Shared care is a term used within the NHS to describe the situation where a specialist doctor wishes to pass some of the patient’s care, such as prescription of medication, over to their general practitioner (GP). This is something that can be requested but the guidance for all medications is that this may only be done if the GP agrees. The GP will need to consider a number of factors to decide if this is safe.
The General Medical Council (GMC) mentions shared care in their guidance:
|80 If you share responsibility for a patient’s care with a colleague, you must be competent to exercise your share of clinical responsibility. You should: a. keep yourself informed about the medicines that are prescribed for the patient b. be able to recognise serious and frequently occurring adverse side effects c. make sure appropriate clinical monitoring arrangements are in place and that the patient and healthcare professionals involved understand them d. keep up to date with relevant guidance on the use of the medicines and on the management of the patient’s condition
81 In proposing a shared care arrangement, specialists may advise the patient’s GP which medicine to prescribe. If you are recommending a new or rarely prescribed medicine, you should specify the dosage and means of administration, and agree a protocol for treatment. You should explain the use of unlicensed medicines and departures from authoritative guidance or recommended treatments. You should also provide both the GP and the patient with sufficient information to permit the safe management of the patient’s condition
82 If you are uncertain about your competence to take responsibility for the patient’s continuing care, you should ask for further information or advice from the clinician who is sharing care responsibilities or from another experienced colleague. If you are still not satisfied, you should explain this to the other clinician and to the patient, and make appropriate arrangements for their continuing care.
If care is transferred, then from this point the primary care prescriber will be responsible for the prescriptions they sign and they must be prepared to explain and justify their decisions and actions. They must also ensure adequate monitoring. This is a significant responsibility and decisions must be made carefully bearing this in mind.
The GMC states that when taking on prescribing, all clinicians must keep informed about the medications they prescribe. They need to be able to recognise serious and adverse side effects and ensure that appropriate clinical monitoring arrangements are in place.
In shared care arrangements then the prescribing Consultant or specialist team would still remain responsible for parts of the patient’s care. These should be defined in the shared care arrangement and usually include any changes to the medication regime or any complications related to the medication. The presence of a specialist is also essential for the GP to be deemed to be operating under ‘shared care’. Shared care is not ‘shared’ unless it is shared by the GP with someone else. Without this then GPs may be deemed to operating outside of Good Medical Practice.
We are aware that there are multiple issues that are affecting patient hospital waiting times and that ICBs and our secondary care colleagues are working hard to try to address these. It is recognised that General Practice is also struggling to meet patient needs. GPs need to be mindful of focussing on undertaking essential services to patients first and foremost before agreeing to take on extra work on top of this. They should not be asked to work beyond their competences or over safety limits in order to cover long waiting times for other services or commissioning gaps.
If GPs feel that it is not appropriate for any reason for them to take over this extra work then appropriate arrangements for their continuing care would be as a default that the prescribing should remain with the specialist service. This may not be what the specialist service expects to happen. If there is any difficulty then please let the LMC know.
NHS providers within your ICB
We would expect the provider to be appropriately accredited and practising in line with UK best practice and willing to follow locally agreed protocols for shared care.
Alternative NHS providers
If a GP is asked to refer to an alternative NHS provider, we would expect the provider to be appropriately accredited and practising in line with UK best practice and willing to follow your locally agreed protocols for shared care.
We would expect the local commissioning teams, in ICS local to the practice, to provide assurance that the alternative NHS provider is appropriately accredited and that the provider is willing to work to locally agreed protocols and has appropriate channels for shared care and expert access as they are effectively commissioning this service albeit vicariously. So, if a patient asks for a referral to an ‘alternative’ NHS provider that the Practice are not familiar with the Practice may wish to seek assurance from their local ICB that the provider has been assessed by them as the commissioner to have the correct parameters for safe shared care arrangements in place.
Right to choose providers
In the current climate it is understandable that some patients are exercising their ‘right to choose’ and requesting referral to independent providers who hold an NHS contract with ICBs outside of Wessex. Some providers are advertising NHS assessment and shorter waiting times.
Patients choosing such services and their GPs should be mindful that some services will only diagnose and will not prescribe or provide the secondary care part of a shared care arrangement. This should be taken into account by the General Practice and the patient when making their decision of whether it is appropriate to refer to those providers only making a diagnosis in terms of what the patient is hoping for as an outcome.
We would expect the local commissioner to provide assurance that the Right to Choose provider is appropriately accredited. The commissioner should also provide assurance that the provider is willing to work to locally agreed protocols and has appropriate channels for shared care and expert access as they are effectively commissioning this service albeit vicariously. The practice may wish to check this with their ICB team prior to referral.
Regarding GPs accepting diagnosis and shared care agreements with private providers we believe that the same principles of the GP being satisfied that the provider is appropriately accredited, practicing in line with UK best practice and will prescribe and monitor patients in line with locally agreed pathways apply. We would expect the private provider to provide evidence to assure GPs that they are meeting all the parameters in our checklist as part of good shared care.
NHS shared care protocols do not apply to private contractors, but a GP may consider extrapolating the principles of such an agreement to share care with a private provider if they choose to. GPs can therefore agree if they feel competent and confident in the private provider.
If the private provider does not provide such evidence or it is not clear of what systems are in place then the Practice should take this into account when making their decision of whether or not it is appropriate to enter a shared care arrangement with a provider.
If the GP does agree to take on prescribing there would need to be agreement with the patient about what would happen should they cease to have regular follow up with their private provider for whatever reason. The patient would need to understand that the GP would need to stop prescribing and would refer the patient to the NHS with understanding that prescribing would not resume until seen and approved by this service. GPs are not in control of waiting times for NHS services.
Ultimately the decision to accept the transfer of prescribing and monitoring care rests with the GP.
Nature of the arrangement
It is also important to remember that formal shared care arrangements, be they NHS or Private, are voluntary on the part of the GP and the GP should be mindful of their own clinical competence and workload capacity when considering agreeing to enter into such an arrangement. Workload requested for an individual patients will need to be considered in balance with the reasonable needs of the practice population and whether further workload can be absorbed by the practice team safely.
Specialist services should only transfer care to primary care if the GP agrees to do so. This step is often forgotten and taken for granted as a fait accompli by secondary care. It should not be. A practitioner’s requirement to work safely within their own competences should be respected to keep patients safe. Practice capacity to safely take on the associated workload of both prescribing and monitoring requirements should also be taken into account. These are both vital aspects of safe patient care.
In the interests of fairness, consistency and patient safety it may be useful for practices to have an agreed practice policy and review process for assessing requests for shared care with NHS or private providers.
The LMC suggests that practices may wish to consider including the following factors in their decision making when reviewing requests. The LMC would suggest that this is done at a practice level rather than individual practitioner level as these medications often involve a number of members of the team to be involved and therefore they all need to have capacity to take on the extra workload for the processes to be safe. You may also wish to discuss this as a PCN so there is a consistent approach between practices.
- Has the specialist sought agreement of the GP before transferring any care or prescribing?
- Are you signed up to an LCS that includes this medicine? (if yes this would only apply to NHS providers).
- Do you feel that the prescribing and awareness of all side effects and complications falls within the scope of your medical practitioners’ professional competence and their workload capacity?
- Are there adequate resources, training and sufficient capacity for the work of managing safe systems for monitoring and prescribing for this medication in your practice before care is transferred?
- For NHS providers, are they locally commissioned or approved by your ICB as working in line with UK best practice and local prescribing guidelines/shared care protocols?
- For private providers are you satisfied that the provider has demonstrated to you that it is appropriately accredited, practicing in line with UK best practice and will prescribe and monitor patients in line with locally agreed pathways apply?
- How would you manage prescribing if a patient, for whatever reason, is unable to continue follow up with a private provider?
Example Checklist for Practices to consider using:
|The specialist has sought agreement of the GP and made clear the nature and responsibilities of each party of the shared care arrangement before transferring any care or prescribing and you feel assured by what you have seen
|Are you signed up to a shared care LCS that includes this medicine? (if yes this would only apply to NHS providers).
|Do you feel that the prescribing and associated knowledge required falls within the scope of your team’s professional competence
|Do you feel this falls within your team’s workload capacity?
|Are there adequate resources and sufficient capacity for the work of managing safe systems for monitoring and prescribing for this medication in your practice?
|For NHS providers, are they locally commissioned or have they been approved by your ICB as working in line with UK best practice and local prescribing guidelines/shared care protocols?
|For private providers are you satisfied that the provider is appropriately accredited, practicing in line with UK best practice and will prescribe and monitor patients in line with locally agreed pathways apply?
|For those under private providers – Has there been an agreement with the patient that prescribing will cease, if the patient for whatever reason, is unable to continue follow up with a private provider?
If the answer to all of these are satisfactory or positive then a GP Practice would be likely to approve the request for the sharing of care. If one or more of these considerations is not met then it would seem sensible to decline the transfer.
In this case then the specialist will need to continue to prescribe and monitor.