Royal College of General Practitioners - Online Learning Environment

Written by Dr Toni Hazell

Shared care is defined by NHS England (NHSE) as ‘a particular form of the transfer of clinical responsibility from a hospital or specialist service to general practice in which prescribing by the GP, or other primary care prescriber, is supported by a shared care agreement’¹. Shared care drugs tend to be those which we would not start in primary care, but where ongoing prescription by the GP is felt to be safe. This makes life easier for the patient, who can get all of their medications in the same place but moves the medicolegal prescribing responsibility from the specialist to the GP. In order for this to be safe, there has to be a shared care agreement in place, with good communication between the specialist and the GP (in both directions). 

Most of the key references in this blog are from NHSE and therefore pertain only to England – shared care issues in the devolved nations of the UK are generally agreed by individual health boards (Scotland/Wales) or health and social care trusts (NI) and so equivalent information should be sought from them.

The NHSE list of shared care drugs² includes disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate and leflunomide, lithium, medications to treat ADHD in adults, sodium valproate for patients of child-bearing potential and ciclosporin for patients using it for a non-transplant indication. The NHSE list is not exhaustive and some ICBs have shared care protocols for medications which aren’t on the NHSE list, including testosterone as part of HRT³, denosumab for the prevention of osteoporotic fractures⁴, and cinacalcet for primary hyperparathyroidism⁵. The GP responsibilities will vary by drug; examples include 3-6 monthly height, weight, blood pressure and pulse for children on ADHD medication and monitoring bloods, usually every three months, for DMARDs. Some of these bloods can pick up potentially serious complications including hepatotoxicity, so it’s important that there is a clear and rapid line of communication for expert advice in the event of an abnormal test result.

Shared care can only start when the following criteria are met¹:

• The patient’s clinical condition is stable.
• The GP has freely agreed to take part in shared care; if the GP feels that it isn’t safe or adequately resourced, prescribing stays with the specialist on a long-term basis.
• There is an agreed, written, shared care agreement, which states how often the patient will be reviewed and gives a ‘route of return’ if their condition changes, allowing specialist review without the need for a new referral.
• The specialist has provided enough medication to cover the transition period.

It follows from the above, that all specialist clinics who manage patients on shared care medications need to be able to prescribe long-term, as there has to be an alternative for those whose GP doesn’t feel that the proposed shared care is safe or adequately resourced. NHSE¹ are clear that the specialist, patient/carers and GP all have to give ‘willing and informed consent’ before shared care can take place, which implies that a referral form cannot state that an agreement to shared care is a pre-requisite of the referral being accepted, because consent given at that point cannot be fully informed. The idea of informed consent would also suggest that shared care agreements should not contain words to the effect that if no response is received from the GP within a certain time period, the acceptance of shared care will be assumed. Good communication is a GMC obligation⁶ which applies to both the specialist and GP, so it would be reasonable to assume that a request for shared care would meet with a prompt reply from the GP, whether this was an acceptance of the shared care, a rejection, or a request for more information.

NHSE guidance on shared care does not explicitly state that the patient can never be discharged from their specialist team. However, the specialist obligations towards a patient for whom the GP is sharing care are harder to meet if the patient is discharged. These include the availability of care and advice without needing a new referral¹ (often impossible in the NHS outside of a defined period of patient-initiated follow-up⁷), and NICE⁸ or other guideline requirements which mandate regular specialist review for some shared care medications. Multiple ICB shared care protocols^9,10 state that the patient should usually stay under the care of both specialist and GP and individual practice should always keep patient safety at the forefront of their minds when deciding whether to share care with a specialist team who propose to discharge the patient.

References

1.    NHSE. Responsibility for prescribing between Primary & Secondary/Tertiary Care. March 2018. 
2.    NHSE. Shared care protocols. January 2022. 
3.    Bath and North East Somerset Swindon and Wiltshire Together. Shared care agreement. Off-label topical testosterone in adult women on HRT. Dec 2023.
4.    Derbyshire joint area prescribing committee. Shared care agreement - denosumab 60mg for the prevention of osteoporotic fractures in men and post-menopausal women aged 18 and over. June 2022.
5.    Hampshire and Isle of Wight ICB. Cinacalcet for patients within Adult Services (Primary hyperparathyroidism and other indications). Share Care Guidelines. Oct 2024.
6.    GMC. Good Medical Practice. January 2024.
7.    NHSE. Implementing patient initiated follow-up: guidance for local health and care systems. May 2022. 
8.    NICE. NG87. Attention deficit hyperactivity disorder: diagnosis and management. Sept 2019.
9.    Hertfordshire and West Essex ICB. A frequently asked questions document: Shared care for medicines and NHS shared care and specialist guided prescribing service specification. Oct 2024.
10.  Nottinghamshire APC. Frequently asked Questions about Shared Care for Patients and Carers. March 2022.