Shared care agreements for ADHD what to do when your GP refuses

What shared care actually is

A shared care agreement (SCA) is a formal arrangement — usually documented in writing — between a specialist service and a GP practice, setting out how clinical responsibility for a particular medicine will be divided. For ADHD, the typical pattern is:

• The specialist (psychiatrist, specialist ADHD nurse, or paediatrician) initiates the diagnosis, selects the medication, and conducts the initial titration — adjusting the dose until it is therapeutically effective and tolerated.
• Once stable, the specialist writes to the GP formally requesting that the GP takes over ongoing prescribing and routine monitoring (typically pulse, blood pressure and weight checks every six to twelve months, plus an annual review).
• The GP issues NHS prescriptions on FP10 forms, which the patient collects from a pharmacy at the standard prescription charge (or free if exempt).
• The specialist remains responsible for clinical decisions outside routine maintenance — dose changes driven by clinical complexity, treatment failures, or new comorbidities.

This is the standard pathway described in NICE guideline NG87 and reflected in the British National Formulary entries for methylphenidate, lisdexamfetamine, dexamfetamine, and atomoxetine — all of which note that prescribing may be initiated by a specialist and continued by a GP under shared care. The arrangement is also governed by NHS England's Shared Care Framework (updated 2023), which sets out national expectations for how shared care should work across NHS England.

Shared care is not an unusual or niche arrangement. It is the standard mechanism by which specialist-initiated medicines for conditions including hypothyroidism, diabetes, epilepsy, and mental health conditions are routinely prescribed in primary care across England.

Why GPs refuse shared care for ADHD

GP refusal of ADHD shared care has become significantly more common since 2021, when the number of adults accessing ADHD assessments via NHS Right to Choose increased sharply. The reasons are layered:

• Local Medical Committee (LMC) opt-out guidance. Several LMCs — the bodies representing GP practices within ICB areas — have issued guidance advising practices not to accept shared care for ADHD from Right to Choose providers or from out-of-area specialists. This guidance often cites concerns about clinical governance (the GP has no existing relationship with the specialist service) and financial pressure (the drug budget sits with the GP practice under primary care contracts). LMC guidance is advisory, not law, but in practice many practices follow it uncritically.
• Cost concerns. ADHD medications — particularly lisdexamfetamine (Vyvanse/Elvanse) and methylphenidate modified-release preparations — are a significant monthly cost. When a Right to Choose provider diagnoses a patient and requests shared care, the GP practice carries the drug cost for a patient whose care was commissioned by the ICB and provided by a separate organisation. Some practices feel this is unfair cost transfer.
• Clinical confidence. Some GPs — particularly older practitioners or those in rural single-handed practices — have limited experience of prescribing stimulant medications and are genuinely uncertain about monitoring requirements and drug interactions. This is a legitimate clinical concern and the solution is education and support from the ICB medicines management team, not permanent refusal.
• Controlled drug administrative burden. Stimulant medications for ADHD (methylphenidate, dexamfetamine, lisdexamfetamine) are Schedule 2 or 3 controlled drugs. They cannot be prescribed on electronic repeat prescription systems in the same way as ordinary medicines — they require individual signed FP10 prescriptions, typically issued for 28 or 30 days at a time. This creates genuine administrative work that practices may resist.
• Supply chain issues post-2022. Sustained global shortages of ADHD medication between 2022 and 2025 led some GPs to refuse shared care on the basis that they could not guarantee supply — and that managing patient distress during shortages was consuming disproportionate appointment time.

What NICE NG87 says about ongoing prescribing

NICE guideline NG87, Attention deficit hyperactivity disorder: diagnosis and management (2018, updated 2019), is the key clinical framework. Paragraph 1.7 covers ongoing management and is explicit that:

• Treatment should be reviewed at least annually, with the review covering effectiveness, side effects, any co-occurring conditions, and whether medication should continue.
• GPs can prescribe and monitor ADHD medication as part of shared care arrangements initiated by a specialist.
• Medication should not be stopped simply because a patient has transitioned from child to adult services, or because they have moved to a new GP practice. Continuity of treatment is a clinical requirement.
• Where a GP is unwilling to prescribe, the specialist should continue to prescribe until an alternative arrangement is made. Patients should not be left without medication.

This last point is important. NG87 places a clinical responsibility on the specialist service to bridge the gap if the GP refuses. Where the specialist is a Right to Choose provider, this creates a practical problem: many independent RtC providers operate as assessment-and-titration services and do not have the NHS prescribing infrastructure to continue issuing FP10 prescriptions indefinitely. This is a system design failure — one that the NHS England 2023 Shared Care Framework was intended to address but has not fully resolved.

Right to Choose and shared care: the gap

NHS Right to Choose gives you the right to choose your provider for a first outpatient appointment. It does not create a contractual obligation on your GP to accept shared care from that provider. The NHS Standard Contract (which all NHS-commissioned services must sign) requires that providers ensure a discharge or transfer plan is in place — but enforcement of shared care obligations sits with the ICB, not with the individual GP.

The result is a structural gap: patients who are diagnosed and titrated by a Right to Choose provider often find themselves with a valid diagnosis, a confirmed effective medication, and no GP willing to prescribe it on the NHS. The ICB is the body responsible for resolving this gap. ICBs have the power to:

• Issue guidance to GP practices within their area requiring them to accept RtC shared care.
• Fund a specialist prescribing service as an intermediate step (some ICBs have done this).
• Commission a shared care support protocol through their medicines management team.

Not all ICBs have done any of these things — which is why escalation to NHS England is sometimes necessary.

ICB blanket bans: what they are and why they are questionable

Several ICBs have issued formal guidance — sometimes published on their websites, sometimes communicated to GP practices through LMC bulletins — stating that GPs should not accept shared care arrangements for ADHD medications prescribed by out-of-area or independent sector Right to Choose providers.

These blanket policies are legally questionable for several reasons:

• NHS England's 2023 Shared Care Framework states that shared care decisions should be made on the basis of individual clinical assessment, not blanket administrative policies. A policy that refuses all shared care regardless of clinical circumstances is incompatible with this framework.
• The NHS Constitution gives patients the right to treatment that meets NHS standards. A blanket policy that leaves diagnosed, titrated ADHD patients without access to their medication on the NHS may breach that entitlement.
• GMC Good Medical Practice (2024) requires doctors to make the care and wellbeing of patients their primary concern. A GP following an ICB policy that results in a patient going without prescribed medication is not insulated from professional accountability by the existence of that policy.

If your ICB has a blanket ban, it is worth requesting the written policy document (use a subject access request or a Freedom of Information request) before escalating — having the policy in writing strengthens any subsequent complaint.

What to do if your GP refuses shared care

Follow these steps in order, keeping written records of every communication:

• Step 1 — Ask in writing. Email or send a letter to the GP practice asking specifically whether they will accept shared care for your ADHD medication, and citing the specialist's name, the medication, and the fact that it was initiated under an NHS Right to Choose referral. Ask for a written response stating their decision and reasons.
• Step 2 — Request a clinical review. If the GP refuses, ask for the decision to be reviewed by the senior or named GP partner, and ask whether the practice will apply to the ICB medicines management team for a shared care protocol.
• Step 3 — Contact the specialist. Notify your specialist of the refusal. Under NG87, the specialist should continue prescribing or arrange bridging until shared care is established. Ask them to write formally to the GP setting out the clinical case and monitoring requirements.
• Step 4 — Formal complaint to the GP practice. If step 2 does not resolve the position, raise a formal NHS complaint to the GP practice under the NHS Complaints Regulations 2009. The practice must respond within 10 working days. State that you believe the refusal is contrary to NICE NG87 and the NHS Constitution and ask for a clear resolution plan.
• Step 5 — Escalate to the ICB. If the practice complaint is not resolved, escalate to your ICB's patient services team. The ICB is contractually responsible for ensuring GP practices meet NHS obligations. The ICB can require the practice to accept shared care or commission an alternative prescribing arrangement.
• Step 6 — NHS England National Contact Centre. If the ICB does not act, contact NHS England on 0800 011 4656. This is the national escalation route for Right to Choose disputes. NHS England can direct the ICB to address the care gap.
• Step 7 — Parliamentary and Health Service Ombudsman. If NHS England and the ICB have failed to resolve the position and you have exhausted local complaints, you can take the complaint to the PHSO. The PHSO can make findings against ICBs and GP practices where they have failed NHS patients.

Specialist liaison letters: what to ask for

A well-written letter from your specialist to your GP is one of the most effective practical tools for unlocking shared care. When you ask your specialist to write to your GP, request that the letter includes:

• The confirmed diagnosis with the clinical reasoning summarised.
• The specific medication, dose, and formulation that has been optimised during titration.
• The monitoring requirements — precisely: what the GP needs to measure (weight, pulse, blood pressure) and how often (typically at six weeks for new patients, then six-monthly or annually).
• A note of which BNF section covers the drug and its shared care classification.
• Direct contact details for the specialist team — a named clinician and a contact number or email for GP queries.
• An offer to provide a shared care protocol document from the Royal College of Psychiatrists or the ICB medicines management team if the GP requests it.

The Royal College of Psychiatrists (RCPsych) has published guidance on shared care for ADHD medication, and your specialist should be able to reference it or provide the relevant document. A GP who is uncertain about monitoring requirements is much more likely to accept shared care if those requirements are clearly set out and a direct clinical contact is provided.

Bridging prescriptions: the stopgap

While you are going through the steps above, do not run out of medication. A break in stimulant medication — even of a few weeks — can cause significant deterioration in functioning. Options for continuity while the shared care dispute is being resolved:

• Specialist private prescription. Your specialist may be willing to issue a private prescription (not NHS-funded) for a further one to three months. You will pay the private prescription charge plus the pharmacy dispensing fee — typically £60–£150 per month depending on drug and dose. This is expensive but far less disruptive than stopping medication.
• Private GP services. Some private GP services (including online clinics) will issue bridging prescriptions for stable ADHD patients where there is documented specialist support. Again, this is self-funded.
• Request NHS emergency supply. In urgent cases, a pharmacist may supply an emergency NHS supply of a controlled drug (subject to Misuse of Drugs Regulations limits). This is not a substitute for a prescription but can provide a small amount of medication in a genuine emergency.

Keep all receipts for bridging prescriptions. If your ICB or PHSO complaint succeeds and a finding is made that you were wrongly denied NHS prescribing, you may be able to seek reimbursement for the private prescription costs as a remedy.

Escalation routes: ICB, NHS England, PHSO

ICB patient services. Every ICB has a patient services or complaints team. Find yours via your ICB's website or by asking your GP practice which ICB covers your area. Escalate in writing (email is fine) with a clear timeline of what happened, what you asked for, and what the GP's response was.

NHS England National Contact Centre. Call 0800 011 4656 (free, Monday to Friday, 8am–6pm) or submit online at england.nhs.uk. State that you are raising a Right to Choose complaint and that a shared care agreement has been refused following an NHS-funded assessment, leaving you without your prescribed medication.

PHSO. The Parliamentary and Health Service Ombudsman investigates complaints about NHS organisations in England. You must have completed the NHS complaints process (practice complaint and ICB review) before the PHSO will accept your case. The PHSO can make binding recommendations including financial remedies. Contact via ombudsman.org.uk or 0345 015 4033.

Realistic outcomes: what to expect

The honest picture is mixed. Some GP practices, when approached with a formal written request citing NG87 and a well-structured specialist letter, will agree to shared care promptly. Others will require ICB pressure before they move. A small number will resist through the entire complaints process and the patient will ultimately need to either switch GP practice or — where the ICB has a blanket policy — wait for NHS England to resolve the systemic issue.

Switching GP practice is often the fastest practical solution when a practice is intractably resistant. You have an absolute right under the NHS Constitution to register with any GP practice accepting new patients in England, with no reason required. Your medical record transfers automatically within days via the NHS GP2GP system. Before switching, it is worth telephoning prospective new practices to ask, as a factual inquiry, whether they routinely accept shared care for adult ADHD medication prescribed by NHS Right to Choose providers.

For patients in ICB areas with blanket bans, the picture is harder. These disputes take months to resolve through formal channels. In the meantime, bridging prescriptions and a parallel formal complaint to both the ICB and NHS England is the recommended approach. Document everything. Pressure from multiple patients in the same ICB area is more effective than individual complaints, so patient advocacy organisations including ADHD UK and CHADD UK can help coordinate collective complaints.

Frequently asked questions