Private Referrals

Introduction

1. Salisbury Medical Practice will refer patients to private providers if that is the wish of the patient.
2. Salisbury Medical Practice will not arrange tests/investigations on behalf of private providers. It is the responsibility of the private provider to arrange these even if this is at a cost to the patient.
3. Drugs required for urgent administration should be prescribed by the private clinician and it should not be expected that general practice will do this. The duration of this prescription should be a minimum of 7 days.
4. Private providers are free to prescribe whatever they feel appropriate, however there cannot be an expectation from the provider or the patient that this will be continued in primary care. There are strict rules that GPs must follow.
5. If the private provider/consultant or patient wish to transfer into NHS Care, this does not require a GP referral. Private providers are expected to do this referral themselves (even if it means a consultant referring to themselves on the NHS). Requests for the GP surgery to do these referrals will be rejected.
6. Salisbury Medical Practice will not enter into shared care agreements for medication that require this with private providers. In these circumstances the patient should ask their private provider to refer them into an appropriate NHS service. The reason for this is that it cannot be guaranteed that a private arrangement will continue between private provider and patient.
7. Salisbury Medical Practice will not prescribe ‘Red’ medications requested or initiated by private providers at all.

Purpose of the policy

Private providers of healthcare are increasingly common. This policy intends to set out clearly for patients and providers, the responsibilities that Salisbury Medical Practice expects of patients, providers and the GP surgery.

It is important that patients are aware of this document at the outset of referral to a private provider as there are some circumstances where ongoing care will be required privately and won’t be taken on by the surgery or available on the NHS.

Private providers

Referrals

• The surgery will refer patients to a private provider just as is done on the NHS. The referral document will include a patient summary including medications, past medical history, allergies and an account of the problem/reason for referral.
• If a private provider requires medical information about a patient, this can be provided by the patient by supplying copies of hospital letters received by the patient or by sharing their medical records via the NHS app or online medical records system. Patients can make a SAR (subject access request) to obtain a free of charge summary of their medical record.
• If a private provider requests more information from a general practice, this can be provided, following consent, and the cost of preparing the report can be charged to the private provider.

NHS guidance states

Patients may pay for additional private healthcare while continuing to receive care from the NHS.

However, in order to ensure that there is no risk of the NHS subsidising private care:

• It should always be clear whether an individual procedure or treatment is privately funded or NHS funded 
• Private and NHS care should be kept as clearly separate as possible
• The patient should bear the full costs of any private services. NHS resources should never be used to subsidise the use of private care
• The arrangement put in place to deliver additional private care should be designed to ensure as clear a separation as possible of funding, legal status, liability and accountability between NHS care and any private care a patient receives.

Investigations

• NHS England has guidance regarding standards for communication of test results. The handing back of test results from secondary care (private or NHS) to General Practice for interpretation is deemed unsafe by the BMA. That responsibility can only be given to someone else if they accept by prior agreement. For the purpose of this document, as a practice we don’t accept interpretation of results requested / initiated by a secondary care/private provider and the responsibility for ensuring that results are acted upon rests with the person requesting the test. Please do not ask the surgery for results of secondary care requested investigations.
• If general practices receive requests from private providers to arrange tests or investigations, it is important to note that complying with such requests - regardless of the GP’s management and treatment of the patient - is outside the scope of NHS primary medical services, hence why the practice will direct the patient back to their private provider to arrange such investigations.
• Salisbury Medical Practice will not arrange tests/investigations on behalf of private providers. It is the responsibility of the private provider to arrange these.

Medications

• Different medications require different levels of monitoring and expertise for follow up. This should be considered by the patient and provider.
• Primary care is required to clearly follow the local formulary and ‘traffic light status’. This applies to patients seen by both Private and NHS providers. All drugs are prescribed subject to level of experience however generally:
  • ‘Green’ – can be initiated, prescribed and monitored in primary care
  • ‘Amber’ – must be initiated and stabilised by secondary care prior to transfer to primary care.
  • Amber with shared care’ – see Shared Care section below.
  • ‘Red’ – must be prescribed be secondary care long term.
• Please see the BSW formulary
• Drugs required for urgent administration should be prescribed by the private clinician and it should not be expected that general practice will do this. The duration of this prescription should be a minimum of 7 days.
• Recommendation for prescribing medications in primary care should come with clear instructions to the patient regarding the time scale for completion of the prescription, and this should be in addition to formal communication in the form of a letter to the surgery.
• The doctor recommending a prescription should ensure that the prescription is appropriate, including carrying out any tests required prior to initiation to ensure safety.
• The doctor should tell the patient about important side effects and precautions, including any need for ongoing monitoring.
• Recommendations should be in line with any agreed local formularies. Individual decisions should be made about recommending a drug as opposed to a therapeutic class.
• Where a GP feels that a prescription recommendation is inappropriate, the private clinician should be informed.
• All prescribers must be aware that the ultimate responsibility for the prescription lies with the prescribing doctor and cannot be delegated.
• Private providers are free to prescribe whatever they feel appropriate, however there cannot be an expectation from the provider or the patient that this will be continued in primary care. As stated above, there are strict rules that GPs must follow.

Transferring to NHS care

• If the private provider/consultant or patient wish to transfer into NHS Care, this does not require a GP referral. Private providers are expected to do this referral themselves (even if it means a consultant referring to themselves on the NHS).
• This is a clear policy that has been approved by local private providers, BSW ICB and Salisbury Foundation trust.
• Requests for the GP surgery to do these referrals will be rejected.

Shared care medications / arrangements with private providers

What is shared care?

• Shared care is a term used within the NHS to describe the situation where a specialist doctor wishes to pass some of the patient’s care, such as prescription of medication, over to their general practitioner (GP). This is something that can be requested but the guidance for all medications is that this may only be done if the GP agrees. The GP will need to consider a number of factors to decide if this is safe.
• In shared care arrangements (SCAs) the prescribing Consultant or specialist team still remain responsible for parts of the patient’s care. These should be defined in the SCA and usually include any changes to the medication regime or any complications related to the medication. The presence of a specialist is also essential for the GP to be deemed to be operating under ‘shared care’. Shared care is not ‘shared’ unless it is shared by the GP with someone else. Without this then GPs may be deemed to operating outside of Good Medical Practice.
• This is particularly pertinent with regards to private medications that fall within the ‘Amber – shared care’ category.
• See the Bath and North East Somerset, Swindon and Wiltshire Together website for a full list of all medications that require SCAs.
• It is also important to remember that formal shared care arrangements are voluntary on the part of the GP and the GP should be mindful of their own clinical competence and workload capacity when considering agreeing to enter into such an arrangement. Workload requested for an individual patients will need to be considered in balance with the reasonable needs of the practice population and whether further workload can be absorbed by the practice team safely.
• Salisbury Medical Practice currently agrees to take on longterm prescribing of medications that fall under the ‘Green’ traffic light status or ‘Amber’ (that have been initiated by the private team and stabilised but don’t require shared care) but we retain the right to refuse if we don’t have sufficient expertise or resources to manage the medication.
• Salisbury Medical Practice will not enter into shared care agreements for medication that require this with private providers. In these circumstances the patient should ask their private provider to refer them into an appropriate NHS service. The reason for this is that it cannot be guaranteed that a private arrangement will continue between private provider and patient.
• Salisbury Medical Practice will not prescribe ‘Red’ medications requested or initiated by private providers at all.

References

• General practice responsibility in responding to private healthcare
• Understanding Shared Care – NHS, Right to Choose and Private Providers
• Duty of care when test results and drugs are ordered by secondary care
• Shared Care Agreements: BSW Area Prescribing Committee
• BSW Formulary
• Good medical practice