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There are many diseases and conditions for which care is shared across primary, secondary, and tertiary healthcare providers, sometimes through formal shared-care arrangements or via ad-hoc referral of patients as and when needed. In these instances, communication and collaboration are paramount to achieving the best outcomes for patients. This need is recognised in many new and updated guidelines, which now include recommendations about shared-care protocols, when and where to refer, and the overall care pathway as patients move between care providers. The articles in this issue of Guidelines in Practice touch on shared care as a common theme.

The 2019 update to the Global Initiative for Asthma (GINA) strategy document brought fundamental changes to the recommendations about asthma treatment. Short‑acting beta2-agonist (SABA)-only treatment is no longer recommended by GINA for treatment of asthma in adults and adolescents. GINA now recommends that these patients should receive either symptom‑driven or daily inhaled corticosteroid (ICS)‑containing controller treatment. This change is based on strong evidence that SABA‑only treatment increases the risk of severe exacerbations and asthma‑related death, and that adding any ICS significantly reduces the risk.

GINA 2019 has also recommended earlier referral of patients for specialist assessment because there are new biological treatments available for people with severe asthma that can only be accessed through specialist care. Dr Mark L Levy provides his personal view on these new recommendations from GINA and shares tips on what to advise patients who wish to continue using their SABA.

Scanning electron micrograph of lung lining, in false colour

Personal view: is it time to change our UK prescribing strategy for asthma?

Image source: © Dr Tony Brain/Science Photo Library

Dr Mark L Levy

Frailty is becoming increasingly recognised as an important complication of diabetes in older people. In 2018, a national UK collaborative stakeholder framework was published, detailing recommendations for the management of type 2 diabetes in older people, including an assessment of frailty. The collaborative framework makes recommendations about tools and methods used to assess frailty that can easily be implemented in primary care, as well as glycaemic targets that are aligned to the severity of frailty.

Professor Alan Sinclair summarises the key recommendations from the stakeholder framework in his article, which also includes a useful pathway for frailty assessment in patients with diabetes, indicating where referral to a diabetes specialist/geriatrician is warranted.

Crohn’s disease and ulcerative colitis, collectively referred to as inflammatory bowel disease (IBD), are chronic conditions centred around inflammation of the gut. There is no cure for IBD and it can have a significant impact on the patient’s quality of life, so treatment is focused on achieving and maintaining remission. Supporting and managing patients with IBD can be complex and often requires a multidisciplinary approach that spans primary and secondary care.

The British Society of Gastroenterology has developed an updated guideline on IBD, which covers almost all aspects of care for patients with suspected and diagnosed IBD. Many of the recommendations are applicable only to secondary care, but there are significant aspects of the guideline that are relevant to primary care, which Dr Kevin Barrett discusses in his article. Dr Barrett focuses on the role of the GP in diagnosing IBD, flare management and prevention of corticosteroid-induced osteoporosis, ongoing medical management, supporting patients, investigating associated symptoms, pregnancy, vaccination, and colorectal cancer surveillance and prevention. Dr Barrett also highlights what information needs to be exchanged between primary and secondary care to ensure good care for people with IBD.

Prostate cancer is another area where different aspects of care are divided and shared between primary and secondary care. In May 2019, NICE published an updated guideline on the diagnosis and management of prostate cancer. The guideline covers diagnosis, risk‑stratification, and management of prostate cancer in secondary care, and follow up in primary care with shared-care protocols. The guideline states that these protocols should clearly define where clinical and prescribing responsibility lies between secondary and primary care, as well as monitoring requirements and actions to be taken if test results are abnormal.

Dr Sadaf Haque highlights recommendations from the updated NICE guideline that are relevant to primary care, discusses the role of primary care in supporting patients living with and beyond prostate cancer, and explains what information should be shared between healthcare professionals across different sectors to improve the quality and safety of patient care.

To learn more about shared care and the guidelines discussed in this issue, come to Guidelines Live 2019—for more information and to see what will be covered, visit