Shared Care

We receive many queries about shared care arrangements; not least about those requested by private or NHS Right-to-Choose providers. At a time of great pressure on services, where more and more patients are seeking alternative routes to diagnosis and care, practices are getting more and more requests, and we thought it would be useful to offer a brief refresher on this.

Whilst the GMC has clear guidance on shared care, which of course should be observed, these arrangements aren’t a contractual stipulation for GPs to enter into under GMS, but the Local Commissioning Agreement of course covers them, and all practices signed up to this should be observing the principles outlined there. However, the LCA does not require you to accede to every request made for shared care by any provider. It is vital that these agreements are seen as first and foremost measures for patient safety, and practices may wish to create their own in-house policies that can be used to determine whether a SCA is entered into.

The key points to consider are:

• It is a non-core voluntary activity. Practices signed up to the LCA should be aware of the arrangements listed on the ICB website and we would expect these to be entered into if signed up, unless there was a clear reason why it would be unwise, that should be patient specific.
• All other arrangements are voluntary, and non-core. They can be declined for any reason, such as capacity within the practice, inadequate competency regarding the specialist medication, despite training, uncertainty about the competency of the specialist provider.

If entering into an agreement outside of the LCA, the practice needs to be content with the quality assurance and clinical governance of the specialist provider. This will be more challenging if the provider is not commissioned by the NHS. It may also be more challenging for NHS Right-to-Choose Providers.

• We would consider a robust, written agreement signed by both parties to be mandatory. This should be passed to the practice, agreed, and returned to the specialist before any agreement starts.
• The appropriate stabilisation period has occurred before prescribing is handed over to the GP practice, as determined by the shared care agreement to the satisfaction of both GP and specialist. Any dose titration should have been completed, alongside any drug monitoring required to date.
• There is ongoing specialist input with continuing out-patient follow-up and a mechanism which allows timely advice from the specialist, which could be converted into an out-patient review.
• Enduring specialist care is challenging when a patient is self-funding. The LMC view is that discharge from specialist care is incompatible with a continuing shared care agreement, by definition.
• Practices should consider what would happen if specialist care stopped and a patient still wished to be prescribed their medication; these situations can be challenging.

Practices might find it helpful to use these safety measures to create their own policies around shared care agreements.

We would advise that these do not refer to specific conditions or providers – this could be seen as discriminatory. Instead, it should be a set of principles that applies to all requests at an individual level. That might mean that a particular service doesn’t fulfil these criteria for all the requests they make, but it is still important that individual decisions are made and communicated to patients accordingly.