breaking the work into phases rather than trying to resolve prescribing, monitoring and service delivery all at once
• Exploring service delivery options across the interface, including primary care prescribing supported by specialist advice
• Working iteratively with GP Subcommittee to build understanding and agreement over time
• Considering funding and contracting alongside pathway development to support a sustainable model 

This has allowed the work to move forward while keeping people engaged and confident in the direction of travel.

In reality, this has taken time and not everything has been agreed at the same pace, but breaking it down has helped keep progress moving.

In practice, this will start to improve consistency and access for patients through:

• More structured and consistent assessment prior to referral
• Better targeted referrals and reduced variation in care
• A clearer and more equitable approach to how patients access treatment across Grampian
• The development of a model that is sustainable over time  

Outcome

• Referral guidance and supporting tools have been developed
• A clear staged delivery approach is in place
• The work has progressed from a stalled position to an active programme of development 

Key Learning

• Breaking complex interface work into manageable stages supports progress
• Service development requires interface working, not just pathway design
• Ongoing engagement with GP Subcommittee builds shared ownership
• Clarity on funding and contracting is essential to enable implementation

For more information on this case study, please contact scotland.interface@rcgp.org.uk