Shared care pathways

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.

1. You must be competent in all aspects of your work including, where applicable, formal leadership or management roles, research and teaching.
2. You must recognise and work within the limits of your competence.
3. You must keep up to date with guidelines and developments that affect your work.
4. You must follow the law, our guidance on professional standards, and other regulations relevant to your work.
5. 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;

1. 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.
2. 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.

Appendix A: example shared care protocol

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.

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.

1. New document for shared care received
2. Review the practice list for shared care medications. There are three possible outcomes respond according to the process chart below.

Medication on approved list		Action as usual.
Medication on not approved list		Reply with standard letter declining request.
Medication not listed		Workflow request to clinical lead. Review at SCT meeting. Inform scanners/prescribers of decision. Update practice list of approved/not approved SCA medications. Informed requesting clinician whether the practice agrees to SCA.

Appendix B: example letter declining shared care arrangement

[Practice headed paper]

Request for <<insert name of Practice>> to agree to shared care protocol

Dear <<insert clinical lead name>>

RE: <<insert name of Shared care protocol>> relating to <<Patient Details>>

As you are aware general practice is under increasing pressure and is currently unable to cope with the workload. General practice is repeatedly asked to take on more work, with no resources to enable this work to be undertaken safely.

Due to current workload within general practice <<insert name of Practice>> is unable to agree to the proposed shared care guidelines and responsibility for prescribing and monitoring the treatment outlined within the protocol must rest with <<insert name of acute trust>>.

We are concerned that taking on further responsibilities under such a shared care protocol would put patient safety at risk at this time.

Yours sincerely,

On Behalf of <<insert name of Practice>>