Shared Care Prescribing as an NHS service where specialists ask GPs if they are willing to agree to share the responsibility of prescribing and monitoring of specialist medication. For any prescriber, entering into any shared care arrangement has implications around governance and quality assurance.
NHS shared care
GPs can enter into shared care prescribing agreements with services commissioned by the NHS. There are local policies for this, agreed between specialists and GPs.
The NHS specialist ensures that the patient is properly started and stabilised on the medication, before asking for the GP to take over prescribing responsibility. There is a system in place to ensure that the patient continues to get specialist reviews in the hospital, and the GP is able to get advice as needed.
Common health conditions where shared care prescribing is used include rheumatoid arthritis, ADHD, inflammatory eye disease, gender dysphoria, Parkinson’s disease and IBD.
Private providers
There has been a significant increase in patients going privately, and then asking the GP to prescribe specialist medication as an NHS prescription on behalf of the private provider. This is not the same as NHS shared care.
Historically, we have been an outlier in prescribing on behalf of private providers. However this is no longer safe or sustainable, and we have reviewed our policy on this.
We cannot issue any new specialist medication prescriptions on behalf of private specialists. You will need to obtain your prescription from your specialist.
Patient safety
Private providers may not adhere to the same safety standards as NHS providers. Patient safety is our priority, and we need to be as certain as we can that we are prescribing safely.
Problems often arise when patients no longer pay to see the private specialist, leaving the GP to prescribe the medication without access to any specialist input. This is risky for patients and GPs are not insured for this.
Commissioning
GPs are not funded to carry out non-NHS work. Undertaking significant amounts of private work can lead to GPs subsidising the cost of private healthcare. At a time of ever increasing demands on primary care, this takes away significant resources from other patients, and promotes health inequality.
British Medical Association Guidance
The BMA has clear guidance on responding to private healthcare, which can be seen here. Therefore, going forward, we are no longer able to prescribe new specialist medication on behalf of private services.
The private clinic will remain responsible for prescribing the medication for you and making sure it is safely monitored.
We can refer you to NHS services and will be able to enter into shared care prescribing with them, once an appropriate agreement is in place.
To ensure this policy is fair and non-discriminatory, this will apply to specialist prescribing on behalf of all private providers, not for specific patient groups or health conditions.
We know this may be a disappointment. The policy has been agreed with all the local practices in our area so that we are all taking the same approach.
Bridging Prescriptions
We have had an increasing number of enquiries from patients about the prescribing and monitoring of medications whilst awaiting specialist assessment, in particular “bridging hormones”. We recognise that there is currently inadequate provision for patients with waiting times in excess of 24 months for initial NHS appointments. However, it is our practice policy that confirmation of diagnosis and commencement of treatment should be made by a specialist services in all cases.
Gender dysphoria
We recognise that GPs are most often the first point of contact with the health care system for patients with gender dysphoria. This is a huge responsibility that we take very seriously. The clinical team at Harborne Medical will:
- Make the initial referral to the specialist gender identity clinic. We will do this referral as rapidly as possible and take into account your preferences as well as waiting times when choosing a clinic.
- Prescribe hormones (and monitor treatment) following the initiation and ongoing recommendation of a specialist gender identity clinic (NHS). This will be as part of a shared care agreement with the specialist endocrinologist, who will offer ongoing support. We are unable to prescribe hormones in any other circumstances.
- Provide support to maintain your mental and physical health. We recognise that accessing specialist clinics can be frustrating and waiting times are long. We can provide mental health support at the surgery by offering advice on self help strategies, treating anxiety and depression (including with medication if appropriate), referring to local NHS mental health services, and sign-posting to other support services if needed.
We recognise there is guidance from the Royal College of Psychiatrists and other organisations that GPs “may prescribe ‘bridging’ endocrine treatments as part of a holding and harm reduction strategy while the patient awaits specialised endocrinology or other gender identity treatment” particularly if patients are already taking hormones from illicit sources. However, we are not experienced in initiating hormonal treatments for gender dysphoria and do not feel able to provide “bridging hormones” safely in any circumstance.
Unfortunately, the appropriate support is just not currently available for us to do this. It should be recognised that all the NHS gender identity clinics only initiate hormonal treatment after a number of investigations and input from a specialist team of psychiatrists, endocrinologists, and psychologists. This includes counselling on the side effects and potential long term risks of hormonal treatment. It is not realistic that the same level of support could safely be provided within our practice.
November 2024