North East London shared care briefing

London is moving towards a more consistent approach to shared care, partly to support a future Single National Formulary and to shift appropriate activity closer to home. Historically, NEL ICB has not funded shared care work, and implementation in general practice on a pro bono basis has been patchy and confusing for both practices and specialists.

A recent NEL policy draft contains several welcome safety principles, but it also exposes a fundamental unresolved question around resourcing the prescribing, monitoring, call-and-recall, results handling and clinical risk transferred from specialist care to general practice.

This is not an abstract contractual debate. From 1 July 2026, shared care became a specific part of the BMA’s GP collective action in England. Practices are being asked to decline new arrangements unless there is a locally commissioned formal agreement, adequate resourcing and clear clinical responsibilities.

A proper shared care arrangement normally includes all of the following:

• A specialist makes the diagnosis, initiates treatment and stabilises the patient.
• The patient agrees to the proposed shared care arrangement.
• The specialist contacts the practice to request shared care.
• The practice receives a complete, current protocol and either declines or accepts the transfer explicitly for that individual patient.
• The record of the agreement to undertake shared care usually takes the form of a contract signed by both the practice and the specialist.
• If the practice declines to undertake shared care, ongoing care and prescribing both remain the responsibility of the specialist.
• If the practice accepts to undertake shared care, the GP undertakes only the agreed prescribing and monitoring for which the practice has capacity and competence.
• The specialist retains responsibility for specialist review, complex decisions and timely advice, with a clear route back into the service.
• The pathway is commissioned and funded to reflect the workload, administration, governance and risk.

• A clinic letter saying “GP to prescribe” or “please monitor”. That is a request, not an accepted transfer of responsibility or an agreement to share care.
• A medicine being coloured amber or green or otherwise listed in a formulary. Formulary status does not amend the GP contract or compel acceptance. It merely provides a framework for the safe use of a medicine for patients.
• The specialist discharging the patient and leaving the GP without enduring specialist support. If nobody else retains a meaningful share of care, it is not shared care.
• An assumption that prescribing automatically includes a responsibility to undertake every associated blood test, recall process, interpretation task and response to abnormal results without appropriate funding.
• A generic policy created by the commissioner or another provider, which substitutes for agreement by the practice and acceptance for the individual patient.
• An instruction that a GP who declines should find another GP or PCN colleague to take the work – commissioning gaps belong to the commissioner, not to an individual practice.

No – it does not suddenly become core GMS because the patient is registered with the practice, the medicine is clinically appropriate and rag-rated amber on a formulary, or a specialist asks the practice to take it on.

The GMS contract requires essential services for the management of illness, chronic disease and appropriate ongoing treatment and care. It does not specify a blanket duty to accept clinical and legal responsibility for specialist medicines under locally created protocols. NHS England’s own prescribing guidance says that issuing a shared care guideline does not mean the GP must agree to accept responsibility; transfer should occur only after agreement in each individual case, with the specialist continuing to prescribe until transfer is successful.

The BMA is more explicit: it describes shared care prescribing as “non-core voluntary activity” and says additional medication-monitoring work should be delivered through a funded commissioned pathway, usually an ICB medicines-monitoring Local Enhanced Service.

Important distinction: Routine clinical care and ordinary medication review remain core. A defined package of specialist prescribing, structured surveillance, recall, results interpretation and escalation is additional work when it depends on a shared-care or medicines-monitoring pathway.

Yes. Acceptance is voluntary at two levels: the practice must choose whether to participate in the commissioned scheme, and the GP must be willing to accept the individual patient. Legitimate reasons include:

• insufficient capacity, competence, training, information, specialist support or assurance about the provider;
• an unstable patient;
• an outdated or incomplete protocol; or
• an unfunded pathway.

Decisions should be consistent, based on defensible practice principles and applied without unlawful discrimination. Until explicit acceptance is received, the initiating specialist should continue prescribing and monitoring.

Models vary, but the common feature is that the commissioner converts an aspiration into a specification. Approaches in current use across the country include:

• A medicines-monitoring or shared-care local/locally commissioned service, with payment per patient, per completed monitoring cycle, or on a per capita basis.
• Tiered payments reflecting medicines with different monitoring intensity and risk.
• A broader medicines-optimisation enhanced service incorporating defined monitoring work.
• Commissioning the activity from another provider where practices do not opt in or where specialist oversight cannot safely be maintained.

For example, where a commissioner views a shared care agreement as simply needing to reimburse a practice for a blood test, the practices needs to consider:

• patient identification,
• invitations and recall,
• appointments,
• prescribing,
• pathology,
• review and interpretation of results,
• actions on abnormal findings,
• coding,
• audit,
• training,
• governance,
• indemnity exposure, and
• liaison with specialists.

The emerging London proposal starts from a reasonable objective: a consistent, funded, system-wide framework, with clearer roles and less postcode variation. The NEL draft also correctly states that specialists should continue prescribing until primary care explicitly accepts.

The concern is what may follow. A Single National Formulary may narrow the list of medicines formally labelled “shared care” by the commissioner in an attempt to cut costs. However, the work associated with medicines removed from that label do not thereby become a core GP contractual responsibility. Some may still require structured high-risk monitoring even if continuing specialist review is limited. In that situation the honest description may be a medicines safety and monitoring service – not shared care – but it still needs specification and funding.

The draft wording therefore needs stronger safeguards, which the LMC is currently arguing for:

• No presumption that amber classification places primary responsibility in general practice.
• Explicit practice-level and patient-level voluntariness.
• Specialist prescribing and monitoring continue until documented acceptance.
• Funding follows the full workload and risk, with recurrent resource rather than a protocol alone.
• Every new medicine or material expansion is subject to workload and financial impact assessment, with funding revised accordingly.
• A commissioned alternative provider route for patients whose practice does not participate.

• Consider following the BMA guidance to decline unfunded shared care requests.
• Do not treat a formulary colour change, clinic letter or protocol as indicating that the work is core contractual work for GPs. If you are unsure, ask your LMC.
• Consider whether the practice has the capacity and competence to undertake shared care in each individual case. Then consider whether the work is appropriately funded. If the answer to any of these is ‘no’, consider declining.
• Check that every request includes diagnosis, stability, dose, treatment history, latest results, monitoring schedule, action thresholds, specialist contact details, review arrangements and a route of return.
• Every request that you accept should be backed up with a signed agreement between the specialist and the GP setting out mutual responsibilities.
• Record acceptance – or refusal – clearly for each patient.
• Review existing arrangements for current protocols, adequate specialist support, workload and funding.
• Escalate unsafe or unfunded requests through the LMC and the ICB rather than allowing ad hoc transfer to become established custom and practice.
• If a monitoring need is real but no commissioned pathway exists, make the commissioning gap explicit; patient safety is not secured by silently agreeing to the transfer of unfunded work.

More information on shared care is available on the Londonwide LMCs website as part of the GP survival guide at this link. This includes template letters to decline shared care and other non-contractual tasks.

Bottom line: Shared care can benefit patients and bring care closer to home – but only when responsibility is genuinely shared. A protocol is not a contract, and a formulary is not a funding mechanism. General practice must not become the default backstop for incomplete pathways, nor a destination for secondary care workload transferred without the governance, capacity and funding needed to deliver it safely.

1. BMA: How to take part in GP collective action in England (July shared-care action)
2. BMA: Principles for Shared Care Prescribing (updated 23 October 2025)
3. BMA: GPs target unsafe and underfunded transfers of hospital work (1 July 2026)
4. NHS England: Responsibility for prescribing between primary and secondary/tertiary care
5. NHS England: Standard General Medical Services Contract (Part 8: Essential Services)
6. NHS England: Shared Care Protocols
7. NHS North West London: Medicines Optimisation Enhanced Service 2026/27