Medico-Legal: Ensuring shared care is seamless

Clear, two-way communication between GP and consultant is essential, says Dr Matthew Lee of the MDU

GPs and hospital consultants regularly provide care to patients under shared care arrangements. This is often provided under well established protocols and agreements that ensure patients receive good continuity of care when they are transferred from hospital to primary care. However, there are cases where difficulties have arisen in communication between GPs and consultants.

These difficulties include communication problems, such as confusion about who is responsible for the patient’s care and ambiguity in the consultant’s instructions about treatment and monitoring, and medication issues. For example, GPs may be asked to prescribe unfamiliar drugs, medications that need careful monitoring, unlicensed drugs or licensed drugs for conditions outside the licence. 

Allocating responsibility

Confusion can arise about who has overall responsibility for the patient’s care and ongoing monitoring of their condition. If you as a GP are prescribing a drug, you may wish to ensure that the treatment will be properly monitored and reviewed, either by you or by the specialist.

The GMC states that, as the patient’s GP, you will usually maintain overall responsibility for treatment. However, in its guidance Good Practice in Prescribing Medicines (2006) it advises that the decision about this should be based on the patient’s best interests rather than on the healthcare professional’s convenience or the cost of the medicine.

Hospital doctors have a responsibility to ensure that letters to GPs contain all the necessary information about the patient, their condition, and the required dose regimen and frequency of the drug prescribed.

Establish a protocol

You may wish to consider establishing a shared-care protocol with consultants, which should include responsibilities and details of follow-up arrangements.

The DoH and National Prescribing Centre have published joint guidance on the responsibility for prescribing between hospitals and GPs. Both documents stress the seamless transfer of care for the patient from hospital to general practice.

Prescribing responsibility

GPs are legally responsible for any prescription signed, so it is important to be familiar with the drug in question. If you are unclear about any aspect of the prescription, you should clarify this with the specialist who recommended the treatment before issuing a prescription.

When prescribing any drug, it is important to take an adequate history to establish contraindications and interactions, as well as to ensure the patient is fully informed of possible side effects and knows how, when and in what dose to take the medication.

GPs may prescribe medications outside the terms of their licence but GMC prescribing guidance says you should be satisfied it would better serve the patient’s needs than a licensed drug, and that there is sufficient evidence base or experience of safe use.

You should also take responsibility for the prescription and for monitoring the patient’s care, or arrange for another doctor to do so, and make a record of your reasoning.

Dr Lee is deputy professional services director at the Medical Defence Union

Learning points

How to avoid communication break-downs in shared care

A patient’s GP will usually maintain overall responsibility for treatment.

Hospital doctors have a responsibility to ensure that letters to GPs contain all the necessary information about the patient, their condition, the required dose regimen and frequency of the drug prescribed.

Consider establishing a shared-care protocol with consultants to avoid problems.

You will be legally responsible for any prescriptions signed, so make sure you are familiar with the drug, and clarify with the consultant any concerns you may have.

Take an adequate history to establish contraindications and interactions and make sure the patient is informed of any side-effects.

You should take responsibility for monitoring the patient’s care.

Resources

DoH and National Prescribing Centre guidance www.npc.co.uk/pdf/gp_prescribing_support.pdf

GMC guidance www.gmc-uk.org

Medical Defence Union www.the-mdu.com

Case Study: Insufficient information 

A patient attended a GP registrar with a letter from an obstetric specialist registrar who had seen her in the antenatal clinic at the local hospital.

The letter requested that the GP registrar prescribe nicotine replacement therapy for the duration of the pregnancy but did not mention a previous history of pregnancy-related hypertension.

The GP registrar was unsure which, if any, nicotine replacement therapies it would be safe to prescribe in pregnancy.

The patient became anxious when the GP registrar expressed reservations about the request and despite offering to make further enquiries from the obstetric team, the patient declined any prescription and continued smoking throughout the pregnancy.

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