Shared Care Prescribing of Antipsychotic Medication Policy

1. Purpose

This policy sets out the Practice's position on shared care prescribing of antipsychotic medication initiated by secondary care or specialist mental health services. It is intended to ensure patient safety, appropriate clinical oversight, and clarity for patients, carers, secondary care colleagues and Practice staff regarding where prescribing responsibility sits.

2. Policy statement

West Gorton Medical Centre will not accept new shared care prescribing arrangements for antipsychotic medication. This decision has been made on a Primary Care Network (PCN)-wide basis and applies consistently across member practices in Gorton and Levenshulme.

Responsibility for prescribing, monitoring and dose adjustment of antipsychotic medication remains with the initiating secondary care or specialist mental health service for as long as the patient requires this medication.

3. Rationale

This decision has been made for the following reasons:

• Unfunded, non-contractual work: shared care prescribing of antipsychotic medication falls outside of core general medical services and is not separately funded or contracted work for general practice.
• Shared care protocols in practice are inconsistently followed by specialist services and frequently contain unclear or incomplete instructions regarding monitoring responsibilities, escalation and dose-adjustment parameters.
• Required baseline and interval investigations (e.g. physical health monitoring) are not reliably carried out by the specialist service prior to shared care requests being sent to the Practice.
• Patients are not always clinically stable at the point a shared care request is made, which is contrary to the basic principle that shared care should only be requested once a patient's condition and dose are stable.
• Patients are regularly transferred or discharged from secondary care or specialist services back to primary care without a shared care agreement being formally in place. Prescribing antipsychotic medication in these circumstances is not shared care, and the Practice does not hold the specialist licence, competence or indemnity to prescribe these medications on an unsupported, independent basis.
• Re-referrals back to secondary care are frequently rejected, despite the Practice citing the shared care rules that responsibility has not transferred. Where referral is accepted, waiting times for specialist services (for example, adult ADHD or community mental health services) are often prohibitively long.
• This combination leaves the Practice in an unsafe position: either stopping medication (causing patients undue distress, relapse or harm), or continuing to prescribe on an unlicensed, unsupported basis without the specialist oversight the medication requires. Neither option is acceptable or sustainable.

4. Scope

This policy applies to all new requests for shared care prescribing of antipsychotic medication, and to patients discharged or transferred from secondary care or specialist services without a valid, currently-agreed shared care arrangement already in place.

Existing shared care arrangements that are currently working safely and effectively may be reviewed on a case-by-case basis by the GP partners, but there is no obligation on the Practice to continue any arrangement that does not meet the standards set out in Section 5.

5. Conditions that would be required for any shared care arrangement

The Practice would only consider any shared care request for antipsychotic medication where all of the following are met:

1. A clear, agreed, PCN/ICB-recognised shared care protocol is provided, with unambiguous monitoring responsibilities and escalation pathways.
2. All required baseline investigations and physical health monitoring have been completed by the specialist service prior to the request.
3. The patient is confirmed to be clinically stable on their current dose, with no recent dose changes or unresolved side effects.
4. The specialist service confirms it remains available for ongoing advice, review and rapid re-acceptance of the patient should their condition deteriorate.
5. The GP partners have reviewed and explicitly agreed to accept the individual request; acceptance is not automatic and remains at the Practice's clinical discretion.

Given the concerns set out in Section 3, it is anticipated that few, if any, new requests will meet these conditions.

6. What this means for patients

• Prescribing, monitoring and dose adjustment of antipsychotic medication should continue to be provided by the secondary care or specialist service that initiated treatment.
• The Practice is unable to accept prescribing responsibility where a patient is discharged or transferred without a valid, agreed shared care arrangement.
• Where a patient's usual prescriber is unclear following discharge or a rejected re-referral, the Practice will support the patient in escalating this with the responsible service, and will not stop medication abruptly without first seeking to safeguard continuity of care.
• Any queries about dose changes, side effects or ongoing monitoring should be directed to the specialist service, not the Practice.

7. Escalation

Where a patient is discharged inappropriately, or a re-referral is rejected in a way that leaves a patient without a clearly responsible prescriber, this should be escalated by the Practice to the relevant ICB commissioning team and/or PCN clinical lead, with the case documented, rather than the Practice absorbing unfunded and unsupported prescribing risk.

8. Communication

Patients affected by this policy will be informed in writing (letter, text message or via consultation, as appropriate) of the Practice's position and signposted to their secondary care or specialist provider for ongoing prescribing. Secondary care and specialist services will be notified of this PCN-wide position where relevant to an individual patient's care.

9. Review

This policy will be reviewed every two years, in line with the PCN-wide position, or sooner in light of updated national guidance, commissioning changes, or significant local service changes.