Shared-care arrangements and the primary/secondary-care interface Jas Khambh MRPharmS, DipPrescSci and Christian Barnick FRCOG Specialist and high-risk drugs are increasingly being prescribed in the community due to a shift in services from secondary to primary care. This article describes the shared-care arrangements that need to be in place to ensure safe and effective treatment. Figure 1. Shared-care guidelines need to provide information for GPs about complex therapies: the details here are from a shared-care guideline for methotrexate Some specialist treatments that have traditionally been provided in hospital settings are now more commonly being provided in the community-care setting. New government initiatives such as practice-based commissioning are enabling a shift in healthcare from secondary to primary care in many specialist areas. This shift in services means that specialist and high-risk drugs are increasingly being prescribed and administered in the community. Shared-care guidelines help to ensure that these drugs are prescribed and administered appropriately. The situation at present The fact that patients can have problems with medicines as they move between primary and secondary care is well established. Research in this area dates back over 10 years. 1 Taking medicines always involves risks, however, and when patients move from one care setting to another that risk is increased. These difficulties usually arise when there is a lack of communication: although the professionals working in each sector are independently doing their best for the patient, their ability to offer www.escriber.com Prescriber 5 April 2007 23
the patient s condition is stable the agreement of the patient s GP is sought prior to the sharing of care the GP is sufficiently informed and able to monitor treatment, identify drug interactions and adjust the dose of any drugs as necessary Table 1. Conditions that should be met before shared care takes place optimal care is restricted by their lack of knowledge about what has happened in the other care setting. Research findings Problems associated with the transfer between secondary and primary care of information relating to medicines, and vice versa, have long been recognised, and pharmacists have addressed this problem using a number of methods. Work has been published that has focussed on the transfer of information from secondary to primary care at the time of discharge from hospital. 2 Information transfer between secondary and primary care needs to be improved to prevent drug errors. Although electronic transmission of information offers a solution to the problem, its success should not be assumed, researchers say. 3 Electronic prescribing and electronic transfer of information will probably take some time before it is fully established, and even when it is established it may not have the capacity to deal with all the problems encountered at present. The need for shared-care arrangements The meaning of shared care has changed over time in response to government policy imperatives and geographical location of care. It also probably means different things depending on which side of the primary/secondary-care interface you work, and indeed on whether you are a service provider or user. Generic shared care has been described as the joint participation of GPs and hospital consultants in the planned delivery of care for patients with a chronic condition, informed by enhanced information exchange over and above routine discharge and referral letters. 4 With rapid advances being made in the areas of therapeutics and drug development, it is becoming increasingly important to recognise the specialist skills and experience that are necessary for clinicians to effectively and safely specialist drugs or drugs used to treat specialist conditions where the consultant considers that only he or she is able to monitor the patient s response to medication, eg because of the need for specialised investigations specialist drugs or drugs used to treat specialist conditions where the GP does not have the specialist expertise to undertake the clinical and prescribing responsibility where a local prescribing group/medicines committee may designate specific medicines as specialist and which would normally be prescribed only by hospital clinicians drugs or appliances are only available through hospitals treatment is part of a clinical trial or research project Table 2. When responsibility for prescribing will more appropriately rest with a consultant manage the drug treatment of certain conditions. The NHS Management Executive issued its guidance on prescribing at the hospital/gp interface through EL(91)127 Responsibility for prescribing between hospitals and GPs. This guidance: reinforces the basic premise that it is for the doctor who has clinical responsibility for a patient to undertake prescribing focusses on the concept of shared care, emphasising the need for proper handover procedures from hospitals. The aim of shared-care guidelines is to provide information to GPs about complex therapies that their patients may receive following a specialist referral (see Figure 1). In cases where it is deemed appropriate for hospitals to retain prescribing, shared-care guidelines may be useful to enable GPs to play a part in patient management. The advent of a unified budget, from April 1999, has facilitated prescribing in the appropriate sector with perceived cost shifting being less of an issue. Prescribing carries with it full clinical and therefore legal responsibility. Generally when a patient has completed a course of inpatient care or specialist treatment and his or her condition is stable, clinical care is transferred wholly to the GP with appropriate advice and information from the specialist. Wherever possible all of a patient s treatment should be prescribed by one practitioner. Increasingly, however, patients with continuing specialist clinical needs can be cared for in the community. Not all GPs will have the relevant clinical experience or specialist expertise to be able to undertake full clinical and, therefore, legal responsibility for prescribing in these circumstances, and a 24 Prescriber 5 April 2007 www.escriber.com
staff training and how this is provided resource allocation from secondary to primary care new treatment protocols and care pathways to incorporate the necessary changes more shared-care guidelines/protocols highlighting the different areas of service provision and the responsibilities of different healthcare professionals a closer working relationship between primary and secondary care Table 3. Factors to consider when developing community-based specialist services shared-care arrangement between the specialist and the GP may be appropriate. Shared care does not necessarily mean that a GP will prescribe, but that he or she will offer routine care to the patient. Table 1 provides a list of conditions that should be met before shared care takes place. Shared-care arrangements must have a protocol for the provision of treatment and be approved by a local prescribing group/medicines committee with GP involvement. A patient-specific protocol should be prepared for each patient and should include: the roles and responsibilities of each prescriber and of the patient/carer details of the medicines included in the shared-care arrangement how the patient will be monitored the circumstances in which treatment will be modified or stopped. In all cases of shared care, the GP should ensure that a patient s practice records contain current and accurate information of all drug treatments, including those prescribed by other practitioners. Over time, as clinical experience and evidence for safety and efficacy of new and/or specialist medicines develops, medicines initially considered as specialist only or prescribable only within sharedcare guidelines may become more widely accepted as routine practice in primary care. All prescribers should be aware of their responsibilities to develop their own and others expertise in the managed introduction of new treatments. When is shared care not appropriate? Table 2 shows when responsibility for prescribing for a patient who is otherwise under the care of his or her GP will more appropriately rest with a consultant. www.escriber.com Prescriber 5 April 2007 25
Case history: A lack of communication A 64-year-old patient died from acute liver failure as a result of massive hepatocellular necrosis caused by the drug flutamide. The patient was treated for prostate cancer with drugs including flutamide and goserelin (Zoladex). Flutamide is a drug known to cause liver damage if used for prolonged periods of time without monitoring. This patient was prescribed flutamide in error over an extended period without monitoring the liver function, and as a result the patient developed irreversible liver damage. The intention was that the flutamide would be given for about two weeks in order to protect the patient from the effects of goserelin. Sadly, due to a series of miscommunications and misunderstandings he continued to take flutamide for approximately nine months and became extremely unwell with liver failure and died. Treatment was initiated at the hospital, and letters were written to the patient s GP. Initially, the GP was not happy to give the drugs as he felt they should be administered and monitored by the hospital. The GP s secretary rang the hospital to inform them of this. For reasons that were not entirely apparent, the GP nevertheless went on to prescribe goserelin and flutamide. The GP did not realise that the flutamide should be given for only a limited period of time, did not know that it caused liver damage and had no clear idea of what treatment his patient was receiving. The GP s initial concerns were around the administration of goserelin and the fact that he felt that he did not have the expertise to administer this injection. As a result of this, the whole issue of the flutamide prescribing and its requirements were overlooked. Key points Letters sent by the hospital to the GP appeared to be significantly delayed. The patient never saw the same doctor twice at the hospital. The patient was used as a method of communication between the hospital and the GP about his treatment. This was not withstanding the fact that he was sometimes described as vague. Copies of communications given to him were not kept on file. The GP and the hospital doctors were diametrically opposed in their views regarding treatment. The GP seemed to think it was a matter for the hospital to prescribe, administer and monitor, while the hospital said that all such treatments should be given by the GP in partnership with the hospital. In spite of the GP s confusion about the treatment, he did not speak to any doctor at the hospital. The GP was never asked if he was happy to prescribe the drugs. A number of professionals were involved in communications between primary and secondary care, eg GP, hospital doctors, secretary, nurses; however, there were no formal procedures to deal with these communications. There were no formal shared-care guidelines in place for these high-risk drugs. There were no formal arrangements in place on how these issues should be communicated across the interface. The impact of shared care on enhanced services and practice-based commissioning Increased enhanced services provided by GPs and the recent government initiatives on practice-based commissioning (PBC) are encouraging the development of more GPs with special interests (GPwSIs) who will deliver specialist services in the community, resulting in a more American style of primary healthcare. Examples of such communitybased specialist services that are already operational include: warfarin clinics hypertension clinics diabetes clinics gynaecology and HRT clinics. This shift in services is resulting in increased prescribing of more complex and high-risk drugs in primary care. In order for this system of healthcare to work effectively, it is essential that a number of factors are considered, as shown in Table 3. This will result in more of a shared-care approach to the whole of healthcare delivery as opposed to just shared-care guidelines for drugs. As a result a broader definition of shared care will probably emerge. The problems that such an arrangement may cause are: the skills gap in primary care may not be adequately filled secondary care may already have well-established services in the areas concerned potential conflict between primary and secondary care as the need for services from secondary care is reduced safety considerations as more specialist services will be provided at the point of entry. The increased provision of specialist services in the community may well be the way forward 26 Prescriber 5 April 2007 www.escriber.com
in some specialist areas. It may help to reduce costs and is more convenient for patients. However, it is vitally important that such services are carefully controlled and that there is early involvement of all stakeholders. A shared-care approach will be necessary if these services are to work effectively. The accompanying case study highlights the importance of shared-care arrangements. interface. The Pharmaceutical Journal 2004;272:210-11. 2. Duncan J. Assessing incoming discharge letters. Primary Care Pharmacy 2000;1:109-11. 3. Discharge information needs to be improved to prevent prescribing errors. The Pharmaceutical Journal 2002;268:81-6. 4. Lester L. Shared care for people with mental illness: a GP s perspective. Advances in Psychiatric Treatment 2005;11:133-9. Jas Khambh is interface pharmaceutical adviser at City and Hackney Teaching PCT, and Mr Barnick is consultant in obstetrics and gynaecology at Homerton University Hospital, London, and chair of the local joint prescribing and medicines management group Conclusion It is important to realise that the purpose of shared care is not to reduce cost, but rather to reduce risk to patients and to ensure continuity of care across the interface. Shared-care guidelines are essential for high-risk drugs if they are to be prescribed and administered properly. Many professionals are relying on the electronic patient record and electronic prescribing to deal with these communication problems. It is important to realise, however, that the electronic transfer of information may well be the answer to some of these problems but it will take time before this is fully established. In the interim these problems need to be dealt with by taking appropriate measures such as the production of procedures and guidelines. Good communication is necessary for shared care to be successful. There should be a commitment to shared care on both sides of the interface. Shared care is now a political priority. It offers a way of working in partnership that can provide better-quality, holistic patient care. 4 References 1. How to improve medicines management at the primary/secondary care www.escriber.com Prescriber 5 April 2007 29