Right to Choose and shared care: guidance for GPs

Right to Choose can help patients access NHS-funded assessment and treatment from an eligible provider. However, supporting a patient’s choice of provider does not require a GP practice to accept responsibility for prescribing or monitoring recommended by that provider.

The key distinction is simple: a patient’s right to choose a provider is not a right to require their GP to enter into shared care.

This guide explains how practices can support patients while making safe, independent decisions about prescribing.

Key message

Agreeing to make a Right to Choose referral does not amount to agreeing to prescribe. Shared care is a separate, voluntary arrangement which requires the agreement of the GP practice.

What is Right to Choose?

Right to Choose is the term commonly used for certain patient-choice rights within the NHS in England. Depending on the service and the patient’s circumstances, an eligible patient may be able to choose the provider and clinical team responsible for a first outpatient appointment.

NHS England’s Patient Choice Guidance explains the responsibilities of commissioners, providers and primary care referrers when supporting patients to exercise these rights. Patient choice applies across eligible physical and mental health services, including some services provided by independent organisations under NHS arrangements. [england.nhs.uk]

Right to Choose does not mean that:

• every provider can be chosen;
• every requested referral is clinically appropriate;
• a provider must offer a particular diagnosis or treatment;
• a patient can demand a particular medicine;
• the GP must prescribe whatever the chosen provider recommends;
• the GP practice must enter into shared care.

The referral and any later shared care request are related, but they are not the same decision.

The two separate decisions

Practices should separate the process into two decisions.

1. The referral decision

The GP considers whether a referral is clinically appropriate. Where the referral falls within the relevant patient-choice rules, the patient should be supported to choose an eligible provider.

The referring GP is not agreeing in advance with the outcome of the assessment. Nor is the GP promising to prescribe treatment which may later be recommended.

2. The prescribing decision

If the provider subsequently recommends medication and asks the practice to prescribe or monitor it, the practice must consider that request separately.

The practice should decide whether the proposed arrangement is:

• clinically safe;
• within the prescriber’s competence;
• supported by sufficient information;
• governed by a clear and appropriate protocol;
• backed by continuing specialist support;
• manageable within the practice’s capacity;
• properly commissioned and resourced.

A practice may accept the referral but later decline shared care.

What is shared care?

Shared care is an arrangement in which a specialist initiates or recommends treatment and responsibility for the patient’s continuing care is divided between the specialist service and general practice.

This may include responsibility for:

• issuing prescriptions;
• arranging blood tests or other investigations;
• reviewing monitoring results;
• recognising adverse effects;
• changing or withholding treatment;
• recalling the patient;
• providing ongoing clinical reviews;
• obtaining specialist advice when problems arise.

Shared care should involve a clear division of responsibility. It should not be used simply to transfer prescribing, workload or clinical risk from a provider to general practice.

The General Medical Council’s shared care standards state that shared care requires the agreement of all parties, including the patient. A doctor prescribing on the recommendation of another healthcare professional must be satisfied that the treatment is needed, appropriate, within the limits of their competence and supported by sufficient information. [gmc-uk.org]

Shared care is voluntary

The British Medical Association’s Principles for Shared Care Prescribing describes shared care prescribing as a non-core voluntary activity. Its guidance states that a GP practice may decline because of inadequate capacity, insufficient competence in relation to the specialist medicine or a lack of assurance about continuing specialist support. [bma.org.uk]

The existence of a Right to Choose referral does not change this position.

A GP practice is not obliged to accept shared care merely because:

• the treatment was recommended following an NHS-funded assessment;
• the patient chose the provider through Right to Choose;
• the provider holds an NHS contract;
• the provider says the patient is stable;
• a national shared care protocol exists;
• the medicine is prescribed by other practices;
• the provider expected prescribing to transfer after titration;
• the patient was told that their GP would prescribe.

NHS England’s Shared Care Protocols state that there is no legal obligation or mandatory requirement to use the national protocols. [england.nhs.uk], [england.nhs.uk]

A protocol may support safe decision-making, but it does not create an obligation to participate.

A provider can request shared care. It cannot impose shared care.

Who is responsible if the GP declines?

If a GP practice does not agree to shared care, the initiating provider should retain responsibility for the treatment it has initiated or recommended, including the associated prescribing and specialist monitoring.

The practice should make its decision clear to the provider and patient. It should not allow silence, delay or an unanswered request to be interpreted as acceptance.

The chosen provider’s arrangements should therefore be capable of supporting the patient where:

• shared care is declined;
• the patient remains clinically unstable;
• the medicine requires specialist adjustment;
• the practice cannot provide the requested monitoring;
• specialist advice or reassessment is required.

A provider should not initiate treatment on the assumption that a patient’s GP will automatically take over prescribing.

What should patients be told before referral?

Patients should be supported to exercise their rights with realistic information about what may happen after assessment.

Where medication or shared care may be recommended, consider explaining before referral that:

• agreement to refer does not guarantee a diagnosis;
• the chosen provider will decide what assessment or treatment it considers appropriate;
• the GP has not agreed in advance to prescribe;
• prescribing and shared care will be considered separately;
• the practice may decline shared care;
• if the practice declines, the provider will need to make arrangements for prescribing and monitoring;
• the patient may wish to ask the provider about these arrangements before choosing it.

This does not prevent or discourage patient choice. It enables a properly informed choice and reduces the risk of the patient being caught between organisations later.

Suggested wording for patients

We are happy to support an appropriate Right to Choose referral. However, agreeing to refer does not mean that the practice has agreed in advance to prescribe any medication recommended by the provider.

If the provider later requests shared care, the practice will consider that request separately. We will look at clinical safety, the information provided, specialist support, monitoring arrangements and whether the practice can undertake the work safely.

Shared care is voluntary, and the practice may decline it. If that happens, the provider will need to retain responsibility for prescribing and monitoring.

What should practices check before referral?

Where possible, the practice or patient should establish:

• whether the provider offers the required NHS-funded service;
• whether the provider can accept the particular referral;
• whether the provider’s service includes treatment as well as assessment;
• whether the provider can prescribe during initiation and titration;
• what happens if the practice declines shared care;
• whether the provider will continue prescribing;
• how physical monitoring will be arranged;
• whether the provider offers continuing clinical reviews;
• how urgent advice or reassessment can be obtained.

It may not always be possible to obtain every answer before referral. A lack of information about future prescribing should not automatically obstruct an otherwise valid referral, but it should be explained to the patient and documented.

Assessing a shared care request from a Right to Choose provider

A request should be assessed on its own clinical and governance merits. Practices should not assume that NHS funding of an assessment automatically establishes a safe prescribing pathway.

Has a proper assessment been completed?

The provider should supply enough information for the GP to understand:

• the diagnosis;
• the clinical basis for the diagnosis;
• relevant history and investigations;
• the indication for medication;
• alternative treatments considered;
• contraindications and identified risks;
• relevant physical health information;
• the agreed treatment plan.

The GP should not be expected to prescribe from a brief letter containing only a diagnosis, medicine and dose.

Has treatment been adequately initiated and stabilised?

The specialist should normally retain responsibility while treatment is initiated and stabilised. Stability should be a clinical judgement rather than merely the completion of a set period.

The request should explain:

• when treatment began;
• what titration has occurred;
• the current dose;
• the response to treatment;
• adverse effects;
• relevant monitoring results;
• the intended duration of treatment;
• the circumstances in which the dose may change.

Is there an appropriate shared care agreement?

The proposed agreement should clearly identify:

• the specialist’s responsibilities;
• the practice’s responsibilities;
• the patient’s responsibilities;
• the monitoring schedule;
• who requests each test;
• who reviews and acts on each result;
• thresholds for withholding or stopping treatment;
• arrangements for dose changes;
• important adverse effects and interactions;
• how specialist advice can be obtained;
• when the specialist will review the patient;
• when the specialist will resume prescribing.

Generic statements such as “GP to monitor” are not enough. Monitoring is a clinical process involving the arrangement of tests, review of results, communication with the patient and appropriate action.

Is continuing specialist support available?

The specialist relationship should continue after prescribing transfers.

The practice should be satisfied that:

• the patient remains under specialist oversight;
• advice is available within a clinically appropriate timescale;
• the provider can reassess the patient;
• the provider will manage treatment which becomes unstable;
• the provider will accept prescribing responsibility back when necessary;
• there is a clear process for missed appointments or loss of follow-up.

The British Medical Association identifies enduring specialist input and access to timely advice as important shared care principles. [bma.org.uk]

Is the work within the GP’s competence?

The prescriber must be able to understand the treatment, recognise important adverse effects, interpret relevant monitoring and act safely when problems arise.

Receiving a protocol does not automatically create competence. If the GP remains uncertain after seeking further information or advice, the request should not be accepted.

Does the practice have sufficient capacity?

Competence and capacity are different.

A GP may understand the medicine but work in a practice that lacks the appointments, recall processes, administrative support or clinical capacity needed to deliver the arrangement reliably.

Capacity is a patient-safety issue. A practice does not help patients by accepting responsibilities it cannot consistently fulfil.

Is the pathway commissioned and resourced?

The practice should establish whether the requested work is supported by an appropriate local commissioned arrangement.

The British Medical Association states that additional work involving medication monitoring should be delivered through a funded, commissioned pathway. [bma.org.uk]

NHS funding of the provider’s assessment does not necessarily mean that every activity subsequently requested from general practice has been commissioned from the practice.

When might a practice decline?

A practice may decide not to accept shared care where:

• the prescriber does not feel competent;
• the practice lacks capacity;
• the patient has not been adequately stabilised;
• the assessment or treatment information is incomplete;
• there is no suitable shared care agreement;
• the protocol is unclear, outdated or inappropriate;
• the proposed monitoring arrangements are ambiguous;
• continuing specialist follow-up is inadequate;
• timely specialist advice is unavailable;
• the provider will not resume prescribing when necessary;
• the provider’s governance arrangements are unclear;
• the required work is not properly commissioned or resourced;
• acceptance would not be safe or in the patient’s best interests.

The decision should be principled and consistent. Practices should avoid blanket decisions based solely on a diagnosis or patient group, and should be able to explain the clinical, governance or capacity reasons for declining.

How to decline safely

Declining shared care is not the same as declining to care for the patient. The patient remains entitled to normal general medical services and appropriate help with unrelated or urgent health needs.

When declining, the practice should:

1. Review the request and supporting information.
2. Identify why the proposed arrangement cannot be accepted.
3. Record the decision and its reasons.
4. Respond promptly to the requesting provider.
5. State clearly that prescribing has not transferred.
6. Ask the provider to continue prescribing and monitoring.
7. Explain the decision to the patient in neutral, supportive language.
8. Escalate commissioning or pathway failures where appropriate.

Suggested response to the provider

Thank you for asking the practice to enter into shared care for this patient following their Right to Choose referral.

We have reviewed the request but are unable to accept the transfer of prescribing and monitoring responsibility because [insert clear reasons].

Supporting the patient’s Right to Choose referral did not constitute advance agreement to shared care. Shared care requires the agreement of all parties, and the practice is not satisfied that it can undertake the proposed responsibilities safely and sustainably.

Prescribing, monitoring and associated specialist follow-up therefore remain with the initiating provider. Please confirm the arrangements that will be put in place to ensure continuity of treatment.

Suggested explanation for the patient

Your referral and your right to choose a provider are separate from the decision about who prescribes your medication.

We have considered the provider’s request carefully. We are unable to accept shared care because [brief explanation]. This does not affect your registration with the practice or your access to our usual services.

The provider remains responsible for making safe prescribing and monitoring arrangements for the treatment it has recommended.

What if the provider refuses to prescribe?

A disagreement between organisations should not be allowed to expose the patient to avoidable harm.

The practice should:

• communicate directly with the provider;
• make clear that shared care was not accepted;
• ask the provider to confirm its prescribing plan;
• document all communications;
• inform the patient about what is happening;
• escalate unresolved commissioning concerns to the appropriate commissioner;
• seek advice from Doncaster LMC or the practice’s medical defence organisation where necessary.

If treatment is at immediate risk of interruption, the GP should assess the individual clinical circumstances and take proportionate action to protect the patient. Any exceptional short-term prescription does not have to mean permanent acceptance of shared care. The limits and purpose of any temporary action should be clearly recorded and communicated.

Can a practice adopt a Right to Choose shared care policy?

A written practice policy can promote consistent and defensible decisions.

The policy might explain that the practice will consider shared care where:

• the arrangement is voluntary and agreed;
• adequate clinical information has been supplied;
• treatment has been appropriately initiated and stabilised;
• a current and suitable protocol is available;
• responsibilities are explicit;
• ongoing specialist support is available;
• the provider can reassess the patient and resume prescribing;
• the work is within the GP’s competence;
• the practice has sufficient capacity;
• appropriate commissioning and resources are in place.

The policy should preserve individual clinical judgement. It should not be used as a substitute for considering the circumstances of the patient and the specific request.

Practice checklist

Before accepting shared care following a Right to Choose referral, ask:

• Was the referral clinically appropriate?
• Is the provider delivering the relevant NHS-funded service?
• Has a sufficiently detailed assessment been supplied?
• Is the diagnosis and treatment plan clear?
• Has the provider initiated and stabilised treatment?
• Is there a current and appropriate shared care agreement?
• Are prescribing and monitoring responsibilities explicit?
• Is the work within the prescriber’s competence?
• Does the practice have the capacity to deliver it safely?
• Is continuing specialist review available?
• Can timely specialist advice be obtained?
• Will the provider resume responsibility if the patient becomes unstable?
• Is the pathway properly commissioned and resourced?
• Is accepting the arrangement in the patient’s best interests?
• Does the practice freely agree to participate?

If the answer to a material question is no, the practice should seek clarification or decline the request.

The bottom line

Right to Choose should be supported where it applies, but it does not remove a GP’s professional responsibility to prescribe safely.

A referral is not a promise to prescribe. An NHS-funded assessment is not automatic shared care. A provider’s recommendation does not compel the GP to sign a prescription.

Shared care must be safe, supported and genuinely agreed.

GP practices can say no to shared care while continuing to support the patient.