NHS GP INTERFACE WITH THE PRIVATE HEALTHCARE SECTOR

The page describes the codes of conduct around how NHS GPs and private healthcare providers work should work with each other

Principles which govern the NHS-private interface

How services interact across the private-NHS interface is guided by three related principles:

Right to choose: Any patient has the right to choose private care if they wish to. There right to NHS remains throughout and is unaffected. The NHS care provided is based on the NHS’s interpretation of patient’s clinical need – not that of the private specialist, or the patient themselves.
Equity: NHS GPs should treat all patients equitably – regardless of whether they chose to go private or exclusively NHS care. In practice, this means a GP should not do for a patient seeking to go private that which they would not do for a patient receiving exclusively NHS care. This includes (but not limited to) communication with specialists, decisions on referrals, pre-referral tests, prescribing, shared care, and follow-ups. Patients who pay for private care should not be put at any advantage or disadvantage in relation to the NHS care they receive.
Principle of separation: The NHS should not ‘prop up’ private care. Where a patient chooses to go private, they should anticipate that they will receive the full episode of care from that private provider, and have to pay for those episodes of care in their entirety.

Relevant national guidance and codes of conduct

This guidance draws upon four key documents which lay out the principles for managing the interface between the NHS and private care:

Department of Health (2009). Guidance on NHS Patients who wish to pay for additional private care.
Department of Health (2004): A Code of Conduct for Private Practice.
Thames Valley Priorities Committee Commissioning Policy Statement (2019): Managing the boundaries of NHS and privately funded healthcare. Policy No. 67d (TVPC 35).
BMA Medical Ethics Department (2009). The interface between NHS and private treatment: a practical guide for doctors in England, Wales and Northern Ireland Guidance.

Referrals

A GP shall do a referral for a patient where the patient is entitled to it and the treatment is considered clinically necessary. This is normally an NHS referral, but the GP should agree to a private referral as an alternative if the patient reasonably requests it. If the GP does not consider the referral to be clinically necessary, then there is no obligation to refer; the patient may then seek treatment without a referral. The GP is still be expected to provide clinically relevant information on valid request, making the patient’s interests and safety their chief concern.
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. 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 GP should not charge for doing a private referral, or charge for communication with a private specialist to coordinate their mutual patient’s care.
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
Whilst there is a lack of clarity in national guidance as to whether a patient can seek both a private and an NHS referral simultaneously for the same condition, the general principles indicate that dual referral should not occur: the GP would be writing two referrals rather than one (which is outside of usual practice and creates avoidable inefficiencies of time), and it runs the risk of patients being unnecessarily subject to two sets of investigations and interventions (which contravenes GMC guidance around unnecessary interventions).

NHS GP investigations for private providers

For a patient wishing to seek appropriate referral to a private provider, a GP should offer to do relevant pre-referral ‘work-up’ investigations that they would normally do as per their usual practice (for example, an ultrasound pelvis prior to a gynae referral).
The private provider should not request that a GP arrange investigations on their behalf and those should be declined by the GP (except where that is within the GP's local agreed practice over the interface with NHS providers). The patient should expect to pay for those to be arranged by the private provider.
Where a patient has arranged and received investigations on a private basis, the responsibility for interpreting those investigations for the patient lies with the requester. However, the GP must make the patient their chief concern, and this sometimes requires responding to those results where there is an risk of harm to the patient from not doing so. This does not absolve the private provider of their responsibilities and the GP might reaosnably hand the task back to the private provider where safe to do so.
Where a patient has arranged and received investigations on a private basis, these investigation results should be used for NHS care where appropriate, so that the patient is not exposed to unnecessary duplicate investigations.

Treatments from private care

Where a patient has sought private care, they should be expected to pay for the entire episode of care, and this includes treatments.
The private provider should inform the GP of any treatments they are providing the patient.
A private provider may ask the patient’s NHS GP to provide or prescribe treatments that are within that GP’s normal practice for their NHS patients (for example, initiation or continuation of a recommended medication). However, the request must be consistent with the local NHS formulary guidance within which the GP works. Requests outside of that local formulary guidance should be declined and the patient should expect to pay for those privately.

The Berkshire West Formulary can be found here: http://www.westberksformulary.nhs.uk/

The Berkshire East & Frimley Formulary can be found here: http://www.frimleyhealthformulary.nhs.uk/

The Buckinghamshire Formulary can be found here: http://www.bucksformulary.nhs.uk/

The Milton Keynes Formulary can be found here: https://formularymk.nhs.uk/

The Oxfordshire Formulary can be found here: http://www.oxfordshireformulary.nhs.uk/

Where the private provider has recommended or initiated treatment for a patient that would normally be under a shared care protocol and has asked the GP to continue that treatment, the private provider should offer to adhere to a shared care protocol equivalent in content to that within the GP’s local formulary; the private provider’s on-going input to shared care is at cost to the patient. If this is declined by the private provider or the patient, the GP may decline to take on the prescribing and the patient may either opt to receive all prescriptions on a private basis from the private provider, or the provider should offer to refer the patient directly into NHS services for shared care.

Re-joining the NHS from the private sector

The patient has a right to re-join NHS care for which they are eligible for at any time when receiving care in the private sector.
Where a patient has sought care through a private provider and wishes to transfer their care into the NHS, the patient should join the NHS system in the same place they left the private sector. For example, if the private provider considered that the patient required follow-up and the patient wished to have this on the NHS, the private provider should refer that person into the relevant service for that follow-up (which may include the private provider’s own NHS clinic). Alternatively, if the private provider considered that onward referral for another specialist opinion was required and the patient requested this on the NHS, the private provider should make the referral into the required NHS service (or to the private specialist, if this is the patient’s request).
The private provider should do a direct referral into the relevant NHS service (for example, a ‘consultant-to-consultant referral’) and not expect the GP to do this. This is to ensure that the patient is not put ‘at the back of the queue’ by a GP referral (which would disadvantage them), is concordant with their clinical responsibilities for the patient, and is consistent with NHS practice to which NHS doctors – including GPs – are expected to adhere to.
NHS providers should have mechanism to accept appropriate referrals across the private NHS interface, without asking the GP to provide this.

Paying for private care

When entering into an episode of private care, the private provider should inform the patient of all reasonably anticipated costs for the entirety of that episode of care, including consultation, tests, treatment, and aftercare.
An NHS GP should not charge their patient for any care they provide, including where that involves coordinating care with a private provider. The GP will continue to be obliged to provide their usual care, as for all NHS patients, to meet their reasonable needs, without charge.
Where a patient chooses to seek private care, the patient should expect to pay for the full cost of that episode of care. This includes the consultation with the private provider, any tests or interventions deemed necessary by the private provider, any medicines prescribed, and any additional costs associated with that private element of care (such as additional treatment needed to manage side-effects).
The private provider should normally deal with emergency and non-emergency complications resulting from the private element of care. However, the NHS should never refuse to treat patients simply because the cause of the complication is unclear. The NHS should continue to treat any patient in an emergency, regardless of whether or not it was as a complication of private care.
The NHS commissioners cannot accept requests for reimbursement (retrospective funding) of any drugs prescribed or treatments received whilst in private practice.