Decisions about who should take responsibility for continuing care or treatment after initial diagnosis or assessment should be based on the patient’s best interests, rather than on your convenience or the cost of the medicine and associated monitoring or follow-up.
Shared care requires the agreement of all parties, including the patient. Effective communication and continuing liaison between all parties to a shared care agreement are essential.
Prescribing at the recommendation of a professional colleague
If you prescribe at the recommendation of another doctor, nurse or other healthcare professional, you must satisfy yourself that the prescription is needed, appropriate for the patient and within the limits of your competence.
If you delegate assessment of a patients’ suitability for a medicine, you must be satisfied that the person to whom you delegate has the qualifications, experience, knowledge and skills to make the assessment. You must give them enough information about the patient to carry out the assessment required. You must also make sure that they follow the guidance in paragraphs 21 - 29 on Consent.
You should check whether the patient needs any additional support to understand information, to communicate their wishes, or to make a decision. You should bear in mind that some barriers to understanding and communication may not be obvious; for example, a patient may have unspoken anxieties, or may be affected by pain or other underlying problems. You must make sure, wherever practical, that arrangements are made to give the patient any necessary support. This might include, for example: using an advocate or interpreter; asking those close to the patient about the patient’s communication needs; or giving the patient a written or audio record of the discussion and any decisions that were made.
You should accommodate a patient’s wishes if they want another person, such as a relative, partner, friend, carer or advocate, to be involved in discussions or to help them make decisions. In these circumstances, you should follow the guidance in paragraphs 7 - 21.
It is sometimes difficult, because of pressures on your time or the limited resources available, to give patients as much information or support in making decisions as you, or they, would like. To help in this, you should consider the role that other members of the healthcare team might play, and what other sources of information and support are available. These may be, for example, patient information leaflets, advocacy services, expert patient programmes, or support groups for people with specific conditions.
You should do your best to make sure that patients with additional needs, such as those with disabilities, have the time and support they need to make a decision. In all cases, you must treat patients fairly and not discriminate against them.
If you think that limits on your ability to give patients the time or information they need is seriously compromising their ability to make an informed decision, you should raise your concerns with your employing or contracting authority. See paragraph 25b of Good medical practice and the explanatory guidance Raising and acting on concerns about patient safety.7
If you are the doctor undertaking an investigation or providing treatment, it is your responsibility to discuss it with the patient. If this is not practical, you can delegate the responsibility to someone else, provided you make sure that the person you delegate to:
- is suitably trained and qualified
- has sufficient knowledge of the proposed investigation or treatment, and understands the risks involved
- understands, and agrees to act in accordance with, the guidance in this booklet.
If you delegate, you are still responsible for making sure that the patient has been given enough time and information to make an informed decision, and has given their consent, before you start any investigation or treatment.
Clear, accurate information about the risks of any proposed investigation or treatment, presented in a way patients can understand, can help them make informed decisions. The amount of information about risk that you should share with patients will depend on the individual patient and what they want or need to know. Your discussions with patients should focus on their individual situation and the risk to them.
In order to have effective discussions with patients about risk, you must identify the adverse outcomes that may result from the proposed options. This includes the potential outcome of taking no action. Risks can take a number of forms, but will usually be:
- side effects
- failure of an intervention to achieve the desired aim.
Risks can vary from common but minor side effects, to rare but serious adverse outcomes possibly resulting in permanent disability or death.
In both cases, you will be responsible for any prescription you sign.
Recommending medicines for prescription by colleagues
If you recommend that a colleague, for example a junior doctor or general practitioner, prescribes a particular medicine for a patient, you must consider their competence to do so. You must satisfy yourself that they have sufficient knowledge of the patient and the medicine, experience (especially in the case of junior doctors) and information to prescribe. You should be willing to answer their questions and otherwise assist them in caring for the patient, as required.
Shared care prescribing
If you share responsibility for a patient’s care with a colleague, you must be competent to exercise your share of clinical responsibility. You should:
- keep yourself informed about the medicines that are prescribed for the patient
- be able to recognise serious and frequently occurring adverse side effects
- make sure appropriate clinical monitoring arrangements are in place and that the patient and healthcare professionals involved understand them
- keep up to date with relevant guidance on the use of the medicines and on the management of the patient’s condition.
In proposing a shared care arrangement, specialists may advise the patient’s general practitioner which medicine to prescribe. If you are recommending a new, or rarely prescribed, medicine, you should specify the dosage and means of administration, and agree a protocol for treatment. You should explain the use of unlicensed medicines, and departures from authoritative guidance or recommended treatments and provide both the general practitioner and the patient with sufficient information to permit the safe management of the patient’s condition.14
Shared care resources are available from the National Prescribing Centre; Midlands Therapeutics Review & Advisory Committee, which has produced 16 ‘Effective Shared Care Agreements’ covering a variety of medicines/indications; UK Medicines Information, which has published many shared care protocols/agreements; and Keele School of Pharmacy which publishes an Effective Shared Care Agreement Toolkit ‘to assist healthcare professionals in the development of their own shared care agreements to support locally agreed prescribing’.
If you are uncertain about your competence to take responsibility for the patient’s continuing care, you should seek further information or advice from the clinician with whom the patient’s care is shared or from another experienced colleague. If you are still not satisfied, you should explain this to the other clinician and to the patient, and make appropriate arrangements for their continuing care.