Requests for prescribing and follow up after private care or from a private provider
We are aware that practices are getting requests to prescribe or provide care following a patient receiving private health care. This is a very grey and complicated area. We have tried to pull together information from the many pieces of guidance to answer the main queries that have been received in recent months.
Below we have initially provided a very simplified flow diagram of the main scenarios.
This is by its very nature over simplified and there are a number of scenarios when services/prescriptions can or should be provided by the GP which this does not cover, and as such if you have a specific issue please first check our FAQ’s below. If these do still not answer your query then please contact us [email protected].
As additional questions come into Enquiries we will update the FAQ’s to include the responses provided.
Questions covered below are:-
- A patient has had surgery, or a procedure, carried out privately in the UK and have we have been asked to carry out a test, monitoring, or provide an acute medication. Do we have to do so?
- A patient has had surgery, or a procedure, carried out privately abroad and we have been asked to carry out a test, monitoring, or provide an acute medication. Do we have to do so?
- What happens if the patient doesn’t arrange follow-up care after having a procedure abroad?
- A patient is seeing a private healthcare provider for ongoing treatment and we have received a request to prescribe a repeat item. Do we have to do this?
- Does there need to be a shared care agreement in place to prescribe on the recommendation of a private consultant?
- Bariatric Surgery: A patient has not purchased follow-up care after having bariatric surgery privately (either abroad or in the UK) and are insisting on the NHS providing follow-up care. What should we do?
- Gender Incongruence: A patient seeing a private provider and they are requesting the GP practice to do the prescribing, or monitoring and testing. Do we have to do this?
- Fertility treatment: A patient is having fertility treatment privately and is requesting tests or medication on the NHS. Do we need to do this?
- Can a patient have care both privately and through the NHS?
- A patient started care privately but wishes to transfer to the NHS. Can they do so?
- A patient has an emergency complication following private care can they seek treatment on the NHS?
- A patient develops a non-emergency complication following a private procedure can they seek treatment on the NHS?
- Can the practice charge the patient for a private referral?
- Are NHS GP’s obliged to provide patient information to private practitioners?
- Who is clinically responsible for the prescribing?
- Do we need ICB Medicines Optimisation approval before prescribing medication on request of a private provider?
No, not in most circumstances
When a patient chooses to have a procedure done privately, they are required to purchase the full episode of care from the private provider. All pre-op assessments, post-op care, medications and follow-up appointments should be included in the episode of care. Short term (acute) medication as part of pre-op or after care should also form part of the package of care.
If you are referring patients to a private provider, it is advisable to ensure they are aware of this at the point of referral. Patients should be advised to understand what is included in any care they are receiving privately so that they don’t request on the NHS something covered within their private package.
Regarding requests from the private provider to carry out tests, or provide prescriptions, the BMA guidance states ‘The NHS General Medical Services Regulations which govern the contract between the NHS and GPs, 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 and would require them in the ordinary course of treating their patient and is competent to both interpret them and manage the care of the patient accordingly, then the clinician may proceed with arranging the investigations for the patient as per the provision of NHS primary medical services.’
It goes on to state ‘…and where the treatment is not being delivered in a manner determined by the GP in discussion with the patient, NHS GPs should not arrange investigations that are requested by private providers.’
As such in most circumstances you are not obliged to carry out any tests requested by a private healthcare provider, or prescribe any acute medication. However, if you are already carrying out routine tests then it is reasonable to provide the results to the private provider to avoid the same tests being run twice.
Any tests carried out by the GP practice, or medications prescribed, would need to be provided to the patient on the NHS, free of charge (see FAQ’s on Providing private services). As such they need to be tests/medication which are ordinarily available on the NHS and the patient needs to meet any criteria set for them.
If a patient does not wish to have the full episode of care privately, in discussion with the patient, they can be referred back to be seen under the NHS (if the procedure required is available under the NHS).
No, not in most circumstances
The guidance for patients receiving private treatment abroad is very similar to that for private treatment within the UK; the patient must purchase the full episode of care privately, this should include any pre and post-operative care, any medications and any follow-up.
If the patient is having the surgery abroad this may mean either going back for any follow-up appointments or purchasing this from another private provider in the UK.
Given the patient may not wish to return to the country that the surgery was performed in for the follow-up care it is for the patient to arrange with a local private provider for this to be provided and have them liaise with their surgeon where necessary.
If the patient doesn’t do this then there needs to be a discussion with the Commissioner regarding moving care back to NHS. This will depend on if the treatment would have been available on the NHS.
If the treatment is available on the NHS and the patient would have met the criteria then the process to refer back to NHS care should be straight forward, although the patient may need to go on a waiting list.
If the treatment is not available to the patient on the NHS, either because they do not meet the criteria, or it is not a treatment available on the NHS then IFR application is likely to be required.
In the meantime, any emergency complications would be treated on the NHS.
Yes, if it is an item usually available on the NHS for the indication it is being prescribe for and the patient meets the criteria then yes it would normally be expected that you would prescribe the item.
Even though individuals opt for private treatment or assessment, they are still entitled to NHS services.
However, there are nuances.
The ability to do this will depend on the medication being requested.
In general patients electing to see a private specialist should do so on the expectation that all recommended tests, procedures and prescribed medicines will be provided privately.
If the medication is specialised in nature and is not something GPs would generally prescribe, it is for the individual GP to decide whether to accept clinical responsiblity for the prescribing decision recommended by another doctors.
In the absence of a shared care agreement between the specialist provider and the practice there is no expectation that the GP will take on the prescribing for a private provider.
[In N&W the shared care agreements have not generally been agreed with private providers. However, if the drug being prescribed is one included in the LCS appendix then claims can be submitted (but a separate shared care agreement will need to be agreed between the GP Practice and the private provider detailing the areas of responsiblity for each party)]
If a GP receives a request they are under no obligation to convert these prescriptions to NHS scripts, and they should always bear in mind that they are clinically responsible for any prescriptions they sign. As such if the GP is at all uncomfortable with the regime being prescribed, or unclear about the clinical indication for it, then they should inform the private clinician that they are not happy to prescribe.
GMC guidance states: “Prescribing at the recommendation of a professional colleague -If you prescribe at the recommendation of another doctor, nurse or other healthcare professional, you must satisfy yourself that the prescription is needed, appropriate for the patient and within the limits of your competence……
If you are uncertain about your competence to take responsibility for the patient’s continuing care, you should seek further information or advice from the clinician with whom the patient’s care is shared or from another experienced colleague. If you are still not satisfied, you should explain this to the other clinician and to the patient, and make appropriate arrangements for their continuing care.”
Patients are at liberty to switch between private and NHS care at any time, but in general shouldn’t mix different parts of the same treatment between NHS and private care (private and NHS care should be able to remain distinctly separate episodes of care).
Patients are also able to supplement NHS care with additional care provided privately (see below).
They should only be provided with an NHS prescription if the medication would have been provided on the NHS had they had an NHS referral. You need to ensure that the medication is:-
- able to be prescribed on the NHS,
- is one which is authorised for prescribing in primary care (see TAG & N&W formulary ),
- is covered in the BNF for the indications it is being prescribed and
- is in line with ICB medicines management guidelines.
If you do not feel able to provide the prescription on the NHS then you should advise the private consultant of this. Responsibility for prescribing then remains with the private consultant.
(The GP practice cannot prescribe the medication privately; this must be done by their private provider.)
In some circumstances you may suggest to the patient that they are referred to the equivalent NHS service before prescribing, or you can get Advice and Guidance from an NHS team to establish the appropriate medication regime.
In summary
A patient, whose private consultant has recommended treatment with a medication normally available as part of NHS commissioned care in the patient’s clinical circumstances, eg. where they are likely to have been prescribed the same medication had they had an NHS referral for the same condition, can ask his or her NHS GP to prescribe the treatment as long as:
- The GP considers it to be medically appropriate in the exercise of the GP’s clinical discretion.
- The drug is listed green on TAG /or in the N&W Formulary as a primary care drug and the drug is normally funded by the ICB. (if unsure check formulary and if still unclear check with [email protected])
- The GP is willing to accept clinical responsibility for prescribing the medication and is competent and comfortable with the medication being prescribed
- There is clear and appropriate process in place for any ongoing monitoring requirements.
Or where the private provider is working under an NHS contract and is providing NHS care.
(also see below for Gender Incongruence)
It depends on the medication requested
Yes - if the medication is specialised in nature and is not something GPs would generally prescribe &/or if there would be if it was recommended by an NHS Trust.
No - if the medication is one normally initiated, prescribed and monitored in primary care (Green on TAG or suitable for primary care in the N&W Formulary).
The same principles for shared care apply as for NHS requests. If the medication is not one normally prescribed in primary care (and/or is listed as Amber on TAG) then a shared care agreement would be required depending on the indication.
The ICB shared care agreements are agreed with the main NHS Trusts in the ICS. They are not agreed with private providers.
A shared care agreement is an agreement between the specialist provider, the prescriber (GP) and the patient. The provider requesting the shared care would normally offer the initial terms of the shared care between the parties and the GP can accept them as initially presented, negotiate until they are happy with them, or not accept them if they are not able to reach a mutual agreement.
It is the responsibility of the parties involved to agree the shared care agreement, not the ICB's. The ICB facilitates the agreement of the shared care agreements with the NHS trusts through TAG but it is the providers who actually agree them, with GP's being represented by GP representatives on the TAG committee.
Shared care agreements should generally be in line with the guidelines set out in Annex 1 of the NHSE guidance Responsibility for prescribing between Primary & Secondary/Tertiary Care
Specific Specialty Scenarios
Complete an Individual Funding Request form
Specialist follow-up care for bariatric surgery would normally be for two years. If a patient has private bariatric surgery and does not purchase all of their follow-up care privately then they will need to be referred into the NHS (this is further complicated if they would not have met the criteria to have the surgery on the NHS).
An IFR (Individual Funding request) should be made for follow-up care following private surgery.
(See IFR info page)
Also see Bariatric surgery threshold policy
& CCG Guidance for Complex Obesity p13
Yes, in most scenarios.
Prescribing for gender incongruence is slightly different from other prescribing requested by private providers and broadly speaking a practice would need to do the work.
Please note the recent legislation regarding prescribing to under 18's.
NHSE guidance and the Legislation
From 26th June 2024 no new under 18's should start on GnRH treatment.
From NHSE guidance
“GPs must cooperate with Gender Identity Clinics and other gender specialists by prescribing medications, providing follow up and making referrals as recommended by those specialists
It may be appropriate for a GP to issue a prescription where an individual is already self-prescribing via an unregulated source, and where the prescription is intended to mitigate a risk of self-harm and is supported by appropriate specialist advice”
‘GPs are therefore advised to consider each request on a case-by-case basis to satisfy themselves that:
- the request is from a reputable company that provides a safe and effective service; and
- the circumstances of the request for the particular individual meets the general principles of the General Medical Council’s “Good Practice in Prescribing and Managing Medicines and Devices”; and
- that the health professional making the request is an appropriate “gender specialist”.’
Exceptions are where:
- The GP is not sufficiently confident to prescribe unfamiliar meds.
- If ‘the GP is not assured that the provider offers a safe service or is not assured that the request has been made by an appropriate gender specialist.’ (this would include the provider not being willing to provide the details of who the clinician is, see guidance page 3 for more details) Even here though there’s a caveat that the GP could only decline on those grounds ‘as long as the GP is also satisfied that declining responsibility would not pose a significant clinical risk to the individual’.
BMA Guidance on gender incongruence.
Responsibilities regarding prescribing hormone treatments for transgender people (this is only 6 pages and worth reading.)
(Unfortunately, there is not currently a list of safe/approved providers for GP’s to refer to. We have raised this as a need with GPC)
Yes, if they are eligible for NHS treatment
No, if they are not eligible for NHS treatment.
Patients have to meet the NHS criteria for fertility treatment for any tests or medication required as part of this fertility treatment to be provided on the NHS.
Yes
Patients can choose to be referred to both private and NHS for the same condition.
NHS organisations should not withdraw NHS care simply because a patient chooses to buy additional private care.
The NHS should continue to provide free of charge all care that the patient would have been entitled to had he or she not chosen to have additional private care.
When a patient chooses to pay privately for additional treatment not usually funded by the ICB, the patient will be required to pay all costs associated with the privately funded episode of care, including accommodation, assessments, inpatient and outpatient attendances, tests, monitoring, medical interventions, management of side-effects and rehabilitation.
The ICB will not make any contribution to the privately funded care to cover treatment that the patient could have accessed via NHS commissioned care.
However, the patient remains entitled to revert to NHS care at any stage and will, at that point, be entitled to be provided with any drugs or other treatment which would have been provided to an NHS patient in the same clinical situation.
Yes
An individual who is having treatment which would have been commissioned by the ICB is entitled to commence that treatment on a private basis but can at any stage request to transfer to complete the treatment in the NHS.
In this event the patient is entitled, as far as possible, to be provided with the same treatment as the patient would have received if the patient had had NHS treatment throughout. This cannot be used as a justification to provide care that is not available to other NHS patients and may mean the patient having to wait for the continuation of treatment, to put that patient in the same position as any other NHS patient.
An individual, who has chosen to pay privately for an element of their care such as a diagnostic test, is entitled to access other elements of care through the NHS, provided the patient meets NHS commissioning criteria for that treatment.
Yes
If the cause of the complication is unclear, or is an emergency, the NHS will treat the patient and in this situation, the patient will not be expected to pay for the treatment.
No
If a patient develops a non-emergency complication as a result of a private procedure/intervention, the private healthcare provider will normally treat these; the patient will be expected to meet these costs which would not be funded.
If they are unable or unwilling to an IFR will be required.
No
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.
Yes
Good communication between colleagues, with the patient's consent, is required 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 'sharing information with other healthcare professionals is important for safe and effective patient care'.
NHS GP's should 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.
The person signing the prescription
Clinical responsibility for prescribing is held by the person signing the prescription, who must also ensure adequate monitoring.
No
Not if the medication is within prescribing guidelines and in the N&W Formulary. If you are in doubt then check with the medicines optimisation team. TAG/N&W Formulary
Email: [email protected]
Definitions
Episode of care = an episode of care is difficult to define as it is different depending on the treatment being provided. In general it is something which can be provided as distinctly separate of other care, and can be done at a separate time and in a separate location. For example:
- an operation (with pre and post-op care included).
- One treatment
- An appointment
- A series of diagnostic tests
- A day case operation with all the supporting clinical activity before and after the operation on that day.
- The initial assessment and prescription of a cancer drug. If the drug is required to be given at a series of outpatient appointments, then each attendance will be a separate episode of care.
A patient is not entitled to “pick and mix” elements of NHS and private care within the same treatment, and so is unable to have privately funded and NHS funded treatment provided as part of the same episode of care. For example, a patient undergoing a cataract operation as an NHS patient cannot choose to pay an additional private fee to have a multifocal lens inserted during his or her NHS surgery instead of the standard single focus lens inserted as part of NHS commissioned surgery.
Helpful Guidance
- BMA Guidance Private Provider requests for investigations under the NHS. This includes a template push back letter to the private provider.
- BMA guidance on Private Practice and GP contracts
- GMC recommendations about shared care prescribing (not specific to private care)
- GMC Good practice in prescribing and managing medicines and devices
- Guidance on NHS patients who wish to pay for additional private care
- NHSE Patient information on private treatment
- Responsibility for prescribing between Primary & Secondary/Tertiary care NHSE guidance. The principles of this also apply to working with private providers.
- Defining the boundaries between NHS and Private Healthcare
- Shared Care Protocols NHSE (Local SCA’s are being reviewed to bring them inline with the national SCP’s and this will happen over time)
- Specialist Pharmacy Service Shared Care for Medicines Guidance [Regional Medicines Optimisation Committee (RMOC)]