How shared care works (NHS GP plus private specialist)

Most long-term conditions in the UK are not managed by a specialist alone. They are managed by a GP, with a specialist involved at specific points (initial diagnosis, complications, medication changes). The mechanism that lets the two work together is called shared care.

This article sets out what shared care is, how it works in practice, which conditions typically use it, what happens when private specialists refer work back to NHS GPs, and what to do if the NHS GP declines to take on shared care. Sources are at the end.

What shared care is

Shared care is a formal clinical arrangement under which a specialist initiates and stabilises treatment, and an NHS GP then takes over ongoing prescribing and monitoring. Both clinicians remain involved, with responsibilities defined in a written shared care agreement or protocol.

The specialist typically:

• Confirms the diagnosis.

• Initiates and titrates the specialist medication.

• Stabilises the patient on a defined dose.

• Writes the shared care agreement to the GP.

• Sees the patient for annual (or more frequent) review.

The NHS GP typically:

• Issues ongoing prescriptions.

• Conducts routine monitoring (blood tests, blood pressure, weight).

• Handles interactions with other medications.

• Refers back to the specialist if the condition changes.

• Manages the patient's general health and other conditions alongside the specialist-managed one.

The point of the arrangement is that the patient gets the specialist's expertise for the things that need specialist expertise, and the GP's continuity and integration for the things that do not. Most UK long-term conditions work this way.

Common conditions that use shared care

Shared care is routine for a long list of conditions, including:

• Adult attention-deficit/hyperactivity disorder (ADHD). Specialist initiates and titrates stimulant or non-stimulant medication; NHS GP continues prescribing under shared care.

• Rheumatoid arthritis and other inflammatory arthritis. Specialist initiates disease-modifying drugs (methotrexate, biologics); NHS GP handles routine prescribing and monitoring.

• Epilepsy. Neurologist initiates; NHS GP continues prescribing and monitors for interactions.

• Severe asthma and chronic obstructive pulmonary disease (COPD). Specialist manages difficult cases; NHS GP handles most ongoing prescribing.

• Hormone replacement therapy (HRT), including perimenopausal and post-menopausal HRT. Specialist (gynaecologist or menopause specialist) often initiates; NHS GP continues.

• Testosterone replacement therapy (TRT). Specialist initiates; NHS GP continues prescribing and monitors.

• Inflammatory bowel disease. Gastroenterologist manages; NHS GP co-prescribes and monitors.

• Bipolar disorder and some other mood disorders. Psychiatrist initiates mood stabilisers; NHS GP may continue prescribing lithium and similar agents under a shared-care protocol.

• Heart failure and some cardiology conditions. Cardiologist initiates specialist drugs; NHS GP continues prescribing and monitoring.

• Some cancer follow-up regimes. Oncologist leads; GP may prescribe supportive medication and handle broader health.

The pattern is similar across all of these. The specialist does the clinically specialist-specific parts; the GP does the parts that need continuity and integration.

The formal shared care agreement

The written shared care agreement is the document that specifies who does what. It typically covers:

• The diagnosis and the rationale for treatment.

• The specialist medication and dose.

• The monitoring schedule (which blood tests, how often).

• Who manages interactions and side effects.

• When to re-refer to the specialist.

• The specialist's contact details for advice.

Local shared care agreements are written by the relevant NHS trust or Integrated Care Board (ICB). The British National Formulary (BNF) and the Royal College of General Practitioners have template protocols for common drugs. Most UK NHS GPs will work to these templates.

Private-to-NHS shared care

This is the part where things get more complicated. When a patient has been assessed and started on treatment by a private specialist, returning to the NHS GP for ongoing shared care is not always straightforward.

The formal position is that:

• The NHS GP is not obliged to take on shared care for treatment initiated privately (or initiated by an independent NHS-funded provider under Right to Choose, in some ICBs).

• The GP's decision depends on clinical judgement, local protocols, and the quality of the specialist's handover.

• A well-written specialist letter, a clearly specified medication plan, and a reliable specialist contact for advice make the transfer substantially easier.

In practice, three patterns are common.

• The NHS GP accepts shared care straightforwardly, usually because the condition is well understood, the specialist letter is comprehensive, and the local protocol supports the transfer. This is the most common outcome for straightforward cases.

• The NHS GP declines shared care, usually citing concerns about the specialist's handover, the local protocol, or the GP's own confidence with the specific medication. The patient then remains under specialist care (either private or, if referred back to the NHS, on the NHS specialist waiting list).

• The NHS GP takes on partial shared care, for example continuing some monitoring but asking the specialist to continue prescribing. This is a pragmatic middle ground that works well when the specialist is willing to continue the prescribing side.

Adult ADHD is the specific area where private-to-NHS shared care has been most actively debated. The pattern of many patients seeking private (or Right-to-Choose independent-sector) ADHD assessment, then needing ongoing NHS prescribing, has produced significant variation in how individual NHS GPs and ICBs handle the transfer. The British Medical Association and the Royal College of General Practitioners have published guidance but the position remains variable.

If the NHS GP declines shared care

If an NHS GP declines to take on shared care after specialist initiation, the patient has several options.

• Ask for a written explanation. The GP should be willing to explain the specific clinical reasoning, which helps the patient understand what to do next.

• Ask the specialist to continue prescribing. If the specialist is an NHS provider, this may involve staying with the NHS specialist clinic. If the specialist is private, this involves continued private prescription fees.

• Ask for a second NHS specialist opinion. A second specialist letter, or a letter from a different specialist in the same specialty, sometimes unlocks shared care where the first letter did not.

• Change GP practice. Different practices take different positions on shared care, and for some conditions the variation is substantial. Changing practice is a legitimate option if shared care has genuinely broken down.

• Escalate to the ICB. For complex or contested cases, the ICB's patient-liaison service can sometimes help.

• Raise with the Royal College of General Practitioners or the BMA if the case involves a systemic shared-care issue that needs attention.

None of these is a first-choice route. Most shared-care transfers work smoothly. Where they do not, the options above are available.

Tips for making shared care work smoothly

A few practical tips, drawn from what tends to go well and what does not.

• Make sure the specialist writes to your NHS GP. Every specialist consultation should produce a letter. If it does not, ask for one and ask for a copy.

• Be specific about what you are asking the GP to do. "My specialist would like me to continue on medication X at dose Y, with monitoring every Z. Can you take this on under shared care?" is a clearer ask than "the specialist said I need ongoing prescribing."

• Bring the specialist's letter to your GP appointment. A printed copy, not just a reference to an email.

• Know the local shared-care protocol if possible. Some ICBs publish patient-facing versions. Your GP's practice pharmacist can tell you what applies locally.

• If you use a private specialist, choose one who writes clearly and is reachable for the GP's follow-up questions. A specialist who does not reply to NHS GP queries is a shared-care problem waiting to happen.

• Be patient with the process. Shared care transfer typically takes a few weeks, not days. Plan ahead for medication supply.

The summary

Shared care is the mechanism by which NHS GPs and specialists manage long-term conditions together, with responsibilities defined in a written agreement. It is routine for most common long-term conditions. The specialist initiates and stabilises; the GP continues prescribing and monitoring.

Private-to-NHS shared care is more variable than NHS-to-NHS shared care. NHS GPs are not legally obliged to take on treatment initiated privately, and the outcome depends on the quality of the specialist handover, the local protocol, and the specific clinician. Most transfers work; a minority do not, and options exist when they do not.

Understanding the mechanism, and being specific in the ask, makes shared-care transfers smoother in most cases.

Sources and further reading

• British National Formulary, bnf.nice.org.uk. The UK national drug formulary, with shared-care guidance on specific drugs.

• Royal College of General Practitioners, rcgp.org.uk. Professional body guidance on shared care.

• British Medical Association, bma.org.uk. Trade-union and professional guidance on shared care.

• NHS England, Integrated Care Boards. Local commissioners that publish shared-care protocols.

• NICE, nice.org.uk. Clinical guidelines for specific conditions, including shared-care sections.

• ADHD UK, Right to Choose and shared care. Patient-facing resource for the ADHD-specific shared-care pathway.

• Electronic Medicines Compendium, medicines.org.uk/emc. UK drug prescribing information.

About the author

Dr Seth Rankin qualified in medicine at Auckland School of Medicine in New Zealand in 1990 and worked as a junior doctor across New Zealand, Australia, and the UK before qualifying as a Member of the Royal College of General Practitioners (MRCGP) through the London Deanery in 2004. He was Managing Partner of Wandsworth Medical Centre from 2006 to 2016 and served as a Board Member of Wandsworth Clinical Commissioning Group for nine years. He is the founder of London Travel Clinic, London Doctors Clinic, London Medical Laboratory, and LoveMyLife.

Read more about Dr Seth Rankin.

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