What is shared care?

Shared care happens when one of a specific list of medicines is started by a specialist and continued by the GP, usually after the patient is taking a stable dose. Continued shared care is contingent on the patient being regularly reviewed by the specialist or a member of their team. All medication used to treat ADHD is prescribed under shared care.

Why share care?

Shared care is more convenient for the patient and makes medication affordable in the long term. Those who started their care in the private sector (often because NHS services were overwhelmed) will otherwise face many years of paying privately for medication, until they reach the top of the NHS waiting list; some will not be able to afford this. However, medicolegal liability rests entirely with the professional who signs a prescription; shared care can therefore only happen if the GP has the resources to take part and agrees that it can be done safely. Shared care is not part of the core GP contract and is often unfunded (or funded at a level which doesn’t cover the costs of sharing care) – many practices therefore have limits on who they can share care with.

Issues with shared care

BAND is aware of the significant increase in workload and decrease in real-terms funding that has affected primary care over the years and understands that practices who are unwilling to share care take this position because they do not have the resources and/or knowledge to do so safely.

We would like to highlight some particular issues:

• The complex system of NHS, Right to Choose (RTC) and private clinics is difficult for primary care to navigate. Some Right to Choose services and private clinics will diagnose and treat, whereas others will only diagnose. Some are run by doctors, others by nurses and pharmacists, who may or may not be able to prescribe.
• The quality of reports from different providers is variable and often doesn’t correlate well with the CQC status of the organisation.
• The responsiveness of the specialist partner in shared care varies widely.
• If a patient is discharged from a RTC service/the service loses their NHS contract, or the patient becomes unable to continue to pay for private care, this puts the GP in a very difficult position. They either have to share care with no-one, while the patient waits years to be seen by the NHS, or they have to stop a medication which is helping the patient to function, thus damaging the doctor-patient relationship and risking a complaint. It is for this reason that many practices have a policy of not sharing care at all with the private sector or with Right to Choose providers.
• NHS waiting lists for a first appointment in an ADHD service are generally measured in years; in some areas even private clinics have a wait of several months for a first appointment. It is extremely unlikely that the consultant psychiatrist workforce can expand quickly enough to deal with both the backlog, and the expected demand going forward.

BAND's recommendations

• Shared care with both the NHS and private sector to be appropriately funded by an enhanced service, which covers the costs of sharing care and is automatically uprated by inflation each year. Ideally this funding would be equal across the country, so there is no postcode lottery.
• GPs who feel that they need extra education on ADHD should be able to access this easily and for free. All vocational training schemes should ensure that their trainees have a session on ADHD, which includes its presentation in adults and how presentation differs in women and girls compared to in men and boys.
• A member of the specialist team should be available on a same-day basis for urgent phone queries from GPs about shared care patients; emails should receive an answer within two working days.
• CQC inspections should specifically look at shared care – any attempt to discharge a patient for whom the GP is sharing care should be seen as an indication of poor practice.
• The current system, in particular, the situation whereby some Right to Choose providers can offer a diagnostic service but no treatment, must be reviewed. It is immensely frustrating for a patient to have a diagnosis and then face a wait of many years for NHS treatment, and this can lead to pressure being put on the GP to act unsafely and initiate prescribing themselves. Commissioners of Right to Choose service should consider only using providers who can initiate medication and prescribe long-term for those whose GPs are unable to share care and should not use contracts that allow Right to Choose providers to discharge patients for whom the GP is sharing care.

A new model of care

• NHS clinics run by GPs with an extended role (GpwER) should be commissioned; the RCGPs framework for GPwERs in ADHD can be used as a benchmark for quality of care.
• Pathways into these clinics should be flexible to allow referral for continuation of care if a suitably detailed assessment was made elsewhere (e.g. by the NHS in another area, in a RTC clinic, or by a private clinic).
• Clinics must run on a multidisciplinary basis, with embedded consultant time for supervision, mentoring, case discussion and to see the most complex patients if needed.
• These clinics must be able to prescribe (including electronic prescribing) until the patient is stable, and long-term for those whose GPs do not feel that they can safely share care.
• They should also be set up to share care with private or Right to Choose providers where the GP is unable to do so.
• Pathways should be set up both for those being referred for a diagnosis and for those who have a diagnosis but are moving care from a private or Right to Choose provider, recognising that many have accessed the private sector not out of choice, but out of desperation at the lengthy NHS waiting lists.
• Clinics such as these (where management of an issue previously dealt with by specialists is now largely done by GPwERs with a multidisciplinary team and consultant support) are not a new concept. Specialist menopause clinics in both the NHS and private sector are increasingly run along these lines, as many GPs have extra qualifications in the menopause, and many gynaecologists do not have a particular interest in this area.

This is a complex issue, made more difficult by the wider resource problems in the NHS. BAND would like to see evidence that senior leadership at NHS England and its equivalents in the devolved nations understand the complexities and are committed to implementing radical change to improve care for a cohort of patients who have often been marginalised.

More information

[1] NHS England. Responsibility for prescribing between primary and secondary/tertiary care.

[2] NHS England. Shared care protocols.

[3] GMC. Good practice in prescribing and managing medicines and devices.

[4] GMC. Shared care.

[5] BMA. General practice responsibility in responding to private healthcare.