Shared care in the UK: failings of the past and lessons for the future

Aims

To explore and evaluate the implementation of shared care in the UK, to identify failings and to make recommendations for successful implementation of shared care in the future.

Methods

The study utilised a triangulation approach, employing three different methods to explore the production and format of shared care protocols (SCPs) and the perceived use and future trends of shared care. A postal survey of hospital pharmacists and pharmaceutical and medical advisers in health authorities and interviews with health care professionals provided insight into perceptions of shared care and recommendations for the future. A content analysis of a sample of SCPs in current use assessed the utility of SCPs in practice.

Results

A total of 321 SCPs were identified that described 99 different drugs and treatments. The protocols varied considerably with no apparent standard either within or between regions, but there was a correlation between the patient-related information available, information across the health care interface (r=0.355, P=0.05) and pharmaceutical information (r=0.401, P=0.05). There were expressions of uncertainty about the benefit of such protocols to patients. Health authority staff in particular expressed predominantly negative attitudes in the questionnaire whereas the pharmacists were more positive. The transfer of prescribing and associated costs from hospital to community (described as “cost shifting”) was repeatedly identified as a barrier, together with competing professional interests and reluctance to change with the times. General practitioners (GPs) were most commonly excluded from the production of SCPs, which may enforce negative feelings around implementation of SCPs across the health care interface. Improved information technology and better use of evidence-based guidelines and protocols were seen as ways forward in developing shared care.

Conclusions

Since 1991, a large number of SCPs have been produced in the UK but the benefits to patients are not clear. There is a general perception of cynicism about their use; “cost-shifting” is perceived as their main purpose. There appears to have been no formal evaluation of their use or mechanisms for their implementation, and distribution has been erratic. This study highlights that, with greater involvement of health care professionals, better communication systems and the removal of identified barriers, shared care is a concept essential in the evolving NHS.