Both hospitals and GP practices have been under extra pressures during the COVID-19 pandemic. To address backlogs in secondary care more GPs may find themselves being asked to establish shared care agreements to help support patients following discharge from hospital or as part of their continuing out-patient care.
It is important that shared care is properly and clearly managed and essential that systems are put in place to maintain continuity of care when a patient returns home from hospital. In the MDU’s experience, particular risks may arise if communication fails or if it is unclear who will be responsible for prescribing.
Decisions about who will take responsibility for the patient’s continuing care need to be made at the outset. The decision should be based on the patient’s best interests and not for reasons such as the cost of medication, monitoring issues or convenience.
Patients should understand the roles of the different healthcare professionals involved in their care and agree to the shared care arrangement.
GP members frequently seek advice about prescribing responsibilities, such as when they are asked to continue prescribing medication initiated in secondary care. Prescribing off-label or unlicensed drugs, and prescribing a drug with which the GP is unfamiliar are also frequent topics.
Medication errors are a recurrent theme in adverse incidents reported to the MDU’s medico-legal advice line. In analysis of claims settled on behalf of GP members, problems included:
- Failure to monitor long-term medication
- Prescribing the wrong drug or the wrong dose
- Prescribing to patients with a known allergy to the drug
- Vaccine errors.
According to GMC guidance, doctors prescribing any medication are responsible for the prescription they sign and must be able to justify their decisions and actions.
If a specialist recommends a treatment, particularly if this is a new, or rarely prescribed medicine, they will be responsible for specifying the dose and means of administration. If you are then asked to continue the patient’s care, the specialist will need to ensure the patient and the GP has sufficient information to allow safe management of the patient’s condition.
GPs being asked to take over or share patient care started by secondary care colleagues are advised to ensure that:
- Patients’ long-term medication is reviewed and monitored appropriately and updated by an appropriately experienced member of staff when a patient is discharged from hospital.
- You are able to recognise adverse side effects of the medication.
- You seek further information from the specialist if follow-up, monitoring and/or prescribing arrangements are unclear.
- There is a robust system for dealing with messages from patients and for giving and documenting telephone advice.
- You have proper communication links with other services the patient requires support from after discharge from hospital and that a record is made of the support others are providing.
- You review a diagnosis if symptoms fail to improve as expected and do not place over-reliance on negative results in the light of continuing symptoms or signs.
- Medical records are organised in such a way that information about admission, discharge, out-patient or other (for example, out-of-hours) care, is easily accessible and summarised.
- Keep yourself informed about other medicines that are prescribed to the patient for co-existing conditions and that the specialist is made aware of any changes.
- Tasks are only delegated if it is appropriate to do so and to colleagues who are appropriately qualified and experienced.
Communication is key
Secondary care colleagues also have responsibilities to ensure you are informed about patient’s needs when discharged from hospital – particularly when those needs are complex. Medication requirements should be clearly stated and discussed with the practice and with the patient and responsibilities for follow up and monitoring clearly communicated.
Communication is the key to a successful shared care arrangement where all parties, including the patient, understand the roles of the healthcare professionals involved in their care. This includes clear documentation so that others who may become involved in the patient’s care at a later stage also have a full understanding of the differing responsibilities.
If you have concerns about continuing a patient’s treatment recommended by a secondary care colleague, get in touch with the MDU or your own medical defence organisation.