This sets out the position of NHS Devon on requests made of GPs by private practice clinicians, or their patients who have accessed private care, to prescribe medications which are subject to formal shared care prescribing guidelines (either as part of a commissioned Local Enhanced Services (LES) or otherwise recommended practice).
The responsibility of GPs and specialists under formal Shared Care arrangements
A number of medications are recommended in the Devon Formulary to be prescribed by GPs only under formal “Shared Care” arrangements.
These Shared Care guidelines clearly describe the responsibilities of the specialist and GP (including monitoring and patient review) to ensure the ongoing safe use of the medicine.
In particular, these guidelines delineate the responsibilities of the specialist on initiating medication and their ongoing responsibility for review at defined intervals and for oversight of their care.
The ongoing nature of these responsibilities requires that the patient and the GP retain access to the specialist.
The specialist is required to undertake the specified reviews and be available to provide ongoing management advice to the GP.
In the case of a diagnosis and treatment plan that has been initiated privately there is no assurance that this ongoing care will be available.
GMC ethical guidance states: make sure appropriate clinical monitoring arrangements are in place and that the patient and healthcare professionals involved understand them.
NHS position on private and NHS care
Department of Health guidance indicates that patients who pay for private care should not be put at any advantage or disadvantage in relation to the NHS care they receive.
They are entitled to NHS services on exactly the same basis of clinical need as any other patient.
The patient should bear the full costs of any private services. NHS resources should never be used to subsidise the use of private care.
Patients are entitled to seek part of their overall treatment for a condition through a private healthcare arrangement and part of the treatment as NHS commissioned healthcare.
However, the NHS commissioned treatment provided to a patient is always subject to the clinical supervision of the NHS treating clinician.
In the case of formal “Shared Care” arrangements, overarching clinical supervision is provided by the specialist, with the GP accepting responsibility for certain aspects of care, which would otherwise be the responsibility of the specialist.
The prescribing of medicines under “Shared Care” arrangements between an NHS prescriber and a private specialist may therefore be viewed as the NHS prescriber subsidising the patient’s private care.
In addition, if the patient were unable to continue funding (e.g. due to a change in financial circumstances) and then discontinue the private care, the GP would be prescribing without the specialist oversight that the medication and patient’s clinical circumstances required, nor would the GP necessarily be in a position to discontinue the medication without specialist input.
Considering the points above, NHS Devon does not support formal “Shared Care” arrangements between privately funded and NHS funded clinicians.
Action supported by the ICB
In the case of treatment which requires formal “Shared Care” arrangements as explained above, and identified as such in the Devon Formulary, the GP should ensure that the patient has been referred to an appropriate NHS funded specialist service.
In some cases, access to this may be subject to a waiting list and the patient will be placed on this list in the same manner as any other NHS patient.
The GP will normally only undertake their elements of prescribing and monitoring described in local “Shared Care” guidelines when the patient is established in an NHS funded treatment pathway.
Patients should be fully informed at the point of seeking private healthcare of the possible restrictions and limitations around ongoing prescribing by an NHS clinician.
Ideally this should be communicated to the patient by the private health care provider. Primary care providers via their practice website may also wish to consider making this clear to patients.
Points on communication between healthcare professionals
BMA ethical guidance on the interface between private and NHS care recognises that many of the problems and concerns that arise in relation to prescribing shared between the private sector and the NHS could be avoided by improved communication between the parties concerned.
Consultants are advised to avoid simply informing patients that their GP will prescribe the recommended medication.
For the reasons described above it is clear that raising a patient’s expectations that their GP will in fact undertake on-going prescribing is not appropriate.
The appropriate course of action is for the private consultant to offer on-going medication and all related elements of care under private arrangements (informing their GP of this), or to write to the patients GP with details of the consultation and that the patient now wishes to enter NHS care for their condition.
