Shared-care has been described as (Horne et al. 2001):
‘the joint participation of hospital consultants and GPs in the planned delivery of care for patients with a chronic condition, informed by an enhanced information exchange over and above routine discharge and referral letters’
and specialist medicines within the context of shared-care as
‘medicines initiated by a hospital doctor that require complex prescribing and/or therapeutic monitoring arrangements not normally undertaken in general practice’
In Northern Ireland a specialist medicine within the context of the Red Amber List have been defined as ‘a medicine, which has significant pharmacological complexity and/or rarity of use to make the prescribing of the medicine relatively uncommon in the community. Patients for whom complex medicines are prescribed, may have particular complex monitoring requirements, which require specialist knowledge for the appropriate interpretation of results.’
Shared-care arrangements for specialist medicines enable GPs to prescribe amber list specialist medicines by providing the GP with the necessary information and support to do so safely and effectively.
Barriers to the Shared-Care of Specialist Medicines
The most significant barriers to shared-care may include (Horne et al. 2001 and Crowe et al. 2009 and Crowe et al. 2010);
- poor communication between primary and secondary care, including the quality, frequency and timeliness of information received from specialists.
- perceived or actual concerns that monitoring and patient follow-up is not being carried out as should be.
- concern by GPs that they lack the necessary knowledge or expertise.
- the mechanism by which shared-care is requested.
- medico-legal responsibilities of the prescriber.
General Medical Council Guidance
Useful guidance on shared-care is provided in the General Medical Council (GMC) document, Good practice in prescribing and managing medicines and devices (2013). This sets out some principles for effective shared-care arrangements including;
- to act in the best interests of the patient.
- acknowledgement of the medico-legal responsibilities of the prescriber.
- the requirement for the agreement of all parties and that effective communication is essential.
- that the prescriber should have sufficient knowledge, experience and information.
- that the specialist should provide the GP and patient with sufficient information to permit the safe management of the condition.
- that if the GP is not satisfied to take prescribing responsibility this should be explained to the specialist and patient and alternative arrangements provided.
Supporting Effective Shared-Care Arrangements
Several factors need to be in place to ensure that a satisfactory shared-care arrangement is in place. This can be achieved by effective communication between all parties, for example via clinic letters, on a patient specific basis. However it is recognised that some degree of standardization of shared-care is helpful for all parties and helps minimize risk. Shared-care guidelines (SCG) for a large number of amber list medicines are available in Northern Ireland to support patient specific shared-care arrangements and the principles contained within the GMC guidance.
The development and maintenance of these SCGs is facilitated by the Interface Pharmacists Network for Specialist Medicines. The regional SCGs follow a standard format and contain information on indications, dose, route of administration, adverse effects, monitoring requirements and responsibilities, and clinically relevant drug interactions.
It is the Regional Group for Specialist Medicines who commission regional SCG for amber list medicines. Factors such as how frequently the medication is prescribed, or how complex the drug monitoring is, will be considered for each amber list medication. Not all amber list medicines will have a regional SCG commissioned. Individual shared-care arrangements should still be agreed for these medicines or for new amber list medicines prior to a SCG being developed.