Shared Care
1. Introduction
Shared care is an important part of long-term ADHD treatment. Once medication has been initiated, titrated and optimised, many patients can have their ongoing prescribing transferred to primary care, while the specialist ADHD service retains responsibility for specialist review and provides advice when treatment needs to be reconsidered. When it works well, shared care allows patients to receive convenient, continuous treatment while maintaining access to appropriate specialist expertise.
For prescribers working in ADHD services, however, shared care is not simply an administrative process. It involves a clear understanding of clinical responsibility, communication between primary and secondary or specialist care, appropriate monitoring, and the circumstances in which prescribing responsibility should remain with or return to the specialist. Particular care is required when medication is still being adjusted, adverse effects emerge, physical health parameters become abnormal, treatment becomes clinically complex, or the patient's circumstances change.
It is also important to understand what shared care does not mean. A specialist cannot simply transfer responsibility for prescribing to a GP. Shared care is a voluntary arrangement requiring agreement between the clinicians involved, supported by appropriate clinical information and clearly defined responsibilities. A GP may decide not to accept shared care, in which case arrangements must be made to ensure that the patient continues to have safe access to treatment and appropriate monitoring.
This topic therefore sits naturally towards the later stages of the prescribing component of the Certificate in ADHD Medicine. Earlier lessons have considered medication selection, initiation, titration, monitoring and management of adverse effects. Shared care considers what happens once treatment has become established and the patient moves from active titration into longer-term maintenance.
Throughout this lesson, we will take a practical approach to shared care in ADHD. We will consider when a patient is sufficiently stable for shared care to be considered, what information should accompany a request, how prescribing and monitoring responsibilities are divided, how to respond when a GP declines a request, and when changes in a patient's clinical circumstances should prompt renewed specialist involvement.
The central principle is straightforward: shared care should make treatment more accessible without making clinical responsibility less clear. A good shared-care arrangement is one in which the patient, specialist and primary-care prescriber all understand who is responsible for each aspect of treatment and what should happen when something changes.
2. Learning Outcomes
By the end of this lesson, learners should be able to:
Explain the purpose of shared care in ADHD treatment and the respective responsibilities of specialist and primary-care clinicians.
Determine when a patient receiving ADHD medication is sufficiently clinically stable for shared care to be considered.
Prepare a safe and clinically appropriate shared-care request, including the information required to support continuity of prescribing and monitoring.
Apply appropriate physical-health, treatment-response and adverse-effect monitoring within a shared-care arrangement.
Recognise situations in which prescribing responsibility should remain with, or be referred back to, the specialist ADHD service.
Manage common difficulties in shared care, including declined requests, changes to medication, emerging adverse effects and uncertainty about clinical responsibility.
3. The Lecture
Understanding What Shared Care Actually Means
Shared care is often discussed as though it simply means that the GP takes over issuing prescriptions once the specialist has finished titration. That is an incomplete way of thinking about it.
Shared care is an agreed arrangement in which responsibility for different aspects of a patient's treatment is divided between the specialist service and primary care. The important word is agreed. Sending a shared-care request does not, by itself, transfer clinical responsibility.
For ADHD medication, NICE recommends that after titration and dose stabilisation, prescribing and monitoring should be carried out under shared-care protocol arrangements with primary care. The specialist therefore has an important role in getting the patient to a point at which such an arrangement is clinically appropriate.
The purpose is not simply to move prescribing elsewhere. It is to provide continuity of treatment while ensuring that specialist expertise remains available when it is required.
A useful way to think about shared care is:
The specialist establishes the treatment → the treatment becomes stable → shared care is proposed → primary care agrees to defined responsibilities → routine prescribing and monitoring are shared → the specialist remains involved in appropriate review and treatment decisions.
The precise division of responsibilities may vary according to local arrangements and the shared-care protocol being used.
Shared Care Is an Agreement, Not an Instruction
This is one of the most important principles in the lesson.
A specialist cannot simply write to a GP stating that prescribing has now been transferred.
NHS England guidance describes shared-care prescribing arrangements as agreements between the initiating specialist service and general practice. It also makes clear that the existence of shared-care guidance does not itself require a GP to accept responsibility for prescribing. The individual prescriber remains responsible for the prescriptions they sign.
This has significant practical implications.
Until shared care has actually been accepted, the specialist service must not simply assume that the GP will issue the next prescription.
Consider an adult who has completed titration of lisdexamfetamine and is doing very well. The specialist writes to the GP requesting shared care and tells the patient that future prescriptions will come from their surgery.
The patient contacts the GP three weeks later and discovers that the request has not been accepted. They have only a few capsules remaining.
This is not simply an administrative inconvenience. It represents a potential failure of continuity of care.
The safer approach is to regard specialist prescribing responsibility as continuing until there is adequate confirmation that responsibility has been transferred.
When Should Shared Care Be Considered?
The broad principle is straightforward: shared care generally follows titration and dose stabilisation.
But what does "stable" actually mean?
It should not be reduced to:
"The patient has been taking the same dose for a few weeks."
Stability is a clinical judgement.
Before requesting shared care, ask yourself several questions.
Is the medication producing worthwhile benefit?
Is the current dose reasonably optimised?
Are adverse effects acceptable?
Are physical observations satisfactory?
Is adherence reasonably established?
Is the current preparation likely to remain unchanged?
Are there unresolved clinical concerns that require active specialist management?
Does the patient understand their treatment and monitoring requirements?
If the answers are reassuring, shared care may be appropriate.
If you are still making frequent medication changes, investigating significant adverse effects or deciding whether the medication is actually effective, the patient is probably still undergoing specialist treatment rather than maintenance treatment.
What Does Dose Optimisation Mean?
This distinction matters because a patient does not need to be completely symptom-free before shared care can be considered.
ADHD medication is titrated against both benefit and adverse effects. NICE describes optimisation in terms of reduced symptoms, positive behavioural change and improvements in areas such as education, employment and relationships, alongside tolerable adverse effects.
In practice, therefore, the question is not:
"Have we eliminated ADHD?"
The better question is:
"Have we reached a treatment regimen that provides a satisfactory balance between clinical benefit and adverse effects and that no longer requires active dose adjustment?"
Imagine an adult taking methylphenidate modified release 54 mg each morning. Their concentration and occupational functioning have improved substantially. They still experience some ADHD symptoms in the evening, but these are manageable. Their blood pressure and pulse are satisfactory, appetite is acceptable and they do not want further medication changes.
That patient may reasonably be considered stable.
By contrast, another patient may have been taking 54 mg for the same period but still experiences troublesome palpitations and is unsure whether the medication is helping.
The prescription is unchanged, but the treatment is not clinically stable.
What Information Should Be Sent to Primary Care?
A shared-care request should allow another prescriber to understand what has happened without reconstructing the entire assessment and titration process.
At minimum, the communication should make the diagnosis and treatment plan clear.
It should identify the medication, formulation, dose and dosing schedule. It should explain that titration has been completed and describe the patient's response and any relevant adverse effects.
Relevant physical-health information and monitoring results should be provided. Significant comorbidities, contraindications, cautions and other medicines should be identified where relevant.
The communication should also explain what the specialist service is asking primary care to undertake and what responsibilities the specialist service will retain.
There should be a clear route for the GP to contact the specialist service if problems arise.
This is particularly important with ADHD because seemingly minor differences in prescriptions can matter. "Methylphenidate 36 mg" is not necessarily enough information. Different modified-release methylphenidate preparations have different release characteristics, and prescribing should make the intended preparation sufficiently clear.
A good shared-care request reduces ambiguity.
The Responsibilities of the Specialist
Shared care does not mean that the specialist disappears.
The specialist remains responsible for those aspects of care assigned to the specialist under the relevant arrangement. This commonly includes providing specialist review, advising on clinically significant problems, reassessing treatment when necessary and supporting primary care when specialist input is required.
The specialist should also make sure that treatment has been appropriately initiated and stabilised before requesting transfer.
If a significant treatment change is subsequently required, responsibility may need to move temporarily back towards specialist care.
For example, suppose a patient is stable on lisdexamfetamine under shared care but later develops problematic adverse effects and wishes to change to atomoxetine.
That is no longer simply routine repeat prescribing.
The specialist should reassess the patient and, where appropriate, undertake or oversee the new titration. Once the new treatment is stable, shared care can again be considered in accordance with the applicable protocol.
The Responsibilities of Primary Care
The exact responsibilities of primary care depend on the agreed shared-care protocol.
Typically, primary care may take responsibility for issuing repeat prescriptions for the established treatment and undertaking specified routine monitoring.
The GP must nevertheless remain satisfied that prescribing is clinically appropriate. Shared care does not remove the professional responsibility of the person signing the prescription. NHS England guidance specifically emphasises this principle.
This means that a GP receiving a shared-care request should not be thought of simply as an administrative prescription provider.
If concerns arise, the GP should be able to obtain specialist advice and, where necessary, refer responsibility back to the specialist service in accordance with the agreed arrangement.
The Patient's Responsibilities
The patient is the third essential participant in shared care.
They need to understand where prescriptions will come from, when monitoring is required, when specialist reviews are expected and whom to contact if problems occur.
Patients should be encouraged to report significant adverse effects and changes in their physical or mental health. NICE specifically recommends monitoring medication effectiveness and adverse effects and encouraging people taking ADHD medication to record adverse effects.
Patients should also understand that shared care does not mean that specialist follow-up has ended.
This is particularly important when patients interpret GP prescribing as evidence that they have been "discharged".
ADHD is a long-term condition, and the need for review should be determined by the person's clinical circumstances rather than simply whether medication is currently being prescribed by primary or specialist care.
Monitoring Does Not Stop After Titration
One of the easiest mistakes to make is to think of monitoring as something that belongs to the titration phase.
It does not.
NICE recommends ongoing monitoring of medication effectiveness and adverse effects and appropriate review and follow-up according to the severity of the person's condition.
Depending on age and medication, ongoing monitoring may include weight, height in children and young people, pulse, blood pressure, cardiovascular symptoms, appetite, sleep, mental state, treatment effectiveness and adverse effects.
The relevant NICE guidance and local shared-care protocol should be followed for the detailed monitoring schedule.
A normal blood pressure six months ago does not guarantee a normal blood pressure today.
Similarly, a medication that was effective when shared care began may become less satisfactory because the patient's health, circumstances, adherence or treatment needs have changed.
Monitoring therefore needs to remain clinically meaningful rather than becoming a tick-box exercise.
What Happens When Monitoring Becomes Abnormal?
Shared-care protocols should make escalation arrangements clear.
Suppose a GP identifies a clinically significant increase in blood pressure during routine monitoring.
The response should not simply be:
"This is ADHD medication, so contact psychiatry."
Nor should the specialist automatically assume that primary care will manage everything because the GP currently issues the prescriptions.
The patient requires an appropriate clinical assessment, and the clinicians should communicate clearly about responsibility for the next steps.
Depending on the circumstances, this might involve repeating observations, considering other causes, reviewing the medication, reducing or withholding treatment where clinically indicated, undertaking further investigation or obtaining specialist medical advice.
The key principle is that abnormal monitoring should trigger clinical reasoning.
Shared care should never create a gap between two services in which each assumes the other is dealing with the problem.
Medication Changes During Shared Care
Routine continuation of an established dose is very different from initiating a significant treatment change.
If a patient asks their GP to increase their stimulant because it "isn't lasting long enough", that request generally requires specialist reassessment rather than an automatic increase in primary care.
Similarly, changing from one ADHD medication to another may require renewed titration and closer monitoring.
There are also situations in which apparently simple formulation changes require care. Modified-release stimulant preparations are not always clinically interchangeable merely because the total milligram dose appears identical.
Prescribers therefore need to understand exactly what preparation the patient is taking and the implications of changing it.
When treatment materially changes, ask:
"Is this still maintenance prescribing, or are we effectively titrating again?"
If it is the latter, specialist involvement is usually required.
When the GP Declines Shared Care
This is a common real-world situation and one that new prescribers sometimes take personally.
A GP may decline shared care for several reasons. They may not feel clinically confident managing the medicine. The local shared-care pathway may not support the arrangement. There may be commissioning or governance issues. Information may be missing. The GP may have concerns about the specialist service or about how monitoring and specialist review will operate.
NHS England's framework makes clear that shared-care guidance does not mean that a GP is obliged to accept clinical and legal responsibility for prescribing.
The appropriate response is not to argue that the GP "has to prescribe because NICE says so".
Instead, establish why the request has been declined.
Sometimes the problem is easily resolved. The GP may simply require additional documentation, confirmation of monitoring arrangements or clarification of who will provide specialist review.
In other cases, shared care will remain unavailable.
The patient should not be left without treatment because two organisations disagree about prescribing responsibility. NHS England's prescribing guidance specifically emphasises that patients should not be placed in a position where they cannot obtain necessary medicines because of poor communication between services.
If shared care is not accepted, the specialist service must therefore ensure that there is an appropriate alternative arrangement for ongoing prescribing and monitoring.
Shared Care Following Private ADHD Treatment
This is an area where clinicians need particular awareness of local arrangements.
A patient may have undergone a private ADHD assessment, completed titration privately and then ask their NHS GP to prescribe under shared care.
The existence of a valid diagnosis and effective treatment does not automatically compel the GP to accept prescribing responsibility.
The GP needs sufficient information to make their own professional decision about whether accepting shared care is appropriate.
For the specialist, the practical lesson is important: do not promise a patient that their GP will definitely take over prescribing.
A more accurate discussion is:
"Once your treatment is stable, we can request shared care from your GP. Whether they accept the arrangement is ultimately a decision for the GP and will also depend on the arrangements operating in your area."
That conversation should happen early enough that the patient understands the potential financial and practical implications of continuing private prescribing if shared care is declined.
National Protocols and Local Arrangements
NHS England has published standardised shared-care protocols for several ADHD medicines in adult services, including methylphenidate, lisdexamfetamine, dexamfetamine and atomoxetine. These documents were designed to provide a consistent framework that could be adopted or adapted through local governance processes.
However, clinicians should not assume that the existence of a national document means that identical arrangements apply everywhere.
Local pathways, formularies, commissioning arrangements and medicines-governance decisions remain important.
There is also an important current caveat: NHS England states that the published national protocols have passed their January 2025 review date and advises organisations to review them through their local medicines-governance processes before use.
For the practising prescriber, this means checking the current local shared-care arrangements rather than relying on an old protocol stored on a computer.
When Should Care Move Back Towards the Specialist?
Shared care works best when there is a low threshold for obtaining specialist advice when the clinical situation materially changes.
Examples include significant loss of treatment effectiveness, troublesome or potentially serious adverse effects, clinically important cardiovascular findings, major changes in mental state, emerging diagnostic uncertainty, significant medication changes, pregnancy or pregnancy planning where relevant, concerns about misuse or diversion, and situations in which the risk-benefit balance of continuing treatment has changed.
Not every new symptom requires transfer of prescribing back to specialist care.
Clinical judgement is required.
The important question is whether the problem falls within routine maintenance management or whether specialist ADHD expertise is now required to make a safe treatment decision.
Shared Care and Controlled Drugs
Many ADHD medications are controlled drugs, which adds another layer of prescribing responsibility.
Shared care does not alter the prescriber's responsibility to prescribe controlled drugs legally and safely.
Stimulant prescriptions must therefore continue to meet controlled-drug prescribing requirements regardless of whether the prescription originates from specialist or primary care.
Prescribers also need to remain alert to early prescription requests, lost medication, escalating use, possible diversion and discrepancies between the prescribed regimen and the patient's reported use.
These situations require clinical assessment rather than automatic replacement prescribing.
Shared care should make responsibility clearer in these circumstances, not more fragmented.
Communication Is the Safety Mechanism
The recurring theme throughout shared care is communication.
A technically perfect protocol cannot compensate for poor communication between clinicians.
When the specialist changes something important, primary care needs to know.
When primary care identifies something important, the specialist needs to be accessible.
When responsibility changes, the patient needs to understand what has happened.
And when there is uncertainty about who is responsible for a particular clinical problem, clinicians should communicate rather than allowing the patient to become the messenger between services.
The strongest shared-care arrangements therefore have three features:
clear responsibility, reliable communication and continuing specialist accessibility.
If any one of those disappears, shared care becomes less safe.
A Final Clinical Scenario
Consider an adult with ADHD who has completed titration with lisdexamfetamine. They have been taking a stable dose with substantial improvement in concentration, organisation and occupational functioning. Appetite is acceptable, sleep is satisfactory, and physical observations are within an acceptable range.
A shared-care request is sent to the GP with the diagnosis, treatment history, current preparation and dose, response, relevant monitoring information, proposed responsibilities and specialist contact arrangements.
The GP accepts.
Several months later, the patient develops persistent palpitations and contacts the GP.
This is where the quality of the shared-care arrangement becomes apparent.
Poor shared care produces uncertainty:
"The psychiatrist prescribed it."
"The GP issues it."
"Who is actually dealing with the palpitations?"
Good shared care produces coordinated action. The new symptom is clinically assessed, relevant physical-health investigation is undertaken, medication safety is considered and the specialist is contacted where specialist input is required.
That is the fundamental purpose of shared care.
It is not primarily about transferring prescriptions.
It is about maintaining safe, coordinated treatment across the boundary between specialist and primary care.
4. Clinical Perspective
Shared care often looks straightforward on paper. The patient has been diagnosed, medication has been titrated, treatment is stable, and the GP is asked to continue prescribing. In practice, many of the difficulties arise not from the pharmacology but from uncertainty about responsibility, communication and what should happen when circumstances change.
Clinical Pearls
Do not confuse sending a request with transferring responsibility
One of the most important habits for a new ADHD prescriber is to distinguish between requesting shared care and shared care actually being agreed.
Until the arrangement has been accepted, do not assume that somebody else is issuing the patient's medication. Make sure there is a safe prescribing plan during the transition.
This is particularly important with stimulant medication, where an interruption can occur surprisingly quickly if everyone assumes somebody else is prescribing.
Stable means clinically stable, not simply "same dose"
A patient may have remained on the same dose for several weeks and still not be ready for shared care.
Ask yourself whether you are genuinely satisfied with the balance between benefit and adverse effects. If you are still considering a dose increase, investigating persistent palpitations, trying to manage significant appetite suppression or wondering whether the medication is actually helping, titration has not really finished.
The question I would encourage you to ask is:
"Would I be comfortable if this exact treatment continued unchanged for the next several months?"
If the answer is no, reconsider whether shared care is appropriate yet.
Make the prescription unambiguous
Do not assume that another clinician will know which preparation you mean.
Document the medication, formulation, strength, dose and timing clearly. This is particularly important with modified-release methylphenidate preparations, where different formulations should not automatically be treated as interchangeable.
Good prescribing communication prevents avoidable medication errors.
Tell primary care what the medication has actually achieved
A shared-care letter is stronger when it says more than:
"Patient stable. Please prescribe."
Briefly describe the clinical benefit. For example, you might explain that concentration has improved substantially, impulsivity has reduced and occupational functioning has improved, with no significant adverse effects.
This gives the receiving clinician a meaningful baseline against which future deterioration can be judged.
Keep specialist access available
Shared care should never mean:
"We have transferred prescribing, therefore this is now the GP's problem."
Primary care needs a realistic route back to the specialist service when difficulties arise. If a GP identifies a significant adverse effect or the treatment stops working, they should not have to make repeated attempts to obtain specialist advice.
Accessibility is part of safe shared care.
Practical Tips for Everyday Practice
Before sending a shared-care request, perform a brief mental checklist.
Confirm the diagnosis, current medication and formulation, dose, clinical response, adverse effects, relevant physical observations and whether any outstanding clinical issue remains.
Then ask one final question:
"If I were the GP receiving this request, would I have enough information to prescribe this medication safely?"
That question catches a surprising number of omissions.
It is also useful to explain shared care to the patient before sending the request. Patients sometimes hear "we are requesting shared care" as "your GP will now prescribe your medication." Those are not the same thing.
Explain that the request is subject to GP agreement and that existing prescribing arrangements continue until the transfer has been confirmed.
Where the patient is receiving private treatment, discuss this particularly clearly. Never guarantee that NHS primary care will accept a private shared-care request.
Common Pitfalls and Misconceptions
"NICE recommends shared care, so the GP has to accept it"
No. NICE recommends shared-care arrangements following titration and dose stabilisation, but an individual GP cannot simply be instructed to assume prescribing responsibility.
Approach a declined request professionally. Establish why it has been declined before deciding what needs to happen next.
"Once shared care starts, the specialist no longer needs to review the patient"
Shared care is not discharge from specialist care.
ADHD treatment still requires appropriate review. Symptoms change, children develop, adults' circumstances change, comorbidities emerge and the balance between benefits and adverse effects can alter.
Long-term prescribing should never become automatic simply because treatment was effective when it was first established.
"The GP is prescribing, so medication problems belong to the GP"
This is another potentially dangerous misconception.
Primary care may be responsible for routine prescribing and specified monitoring, but significant questions about ADHD treatment may require specialist input.
A patient whose medication has become ineffective, who develops significant adverse effects or who requires a major treatment change should not simply be left to negotiate between services.
"Every abnormal observation means the medication must immediately be stopped"
Not necessarily.
An abnormal observation requires clinical assessment. Consider its severity, whether it persists when repeated, the patient's symptoms, previous measurements, other medications, underlying medical conditions and the potential relationship with ADHD treatment.
Some findings require urgent action. Others require confirmation, monitoring or investigation.
The skill is not simply recognising an abnormal number. It is knowing what that number means in the context of the patient in front of you.
"A medication switch is just another repeat prescription"
Often it is not.
Changing stimulant preparation, substantially altering the dose or moving to another medication may effectively represent a new period of titration.
When treatment becomes unstable again, specialist responsibility should increase accordingly.
Advice for Newly Qualified Prescribers
Early in your prescribing career, there can be pressure to demonstrate confidence by making decisions independently.
Good ADHD prescribing does not require you to know the answer to every problem immediately.
If a patient under shared care develops persistent tachycardia, significant hypertension, chest pain, new psychiatric symptoms or another potentially important adverse effect, seeking senior or relevant medical advice is good clinical practice.
Equally, do not allow the existence of shared care to falsely reassure you.
Ask yourself:
"What would I do if I were still issuing this prescription myself?"
If you would be concerned enough to review the patient, investigate something or seek advice, the fact that the prescription currently comes from primary care should not remove that concern.
Document important decisions clearly, particularly when there has been communication between services. If you advise continuing medication despite an abnormal finding, document the reasoning. If medication is withheld, document why. If responsibility temporarily returns to specialist care, make that explicit.
Ambiguity is the enemy of safe shared care.
Situations Requiring Particular Clinical Judgement
Some situations do not fit neatly into a protocol.
A patient may be benefiting greatly from treatment but have borderline cardiovascular observations.
A child may be responding well academically but experiencing significant weight suppression.
An adult may request a higher dose because medication no longer lasts through their working day.
A previously stable patient may develop anxiety, depression or another mental-health difficulty.
A patient may repeatedly lose controlled-drug prescriptions or request medication earlier than expected.
A patient may become pregnant or start planning a pregnancy.
In these situations, avoid reflex decisions based purely on the fact that the patient is "under shared care".
Return to first principles.
What has changed?
Is there an immediate safety issue?
Could the medication be contributing?
Does treatment remain beneficial?
Does anything require investigation?
Is this still routine maintenance prescribing?
And, most importantly, who is best placed to make the next clinical decision?
Sometimes the answer will be primary care. Sometimes it will be the ADHD specialist. Sometimes another medical specialty will need to become involved.
The purpose of shared care is not to force every problem into one service. It is to make sure that the patient reaches the clinician with the appropriate expertise.
The Consultant's Perspective
When reviewing a shared-care problem, try to resist starting with:
"Whose responsibility is this?"
Start instead with:
"What does this patient need?"
Once you have established that, clarify who should provide it.
That approach prevents organisational boundaries from becoming clinical boundaries.
The best shared-care arrangements are often almost invisible to the patient. Prescriptions arrive when expected, monitoring occurs when required, specialist reviews take place appropriately and concerns are dealt with without the patient having to repeatedly explain the situation to different clinicians.
That is the standard to aim for.
Shared care is successful not when responsibility has been transferred, but when responsibility remains clear.
5. Summary
Shared care is an important component of long-term ADHD medication management, allowing routine prescribing and monitoring to be undertaken in primary care while maintaining appropriate specialist involvement.
The key learning points from this lesson are:
Shared care is an agreed arrangement between clinicians. Sending a shared-care request does not automatically transfer prescribing responsibility.
Shared care should generally be considered once medication titration has been completed and treatment is clinically stable, effective and reasonably well tolerated.
Clinical stability involves more than remaining on the same dose. Prescribers should consider treatment response, adverse effects, physical observations, adherence and whether further medication changes are anticipated.
Shared-care requests should clearly communicate the diagnosis, medication and formulation, dose, treatment response, relevant adverse effects, monitoring information and the proposed responsibilities of each clinician.
The clinician signing a prescription retains professional responsibility for that prescription. Shared-care protocols support clinical decision-making but do not remove individual prescribing responsibility.
Monitoring must continue after titration. Treatment effectiveness, adverse effects and relevant physical-health parameters should continue to be reviewed throughout long-term treatment.
Significant adverse effects, abnormal monitoring results, loss of treatment effectiveness or major medication changes may require renewed specialist assessment and, where appropriate, a return to specialist prescribing during further titration.
Patients should understand how their shared-care arrangement works, including where prescriptions will come from, what monitoring is required and whom they should contact if concerns arise.
A GP may decline a shared-care request. When this occurs, the reason should be explored professionally and alternative arrangements made to ensure continuity of safe treatment.
Shared care should never leave the patient caught between services. Clear communication, defined responsibilities and continuing access to specialist advice are fundamental to safe practice.
Ultimately, successful shared care is not simply about transferring the task of issuing prescriptions. It is about creating a coordinated system in which the patient continues to receive effective ADHD treatment while every clinician involved understands their responsibilities and knows when specialist input is required.
6. Further Reading
The following resources are recommended to consolidate understanding of shared care, long-term prescribing responsibility and monitoring of ADHD medication. Learners should prioritise current UK guidance and the shared-care arrangements operating within their own locality.
Essential UK Guidance
NICE Guideline NG87: Attention Deficit Hyperactivity Disorder – Diagnosis and Management
National Institute for Health and Care Excellence (NICE). Attention deficit hyperactivity disorder: diagnosis and management (NG87).
This should be considered essential reading for ADHD prescribers in the UK. Of particular relevance to this lesson are the sections on medication titration, shared care, maintenance and monitoring.
Recommendation 1.7.29 states that after titration and dose stabilisation, prescribing and monitoring of ADHD medication should be undertaken under shared-care protocol arrangements with primary care. The subsequent recommendations provide guidance on monitoring effectiveness, adverse effects, growth and cardiovascular parameters during continuing treatment.
NHS England: Shared Care Protocols
NHS England. Shared Care Protocols.
These provide useful practical examples of how responsibilities can be divided between specialist services and primary-care prescribers. ADHD-specific protocols are available for adult patients receiving atomoxetine, dexamfetamine, guanfacine, lisdexamfetamine and methylphenidate.
An important contemporary caveat is that the national protocols were last updated in January 2022 and have passed their January 2025 review date. NHS England currently states that there are no plans to update them and advises organisations to review the protocols through their local medicines-governance processes before use. They should therefore be considered alongside current NICE guidance, prescribing information and locally approved shared-care arrangements rather than adopted uncritically.
NHS England Shared Care Protocols
Local Shared-Care Protocols and Formularies
Prescribers should familiarise themselves with the current shared-care protocols, formularies and medicines-optimisation guidance applying within their own area.
National guidance provides the overarching principles, but the practical arrangements for accepting shared care, monitoring patients, obtaining specialist advice and returning prescribing responsibility may differ between local systems.
This is particularly important when working across different NHS organisations or when requesting shared care following treatment initiated by an independent provider.
International ADHD Guidelines
Canadian ADHD Practice Guidelines – CADDRA
Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines, 4.1 Edition.
These guidelines provide comprehensive guidance on ADHD assessment and treatment across the lifespan, including medication management, treatment monitoring and follow-up. CADDRA identifies the current published edition as version 4.1, originally released in 2020.
Although Canadian healthcare arrangements differ from those in the UK, the guidance provides useful additional perspectives on longitudinal ADHD management and monitoring.
Canadian ADHD Practice Guidelines
Australian Evidence-Based Clinical Practice Guideline for ADHD
Australian ADHD Professionals Association (AADPA). Australian Evidence-Based Clinical Practice Guideline for Attention Deficit Hyperactivity Disorder.
Published in 2022, this comprehensive evidence-based guideline covers assessment, pharmacological and non-pharmacological treatment, dose optimisation and ongoing ADHD management.
Although the organisation of prescribing differs from UK shared-care arrangements, it provides a valuable international comparison of evidence-based medication management and continuity of ADHD treatment.
Australian ADHD Clinical Practice Guideline
Prescribing References
British National Formulary and BNF for Children
Prescribers should regularly consult the current British National Formulary (BNF) and, when treating children and young people, the BNF for Children (BNFC).
These resources should be used alongside NICE guidance and the relevant Summary of Product Characteristics when considering doses, contraindications, cautions, interactions, adverse effects and prescribing requirements.
Summaries of Product Characteristics
The current Summary of Product Characteristics for the individual medication and preparation should be consulted where detailed product-specific information is required.
This is particularly relevant because ADHD prescribing involves several different stimulant and non-stimulant preparations, and clinicians should not assume that information applying to one formulation necessarily applies identically to another.
Recommended Approach to Further Learning
Learners should not attempt to memorise every detail of an individual shared-care protocol. Protocols and local arrangements can change.
Instead, develop a working understanding of the principles:
shared care follows appropriate stabilisation; responsibility must be explicitly agreed; the prescriber issuing the prescription retains professional responsibility; monitoring continues during maintenance treatment; specialist expertise must remain accessible; and significant changes in the patient's clinical circumstances should trigger appropriate reassessment.
The final step is to locate and read the current shared-care protocol used in your own clinical area. For a practising ADHD prescriber, understanding the local pathway is just as important as understanding the national guidance.
7. Knowledge Check
The following questions are designed to consolidate the principles of safe shared care in ADHD prescribing. Select the single best answer for each question before reviewing the explanation.
Question 1
A 29-year-old patient has completed titration with lisdexamfetamine. Their ADHD symptoms have improved substantially, the dose has remained unchanged, adverse effects are mild and physical observations are satisfactory. What is the most appropriate next step?
A. Discharge the patient to their GP and stop specialist involvement
B. Request shared care with primary care
C. Continue specialist prescribing indefinitely because stimulants cannot be prescribed in primary care
D. Ask the GP to prescribe immediately without providing further clinical information
Correct answer: B. Request shared care with primary care.
Explanation:
A is incorrect because shared care does not necessarily mean discharge from specialist involvement. Appropriate specialist review and access to specialist advice should continue.
B is correct. NICE recommends that after titration and dose stabilisation, prescribing and monitoring of ADHD medication should be undertaken under shared-care arrangements with primary care where an appropriate arrangement is agreed.
C is incorrect. ADHD stimulant medication can be prescribed in primary care under an appropriate shared-care arrangement.
D is incorrect. The GP requires sufficient clinical information and must agree to accept the proposed prescribing responsibilities.
Question 2
A specialist sends a shared-care request to a patient's GP on Monday. The patient will run out of methylphenidate the following week. What should the specialist assume?
A. The GP became responsible for prescribing as soon as the request was sent
B. The GP will automatically accept because the medication has been recommended by a specialist
C. Existing prescribing responsibility continues until shared care has been appropriately agreed
D. The patient should obtain an emergency prescription from another doctor if the GP does not respond
Correct answer: C. Existing prescribing responsibility continues until shared care has been appropriately agreed.
Explanation:
A is incorrect. Sending a shared-care request does not itself transfer prescribing responsibility.
B is incorrect. Shared care requires agreement. A GP is not automatically required to accept responsibility simply because treatment has been recommended by a specialist.
C is correct. The specialist service should ensure continuity of prescribing until an appropriate transfer of responsibility has been confirmed.
D is incorrect. Patients should not be placed in the position of having to find another prescriber because communication between services has not been completed.
Question 3
Which patient is least suitable for transfer to shared care at the present time?
A. A patient taking a stable dose of methylphenidate with substantial improvement and tolerable adverse effects
B. A patient taking stable atomoxetine with satisfactory physical observations and sustained clinical benefit
C. A patient taking lisdexamfetamine whose dose is still being adjusted because symptoms remain inadequately controlled
D. A patient established on ADHD medication who understands their ongoing monitoring requirements
Correct answer: C. A patient taking lisdexamfetamine whose dose is still being adjusted because symptoms remain inadequately controlled.
Explanation:
A is incorrect because this describes the type of clinically stable patient for whom shared care may be appropriate.
B is incorrect for the same reason. Provided other requirements are met and an appropriate shared-care arrangement is available, stable treatment may be suitable for shared care.
C is correct. Active dose adjustment indicates that titration has not been completed. The specialist should generally retain responsibility while treatment is being optimised.
D is incorrect. Understanding monitoring requirements supports safe shared care rather than preventing it.
Question 4
Which statement best describes clinical stability before requesting shared care?
A. The patient has taken the same dose for at least one week
B. The patient's ADHD symptoms have completely disappeared
C. The patient has reached a satisfactory balance between treatment benefit and tolerable adverse effects without an immediate need for further titration
D. The patient says they are happy for their GP to prescribe
Correct answer: C. The patient has reached a satisfactory balance between treatment benefit and tolerable adverse effects without an immediate need for further titration.
Explanation:
A is incorrect. Duration on an unchanged dose alone does not demonstrate clinical stability.
B is incorrect. Successful ADHD treatment does not require complete elimination of symptoms. Treatment aims for meaningful improvement in symptoms and functioning while maintaining acceptable tolerability.
C is correct. Stability is a clinical judgement incorporating treatment response, functioning, adverse effects, physical observations and whether further dose adjustment is required.
D is incorrect. Patient agreement is important, but it does not establish clinical stability or oblige the GP to accept shared care.
Question 5
A GP declines a shared-care request for a patient who is stable on ADHD medication. What is the most appropriate response from the specialist?
A. Tell the GP that NICE requires them to prescribe
B. Immediately stop the patient's medication
C. Establish why the request was declined and ensure an appropriate alternative prescribing arrangement remains in place
D. Tell the patient to complain until the GP agrees
Correct answer: C. Establish why the request was declined and ensure an appropriate alternative prescribing arrangement remains in place.
Explanation:
A is incorrect. NICE supports shared-care arrangements after stabilisation, but this does not mean that an individual GP can simply be compelled to accept prescribing responsibility.
B is incorrect. Failure to establish shared care is not, in itself, a clinical reason to stop an effective medication.
C is correct. The specialist should establish the reason for refusal. Missing information or uncertainty may sometimes be resolved. If shared care remains unavailable, safe alternative arrangements for prescribing and monitoring are required.
D is incorrect. Patients should not be placed between clinicians or expected to resolve professional disagreements themselves.
Question 6
A patient has been stable under shared care for eight months. Their GP identifies persistent tachycardia during routine monitoring. What is the best approach?
A. Continue treatment automatically because the specialist originally initiated it
B. Stop all ADHD treatment permanently without further assessment
C. Clinically assess the finding, consider its relationship to treatment and involve the specialist or other appropriate services where required
D. Ignore the finding unless the patient requests a medication change
Correct answer: C. Clinically assess the finding, consider its relationship to treatment and involve the specialist or other appropriate services where required.
Explanation:
A is incorrect. Previous treatment stability does not make subsequent abnormal findings irrelevant.
B is incorrect. Although some cardiovascular findings may require withholding or changing medication, permanent discontinuation without appropriate assessment is not automatically indicated.
C is correct. Abnormal observations require clinical interpretation. This may include repeating observations, assessing symptoms and other possible causes, reviewing medication and obtaining specialist or medical input where indicated.
D is incorrect. Cardiovascular monitoring is undertaken for patient safety. Potentially significant abnormalities require appropriate clinical action whether or not the patient requests it.
Question 7
A patient under shared care says that their stimulant is no longer lasting through the working day and asks their GP to substantially increase the dose. What is the most appropriate principle?
A. The GP should always increase the dose because they now issue the prescription
B. The request may represent renewed titration and should generally prompt specialist reassessment
C. Shared care means the dose can never be changed again
D. The patient should independently alter the timing and dose until they find an effective regimen
Correct answer: B. The request may represent renewed titration and should generally prompt specialist reassessment.
Explanation:
A is incorrect. Routine prescribing responsibility does not necessarily include independently undertaking substantial changes to specialist treatment.
B is correct. A significant dose alteration may represent renewed titration. The patient's symptoms, duration of effect, adherence, adverse effects and overall clinical circumstances should be reassessed before treatment is changed.
C is incorrect. Medication can be changed when clinically appropriate. Shared care does not permanently fix the patient's treatment regimen.
D is incorrect. Patients should not independently alter prescribed stimulant doses.
Question 8
Which statement about monitoring during shared care is most accurate?
A. Physical monitoring is only required during initial titration
B. Monitoring can stop once the patient has been stable for six months
C. Ongoing monitoring of treatment effectiveness, adverse effects and relevant physical-health parameters remains necessary
D. Monitoring is unnecessary if the patient feels well
Correct answer: C. Ongoing monitoring of treatment effectiveness, adverse effects and relevant physical-health parameters remains necessary.
Explanation:
A is incorrect. Monitoring continues during maintenance treatment and is not confined to titration.
B is incorrect. Long-term treatment continues to require appropriate monitoring according to the medication, patient's age, clinical circumstances and applicable guidance.
C is correct. ADHD medication requires continuing assessment of effectiveness and adverse effects together with relevant physical-health monitoring.
D is incorrect. Some clinically important changes, including changes in blood pressure, pulse, weight or growth, may not initially produce symptoms. Feeling well does not replace appropriate monitoring.
Question 9
A patient completes private ADHD titration and asks whether their NHS GP will now definitely provide prescriptions under shared care. Which response is most appropriate?
A. "Yes. Once titration is complete, your GP has to prescribe."
B. "Yes, provided you have been taking the medication for at least one month."
C. "We can request shared care once treatment is appropriately stable, but your GP must decide whether they are able to accept the arrangement."
D. "No. NHS GPs cannot enter shared-care arrangements following private treatment."
Correct answer: C. "We can request shared care once treatment is appropriately stable, but your GP must decide whether they are able to accept the arrangement."
Explanation:
A is incorrect. Completion of private titration does not compel an NHS GP to accept prescribing responsibility.
B is incorrect. There is no simple duration threshold that automatically creates a shared-care obligation. Clinical stability and the applicable shared-care arrangements are more important.
C is correct. This accurately explains the distinction between requesting shared care and the GP accepting it. Patients receiving private treatment should understand this distinction, particularly because refusal may have financial implications for continued private prescribing.
D is incorrect. Shared care following privately initiated treatment may be possible, but acceptance depends on the individual circumstances and applicable local arrangements.
Question 10
Which statement best captures the overall principle of safe shared care in ADHD?
A. Shared care is primarily a mechanism for reducing specialist prescribing workload
B. Once the GP prescribes, the specialist no longer has responsibility for the patient's ADHD treatment
C. Shared care works best when prescribing, monitoring and specialist responsibilities are clearly agreed and there is effective communication when the patient's clinical circumstances change
D. Shared care means primary and specialist clinicians are equally responsible for every aspect of treatment at all times
Correct answer: C. Shared care works best when prescribing, monitoring and specialist responsibilities are clearly agreed and there is effective communication when the patient's clinical circumstances change.
Explanation:
A is incorrect. Although shared care may distribute workload appropriately, its clinical purpose is to provide safe, accessible and coordinated long-term treatment.
B is incorrect. Shared care does not mean that specialist involvement automatically ends. The specialist continues to undertake the responsibilities assigned to them and should remain accessible when specialist reassessment is required.
C is correct. Clear allocation of responsibility, appropriate monitoring, continuity of treatment and reliable communication are the foundations of safe shared care.
D is incorrect. "Shared" does not mean that every clinician is simultaneously responsible for everything. One of the purposes of a shared-care arrangement is precisely to define which clinician is responsible for which elements of treatment.
Key Learning Point
The central principle running through all ten questions is that shared care is not simply the transfer of a prescription from one clinician to another. It is a structured clinical arrangement.
Before shared care begins, treatment should be appropriately stabilised and responsibilities agreed. During shared care, monitoring and specialist review continue as required. When treatment becomes unstable or clinically significant concerns emerge, responsibility should be reconsidered rather than allowing the patient to become caught between services.
Safe shared care therefore depends on three things: clear responsibility, effective communication and appropriate access to specialist expertise.
