Shared Care Prescribing Policy

A Shared Care Agreement (SCA) is an agreement between you, your GP practice, and your hospital consultant or specialist doctor.

This may only be done by mutual agreement; under an SCA you will not be discharged by the specialist but you, your consultant, and your GP will each accept joint responsibility for managing your care. Your GP will need to consider a number of factors to decide if this is safe, suitable and in their patient’s best interests. Our GPs assess requests to enter into SCAs on a case by case basis so that the approach is tailored to what is safe and clinically appropriate for each individual patient. The Practice will consider all requests from both private and NHS providers, where prescribing is within their level of competence as GPs, in line with the following criteria:

The patient’s clinical condition is stable or predictable and they are established on the medication; patients must be stabilised on their current dose
Requests for prescribing or monitoring must be in writing from provider in the form of a standardised shared care agreement.  
Shared Care Templates from private providers must be of at least equivalent standard to NHS providers – the templates for this can be found here NHS England » Shared Care Protocols (SCPs)
The patient must remain under the care of their specialist whilst on treatment and must be assessed at least annually.  
If a patient has been prescribed medication abroad previously, they must be under the care of a UK provider before we can take on shared care.
Medicines accepted for shared prescribing should be on an approved list from the Surrey Heartlands Area Prescribing Committee (i.e. amber drugs, see Drug Profiles By BNF Section (res-systems.net) for details)
We will not initiate any changes to a patient's current dose. Any titration or discontinuation needs to be done by the specialist provider.
We will not perform baseline investigations or examinations needed to initiate medications for external providers.   
GPs reserve the right to decline requests to prescribe unlicensed medication or licensed medicines for unlicensed indications; these will be considered in line with the Surrey Prescribing Advisory Database policy, available https://surreyccg.res-systems.net/PAD/Guidelines/Detail/4413
The SCA must be with a named, appropriately qualified, GMC registered specialist doctor and should include:

A date and signature 
The frequency of patient review by the specialist clinic, which must be at least annually.  
If monitoring is requested, the thresholds for normal/abnormal findings and acceptance of responsibility for actioning abnormal findings 
Contact details for the private provider if the need for clinical advice is required. 
Details about the medication requested, including licensed indications, dose, route, administration, duration of treatments, adverse effects, cautions and contraindications and clinically important drug interactions.

Our GPs reserve the right to decline a shared care agreement, or to decline a prescription request if prescribing is thought to no longer be safe, or that the medication has not been taken as originally prescribed.  In some cases we have seen proposed shared care arrangements resulting in a complete transfer of care into primary care, leaving patients unwell and unsupported on potent medications and the practice unsupported and prescribing contrary to local guidelines and, potentially, the best interests of the patient. To ensure our patients’ safety, we have outlined our requirements for shared care with the responsibilities of each party as below:

Specialist responsibilities:

Assess the patient and provide diagnosis.
Use a shared decision making approach; discuss the benefits and risks of the treatment with the patient and/or their carer and provide the appropriate counselling to enable them to reach an informed decision. Obtain and document consent. Provide an appropriate information as required.
Ensure the patient and/or their carer understands that treatment may be stopped if they do not attend for monitoring and treatment review. 
Assess for contraindications and cautions and interactions. 
Conduct required baseline investigations and initial monitoring.
Initiate and optimise treatment as outlined in the SCA. Prescribe the maintenance treatment for at least 4 weeks and until optimised.  
Prescribe in line with controlled drug prescription requirements. 
Once treatment is optimised, complete the shared care documentation and send to patient’s GP practice detailing the diagnosis, current and ongoing dose, any relevant test results and when the next monitoring is required.  Contact information must be included.  
Prescribe sufficient medication to enable transfer to primary care, including where there are unforeseen delays to transfer of care. 
Conduct the required monitoring and communicate the results to primary care.
Determine the duration of treatment and frequency of review. The review should be at least annually as a minimum with the appropriate clinical monitoring. After each review, advise primary care whether treatment should be continued, confirm the ongoing dose, and whether the ongoing monitoring outlined in the SCA remains appropriate.  
Trial discontinuations and dosage changes should be managed by the specialist
Reassume prescribing responsibilities if a woman becomes or wishes to become pregnant. 
Provide advice to primary care on the management of adverse effects if required.

Primary care responsibilities:

Respond to the request from the specialist for shared care in writing.
If accepted, prescribe ongoing treatment as detailed in the specialists request and as per local formulary and NHS England Shared Care guidance.
Prescribe in line with controlled drug prescription requirements. 
Conduct an annual review so that the patient will have a 6 monthly review (as a minimum), alternating between the specialist and primary care. The review should include the appropriated clinical monitoring as outlined in the SCA. Communicate the results to the specialist. 
Assess for possible interactions when starting new medicines  
Manage adverse effects and discuss with specialist team when required. 
Stop medication and make an urgent referral for appropriate care if any serious/life threatening complications are suspected.  
Refer the management back to the specialist if the patient becomes or plans to become pregnant. 
Stop treatment as advised by the specialist.

Patient and/or carer responsibilities:

Take medication only as prescribed and avoid abrupt withdrawal unless advised by primary care prescriber or specialist. 
Attend regularly for monitoring and review appointments with primary care and specialist, and keep contact details up to date with both prescribers. Be aware that medicines may be stopped if they do not attend.  
Report any adverse effects or symptoms to the GP.
 Report the use of any over the counter medications to their primary care prescriber and be aware they should discuss the use of their medication with their pharmacist before purchasing any over the counter medicines. 
Be aware that some medications can affect cognitive function and are subject to drug driving laws, therefore patients must ensure their ability to drive is not impaired before driving  
Follow specialist advice around avoiding alcohol and recreational drugs if advised to do so.   
Patients who have been prescribed a controlled drug are responsible for storing it securely. 
Patients must not share their medication with anyone else.  
Patients of childbearing potential should take a pregnancy test if they think they could be pregnant, and inform the specialist or GP immediately if they become pregnant or wish to become pregnant. 
If a switch in the type of medication is required, either for clinical reasons or because that medication is not available, this needs to be managed by the specialist.

ADHD Medications

There are many patients living with undiagnosed ADHD. Increased awareness in recent years of this has led many patients to suspect they have ADHD and to come forward requesting referral for an assessment. We can appreciate why looking to confirm a diagnosis of ADHD is important and potentially life-changing. Unfortunately, as a result of the huge increase in patients with suspected ADHD, the waiting times for assessments on the NHS has become very long. Understandably some patients are reverting to self-funding private assessments and often this results in requests to enter SCAs with various private providers whose standards of care and SCA terms can vary widely.

Stimulant ADHD medicines are a controlled drug. They can also be associated with significant side effects or exacerbate many underlying mental health conditions. They are also a specialist drug which can only be prescribed under an approved shared care agreement. Until a shared care agreement is in place all prescribing needs to occur in secondary care (within the specialist clinic). Once the patient is stable on medication, in order for the Practice to be able to enter into a SCA the following criteria will need to be met:

Patients should never be used as a conduit for informing the GP that prescribing is to be transferred. The request to enter into a SCA needs to come directly from the Psychiatrist. The Psychiatrist must be readily available for both the patient and GP should any issues or queries arise. Any requests to enter into a shared care agreement should come directly from the specialist to GP.
The diagnosis must have been made by a Psychiatrist specialising in ADHD and in accordance with UK criteria (the diagnostic criteria in some countries is different) and that we can be confident that the assessment has been sufficiently comprehensive.
The patient must remain under the care of that Psychiatrist for the entire period treatment is occurring.
The specialist is recommending a treatment course in line with the local protocols. The terms of the SCA should be aligned with the local Surrey Heartlands shared care protocol, which is available at:https://surreyccg.res-systems.net/PAD/Search/DrugConditionProfile/5735

In a situation in which the four points above are not met it is highly unlikely that it will be possible to take over prescribing.

Hormones for Trans Individuals

Our practice adheres to the GMC guidance on transgender prescribing and applies it on a case by case basis so that the approach is tailored to what is safe and clinically appropriate for each individual patient. You can find the GMC guidance on this matter at: https://www.gmc-uk.org/ethical-guidance/ethical-hub/trans-healthcare#prescribing

In general terms, our approach to these requests includes contacting the author of the letter, discussing the issue with the patients, reviewing prescribing guidelines and seeking specialist advice. Generally, our doctors are able to prescribe hormone treatment to trans patients under the advice and guidance of appropriately qualified, experienced and UK registered gender specialist, who adheres to local prescribing formulary guidelines, see here for further information: https://surreyccg.res-systems.net/PAD/Guidelines/Detail/5708

Before entering in to a SCA with a gender specialist, our GPs will need to be assured that any requests to prescribe are from a reputable company that provides a safe and effective service, that the health professional making the request is an appropriate gender specialist and that the circumstances of the request for the particular individual meet the general principles of the GMC’s Good Practice in Prescribing and Managing Medical Device professional standards.

The GMC sets out the expectation that ‘an experienced gender specialist will have evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS GIC.’ Providers will be asked to provide evidence of this where required.