1. Background

Many ‘secondary care’ conditions can be appropriately managed with a shared care approach with primary care where some of the monitoring is carried out in primary care with a clear management plan for escalation back to the secondary care specialist. Examples are monitoring of PSA in stable prostate cancer patients or monitoring of disease-modifying rheumatology drugs.

These shared care arrangements need to be planned and agreed by both parties. This work is not included in the GP contract core service so participation in a shared care agreement requires funding and is optional for practices to participate in.

Patients are increasingly seeking for GPs to provide prescriptions or monitoring for conditions where the specialist treatment is initiated by a private provider who may be based abroad.

There are long waits for some NHS specialist services, in particular gender clinics, and many patients are seeking interim treatment from GPs or are sourcing treatment online from uncertain sources and asking GPs to continue these on the NHS.

2. Underlying Principles

• Doctors should work within the limits of their competence.
• Patients have a right to care being transferred to NHS from private (as long as that care is provided by NHS).
• Doctors working in the UK are bound by GMC Duties of a doctor which includes an obligation to provide safe handover of care.
• Specialist only medication can be prescribed by GPs only as part of a shared care agreement.

3. General Scenarios

3.1 NHS Specialist Requesting Monitoring or Prescribing by GP

This requires an agreement by both parties and is usually done under an Enhanced Service. Shared care is not core General Medical Services and therefore not all practices may choose to participate. Specialist services, therefore, need to have an option for prescribing and monitoring to continue to be carried out by them.

Where the only involvement of Primary Care is to issue a prescription under direct specialist guidance a funded enhanced service may not be required.

3.2 Private UK Based Specialist Providing Equivalent Care to NHS

Patients may choose to move back to NHS care from a private provider. This should be arranged directly by the private clinic to the NHS specialist who may then be in a position to arrange shared care. In the interim period patients should continue to source prescriptions and monitoring from the private clinic.

Where there is ongoing monitoring/supervision by the private clinic, patients should continue to obtain private prescriptions. GPs may choose to issue NHS prescriptions as long as they are satisfied care is equivalent to NHS care. They are not under any obligation to do so.

3.3 Private Specialist Based Abroad

If the treatment that has been procured privately is not available on NHS (e.g. bariatric surgery outwith NHS criteria) then patients require to have monitoring/prescribing continued by the private provider abroad or need to find a UK private provider to take over their care. Any emergency needs still fall within NHS.

If the treatment would be available on the NHS, then patients can transfer to NHS. This should be arranged by the private provider but for private specialists abroad this is unlikely, and GPs may need to facilitate the referral. Interim prescribing and monitoring should continue from the private provider abroad or transfer to a UK private provider.

4. Specific Scenarios

4.1 Adult ADHD

• The diagnosis of Adult ADHD can only be made by a suitably trained specialist (Often a psychiatrist but may be a specialist nurse or psychologist).
• Methylphenidate is unlicensed for use in adults for ADHD, but BNF gives guidance on appropriate doses which can be prescribed under specialist guidance.
• Monitoring requirements – BP, pulse, psychiatric symptoms, appetite, weight, and height should be recorded at initiation of therapy, following each dose adjustment, and at least every 6 months thereafter.

Patients diagnosed by private service

• Psychiatry will not reassess patients for the sole purpose of confirming a diagnosis made by a private clinic.
• If patients have been diagnosed and treatment initiated by a private service, they can request transfer to NHS care. A reputable clinic will include a period of assessment and adjustment within the initial package, usually at least a year.
• A handover should be obtained by the patient from the private provider giving details of diagnosis, basis for diagnosis, treatment plan and monitoring requirements. If the clinic will not provide this, then the patient will need to continue to receive prescriptions and follow-up privately.
• Psychiatry will advise by means of a SCI-Gateway advice request, attaching the handover management plan, if the assessment and management seems appropriate and equivalent to NHS and will be able to give ongoing advice as needed and thus take over the secondary care element of shared care.

Patients diagnosed by NHS

• Supervision and monitoring is done by psychiatry, prescription issued by GP.

4.2 Bariatric Surgery

• NHS bariatric surgery is done at tertiary centres via local weight management clinics.
• Criteria for NHS surgery are very restrictive.
• Following bariatric surgery patients require lifelong biochemical monitoring.
• For the first 2 years this should be directly under the surgical centre, including nutritional and dietary assessment, advice and support.
• Ongoing monitoring of Bloods at least annually – varies with procedure.
• Ongoing nutritional supplements – varies with procedure.

Patients receiving surgery on NHS

• 2-year follow-up by regional centre.
• A clear monitoring plan will be issued, and the regional centre will continue to be available for review and advice.
• After an initial monitoring period care will be transferred locally and the local weight management clinic will advise as necessary via advice request.

Patients receiving surgery privately who would fit criteria for NHS treatment

• Follow-up should be arranged as part of the surgery package with the private provider.
• Patients can request to transfer to NHS after the initial follow-up period. The patient should ensure that an appropriate handover is given clearly documenting the procedure and the requirement for supplements and blood monitoring.
• The local weight management clinic can advise as necessary via a SCI-Gateway advice request.

Patients receiving surgery privately not fitting criteria for NHS treatment

• Lifelong follow-up and monitoring should be arranged with a private provider.
• NHS Scotland policy states this will not be provided by NHS, although emergency treatment will still be provided.
• It is accepted that both the above statements are unrealistic, and a pragmatic approach may be needed in dealing with these patients.
• The local weight management clinic will advise on appropriate follow-up and monitoring.

4.3 Gender Dysphoria

• NHS treatment is done by tertiary centres with no local clinics.
• Wait for assessment and treatment is very long and assessment is extensive.
• Hormone prescribing is initiated by tertiary clinic with potential for shared care prescribing.
• The specialist centre remains available for prompt advice even after discharge.
• Hormone prescribing for gender dysphoria is off licence.

Patients receiving diagnosis at private gender clinic

• Prescribing and monitoring should continue to be by the private provider.
• If the GP is satisfied the gender clinic is equivalent to NHS, and if there is clear guidance and ongoing monitoring of the patient by the private provider, they could issue NHS prescriptions in a similar way to NHS. However, there is no local expertise in this area and no mechanism for advice from the regional centre to advise if a clinic is giving equivalent treatment to NHS so the default position for GPs should be not to prescribe and for the patient to continue to receive prescriptions from the private provider.

Patients requesting prescription while waiting for gender clinic

• Initiating hormone treatment should only be done after expert multidisciplinary assessment and should not be initiated by GPs.
• GPs should not issue prescriptions to patients who are requesting them even if they are already sourcing medication online or from another unauthorised source unless they feel there is risk of suicide or self-harm AND they have received advice from a specialist on the minimum acceptable dose. A SCI-Gateway advice request can be sent to the regional clinic (Sandyford) in these very unlikely circumstances.