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Report To: Area Prescribing Committee
Date:
Reporting Officer: Helen Stubbs
Contact Officer:
Subject
Helen Stubbs
Application of revised RAG criteria to existing Shared Care Agreements
Introduction
The revised RAG criteria were approved by the APC in January 2015 and the Shared Care
Group have subsequently applied the criteria specifically for shared care to the following
existing shared care agreements:
Apomorphine
Atypical antipsychotics
ADHD for children
ADHD for adolescents and adults
Cholinesterase inhibitors for Dementia
Disease Modifying Anti-rheumatic Drugs
Disease Modifying Drugs for non-rheumatological conditions
GnRH analogues
Lithium
Low molecular weight heparins
Application of the RAG criteria
The Shared Care Subgroup members applied the criteria in a consistent and logical manner
to generate a minimum category rating.An important consideration was that the criteria were
applied to the drug and not the condition and as a result, some drugs/drug groups no
longer satisfy the required criteria for Shared Care.
The attached table is a summary of the application of the revised criteria. All of those drugs
which no longer satisfied the Shared Care criteria fell into one of the revised Amber
categories. It is important to consider that the revised RAG criteria represent guidance for the
majority of patients on a specific drug. However, even if a drug is rated at a particular
category, the patient may not be suitable for treatment at that minimum level and so different
arrangements may need to be put into place on an individual basis.
The summary of the categories is described in Appendix 1.
Summary Review of Current Pan-Mersey Shared Care Documents
Drug
Apomorphine
Current
category
Shared Care
Suggested
category
Amber
patient
retained
Explanation
The dose of apomorphine is likely to require frequent re-titration to
maximise benefit from the treatment as the condition worsens over
time. The patient will not be discharged whilst receiving this treatment
Southport & Formby and South Sefton CCGs agreed with this
decision
Atypical Antipsychotics
Shared Care
Amber
Initiated
This status allows for very settled patients to be discharged where the
specialist considers it is appropriate and the GP is in agreement.
It is anticipated the request to prescribe will precede, and inform, any
request to discharge.
Secondary care mental health services are designed to respond to
primary care referrals in a timely manner should there be a need.
Monitoring requirements do not fulfil the new Pan-Mersey criteria for
Purple shared care (SC3)
The Sefton CCGs support the move from Shared Care to Amber
but suggest that Amber patient Retained is more appropriate,
given that the patient would need an annual review to ensure the
appropriate management of the drug in response to any changes
in the patient’s condition.
Cholinesterase inhibitors for
Dementia
Shared Care
Amber
Initiated
This status allows for very settled patients to be discharged where the
specialist considers it is appropriate and the GP is in agreement.
It is anticipated the request to prescribe will precede, and inform, any
request to discharge.
Secondary care mental health services are designed to respond to
primary care referrals in a timely manner should there be a need.
The need for specialist input in dementia is no different to many other
long term chronic conditions e.g. heart failure; where the drugs are
RAG rated amber initiated or green. To do so would be discriminatory
and it is important to maintain parity of care between physical and
mental health conditions
No monitoring of the drugs are required in primary care.
The Sefton CCGs support the move from Shared Care to Amber
but suggest that Amber patient Retained is more appropriate, as
there is a need to manage the inter-relationship between the
deteriorating condition and assessment of ongoing drug
efficacy. (Drug dose changes are commonly managed in primary
care where the shared care agreement is in place and Sefton GPs
have been willing to work with Mersey Care to support the
management of patients in the community)
ADHD in Children
Shared Care
Purple
(shared
care)
BP and pulse rate, height and weight should be monitored at least
every 6 months and can be undertaken in primary care
Southport & Formby and South Sefton CCGs agreed with this
decision
ADHD in Adults
Shared Care
Purple
(shared
care)
BP and pulse rate and should be monitored at least every 6 months
and can be undertaken in primary care.
Southport & Formby and South Sefton CCGs agreed with this
decision
Lithium
Shared Care
Purple
(shared
care)
Lithium monitoring required minimum every 3 months, LFTs every 6
months. This can be undertaken in primary care.
Southport & Formby and South Sefton CCGs agreed with this
decision
Disease Modifying Antirheumatic Drugs
Shared Care
Purple
(shared
care)
Disease Modifying Drugs
for non-rheumatological
conditions
Shared Care
Purple
(shared
care)
GnRH analogues eg
triptorelin
Shared Care
Amber
patient
retained
Low Molecular Weight
Heparins
Shared Care
Amber
Initiated
Regular multiple biochemical monitoring is required 3monthly
minimum which can be undertaken in primary care
Southport & Formby and South Sefton CCGs agreed with this
decision
Regular multiple biochemical monitoring is required 3monthly
minimum which can be undertaken in primary care
Southport & Formby and South Sefton CCGs agreed with this
decision
The biochemical testing is currently carried out in the hospital setting,
not in primary care (as stated in the current shared care
documentation). If this situation remains in place then the Amber
patient retained category would be more appropriate. Prescribing in
primary care would be supported by a Prescribing Support Document
which could be approved by the APC
Southport & Formby and South Sefton CCGs agreed with this
decision
SPCs are non-specific about monitoring requirements and monitoring
is not indicated for most indications. Regular monitoring is only
required for patients at high risk of hyperkalaemia. If a change in
status is agreed, prescribing in primary care would be supported by
prescribing support information at the time of the request.
Southport & Formby and South Sefton CCGs both felt that due to
the monitoring arrangements currently included in the Shared
Care Agreement, this group of drugs should remain as Shared
care eg dose adjustments in relation to weight changes.
However, clarification of the monitoring requirements for the
various indications should be sought from local haematologists
to inform the decision.
Appendix 1
Amber
Definition
These medicines are considered suitable for primary care prescribing following varied levels of specialist
input as described below:

Amber Recommended requires specialist assessment and recommendation to GP to prescribe
in Primary Care

Amber Initiated requires specialist initiation of prescribing. Prescribing to be continued by the
specialist until stabilisation of the dose and the patient’s condition is achieved and the patient
has been reviewed.

Amber Patient Retained requires specialist initiation of prescribing. Prescribing to be continued
by specialist until stabilisation of the dose and the patient’s condition is achieved and the patient
had been reviewed. Patient remains under the care of specialist (ie not discharged) as
occasional specialist input may be required.
Amber recommended medicines must meet criteria A1 and A2:
A1
Requires specialist assessment to enable patient selection
A2
Medicine is suitable for on -going prescribing in Primary Care.
Amber Initiated medicines must also meet criterion A3.
A3
Requires short to medium term specialist prescribing and monitoring of efficacy or
toxicity until the patient’s dose and condition is stable
Amber Patient Retained medicines must meet criteria A1, A2 and A3 and must also meet criterion
A4
A4
May require occasional specialist input indefinitely and therefore the patient should not be
discharged from specialist care.
Prescribing support information will be available as required.
Purple Shared Care
Definition
Medicines are considered suitable for Primary Care prescribing and/or management, following
specialist initiation of therapy, with on-going communication between the Primary Care prescriber and
specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring
Shared Care require on-going input from both Specialist and Primary Care clinicians and patients
should not be discharged from Specialist care.
Where prescribing and monitoring are required under shared care, it is implicit that the responsibility
for both of these tasks rests with the prescriber.
A Shared Care Agreement will always be available for Shared Care medicines and this document will
include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This
pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going
prescribing for the individual patients.
A policy detailing clinician responsibilities in Shared Care Agreements can be found in Appendix 1 of
this document. This policy must be referred to in all cases of Shared Care.
All drugs to be included in this category must meet Shared Care criteria 1 to 3
SC1
Requires specialist assessment to enable patient selection and also initiation,
stabilisation and review of treatment and the patient`s condition.
SC2
Prescribing and/or management of the drug in Primary Care with specialist
support and input, within the framework of the Shared Care Agreement is safe and
convenient and that there is an appropriate mechanism for individual patient access in
Primary Care.
SC3
Requires specific long-term monitoring (blood test or other measurement) for
adverse effects and / or efficacy of the drug to be completed in Primary Care, and
requires on-going specialist support for the dose changes or management of adverse
effects. Monitoring is required on a regular basis (typically four times a year).
Implicit in any shared care agreement is the understanding that participation is at the discretion
of the Primary Care prescriber subject to their clinical confidence.