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Shared care
Shared care: step down or step up?
  1. E J Maher,
  2. D Millar
  1. Mount Vernon Hospital, Northwood, Middlesex HA6 2RN, UK
  1. Correspondence to:
 Dr E J Maher, Mount Vernon Hospital, Northwood, Middlesex HA6 2RN, UK; 
 jane.maher{at}mvh-ljmc.org

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Shared care arrangements between hospitals and primary care for the management of patients with cancer must be seen as a step up from “usual” care in general practice rather than a step down from hospital practice.

Formal “shared care” in cancer remains controversial. It is promoted as offering patients care closer to home while, at the same time, reducing the burden on specialist services. Primary care practitioners are divided on the issue, some viewing shared care as enhancing their practice and others as another example of hospitals offloading work onto an already overloaded primary care sector. There is some evidence to suggest that primary care based follow up alone is acceptable to patients and provides similar outcomes to specialist follow up in breast cancer,1,2 although this is disputed by others who cite patient preference3 or difficulties with detection of recurrence4 as arguments for continued specialist review. There is also increased interest in models of self-management, with patients accessing the most appropriate healthcare professionals to meet their needs.5 What is clear is that much follow up activity is based on historical practice rather than evidence.

The study from Aarhus University by Nielsen et al6 in this issue of QSHC suggests a positive effect on patient evaluation of the healthcare system following the introduction of a shared care programme for newly diagnosed cancer patients. This enhancement of care is achieved in part by the provision by specialists of comprehensive information about the individual, their cancer and its management to the GPs, and also by providing communication channels and clear guidance to patients themselves about whom to contact and in what circumstances. This information transfer across the interface between secondary and primary care allows GPs and their healthcare teams to offer optimal care and support to cancer patients and their families and enhances relationships and communication between the different care agencies. It follows therefore that such information ought to be available as a matter of good practice whether or not formal shared care arrangements are in place.

Some guidance7 exists for best practice in terms of information transfer on discharge from hospital. Unfortunately, even the basic minimum data are often unavailable to primary care on discharge, and significant delays often occur before it is received. This seriously hampers the ability of GPs to manage cases effectively. Continuing efforts are required to rectify this persisting problem.

A report produced jointly by the UK Royal College of General Practitioners and the Faculty of Oncology, Royal College of Radiologists8 suggested that, given the lack of evidence of effectiveness for structured follow up arrangements, as many as 70% of patients might safely stop hospital based follow up without detriment to the desired outcomes of early recognition of recurrence of new disease, psychosocial support, and opportunities for audit, research and training. It states that “the effectiveness of these arrangements would depend on fully informing the patient, gaining their complete compliance and the prompt referral and assessment on discovery of new signs of symptoms of disease” and “there appears room for further development of both primary care based follow up and some shared care arrangements in those patients willing to accept these forms of care”.

Any development of formal shared care arrangements in cancer should involve discussion with all those involved and, most importantly, with the patients and carers themselves. Rigorous evaluation of such schemes is required and further research needed to identify which groups of patients with which cancers are best managed in this way. Such collaborative work can only improve intersectoral understanding of roles and responsibilities, so long as provision of the patients’ needs is kept central. Such schemes will only work if, after appropriate training, GPs with an interest in this work see it as enhancing patient care, improving job satisfaction, and associated with appropriate remuneration. It must be seen as a step up from “usual” care in general practice rather than a step down from hospital practice.

Shared care arrangements between hospitals and primary care for the management of patients with cancer must be seen as a step up from “usual” care in general practice rather than a step down from hospital practice.

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