Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish.
Clinical governance encompasses quality assurance, quality improvement and risk & incident management.
Shared Care Prescribing (Clinical governance risk management)
Amber list drugs, ‘shared Care’ arrangements and Acute Prescriptions between the GP and private providers
Definitions
Acute prescriptions – medications required to deal with a short term/immediate condition/s or issue/s with the medication course in most cases lasting 3 months or less.
Amber list drugs – are as defined on the Northern Ireland Primary Care intranet.
Private provider/s – any health care professional/worker who is working in a private capacity of any sort even if said private provider is also employed/contracted by an NHS service in another capacity.
‘Shared care’ arrangements – can be any form of relationship or communication between us (NHS GP service) and any type of private provider in the care/treatment/management of our registered patients.
When patients see a doctor in the outpatient clinic they are often given a prescribing advice note or letter requesting that a GP prescribe medication in the community. Your GP will review this request and if it is felt appropriate and it is safe, will normally prescribe the medication.
Some medications are more complicated and fall into the category of medications that require ongoing input from a specialist, usually alongside the patient’s GP. These arrangements are often termed ‘shared care’.
Within the NHS in Northern Ireland, these ‘shared care’ arrangements often involve what are classed as Amber list drugs. These drugs are usually potent medications with the potential for harm if prescribed incorrectly and have specific monitoring requirements such as regular blood testing or physical checks that have to be carried out in order for the medication to be prescribed safely.
There are formalised ‘shared care’ guidelines for Amber list drugs which outline the responsibilities of the NINHS specialist/doctor and the GP.
These ‘shared care’ arrangements are uniform and a voluntary agreement is sought between the NI NHS specialist/doctor and the GP. Where a GP is unable to undertake safe prescribing for whatever reason, the responsibility for prescribing remains with the NI NHS specialist/doctor. In these cases, patients would then receive their medications from NHS hospital service and have monitoring undertaken at their hospital clinic. ‘Shared care’ prescribing in Primary Care is always voluntary on the part of the GP.
In recent years there has been a huge growth in private specialists/doctors reviewing patients in the private sector and subsequently requesting NI NHS GPs to take over prescribing of medications and/or enter into ‘shared care’ arrangements. This has created significant problems for a number of reasons which include:
- The requirement to confirm the credentials of private specialists/doctors;
- Correspondence from private specialists/doctors lacking in detail or clarity to assure us that reviews are happening as stipulated;
- Difficulties with regular review as the patients often pay each time they see the private specialist/doctor and this can lead to reviews not occurring as often as required;
- Issues with contacting private specialists/doctors to obtain advice raising significant safety concerns;
- No funding or resource allocation for Primary Care to cover the work private specialist/doctors generate. Time spent dealing with these issues directly impacts on our ability to provide the NHS care we are actually funded for.
We are aware that most GPs in Northern Ireland are now declining to get involved with private providers in prescribing Amber list drugs and/or entering ‘shared care’ arrangements. We have decided that in the interests of safety and our ability to provide an equitable NHS service for all our patients that we will not be able to prescribe Amber list drugs or enter ‘shared care’ arrangements with private specialists/doctors.
Going forward, patients who are seen privately by a specialist/doctor and are advised that they need an Amber list drug or a ‘shared care’ arrangement will have to pay for this (including medication and monitoring costs) as part of their private treatment. These prescriptions will need to be privately prescribed by the specialist/doctor concerned. We will not be making exceptions.
If patients hold private medical insurance this may cover the cost of medication. Any patient can be referred into the NI NHS at any time and if they are seen by a NHS specialist/doctor and the advice remains that a ‘shared care’ arrangement is required, we will provide this under the NI NHS ‘shared care’ arrangements where it is safe to do so. We appreciate there are long waiting lists for NI NHS treatment and we share your frustrations with these delays.
We will be reviewing our patient population to identify any patients who are currently receiving Amber list drugs or ‘shared care’ arrangements with a private specialist/doctor. We will be contacting affected patients to inform them of our updated policy and the implications of this for their treatment going forward.
Please note: if any of our patients are receiving medications from a private specialist/doctor, we would advise that they let us know so that it can be recorded on their records in case there are any interactions with other treatments.
To summarise, the British Medical Association (BMA) have stated the following:
“Shared Care with private providers is not recommended due to the general NHS constitution principle of keeping as clear a separation as possible between private and NHS care. Shared Care is currently set up as an NHS service, and entering into a shared care arrangement may have implications around governance and quality assurance as well as promoting health inequalities. A private patient seeking access to shared care should therefore have their care completely transferred to the NHS. Shared care may be appropriate where private providers are providing commissioned NHS services and where appropriate shared care arrangements are in place.
All shared care arrangements are voluntary, so even where agreements are in place, practices can decline shared care requests on clinical and capacity grounds. The responsibility for the patient’s care and ongoing prescribing then remains the responsibility of the private provider.”
Acute private Prescription requests
Acute prescriptions – medications required to deal with a short term/immediate condition/s or issue/s with the medication course in most cases lasting 3 months or less.
Acute prescriptions from private providers will be declined and patients redirected back to private provider to fulfil these requests.
Other prescriptions from private providers will be reviewed on a case-by-case basis but the following general rules we will apply:
3.2.a. Amber list drugs and ‘shared care’ arrangements will be excluded as previously noted in this policy.
3.2.b. NI formulary medication requests may be considered for NHS GP prescription where they do not fall under the definition of Acute prescription in this document. However we reserve the right to decline such requests.
Disclaimer: This policy is a guideline of our Practice policy for approaching the interface between NHS and the private sector. It is not exhaustive or complete and therefore we reserve the right to review and amend this document and therefore our policy approach at any time.
However when significant changes are made to our Policy, we will take reasonable steps to inform our patient population in a timely manner; in most cases this will involve a policy update on our website within 3 weeks of the change.
