At Nightingale Valley Practice we follow the BMA general practice responsibility in responding to private healthcare. For more information you can visit the bma website by clicking below:

General practice responsibility in responding to private healthcare


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Included in this section
- Shared care principles for private services
- Shared care principles for prescribing as published by the Avon LMC 

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Introduction

With nearly 7.6 million people on NHS waiting lists in December 2023, patients are increasingly resorting to seeking private healthcare to deal with their health problems. This is adding extra workload for general practices due to private providers making requests in several areas:

• to make private referrals
• to provide medical information about patients
• to organise further tests
• to issue prescriptions
• for onward NHS referrals.

This guidance is written to help support practices to reduce this extra workload.


Patient referrals from a GP for private services

If a patient chooses to seek private treatment, they can self-refer. However, some consultants will only see patients that have a referral from a GP.

If a private insurer requests a GP referral, this would be classed as a transfer of care and therefore contractual work, and the private company cannot be charged for it.

If a private provider requires medical information about a patient, this can be provided by the patient by supplying copies of hospital letters received by the patient or by sharing their medical records via the NHS app or online medical records system. Patients can make a SAR (subject access request) to obtain a free of charge printed summary of their medical record.

If a private provider requests more information from a general practice, this can be provided, following consent, and the cost of preparing the report can be charged to the private provider.

 

Organising tests requested by private providers

If general practices receive requests from private providers to arrange tests or investigations, it is important to note that complying with such requests - regardless of the GP’s management and treatment of the patient - is outside the scope of NHS primary medical services.

The NHS GMS Regulations define essential services as services which are delivered in the manner determined by the GP in discussion with the patient. Therefore, a GP provider should only carry out investigations and prescribe medication for a patient where it is necessary for the GP’s care of the patient and the GP is the responsible doctor.

If the GP considers the proposed investigations to be clinically appropriate, is competent to both interpret them and manage the care of the patient accordingly, then the GP may proceed with arranging the tests or investigations.

However, if the GP does not have the knowledge or capacity to undertake these actions, they should decline to organise the investigation and advise the patient and the provider that the services do not fall within NHS primary medical services and to make alternative arrangements.

Patients are of course entitled to access their medical records, so GPs can provide access to the results of any such investigations for the patient to take back to the private provider.

NHS guidance states

Patients may pay for additional private healthcare while continuing to receive care from the NHS.

 

However, in order to ensure that there is no risk of the NHS subsidising private care:

 

• It should always be clear whether an individual procedure or treatment is privately funded or NHS funded.
• Private and NHS care should be kept as clearly separate as possible.
• The patient should bear the full costs of any private services. NHS resources should never be used to subsidise the use of private care.
• The arrangements put in place to deliver additional private care should be designed to ensure as clear a separation as possible of funding, legal status, liability and accountability between NHS care and any private care that a patient receives.

With regards to indemnity, it is important to consider whether the treatment provided is considered NHS or private. The table included in Scheme Scope for the CNSGP and ELSGP indemnity schemes states:

NHS services following private treatment

Any primary medical services provided under a GP contract or any other NHS services that fall within the definition of ancillary health services that are provided to a person, even if they have previously been treated privately for the same condition are covered.

For example, clinical negligence cover is available under the CNSGP/ELSGP for suture removal by a GP practice (for example, following private cosmetic surgery) and blood tests provided as part of the primary medical services provided by general practice even where the results of the blood tests are relevant to or are to be relied upon for the purposes of ongoing private treatment.

 

Prescribing medication requested by a private provider

GMC Good Medical Practice states that doctors in the NHS and private sector should "prescribe drugs or treatment, including repeat prescriptions, only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs."

If requested by a private consultant to initiate or continue prescribing medications, and if the GP agrees with this advice, then this could be appropriate. However, if the GP does not feel competent to prescribe the requested medication, or they do not know if the medication best serves the patient’s need, the GP should inform the private provider that the prescriptions should be provided by a specialist.

It should also be remembered that NHS guidance states that

"where a patient has an immediate clinical need for medication as a result of attending an outpatient clinic, the secondary care provider must supply medication sufficient to last at least until the point at which the outpatient clinic’s letter can reasonably be expected to have reached the patient’s GP, and when the GP can therefore accept responsibility for subsequent prescribing. Consideration should be given to providing a minimum of 7 days’ supply to allow patients sufficient time to contact staff at their general practice."

This applies equally to private and NHS providers.

 

"Shared care" with private providers

Sometimes the care of a patient is shared between two doctors, usually a GP and a specialist, and there is a formalised written ‘shared care agreement’ setting out the position of each, to which both parties have willingly agreed. Where these arrangements are in place, GP providers can arrange the prescriptions and appropriate investigations, and the results are fully dealt with by clinicians with the necessary competence under the shared care arrangement. There is NHS guidance available about this.

Shared Care with private providers is not recommended due to the general NHS constitution principle of keeping as clear a separation as possible between private and NHS care. Shared Care is currently set up as an NHS service, and entering into a shared care arrangement may have implications around governance and quality assurance as well as promoting health inequalities. A private patient seeking access to shared care should therefore have their care completely transferred to the NHS. Shared care may be appropriate where private providers are providing commissioned NHS services and where appropriate shared care arrangements are in place.

All shared care arrangements are voluntary, so even where agreements are in place, practices can decline shared care requests on clinical and capacity grounds. The responsibility for the patient’s care and ongoing prescribing then remains the responsibility of the private provider.

 

Caring for patients who have had private treatment abroad

Patients can transfer their care from private to NHS as per the NHS Constitution. Thus, if a patient would normally receive follow up in general practice following specialist treatment, they should receive this if they transfer from private care, whether in the UK or not.

However, if follow up is of a specialist nature, or not within normal general practice remit, the patient should be referred to the appropriate service in the UK for this follow up.

If an appropriate service is not available, or rejects the referral, this should be directed to the local commissioner whose responsibility it is to commission the service.

 

Private providers making onward referrals to NHS provider

Private providers can make referrals to NHS services, without referral back to the GP, provided the patient would be eligible for NHS referral. Any patients referred should be treated based on clinical need. Read NHS England guidance around consultant-to-consultant referrals within the NHS


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Principles for Shared Care Prescribing

 Shared Care Prescribing refers to medication which is initiated by a specialist and ongoing prescribing and monitoring is shared with a GP practice, usually accompanied by guidance or a shared care protocol. The GMC has guidance on shared care prescribing which requires a clinician to be informed about the side effects of the medication and undertake the required monitoring.

The following principles should apply to ALL shared care prescribing:

 

Ø It is a non-core voluntary activity that can be declined by the GP practice for any reason, such as:

o Inadequate capacity within the practice

o Inadequate competency about the specialist medication, despite training

o Lack of assurance to provide the ongoing specialist support require for shared care

NB: ensure any refusal is consistent and framed by a set of principles so it not discriminatory to specific patient groups

 

Ø The GP practice is satisfied with the quality assurance and clinical governance of the specialist provider

o This will be more challenging if the provider is not commissioned by the NHS

 

Ø If any ongoing medication monitoring is required, accountability for this should be clear within associated guidance in the form of a shared care protocol

 

Ø The appropriate stabilisation period has occurred before prescribing is handed over to the GP practice

o The duration is determined by the shared care protocol (often 3 months)

 

Ø There is enduring specialist input such as:

o Ongoing out-patient follow-up

o A mechanism which allows timely advice from the specialist, which could be converted into an out-patient review

NB: Enduring specialist care is challenging when a patient is self-funding. Practices must consider their choices should this cease, as this may be associated with an element of moral injury, despite a patient contract being in place.

 

Ø Any additional work undertaken by general practice in the form of medication monitoring, is delivered through a funded, commissioned pathway

o This would usually be in the form of an ICB medicines monitoring Local Enhanced Service