Shared care: step down or step up?

ormal " 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 preference 3 or difficulties with detection of recurrence 4 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 al 6 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 guidance 7 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 Radiologists 8 suggested that, given the lack of evidence of effectiveness for structured follow …