This resource forms part of our GP Survival Guide.
This page was updated in January 2026 to include Appendix C, which provides template text for explaining to patients what shared care is, why a GP may decline it and what this means for them.
Shared care pathways/guidelines
Shared care guidelines are designed to outline the role and responsibilities of the patient, the GP and the specialist in prescribing medication that would not normally be prescribed in primary care. A shared care guideline should describe the responsibilities expected of the GP with regards to monitoring, side effects and drug interaction. The patient continues to be under regular follow up in secondary care, where overall response to treatment and the future need for treatment will be monitored.
As part of Londonwide LMCs’ previous GP State of Emergency campaign, guidance and a template letter were produced relating to shared care. Since that campaign, there has been an increase in the number of shared care pathways developed across ICBs, resulting in the further transfer of un-resourced work into general practice. General practice, despite offering more appointments now than prior to the Covid pandemic, has finite capacity and a reducing GP workforce, which impacts on the ability to safely support patients who could potentially be on a shared care pathway.
There is GMC guidance relating to shared care. This states that if you prescribe based on the recommendation of another doctor, nurse or other healthcare professional, you must be satisfied that the prescription is needed, appropriate for the patient and within the limits of your competence. The presence of a shared care arrangement does not mean that a practitioner must agree to taking part and you should only prescribe if it is safe to do so. The GMC is very specific about shared care, in that all three parties (specialist, GP and patient) need to agree for it to take place.
‘Shared care requires the agreement of all parties, including the patient. It’s essential that all parties communicate effectively and work together.’
Some practices have a policy that states that they do not agree to certain shared care agreement. Other practices will feel able to agree to a shared care agreement. What is important is that you have a policy, that is applied consistently, so you cannot be accused of bias, Appendix A is an example policy. A shared care protocol is specific between the trust and GP practice. It would have been through the local governance processes. Private providers need to have in place their own shared care pathway, which had been through the local governance process and agreed locally.
Declining to take part in shared care
If declining to take part in a shared care arrangement, there should be a justifiable reason.
If declining because of a lack of knowledge, the GMC would expect you to address this learning need, if a practitioner or practice is not able to do this, it should be justifiable as to the reasons why and should fall outside of what would be expected of a competent GP. GMC Good Medical Practice requires doctors to be competent.
- You must be competent in all aspects of your work including, where applicable, formal leadership or management roles, research and teaching.
- You must recognise and work within the limits of your competence.
- You must keep up to date with guidelines and developments that affect your work.
- You must follow the law, our guidance on professional standards, and other regulations relevant to your work.
- You must have the necessary knowledge of the English language to provide a good standard of practice and care in the UK.
As stated in the GMC – Good practice in prescribing and managing medicines and devices guidance, 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.
A practice can decline to take part on safety grounds. The GMC does state that we have a duty to act on safety concerns.
‘You should make patient safety your first priority and raise concerns if the service or system you are working in does not have adequate safeguards, which are relevant to the nature and mode of the consultation. This includes appropriate identity and verification checks.’
If due to the system pressures, a practice is unable to implement a system to properly monitor patients on a share care pathway and/or you cannot be confident that the provider recommending medications can fulfil their responsibilities of the shared care guidance, then you have the right not to agree to take part in the process on the grounds of safety.
Other justifiable reasons to decline to engage in a shared care arrangement are;
- If you are unable to reassure yourself that the medication is needed and appropriate for the patient. However, in such a situation you should revert to the specialist requesting the shared care pathway for clarification.
- If having delegated the assessment of a patient’s suitability for a medicine, but you are not satisfied that the person you delegated to has the qualifications, experience, knowledge and skills to make the assessment. This can be a particular issue in relation to ADHD treatment requests following a patient’s assessment by a private provider under the ‘right to choose’ scheme.
If declining a shared care arrangement, the practice should inform the referring clinician of the outcome and that prescribing responsibility continues with them, see Appendix B for example of a standard response letter.
Scope
Shared care guidelines/ agreements (SCG/SCA) are utilised within the NHS to transfer work and the care of patients from secondary/tertiary care of the primary care.
SCG are designed to outline the role and responsibilities of the patient, the GP and specialist in prescribing medication that would normally be prescribed in secondary / tertiary care. It describes the responsibilities expected of the GP about monitoring, side effects and drug interactions etc. The patient continues to be under regular follow up in secondary care, where overall response to treatment and the future need for treatment will be monitored.
GMC regulation
The GMC Good Medical Practice 2024 states:
- You must recognise and work within the limits of your competence.
- The signatory on a prescription is the person clinically responsible for that drug.
Considering this, the doctor and practice must only participate in a SCA if they have the competence and safe infrastructure to prescribe and fulfil responsibilities such as those described above within the SCA.
GPs are under no obligation to participate in a shared care agreement. If the GP decides not to participate, the clinical responsibility for the patient remains with the specialist service.
Tip: the SCA document can usually be identified by multiple pages describing the responsibilities of each party involved. Additionally, there is a section clearly requiring a GPs signature to accept and return the agreement.
Aim
The aim of this protocol is to ensure each SCA is reviewed against the criteria above by the clinical lead partner, lead clinical pharmacist & lead nurse (senior clinical team – SCT) for safe prescribing before accepting/ rejecting. Accepting a new drug for SCA is a practice level agreement and not an individual clinician decision.
Pathway
SCA which have been reviewed as such, will be added to a list indicating whether approved or rejected for prescribing at the practice. The list should be readily accessible to all at the practice, clearly listing those medications approved and not approved for prescribing at the practice.
| SCA Approved for prescribing @ <<practice>> | SCA NOT Approved for prescribing @ <<practice>> |
| XX | XX |
The list should then be updated each time a new drug is reviewed by the SCT and emailed to all staff. It can be accessed via <<details of the location within the share site for practice protocols>>.
For patients with an SCA which was started prior to this protocol where the practice is prescribing medication that is now on the not approved list, the practice will continue to prescribe for these patients.
Pathway for scanners and prescribers.
- New document for shared care received
- Review the practice list for shared care medications. There are three possible outcomes respond according to the process chart below.
| Medication on approved list |  |
|
| Medication on not approved list | |
|
| Medication not listed | |
|
Dear Dr <<>>
RE: unable to fulfil request – returned to trust to action
Patient full name:
Patient DOB:
Patient NHS number:
Patient home address:
Patient phone contact/email:
We refer to your request (attached) to: (Please tick box)
☐ Prescribe medication
☐ Follow-up results
☐ Issue MED3 Certificate
☐ Arrange Investigations
☐ Undertake monitoring/ post-operative checks
☐ Refer patient back
As per the standard hospital contract, this activity should be provided by secondary care. Due to extreme workforce pressures we need to prioritise access and primary medical care to our patients and we are therefore unable to undertake unresourced secondary care work.
General practice is struggling to match staffing levels to demand, and very much appreciate your collaborative approach in making every patient contact count, without overburdening other system partners across our local NHS. We shall endeavour to do the same.
A copy of this letter has also been sent to our patient, who will be aware that you as their specialist team will now be contacting them directly, to manage this request.
With thanks,
<<Name of practice>>
Further details are set out below:
RE: unable to fulfil request – returned to trust to action
Medication
☐ Shared care declined Reason: e.g. patient safety, not satisfied by monitoring arrangements.
☐ Unable to prescribe Reason: eg: hospital formulary drug/specialist indication only/not in GP formulary.
☐ Failure to initiate/titrate/prescribe sufficient medication from specialist team.
☐ Inappropriate request this service is not commissioned from London general practice and is delivered within the contract between the trust and the commissioner.
Investigations
☐ Please arrange the necessary investigations directly on your trust’s clinical systems this will be in the best interests of our patient in terms of accessing care as soon as possible.
☐ This is a specialist investigation which is not accessible to general practice on our clinical systems.
Results
☐ As per GMC Good Medical Practice, the responsibility to follow-up and take appropriate action on a result, rests with the requesting clinician.
Monitoring
☐ Monitoring declined for safety reasons/ requires specialist input.
☐ Post-operative checks declined as this is the responsibility of the original provider.
☐ Monitoring request declined as not commissioned from general practice locally.
Med 3/other certification
☐ Please issue an electronic Med 3 for the full duration of the patient’s absence, as per DWP guidance for patients seen by secondary care clinicians.
Referrals
☐ Please refer onwards to consultant within the same trust N.B. The Standard Hospital Contract states that for a non-urgent condition directly related to the complaint or condition which caused the original referral, onward referral to and treatment by another professional within the same provider can be enacted by the specialist. Re-referral for GP approval is only required for onward referral of non-urgent, unrelated conditions.
☐ Please action as a recall & send the patient a new outpatient appointment.
<<Add any further relevant comments or information required>>