GP training: What to do when a patient wants a private referral

MDU medico-legal adviser Dr Ellie Mein answers some common questions GPs have about private referrals.

GP in a patient consultation
(Photo: sturti/Getty Images)

While the NHS is still delivering a significant amount of elective treatment, inevitably the strain of treating huge numbers of patients during the pandemic has impacted waiting times.

Due to the expanding waiting list, an increasing number of patients are opting to pay for private care. The interface between NHS and private care can be difficult to navigate for both patients and doctors.

It’s important to send patients down the right pathway to ensure efficient access to the right specialist and to avoid complaints. Below we answer frequently asked questions about referring patients to independent practitioners which are raised by MDU members.

Can I decline to make a referral to an independent practitioner if I don’t think it’s appropriate?

While many independent specialists will see patients without a GP referral, others may request a letter from you setting out relevant health information about the patient. Sometimes this is necessary to enable the patient to access care via private medical insurance.

Patients will sometimes wrongly assume that if they are paying for private healthcare then the GP is duty bound to refer them. However you do not have to refer patients to a specialist, for either NHS or private care, if you do not think that the assessment or treatment requested is clinically necessary.

In this situation it can be helpful to direct the patient to the relevant NHS patient information page. Advise them that the reason a referral is not being made is because it is not clinically indicated and offer them the option of a second opinion from another GP.

Can I charge for private referral letters?

In some circumstances you can charge patients for a private referral. The rules vary however and it’s best to check this contractual query with your LMC, CCG or the BMA.

Should I prescribe medications recommended by an independent practitioner?

You are not obliged to prescribe medication at the request of an independent practitioner or provider if you do not feel it is clinically appropriate.

The GMC’s Good practice in prescribing and managing medicines and devices states: 'If you prescribe based on the recommendation of another doctor, nurse or other healthcare professional, you must be satisfied that the prescription is needed, appropriate for the patient and within the limits of your competence.'

When considering whether to prescribe the medication being recommended ask yourself:

  • Would I be happy to prescribe and monitor the medication without specialist oversight?
  • Am I happy that the specialist recommending it is appropriately qualified?
  • Would I prescribe the medication had the same treatment been recommended by a colleague working for the NHS?  

If the answer to these questions is yes then you may be happy to write the prescription. Alternatively, if you do not feel comfortable prescribing the recommended drug because doing so is outside of your knowledge and expertise, explain this to the patient. Recommend that the specialist retains responsibility for prescribing as the medication is not suitable to be managed in primary care.

Can I enter into a shared care agreement with an independent practitioner?

It is best to check your CCG policy as some will not allow you to enter into shared care agreements with private providers. One reason for this is to keep as clear a separation as possible between private and NHS care. Another is because the specialist may not be able to continue with the shared care arrangement if the patient doesn’t continue to see them in a private capacity.

NHS England guidance contains useful information on shared care agreements within the NHS and the principles involved. This makes clear shared care agreements are to enable patients to receive integrated care and seamless prescribing and monitoring of medicines with clinical responsibility for this transferred from a hospital or specialist service to general practice.

It also states that when proposing shared care agreements, ‘a specialist should advise which medicines to prescribe, what monitoring will need to take place in primary care, how often medicines should be reviewed, and what actions should be taken in the event of difficulties’.

If you are unable to enter into a shared care agreement, explain this to the patient and specialist and see if a resolution can be found, for example, can the specialist issue the prescriptions or can care be transferred to an appropriate NHS specialist. The Medicines Optimisation Team may be able to advise further.

What about patients who feel they should have opted for NHS treatment?

Patients will occasionally complain that the waiting time for NHS treatment was overstated, leading to them paying for a private referral. Patients in this situation may ask for the fee to be reimbursed as a result of being given incorrect information.

As such, it is important to ensure that estimates of waiting times for treatment are up to date and as accurate as possible; that all options for NHS services have been considered; and that there is clear documentation in the notes about what has been discussed.

  • MDU medico-legal advisers are on hand to answer members’ queries about private referrals. GPs beginning their training in England and Wales can find out more about savings on becoming an MDU member: First year GP - The MDU

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