Times are changing and the more politicians seem to misunderstand general practice, the more damage is done to the goodwill which maintains the commitment to the NHS. Older GPs are seeking to retire earlier, younger GPs are looking to work overseas and the patients are not getting the service, the access, or the time they want with their GP
Some GPs think that undertaking more private work could be the answer. So can working outside of the NHS bring much-needed funding into general practice and provide GPs with more control over their workload?
What is private work?
It is not always clear what is meant by private work in general practice, but the rules are set out in Regulation 24 of the the National Health Service (General Medical Services Contracts) Regulations 2004.
These state that ‘the contractor shall not, either itself or through any other person, demand or accept from any patient of its a fee or other remuneration, for its own or another’s benefit, for –
(a) the provision of any treatment whether under the contract or otherwise; or
(b) any prescription or repeatable prescription for any drug, medicine or appliance, except in the circumstances set out in Schedule 5.’
The BMA clarify the point in its Focus on Private Practice which says: ‘For instance, GPs cannot charge a patient in their practice for seeing them out-of-hours even though the patient may have requested it and may be happy to pay for it. If the patient is a registered patient they cannot be charged.’
The ban on charging patients of the contractor is absolute, even if the service requested by the patient is not available in the NHS. There are limited exceptions listed in schedule 5 – for example travel vaccinations which are not remunerated on the NHS, or writing medical reports for schools, employers etc.
These rules do not mean that practices cannot undertake private work for patients not on their list. According to the BMA’s Contract Guidelines for GPs neither GMS or PMS contracts preclude accepting private practice ‘but they cannot simultaneously be NHS registered patients with the practice holding the GMS or PMS contract’.
What about setting up a separate company to do private work?
However, there are some interesting questions to consider. Can GPs provide private services to their patient through a separate legal entity such as a limited company? Recent media reports suggest that some LMCs are looking into this option as a way of enabling practices to increase their income.
If the GP is working for a separate entity, this would seem to be a way to allow a patient of the NHS practice to see the same GP privately (even if they were a partner).
The BMA has taken legal advice on this point and the advice hinges on the nature and definition of the contractor.
For GMS, a contactor is either a single-handed GP, or a partnership or a company limited by shares. Since the regulations are intended to prevent these GPs from charging patients privately, if the GP set up an entity different from that which holds the contract, they could arguably charge those private patients.
The advice concludes by suggesting that GPs inform their area team director if they intend to provide private services to patients via another entity.
Importantly, the same does not apply to PMS GPs. Since PMS GPs contract with individual GPs rather than entities, it is more difficult to differentiate the entity providing the private service.
What happens if you want to treat patients not on the practice list privately?
There is no restriction on a GP contractor providing private services to patients who are not on their NHS list of patients, but there is a limit as to what is acceptable. This is because the NHS is reimbursing the practice for the provision of its premises through the Rent and Rates Reimbursement scheme.
The acceptable limit was explicitly stated in the 2004 GMS Premises Directions, which contained a table showing how the rent and rates reimbursements would be reduced if the practice had private income exceeding up to 10% of total income.
These have been replaced by the 2013 GMS Premises Directions, which surprisingly do not have the same abatements explicitly stated, but the DH has stipulated separately that any practice found to be doing particularly high levels of private work will still find their reimbursement reduced.
This needs to be factored in when considering whether the practice wants to undertake more private work. If the practice is located in an area where property values and rents are high, the need to secure these reimbursements is vital. However, if the practice is receiving a low level of reimbursements due to local costs, it may be worth sacrificing some of this for the extra income that can be earned undertaking private work.
This is one area where it is worth seeking specialist advice before significantly increasing the proportion of your earnings from private work.
How does the NHS know what private income is being earned?
The annual superannuation certificates state the amount of NHS income and non-NHS income and this can be used as a basis for working out the percentage for abatement. But bear in mind that the reduction for the rent and rates should only apply where the premises is being used to generate the income.
Our firm was involved in a case in which a GP with a GMS contract was earning more than 10% of his total income from medico-legal work. NHS England noted this from his superannuation certificate and demanded an abatement to the rent and rates reimbursements.
The counter-argument was that half of the work was undertaken in the surgery and half at the GP’s home writing the reports. On that basis, only half the income should be considered in determining the private income percentage, and since this was less than 10% of total income, no abatement was necessary. This argument was accepted.
How would private practice integrate in an NHS practice?
While GP contractors cannot charge their own patient list, they can charge patients of other GP practices if they provide private services to them. Given the problems that patients have with access, paying to see a GP at a convenient time, and to have more than the usual 10-minute appointment is becoming more common.
Some practices successfully run a private service alongside their NHS contract and take on private fee-paying patients, although there are obviously many organisational and practical issues you will need to consider with regards to how this works.
Meanwhile, services such as Doctaly aim to put patients with an acute condition who are willing to pay in touch with a GP - with the restriction that the patient cannot be on that GP’s NHS list.
There are also specific services that your practice may want to provide and which you could advertise to patients outside of your list, for example aesthetics or minor surgery. However, you would not be able to provide these services to any patient on your list, unless you had set this business up as a separate company (see above).
The BMA Medical Ethics Department states that if a GP sees a patient privately, they can provide that patient with an NHS referral just as well as a private referral.
The DH has confirmed 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 a diagnostic test should not be any different from an NHS GP referral’.
However, GPs cannot issue NHS prescriptions to private patients. GPs can charge private patients for private prescriptions and they can also charge NHS patients for private prescriptions for providing drugs or medicines in relation to overseas travel or for malaria chemoprophylaxis (see schedule 5).
If you are thinking about developing private practice it is advisable to get proper advice in advance.
- Laurence Slavin is a partner with Chartered Accountants Ramsay Brown and Partners, specialists in advising GPs and their practices