Shared Care Third Parties Policy

Prescribing Policy for third party requests

v1 December 2025

 

We recognise that pressure on NHS services has increased in recent years, and that many patients are turning to private providers for diagnosis and treatment as a result. This letter explains our practice policy on taking over treatment initiated by third parties (including both NHS and private providers).

The legal responsibility for any prescription rests with the clinician who signs it. Each prescriber must only prescribe within their own level of competence.

Shared care agreements are designed to support smooth, integrated prescribing and monitoring between specialist services and general practice. Under shared care, clinical responsibility for a patient’s treatment may transfer from a hospital or specialist provider (NHS or private) to a GP or other primary care prescriber, but only when a formal shared care agreement is in place.

It is important to note that the existence of shared care guidelines does not oblige a GP to take on prescribing. A GP should only accept clinical and legal responsibility if they feel confident managing the condition and the treatment safely.

Our practice uses the BNSSG Traffic Light System (TLS) to guide decisions about prescribing responsibilities. This system categorises medicines to indicate where clinical responsibility should sit:

• Red: Specialist-only medicines. Prescribing and monitoring must remain with the specialist team (usually secondary care, though some specialist services operate in the community or primary care).
• Amber: Medicines suitable for shared care. Prescribing may transfer from the specialist team to primary care, but only with the agreement of the individual GP.
• Green: Medicines suitable for prescribing across the ICS by any prescriber within their competence. If initiated by a private provider, prescribing may transfer to primary care with the agreement of the individual GP.
• Blue: Medicines suitable for prescribing across the ICS by any prescriber within their competence.

Where there is no clinical reason to prescribe a more expensive drug or formulation, we will prescribe the most cost-effective option. This may mean explaining to patients that personal preference alone is not sufficient justification for using a less economical preparation when an effective alternative exists. If your treatment requires doses above the licensed limits, you will need to obtain your full medication supply privately.

 

In some situations, a GP may agree to shared care while a patient continues to see a private consultant for monitoring. However, if the consultant prescribes doses above the licensed range or recommends a medicine that is not included in our formulary, prescribing responsibility must remain with the consultant, whether private or NHS.

 

Certain medications require regular monitoring—such as blood pressure, pulse, ECGs, or blood tests. These investigations will remain the responsibility of the private provider unless the practice has agreed otherwise in advance.

 

If you are unable to reduce your dose or cannot afford to continue private treatment, please contact us to discuss whether a referral to an NHS clinic may be appropriate.

 

Possible circumstances where it may not be appropriate for a shared care agreement to be agreed, or where an exception to an agreement may be appropriate, so that the hospital/specialist retains responsibility for prescribing:

1. Medicines, which are unlicensed and/or are being used outside of product license (e.g. licensed medicine used for unlicensed indication or at an unlicensed dose) unless there is a recognised evidence base and/or it is standard treatment. In terms of paediatric medicines, that inclusion of dosage guidance in the Children’s BNF provides a suitable evidence base.

2. Medicines requiring ongoing specialist intervention and specialist monitoring.

3. Patients receive most of the ongoing care, including monitoring, from the provider and the only benefit of transferring care would be to provider costs.

4. Medicines, which are only available through the provider, i.e. are not available on FP10, including any ‘borderline’ products when used outside approved indications.

5. The GP has insufficient information to participate in a shared care prescribing arrangement where applicable.

6. No shared care prescribing agreement exists

7. Medicines and other prescribable products, which have not been approved for addition to the provider’s formulary.

8. Medicines subject to High-tech Hospital at Home guidance (EL(95)5).

9. All other treatments funded by NHS England unless specifically agreed to be provided through a shared care prescribing agreement, or other process as agreed by the local APC.

10. Without collaboration and agreement with the patient and/or carer.

 

Hormone Replacement Therapy

In April 2023, a joint safety alert was issued by the British Menopause Society, the Faculty of Sexual and Reproductive Health, the Royal College of General Practitioners, and the Royal College of Obstetricians and Gynaecologists. This alert highlighted concerns about an increasing number of women being prescribed high doses of oestrogen that exceed licensed product limits.

Oestrogen should not be routinely prescribed at doses higher than those established and tested in clinical research. The upper recommended limits are:

• Estradiol 0.06% gel:Maximum of 4 pumps
• Estradiol patch:Maximum of 100 mcg
• Oral Estradiol tablets:Maximum of 2 mg

We are aware that some private providers may prescribe oestrogen above these recommended limits. However, our practice policy is that we cannot prescribe any medication that would contribute, even in part, to an overall treatment dose exceeding these limits, as this would constitute prescribing beyond established safety guidelines. This decision was made with careful consideration, as prolonged use of excessive oestrogen doses may pose significant health risks.

Therefore, if you are receiving oestrogen and/or progesterone above the recommended limits, we request that you obtain your full medication supply privately. Alternatively, you may choose to reduce your prescribed oestrogen dose. If you feel unable to lower your dose and are unable to fund private treatment, please speak with us about the possibility of referral to an NHS complex menopause clinic for further management.

If you believe you may be taking a dose higher than the recommended limits or a combination of different oestrogen products (excluding vaginal oestrogen cream 0.1% or pessary 10 mcg), we strongly advise booking an appointment with our clinical pharmacist. This will allow us to review any potential risks and ensure your HRT regimen is safe.

Excessive oestrogen intake may increase the risk of uterine (womb) cancer, as well as potentially raising the risk of breast or ovarian cancer.

Some private menopause clinics choose to prescribe testosterone in women with low libido. GPs are not specialists and can’t prescribe amber drugs such as testosterone, so prescribing responsibility will remain with your consultant.

For further details, please refer to the British Menopause Society news update. The full technical statement can be accessed via the following link:

https://thebms.org.uk/2023/04/joint-bms-fsrh-rcgp-rcog-sfe-and-rcn-womens-health-forum-safety-alert/

 

Attention Deficit Hyperactivity Disorder (Adults)

Attention Deficit Hyperactivity Disorder (ADHD) can affect many aspects of a person’s life. Diagnosis is complex and requires a specialist, usually a consultant psychiatrist to do this.

As a practice, we are committed to supporting adult patients with neurodevelopmental diagnoses.  There is a clear pathway in Bristol for assessing ADHD –  Bristol Adult ADHD pathway.

Commissioned Services in Bristol, North Somerset & South Gloucestershire (BNSSG)

There are currently only 2 fully commissioned services in BNSSG:

• Avon & Wiltshire Partnership (AWP)
• Clinical Partners

 

Private ADHD Assessments and Shared Care with Right To Choose Providers(RTC)

We are mindful that patients seek private diagnosis and treatment; many make this decision as they can receive an assessment and diagnosis more quickly.  Alternatively, patients can also exercise their ‘right to choose’ and ask to be referred to a private provider who has an existing contract to provide NHS services.  This may be because the wait times are shorter.   Details of right of choose providers can be found at https://adhduk.co.uk/right-to-choose 

Ongoing prescriptions and review once an ADHD diagnosis has been made (Adult only)

Once a diagnosis has been made, the specialist is responsible for initiating medications, making any adjustments until the dose has been stabilised.  The specialist will also remain responsible for arranging an annual review, which includes a review of your ADHD symptoms, your medication and a physical assessment.

Once an established dose of the appropriate medication has been established, we may take on responsibility for on-going prescribing and monitoring under a shared care agreement with the NHS service specialist, however responsibility for reviewing the condition remains with the specialist.

Frome Valley Medical Centre will provide shared care and ongoing prescribing for the above 2 providers (AWP and Clinical Partners) following initial diagnosis and stabilised prescribing.

We will consider taking on the prescribing (under shared care following the BNSSG SCP - SCPs (Remedy BNSSG ICB)) from other RTC and private providers, providing we have assurance that the specialist will continue to monitor the patient and the condition annually as a minimum.  If this does not happen, we will not be able to continue prescribing as this would not be safe.  It is important that the patient considers this before they begin the process of diagnosis and starting treatment. If patients decide to discharge themselves from third party provider (private or NHS Right to choose), the GP will stop prescribing the ADHD medication as this is no longer considered safe without specialist input.

 

Attention Deficit Hyperactivity Disorder (children >5 years old)

Children with suspected ADHD should be referred by school Special Educational Needs Co-ordinators (SENCo) where possible rather than via a GP. They will be asked to complete the school questionnaire for assessment of ADHD.

Shared Care prescribing from NHS providers can be considered depending on child individual needs; however, the full responsibility and monitoring will remain with secondary care.

Frome Valley Practice does not accept Shared Care prescribing from private providers.