• Drug safety
• Adherence

In the early 1990s, David M Eddy, the physician, mathematician and healthcare analyst, was fundamental in the introduction of a national approach to the development of evidence-based clinical practice guidelines in the USA.1 Describing a guideline as ‘a simple, operational recommendation about a preferred practice’, he recognised that they are necessary because ‘the appropriate practice of medicine is far too complex for the unaided human mind’.2 Nevertheless, he understood that doctors had concerns over how guidelines were developed and the factors that were taken into account; he described the relationship between doctors and guidelines as one of love and hate. At the same time, there was increasing emphasis on the integration of primary and secondary care to bring benefits in terms of seamless patient care, better collaboration between health professionals and an effective balance between community-based and hospital-based care.3 It was recognised that the management of some conditions can be complicated and that it may not be possible to fully discharge patients from hospital back to the care of their GP; hence, a system of shared care encompassing primary care and hospital outpatient care was developed for several long-term conditions including asthma and diabetes. These arrangements have been described as ‘the joint participation of primary and specialty care practitioners 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 notices’.4

Parallel with the development of shared care, changes in hospital outpatient dispensing policies in the UK meant that GPs were being asked to take over the prescribing of specialist medicines and to be involved in the ‘shared care’ of patients requiring these medicines. Typically, such medicines required a complex level of monitoring that was likely to exceed the expected expertise of the prescriber. Ideally, therefore, formalised shared care arrangements for specialist medicines were needed to provide the GP with the necessary information and support to prescribe safely and effectively. However, one influential study found that many GPs felt unable to assume clinical responsibility for prescribing specialist medicines that were outside their therapeutic experience and reported high levels of uncertainty towards repeat prescribing following patient discharge from hospital.5 NHS guidance in the form of an Executive Letter was issued to address concerns that doctors had voiced about prescribing specialist medicines.6 Problems included patients going without the medication they needed when there was a lack of agreement over prescribing responsibilities; perverse cost incentives to shift responsibility for medicines between secondary care and primary care; GPs’ concerns over taking responsibility for unfamiliar treatment and lack of consultation between professionals over the transfer of prescribing responsibilities. This guidance, which supported the concept of appropriate shared care, was widely referenced, has been supported by other guidance and has since been refreshed.7–9 However, over the past two decades a number of studies have examined barriers to the implementation of shared care guidelines, with similar issues arising time and time again. These include poor communication between primary and secondary care with complaints relating to 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 appropriately; GPs’ concerns that they lack the necessary knowledge or expertise; the mechanism by which shared care is requested; uncertainty over the medico-legal responsibilities of the prescriber; and cost shifting.10–14

Unfortunately, individuals working in different sectors—primary care, secondary or tertiary care and commissioning organisations—may perceive these barriers through different lenses. The specialist may question why some GPs will agree to prescribe a medicine as part of a shared care guideline, while other GPs refuse to do so. The specialist may not understand why a GP claims to be unfamiliar with prescribing a medicine that is deemed common practice within the specialty. The GP (and their Local Medical Committee) may feel that the monitoring of a medicine that has to occur alongside the prescribing is extra work for an already pressurised primary care service and is not part of the core GP contract. Specialists and GPs may complain about poor communication around the initiation of shared care and the delays involved in getting a response to such a request. Individual commissioning organisations may wonder why a problem that faces the whole health service is not managed centrally.

With such organisational challenges, it is easy to lose sight of the patient. Shared care arrangements should be designed around the needs of the patient and aligned with the medicines optimisation principle of understanding the patient’s experience. In 2017, DTB noted that patients still find themselves caught in the middle of poorly planned services, resulting in contractual, budgetary and professional disputes over prescribing responsibility.15 Shared care should only happen if it is appropriate, in the patient’s best interest and has the consent of the patient or carer. Patients should be allowed to decline shared care if they wish and a system for recording agreement to participating in a shared care arrangement is required.

Several other factors need to be in place to ensure that shared care arrangements are appropriately managed. Some can be achieved by effective communication between all parties, for example, via clinical letters on a patient specific basis. However, it is recognised that a degree of standardisation of shared care is helpful and helps minimise risk, which is why shared care guidelines have been developed between primary care and hospital care with the input and oversight of clinical commissioning groups. With the introduction of integrated care systems, a variety of solutions are needed including better IT systems, so there is more effective information sharing between care settings, organisations and geographies; support for patients to access their medical records and test results to enable them to manage their medicines and their illness; and collaboration and support between hospital pharmacists and primary care clinical pharmacists who are expected to take a central role in the clinical aspects of shared care protocols (as part of the Network Contract Directed Enhanced Service for primary care).16 Encouragingly, the latest national guidance provides a useful template of principles for shared care and attempts to cover the challenges that have been outlined above.9 Regional Medicines Optimisation Committees in England have shared care guidelines on their work agenda with a view to developing a standardised approach.17 However, the situation will remain patchy until we have adequately resourced commissioning pathways that enable the implementation of seamless patient-centred shared care.