This is a complex area and needs careful navigating to ensure you don’t fall foul of the GMS/PMS Regulations.
Firstly, a patient cannot be simultaneously registered with a practice as an NHS and as a private patient as, under the GMS Regulations, you are not permitted to provide private services (with only a few, specified exceptions) to registered patients.
If there is a scenario whereby the practice partner/s offer a specific private service, you would need to be very careful and transparent about the expectations of the patient. Patients looking for private treatment should be given a list of organisations who provide this and if you are one of those organisations this needs to be transparent.
It is strongly recommended you take into account the information from the BMA on private services – see below.
However, you also need to also bear in mind where any private services are to be delivered.
Practice GMS/PMS rent reimbursable space cannot be used for private services during GMS/PMS core working hours.
Responding to Private Healthcare Requests
With nearly 7.5 million people on NHS waiting lists in May 2023, patients are increasingly resorting to seeking private healthcare to deal with their health problems. We are often asked can practices charge for referrals to private providers. As we know, practices cannot normally charge their registered patients which would include for making referrals to private services. However, it is probably acceptable for practices to suggest to patients that they may not need a referral letter and for patients to see if they can self-refer first.
Our colleagues at Berks, Bucks and Oxon LMC (BBO) have some excellent guidance on GP Interface with the Private Sector and have kindly agreed that we share the link to this with our practices. With our grateful thanks to BBO LMC, please see Private | Berks, Bucks & Oxon LMCs (bbolmc.co.uk). In particular, we thought the following from page 8 onwards is very helpful, however we would strongly recommend taking a look at the full content for other private interface scenarios that they cover.
- Does an NHS GP have to do a private referral whenever asked by a patient?
No. A GP should do a referral where the patient is entitled to it and, in the view of the GP, the referral is clinically necessary. This is the case whether the referral is through the NHS route or a private referral.
If the GP does not consider the treatment to be clinically necessary, then there is no obligation to refer; the patient may then seek treatment without a referral.
The GMC no longer requires specialists to accept patients only with a referral. However, the BMA considers a referral good practice, and insurance companies usually require a letter of referral. This can create some conflict between what the patient wants and what the GP feels is clinically necessary. In these circumstances, the GP should be open with the patient about this. They may want to offer the patient a second opinion from another GP.
Doctors cannot be compelled to arrange treatment where it is not clinically indicated and GMC guidance states that investigations or treatment must be arranged and provided on the basis of clinical judgement of the patient’s needs. The quality standard of the referral is the same, whether the patient is being referred privately or through the NHS. A referrer must provide relevant information about the patient’s condition and history, and the purpose of transferring care or arranging the investigations and treatment the patient needs .
- Can a GP charge for doing a private referral?
GPs may not charge their NHS patients for private referrals, nor may they charge for the provision of relevant information to other doctors providing care for the patient .
Part 5, Regulation 24 of the National Health Service (General Medical Services Contracts) Regulations 2015 (which are replicated in any PMS contract), sets out the basic exclusion in charging NHS patients for care. It states:
“the contractor must not, either itself or through any other person, demand or accept from any of its patients a fee or other remuneration for its own benefit or for the benefit of another person in respect of the provision of any treatment whether under the contract or otherwise; or a prescription or repeatable prescription for any drug, medicine or appliance”
NB: The above refers to not charging for the care GPs are contracted to do for patients. It does not mean GPs are unable to charge for anything. Indeed, there are some situations where a GP can (and should) charge (such as some certificates, reports, malaria medicines and some non-NHS travel immunisations). Further details can be found here.
The BMA have also issued guidance on responding to private healthcare to help practices reduce extra workload generated from such requests. You will find information under the following headings in their guidance: –
- Patient referrals from a GP for private services
- Organising tests requested by a private provider
- Prescribing medication requested by a private provider
- “Shared care” with private providers
- Caring for patients who have had private treatment abroad
- Private providers making onward referrals to NHS provider
Restrictions on private practice for GPs
This following is the guidance issued by the BMA.
Private practice is significantly restricted in terms of NHS registered patients for GMS (general medical services) and PMS (personal medical services) contractors. Part 5, Regulation 24 of the National Health Service (General Medical Services Contracts) Regulations 2015 (which are replicated in any PMS contract), sets out the basic exclusion in charging NHS patients for care. It states:
- the contract must contain terms relating to fees and charges, which have the same effect as those set out in paragraphs (2) to (4)
- the contractor must not, either itself or through any other person, demand or accept from any of its patients a fee or other remuneration for its own benefit or for the benefit of another person in respect of the provision of any treatment whether under the contract or otherwise; or a prescription or repeatable prescription for any drug, medicine or appliance.
There are some very limited circumstances where a fee may be charged for services to an NHS registered patient, which are set out in Regulation 25. (These include, for example, malarial chemoprophylaxis and medicines that may be required to treat an illness once the patient is abroad).
New contractual regulations introduced in October 2019, restrict GP practices from offering or advertising – during NHS working time and on NHS funded property – private services to anyone (whether a registered patient or not), if those services fall within the scope of primary medical services.
This means that if a practice provides an NHS commissioned service, they cannot then charge for (or host) that same service during hours where they provide those NHS services and on their practice premises.
This does not affect a practice’s ability to charge non-registered patients for services that are not part of primary medical services (ie not NHS commissioned services) or to charge their own patients in the limited circumstances outlined above.
Charging patients for services through private companies
Some GPs may choose to hold shares or be partners in private companies providing medical services, and the question arises whether the private company can charge the GPs’ NHS patients for private services.
Even where the GP is not personally charging his/her own patients for the service, but it is, instead, the company that is charging the patients at arm’s length, it is likely that the arrangement will fall foul of Regulation 24.
There is an argument that the ability of any GP to charge patients through a private company hinges on the nature and definition of the ‘contractor’. For GMS, a contractor is defined as a person or entity that can hold a GMS contract.
Part 2, Regulation 5 of the GMS regulations, defines who can hold a GMS contract as:
- a medical practitioner
- two or more persons practicing in a partnership
- a company limited by shares.
It has been proposed that any one or more individuals falling outside these groups, could arguably be entitled to charge a fee or remuneration for the provision of any treatment. In other words, GPs would have to be – or be set up as - a different entity from the one that holds the contract.
For example, single handed doctors could arguably set up a company or partnership that could charge patients. However, as we have seen, the regulations prohibit these entities or groups of people from charging their NHS patients for private services and it is not clear that providing services in this way would avoid them successfully.
Private GP referrals to the NHS
Section 8.2 of the Department of Health’s ‘ Guidance on NHS patients who wish to pay for additional private care ‘ (2009) is still extant and was not altered by the Health and Social Care Act 2012.
The Department of Health clarified that “patients who have chosen to pay privately for an element of their care are entitled to receive NHS diagnostic tests free of charge as long as they are eligible. A referral by a private GP for an NHS diagnostic test should not be any different from an NHS GP referral”.
Private GPs are free to refer their patients to the NHS in the same way as NHS GPs can refer their patients to the private sector.
The 1986 handbook ‘Management of private practice in health service hospitals in England and Wales’, which sets out the key principles that govern private practice in the NHS, clearly states:
“All fully registered general medical practitioners may refer patients to NHS hospitals irrespective of whether they are treating them under the NHS or privately.”
This principle is also underpinned in paragraph four of the handbook: that patients wishing to be treated privately are entitled to the same NHS services as any other patient with the same clinical need. However, it should always remain clear whether the patient is receiving private or NHS care.
Wholly private GPs cannot issue NHS prescriptions but can only provide private prescriptions.
NHS GPs on the other hand, cannot charge NHS patients for prescriptions but can charge private patients who are not on their NHS list for prescriptions. Additionally, NHS GPs cannot issue NHS prescriptions to private patients.
However, it should be noted that there are certain prescriptions that NHS GPs can charge their registered NHS patients for.
These are covered under Part 5, Regulation 25 of the National Health Service (General Medical Services contracts) Regulations 2015 and include, for example, malarial chemoprophylaxis and medicines that may be required to treat an illness once the patient is abroad.
Patients who are on a course of treatment requiring an expensive course of drugs are more likely to opt for NHS prescriptions. As such, some patients might have two GPs – an NHS and a private GP to keep the management of their care cost effective.
We have further information at Wessex LMCs: Requests to convert private prescriptions to NHS FP10
Responding to Private HPV Self-sample Tests
The purchase of Human Papillomavirus (HPV) self-sampling home testing kits is increasing. Results of these private tests will not be acted on by the NHS Cervical Screening Programme (NHS CSP) and cannot be recorded in an individual’s NHS screening record.
If a private test result is positive, the person should be advised that having HPV does not mean they have or will get cervical cancer.
HPV is common; over 80% of the population will get it at some point during their lives.
Individuals eligible for the NHS CSP remain so, even if they have had a private test. Most HPV infections clear themselves without causing problems. If someone has persistent HPV infection, it will be identified when they accept their next NHS CSP invitation.
Cervical cancer usually develops slowly over 10 years in three stages:
- Infection with HPV
- Development of abnormal cells if the immune system does not rid the HPV infection
- Development of cancer if abnormal cells are not treated.