Interface between NHS and private treatment
Guidance from the Ethics Department
February 2004
Issues for general practitioners
Can general practitioners raise the issue of private practice with NHS patients?
General practitioners have an important role as their patients’ advocate and ensuring that patients have all necessary information about the treatment options open to them. This may include asking patients whether they wish to be referred within the NHS or privately and, if they request a private referral whether they have private medical insurance. This needs to be handled carefully to ensure the patient does not feel pressured to opt for private treatment.
Are NHS general practitioners obliged to issue a private referral at the patient’s request?
Whether there is any obligation on a NHS general practitioner to issue a referral letter for a particular patient will depend on whether, in the view of the GP, the referral is clinically necessary. If specialist assessment or treatment is needed, the GP is obliged to refer the patient and, if the patient wishes to seek the treatment privately, a private referral should be made. The General Medical Council (GMC) states that “when you refer a patient, you should provide all relevant information about the patient’s history and current condition”.[Go to reference 10] Referrals are usually made to a named consultant and some GPs have concerns about referring to a consultant they do not know, either at the request of the patient, or because the patient’s medical insurance company has its own list of consultants. Such concerns should be explained to the patient. 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, although the BMA believes this to be best practice in most cases.
All specialists are advised by the GMC that “if you provide treatment or advice for a patient, but are not the patient’s general practitioner, you should tell the general practitioner the results of the investigations, the treatment provided and any other information necessary for the continuing care of the patient, unless the patient objects. … If you do not tell the patient’s general practitioner, before or after providing treatment, you will be responsible for providing or arranging all necessary care until another doctor agrees to take over.”[Go to reference 11]
Are NHS general practitioners obliged to provide patient information to private practitioners?
When patients self-refer to private practitioners, this is frequently followed by a request to the general practitioner for any information that might be relevant to the treatment in question. The exchange of information between those providing care for a patient, including liaison between NHS and private practitioners, is important. The GPs’ primary concern should be for the interests and safety of their patients, with due regard to confidentiality. This requires good communication between colleagues, with the patient’s consent, so that medical information can be exchanged on the basis of a clear “need to know” in connection with the care of the patient. This is in line with the GMC’s guidance, which states that doctors must “keep colleagues well informed when sharing the care of patients”.[Go to reference 12] NHS general practitioners should therefore provide relevant information on request about the patient’s medical history or current condition to other doctors providing care, including doctors working in the private sector. If the GP is aware that treatment is being sought privately and has information that might affect the safety or outcome of the treatment, this should be shared, with the patient’s consent. Failure to provide relevant information in this way could result in a complaint against the GP – either to the GMC or through the courts – if the patient is harmed as a result.
Can NHS general practitioners charge their patients for referral or information?
General practitioners 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.
Are NHS general practitioners obliged to complete medical insurance claim forms for their patients?
There is no obligation on NHS general practitioners to complete medical insurance claim forms and, if they decide to do so, they may charge the patient. In most cases the doctor who has provided the treatment is in a better position to provide the information needed.
Should general practitioners issue NHS prescriptions for medication recommended during a private consultation with a consultant?
When patients seek specialist treatment privately, the private consultant may prescribe any necessary medication. Often, however, consultants recommend a particular medication and patients ask their GP to issue a NHS prescription rather than paying for it privately. Even though individuals opt for private treatment or assessment, they are still entitled to NHS services. If the GP considers that the medication recommended is clinically necessary, he or she would be required under the NHS terms of service to prescribe that medication within the NHS, even if the assessment from which the need was identified was undertaken in the private sector. The exception to this would be if the medication is specialised in nature and is not something general practitioners would generally prescribe. In these cases, it is for the individual GP to decide whether to accept clinical responsibility for the prescribing decision recommended by another doctor. (The same principles apply to requests to undertake diagnostic tests or other procedures within the NHS.) The issues raised are the same as those where a NHS consultant asks a GP to prescribe, and the existing procedures for shared care should be followed.[Go to reference 13] In all cases there should be proper communication between the consultant and the general practitioner about the diagnosis or other reason for the proposed plan of management, including any proposed medication.
The obligation to prescribe does not arise if the medication recommended is not clinically necessary or if the medication is generally not provided within the NHS. A common enquiry to the BMA concerns fertility treatment, where patients seek IVF in the private sector and ask their GP to issue NHS prescriptions for the drugs. The decision about whether to comply with such requests in these cases, rests with the individual GP or commissioning body. In the past, these requests have caused some concern amongst GPs who felt they were being placed in the invidious position of either appearing unsupportive of their patients or accepting legal, financial and ethical responsibility for a course of medication which they had not initiated and which, in some cases, they may not consider to be clinically necessary. Where the product is of a very specialised nature, requiring ongoing monitoring, some GPs may feel they have insufficient expertise to accept responsibility for the prescription and so refuse such requests. Others initiate discussions with the relevant consultants to reach a position with which all parties are content. Other examples concern medications recommended by private consultants that are more expensive, but without good evidence that they are more effective, than those locally prescribed for the same condition within the NHS. In such circumstances, local prescribing advice from the Primary Care Trust may be followed by the NHS GP. This advice should be explained to the patient who will retain the option of purchasing the more expensive drug via the private consultant.
Many of the problems and concerns that arise in relation to prescribing shared between the private sector and the NHS could be avoided by improved communication between the parties concerned. In many cases patients are simply informed that their GP will prescribe the recommended medication rather than being advised to ask their GP or, more appropriately by the consultant communicating directly with the GP as in NHS referrals. This is not simply a matter of etiquette. If the GP does not feel able to accept clinical responsibility or, in the case of medication that is not clinically necessary, financial responsibility for the recommended medication, this could cause difficulties for the doctor–patient relationship. Those requesting GPs to take over prescribing should be sensitive to these points when discussing the matter with patients.
Can NHS general practitioners offer specialist treatments on a private basis?
Increasing numbers of general practitioners are able to provide specialist treatments, such as complementary therapies or minor surgery, in addition to their general practice. These treatments may be offered to private patients and advertised in the usual way (see below) but general practitioners may not charge patients of their NHS practice for these services.
What should general practitioners do if they believe a consultant is inappropriately directing patients towards private practice?
As with any suspicion of inappropriate behaviour, if a GP suspects that a consultant is using NHS time and patient lists to promote his or her private practice, or may be putting pressure on patients to switch to private treatment, he or she should first seek to establish the facts. This might involve seeking information from the patients involved about the way in which the option of private treatment was raised with them as well as discussing any worries either with other partners in the GP practice or other GPs in the locality and/or directly with the consultant concerned. If these steps do not resolve the suspicion the GP may need to invoke the established local procedures to investigate the concerns. Advice can be sought from BMA regional offices or from the medical defence organisations about how to take such matters forward.
Can patients seek private treatment abroad and claim the cost from the NHS?
Following a high profile case before the courts,[Go to reference 14] considerable media attention has been given to the possibility of patients seeking private treatment overseas and recouping the cost from the NHS. It is likely that this publicity will lead to an increase in the number of such enquiries to NHS doctors.
In October 2003 the High Court confirmed that where treatment cannot be provided “without undue delay” in the United Kingdom, patients have the right, under European Community law, to seek treatment in another member state and receive reimbursement of the cost from the NHS.[Go to reference 15] The court confirmed that “undue delay” does not mean the same as being outside the Government’s waiting list targets and, although relevant, waiting time targets are not determinative. In assessing what amounts to “undue delay” the Department of Health is required to have regard to all the circumstances of each specific case including the patient’s medical condition and, where appropriate, the degree of pain and the nature and extent of the patient’s disabilities.[Go to reference 16] In the particular case under consideration, Mr Justice Munby held that an “undue delay” was “very much less than [a] year” but “a period significantly (though probably not substantially) greater” than two to three months.[Go to reference 17] The government has been given permission to appeal against this judgment.
Doctors who are approached by patients who wish to seek treatment in another country, on the basis of “undue delay” in the UK, should advise them that they need to receive prior approval from the Department of Health by making an application using form E112. The form must be accompanied by an opinion from a NHS consultant in the UK and the local commissioning body. Patients considering such an application should be referred to the information available from the Department of Health.[Go to reference 18]
Can private general practitioners refer patients for NHS diagnostic services and treatment?
Provided patients are entitled to NHS treatment they may opt into or out of NHS care at any stage. Private general practitioners are entitled to make referrals to NHS facilities,[Go to reference 19] if that is the patient’s wish, and the referral should be treated in the same way as if the referral came from within the NHS. Patients’ need should be assessed to determine his or her place on the waiting list.