Most over-the-counter requests end with a sale. A small number end with the pharmacist saying no — or, more precisely, saying "I'd like you to see a GP first". That refusal is not arbitrary. It follows a short list of well-established red flags that every pharmacist is trained to screen for, and that the General Pharmaceutical Council expects registrants to apply.

This guide walks through the most common situations where supply is declined, from the pharmacist's side of the counter. It is not a comprehensive clinical reference — it is an explainer aimed at patients who have been refused and want to understand why.

The underlying rule

Supply of any pharmacy (P) or general sale (GSL) medicine carries a duty of care. The pharmacist is not a cashier. Every P request requires an assessment — indication, duration, concurrent medicines, red flags — and if the assessment suggests the problem is not self-manageable, the correct action is to refer. Refusing supply is the same professional decision as referring to a GP; it just looks different at the counter.

The common red flags, by medicine class

Loperamide (diarrhoea)

Loperamide will not be supplied when the patient reports bloody stools, persistent fever, diarrhoea longer than 48 hours, recent foreign travel with systemic symptoms, or any suspicion of inflammatory bowel disease. The reason is that loperamide slows gut motility, which can worsen the course of dysentery or toxic megacolon in ulcerative colitis. Patients under one year old cannot have it at all, and under-12s need a GP.

Codeine-containing analgesics

Co-codamol 8/500 and similar products are licensed for short-term pain relief — three days is the standard supply limit under the pharmacy code. A pharmacist will decline a purchase that looks like dependency use: repeat visits, requests for multiple packs, patients switching pharmacies to accumulate supply, or where the patient admits longer-term use. Codeine is a weak opioid and physical dependence can develop within weeks.

PPIs (omeprazole, pantoprazole, famotidine, etc.)

Short-course PPI supply is routine. Repeat requests are not. If a patient returns for a third or fourth OTC course of omeprazole for the same reflux, the pharmacist will refer to the GP rather than continue supply. Long-term PPI use can mask a more serious cause of symptoms — oesophagitis, H. pylori infection, or in rare cases early upper GI malignancy — and needs proper investigation. Red flags that trigger immediate referral include difficulty swallowing, unintentional weight loss, vomiting blood, or black stools.

Topical steroids

Hydrocortisone 1% is P for short-term use on small areas of inflammation. It will be refused for use on the face (except a specific short-course eczema brand), for use on broken skin, for suspected fungal or bacterial infection, or in children under 10 without medical advice. Chronic use of topical steroids on the face can cause perioral dermatitis and skin atrophy.

Ibuprofen and other NSAIDs

Ibuprofen looks benign but carries real contraindications. A pharmacist will decline supply in patients with active peptic ulcer disease, in the third trimester of pregnancy, in anyone taking warfarin or a DOAC without discussion, and in patients with severe renal impairment or heart failure. Asthma history is a more nuanced check — aspirin-exacerbated respiratory disease is rare but genuine.

Emergency contraception

Pharmacist-supplied emergency hormonal contraception follows a structured consultation. Supply may be deferred if the patient is outside the licensed window (72 hours for levonorgestrel, 120 for ulipristal), is on an interacting medicine, or where there is safeguarding concern with a very young patient. The consultation is confidential but the safeguarding layer is non-negotiable.

Cough medicines in children

Most children's cough syrups cannot be sold for children under six, and the few licensed for 6–12 year olds are restricted to short-course use. The MHRA tightened the rules a decade ago after a review of paediatric cough medicine safety, and pharmacists will refuse to sell an adult-strength product for a child even at parental insistence.

What a refusal actually looks like

The conversation at the counter follows a predictable shape: the pharmacist asks a few questions — how long have you had this, have you had it before, what else are you taking, any other symptoms. If a red flag surfaces, the pharmacist will say something like "I'd rather you saw your GP about this" and will usually help the patient work out how to get an appointment. For urgent red flags — bloody stools, suspected meningitis, chest pain, anaphylaxis triggers — the pharmacist will refer directly to A&E or call an ambulance.

The pharmacist may also refuse if the request looks like it is for someone else without that person being present. "It's for my husband" is not always a problem, but "it's for someone I don't know, they're in the car" is — consent and dose appropriateness can't be confirmed.

Why the rules exist

Pharmacy medicines are a deliberate category that sits between prescription control and open sale. The justification for that category is the pharmacist's assessment — without which every P medicine could just as well be a GSL. The refusal, in other words, is what earns the medicine its P status.

What to do if you're refused

Most refusals come with a route forward: a GP referral, an NHS 111 number, or a signpost to a local urgent treatment centre. If the refusal feels arbitrary, ask the pharmacist to explain which red flag triggered it — they are trained to do this, and the General Pharmaceutical Council's standards require it. A second pharmacist may reach the same conclusion, but rarely for a different reason.

For specific conditions and the Pharmacy First pathway that lets a pharmacist supply prescription-only medicines for seven common illnesses, see Pharmacy First eligibility. For branch locations and opening hours, PharmSee's pharmacy finder covers every NHS community pharmacy in England.

Caveats

The examples above describe the standard professional response as set out by the Royal Pharmaceutical Society's Responding to Symptoms resource and the GPhC's Standards for Pharmacy Professionals. Individual pharmacists may reach different judgements based on the consultation, and local variation is expected.