GP versus private doctor - can anyone help me work this out?

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I'm trying to help a member of my family was diagnosed with bipolar at 17, now an adult. They have never really found the right treatment, mainly because with youth being the chaotic thing it can be, they didn't give the drugs they were prescribed enough time or their lifestyle impacted on them working well etc.

I got them a private appointment with a psychiatrist which they found really positive. This doctor prescribed lithium and ask her to arrange blood tests. We did this right away. He was going to write to her doctor to get some info on what treatments she had followed.

She has just had a telephone appointment with her GP who has known her a long time.

Her GP has told her if she goes private she will not take her prescription back into the NHS and she will have to pay for a private prescription forever. She has advised her to go back to the mental health team and ask to be prescribed lithium and go through all the blood tests (again). She says this is the only route.

Even though I would pay for the prescription, she doesn't want that, which I understand.

I'm guessing she is going to be waiting a while for this process on the NHS.

Can anyone please advise? I thought the consultant would write to her GP, with the tests results showing the levels as x and the dose required as y. and she could ask for the prescription. But it seems I'm wrong.

This is true and lots of people paying for private ADHD assessment are finding the same with their meds. GPs can do shared care, but they don't have to, as yours has demonstrated.

The other thing is if/when she does go through the NHS she can't juts ask for lithium, they will make their own assessment and decide what to prescribe which may or may not be lithium.

I think the problem with lithium is the monitoring that has to go with it, and GPs might not be commissioned to do this, which might be the problem.

I don't think any GPs in my area will take responsibility for lithium. There is a lot of monitoring that goes with it of physical obs and you can only give the meds if their bloods are okay. It's unlikely that GPs will feel comfortable with lithium toxicity and lithium is almost never used as a first medication for bipolar

It's usual that lithium remains monitored by secondary care eg cmht rather than gp. A routine referral often has a 3 month wait where I am

The issue with private care is that often its a one off, so they leave nhs care in charge of monitoring efficacy and potentially fatal side effects of a drug someone else started. For example in this situation a gp has been handed over a drug they would have never had started, that has potentially fatal side effects as well as the need for intense physical and mental health monitoring. Your gp for example will struggle to change the doseage

Also who is monitoring if its helping or how it impacts his mental health?

Thank you for your replies.

@Flamedmoth Lithium was the first medication they were prescribed on diagnosis back when they were 17 but they didn't keep up with the treatment, so the doctor tried other things. Lithium is apparently the gold standard for treating their condition. GP has referred them to mental health team so I assume they would be taking charge of monitoring, if it's prescribed.

https://www.nice.org.uk/guidance/cg185/chapter/Recommendations#recognising-and-managing-bipolar-disorder-in-adults-in-primary-care

This is the nice guidance for bipolar, and lithium .I find it difficult to read but has lots of information about the role of gp in suspected bipolar, but you'll see it says that GPS shouldn't commence lithium.

I've also included one of the nhs trusts lithium guidance summary.

In short I would assume that of a private psychiatrist wished to prescribe lithium that they would continue to monitor it for period at least, until they are sure its helping and doesn't make you unwell physically or mentally

I'm surprised that they thought a gp would solely manage it and didn't offer their own follow up

My preference would be for them to continue with the private doctor and be monitored by them with regular blood tests with me paying for it all but they don't want to do that and I can understand why of course.

@Flamedmoth they have only had their first appt with the psychiatrist, he was intending to continue treatment and monitor her. So I don't think it was intention to shuffle her off to her gp.

@Flamedmoth thank you very much for that info. I'll read through it.

The GP has made the referral to mental health team, we will have to wait and see what happens. It is something they have been prescribed before though, so hopefully they will take on the treatment.

I would suspect that they only thing the gp can do is to provide a referral to the cmht and follow that route although if the case isn't urgent its likely to be a fair weight.

My local cmht doesn't provide lithium without trying new mood stabilisers first (except in very acute cases), as while lithium is very effective its a harsh drug.

It's a bit like morphine being a gold standard for pain killers, but it shouldn't be your first offer unless your sure that others wouldn't work first.

The psychiatrist who prescribed the lithium must know his job though, he's a consultant, and I do think it is possibly a fairly severe case that hasn't responded to the other drugs, which have been tried. So it seems that this treatment isn't likely to happen on the NHS. Feeling pretty deflated, I've been trying to get them the best treatment for a year now.

Apologies obviously I know nothing of the intricacies of this case, and obviously have no idea whether you everyone of the lithium criteria. The consultant who's actively seen the case will have a better idea than me!

For my local cmht it would depend on how long ago those meds were tried, what they were, and if as you described they taken regularly and for a period long enough to know if they work or not. I was assuming that he hadnt previously been on the other meds regularly

People are prescribed lithium regularly by the nhs, so it may be the cmht do continue it on.

I guess the tricky bit is being in this no man's land between private, gp and cmht.

If it was my family member I would pursue it through the private route until there was a nhs appointment to take it over, if I felt like it couldn't wait for the nhs appt

What is clear is that having supportive family members always makes a world of difference so he's lucky to have you on his side!

It is not true that lithium has to be monitored by secondary care.
Speak to Bipolar UK. They are excellent.

And Bipolar UK see lithium as the gold standard treatment, not the newer drugs. It tends to be far more effective, but pharmaceutical companies make very little money from it. Its why the companies push the newer drugs.
The real difficulty is being stuck between private and NHS.in this specific case the gp is taking responsibility for prescribing if he issues a lithium prescription but has no idea if the private psychiatrist is any decent. It is a risk for the gp and I can see why a gp would not be willing to take the risk.

There are various issues here. Lithium is shared care - the patient has to remain under a psychiatrist. As a GP, I would be extremely uncomfortable sharing care with a private psychiatrist, unless I knew that, say, the patient had paid up front for 1-2 years care, because if they stop paying, then I'm sharing care with no-one. Plus I get a variety of letters from people who call themselves private psychiatrists and their qualifications/credentials are very variable. Most patients with bipolar aren't on lithium these days.

In a case like this I would refer to the MH team urgently and expect them to be seen within a month or two - if they want lithium in the meantime they'd have to get it privately. It's not terribly expensive, I just checked - 100 tablets of one of the common preparations costs £14, plus whatever the dispensing fee is from the pharmacy.

The view of single issue charities is often not the same as the view of the medical profession - several charities gave out completely incorrect information about who with their disease should shield in the pandemic, for example.

It is simply wrong to say that a patient on lithium has to remain under a psychiatrist.
GP manage patients on lithium
The initial prescribing has to come from the psychiatrist though.

Just to say as a GP you may take that view. But other GPs do not. I am talking from personal experience here.

I agree, individual GPs will make their own decisions about what they are comfortable with.