ADHD medication in the UK is initiated by a specialist and, once the dose is stable, is intended to pass to the patient's GP for ongoing prescribing under a shared care agreement. That is the model NICE guideline NG87 describes, and for years it worked quietly. It is now one of the most contested arrangements in primary care. Waiting lists have pushed patients into Right to Choose and private providers, the volume of requests has multiplied, and in 2025 a number of Local Medical Committees advised practices to decline new ADHD shared care altogether. For any prescriber working with ADHD, understanding how shared care is meant to work — and why it is failing — is now part of the job.
What a shared care agreement is
A shared care agreement (SCA) is a documented arrangement between a specialist service, a GP practice and the patient. The specialist retains responsibility for diagnosis, choice of medication, titration to a stable dose and periodic specialist review. The GP takes on routine repeat prescribing and the interim monitoring, and agrees to refer back if problems arise. The patient agrees to attend monitoring and reviews. Crucially, the GP takes on clinical responsibility for the prescriptions they sign; shared care is not a rubber stamp on a specialist's decisions, which is why the GP must be satisfied the arrangement is safe before accepting it.
Shared care is voluntary for the GP. NHS England guidance is clear that a practice should not decline shared care solely because the diagnosis was made privately or through Right to Choose, but it is equally clear that a GP is not obliged to accept a request they consider outside their competence, unsafe or unresourced. Most Integrated Care Boards publish a local ADHD shared care protocol; the specialist's request should be on that template, and the GP is entitled to insist on it.
What the specialist must do before asking
A request that arrives before titration is complete, without baseline observations, or on a provider's own form rather than the ICB protocol is a request most practices will — reasonably — refuse. Before transferring, the specialist should have: a documented diagnosis by an appropriately qualified clinician; a stable dose for a sensible period, typically several months; baseline and post-titration blood pressure, heart rate and weight; a cardiac history and, where indicated, an ECG; a clear statement of who to contact and how quickly they will respond; and a commitment to the specialist reviews the protocol requires, usually annually. The 2026/27 NHS Payment Scheme now explicitly recognises the adult annual review with shared care as a distinct activity, which is a small but real acknowledgement that the specialist side of the bargain has to be resourced too.
What the GP is monitoring
Under NG87, patients on ADHD medication need heart rate and blood pressure checked before and after each dose change and at least every six months thereafter, weight monitored (every six months in adults, more often in children, with height as well for those still growing), and a review of effectiveness, adverse effects and adherence. The stimulants — methylphenidate and lisdexamfetamine — are Schedule 2 controlled drugs, with the prescribing rules that follow. Atomoxetine and guanfacine have their own monitoring points. The GP should know the red flags that warrant urgent referral back: sustained tachycardia or hypertension, chest pain or syncope, new or worsening psychiatric symptoms including tics, psychosis, mania or suicidal ideation, significant weight loss, and any suspicion of diversion or misuse.
Why practices are declining, and what happens to the patient
The objections are about workload, resourcing and risk rather than about ADHD. A practice taking on shared care for a controlled drug takes on the monitoring appointments, the prescribing checks and the liability, often with no additional funding and with a specialist provider that may be hundreds of miles away and slow to respond. Multiply that by the number of patients now reaching diagnosis through Right to Choose, and practices that once accepted a handful of SCAs a year face dozens. Some decline private requests; some decline all new ADHD shared care; some accept only from NHS services in their own area.
The consequence falls on the patient. Where shared care is refused, the specialist service continues prescribing — if it can — usually privately and at a cost, or the patient loses access to treatment that was working. Some are left on medication with no monitoring at all. Prescribers on both sides should be honest with patients at the outset about whether shared care is likely to be accepted locally, rather than discovering it after titration.
Making shared care work
For specialists: use the ICB template, transfer only stable patients with complete baseline data, name a responsive contact, keep to the review schedule and write in a way a busy GP can act on. For GPs: judge each request on its merits rather than its source, use the local protocol as the safety standard, and where you decline, say why, so the specialist can address it. For both: keep the patient informed at every step. Shared care exists so that a person with ADHD can have their prescription renewed and their blood pressure checked near home, by a practice that knows them, without waiting months for a specialist slot. That is worth making work.
Confident prescribing in ADHD — knowing the medications, the monitoring, the interactions and the point at which shared care is appropriate — is a learnable skill, and one that a growing number of GPs, pharmacists and non-medical prescribers are choosing to develop through structured CPD rather than picking up under pressure.