GPs Guide to Professional and Private Work Outside the NHS

John Lindsay, Norman Ellis

• Publisher: CRC Press
• Year: 2018
• eBook ISBN:
  9781315342733
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

All GPs undertake the non-NHS work some of which can add substantially to practice income. This book describes a wide range of fee-paying work which GPs are uniquely qualified to undertake; it shows how opportunities for this work arise and how to become involved in it. For many the financial benefits are greatly enhanced by the professional satisfaction such work brings.

1 Everyday work for GPs outside the NHS contract

David Pickersgill

A working day can scarcely go by for the average GP without being asked to undertake some form of patient service that is outside the scope of the GP’s contract with the NHS. Not only is this contract poorly understood by the public, but also it is often misunderstood by GPs themselves. This can lead to confusion about which services should be provided free of charge and, more importantly, when it is acceptable to charge a patient for a particular service. Happily, the NHS (General Medical Services) Regulations are quite explicit about which services must be provided free of charge (see paragraph 12 of the GMS Regulations).

Types of private service

The requests that GPs receive in their surgery to provide private services fall into two types; the provision of a certificate or written report, and a request to undertake an examination and then provide a written report, which may or may not also involve expressing an opinion. The information is often required in order for the patient to gain access to a State benefit, for the submission of claims in connection with various types of insurance or to confirm that the patient is medically fit to undertake some particular activity.

Much of the work has a high ‘irritation’ factor, patients often demanding the immediate completion of notes or certificates during time that the doctor has set aside for NHS consultations, and not infrequently for matters that are entirely unrelated to the patient’s need for treatment. Doctors are, of course, free to refuse to undertake work of this type, but this almost inevitably leads to confrontation with patients, many of whom feel that doctors’ NHS contracts require them to provide for the patient, whatever the patient demands. The patient (and some doctors) frequently fails to understand the legal implications of signing various certificates and statements, and prudent GPs should always pause and carefully consider what is being signed and whether they are truly in a position to make that particular statement about that patient. This is particularly important in connection with, for example, signing applications for shotgun licences, certificates of fitness to drive and certificates of fitness to undertake hazardous sporting activities. The doctor could easily find himself legally liable if he has certified an elderly patient fit to drive if that person is subsequently involved in an accident that is shown to be due to some aspect of the patient’s health, such as failing eyesight or loss of mobility; making adequate control of the vehicle difficult.

Another matter for consideration is whether, by always acceding to patients’ requests for private notes and certificates, doctors in general are making a rod for their own backs in terms of increasing work-load and patient expectation. Some employers make unreasonable demands of their employees always to obtain a private certificate from a doctor for minor self-limiting illnesses that have not required medical intervention. Some schools and teachers instruct parents to obtain a certificate from a doctor to cover children’s absence from school or to confirm that they should be excused from gym or sporting activities. Our professional negotiators fought long and hard to remove the statutory requirements for short-term certification by doctors, and we, as GPs, should not allow ourselves to be forced back into this practice simply because a fee may be charged for work that we know in our hearts is unnecessary and wasteful of our time and skills.

Are doctors entitled to charge?

All registered doctors are obliged by statute to provide death certificates and stillbirth certificates without charge. Doctors in relevant posts are obliged by statute to provide certain services for which they are remunerated:

• infectious disease notification
• professional evidence in court when directed
• post mortems (when directed by the coroner).

The NHS terms of service for GPs impose certain contractual requirements on them. Paragraph 12 of the terms of service states ‘That a doctor shall render to his patients all necessary and appropriate personal medical services of the type usually provided by general medical practitioners’. These services are further defined in that same paragraph:

12.2 The services which a doctor is required by sub-paragraph (1) to render shall include the following:

(a) giving advice, where appropriate, to a patient in connection with the patient’s general health, and in particular about the significance of diet, exercise, the use of tobacco, the consumption of alcohol and the misuse of drugs or solvents;

(b) offering to patients consultations and, where appropriate, physical examinations for the purpose of identifying, or reducing the risk of, disease or injury;

(c) offering to patients, where appropriate, vaccination or immunisation against measles, mumps, rubella, pertussis, poliomyelitis, diphtheria and tetanus;

(d) arranging for the referral of patients, as appropriate, for the provision of any other services under the Act; and

(e) giving advice, as appropriate, to enable patients to avail themselves of services provided by a local social services authority.

In addition to the services that have to be provided to patients free of charge, the terms of service also contain, in Schedule 9, a list of prescribed medical certificates that must be provided free of charge (Table 1.1).

Table 1.1: Schedule 9 – list of prescribed medical certificates

Also provided free of charge are certificates for patients claiming sickness and disability benefits, including Incapacity Benefit, Statutory Sick Pay, Disabled Living Allowance and Attendance Allowance, and replies to the Regional Medical Service on form RM2. Doctors may charge a fee for social security claims in relation to the Income Support scheme and the Social Fund. In relation to the former list of benefits, certificates must be issued free of charge for initial claims but not in connection with appeals and subsequent reviews, for which GPs can charge a fee for supplying letters or reports in support of these claims.

Private work in NHS hospitals

Doctors who work in hospitals (which also applies to GPs who hold clinical assistant or hospital practitioner posts) are subject to a separate set of terms of service, (the Hospital Medical and Dental Staff terms and conditions of service). They may not charge for work that is considered ‘Category 1’, i.e. work that is part of the normal NHS duties of hospital doctors. This includes:

1. the examination, diagnosis and furnishing of reports required in connection with treatment or prevention of an illness (paragraph 30 of the terms and conditions of service for hospital doctors)
2. furnishing reports on patients currently under treatment to the patient or a third party (including employers, the DSS and employment services) where it is reasonably incidental to treatment and does not involve substantial extra work
3. various other matters, for example mental health, court appearances etc listed in paragraph 36 of the terms and conditions of service for hospital doctors.

Hospital doctors may charge for so-called ‘Category 2’ work, which is described in paragraph 37 of the terms and conditions of service and includes:

1. examination of and reports on patients not under treatment
2. examination of and reports on patients who are under treatment but which involves an appreciable amount of extra work
3. examinations and reports requested by various authorities, government agencies, employers, insurance companies, solicitors etc
4. attendance at court (including the coroner’s court)
5. mental health examination and reports at the behest of social services
6. other government work, medical boards, tribunals for the DSS/Benefits Agency etc.

All this work is so-called ‘Category 2’ work and is subject to the ‘one-third’ rule.^a This requires that where laboratory, radiological or technical facilities are used, doctors have to pay one-third of the gross fee to the hospital. These facilities do not include secretarial or administrative support. The ‘one-third’ rule does not apply to coroner’s post mortems but does apply to other analytical work for coroners.

Charging for ‘treatment’

GPs may not charge their own NHS patients for treatment. The interpretation of the word treatment is very wide and includes referral to specialists, whether NHS or private. Paragraph 38 of the terms of service (schedule 2 of the NHS General Medical Services Regulations 1992) lists the strictly limited circumstances in which GPs may charge fees to their NHS patients. The GP’s NHS patients are defined in paragraph 4 of the terms of service. GPs contemplating making any charge to their NHS patients must ensure that they comply with the strict requirements of the terms of service and that they act in accordance with the ethical duty not to use, or appear to use, their position of trust to influence patients to follow a particular course of action that may offer the doctor some advantage, financial or otherwise. GPs must bear in mind that their action, in making a charge, could be alleged to involve accepting remuneration for treatment, which could be construed as breaching either their terms of service or their ethical duty not to abuse this position of trust. The consequences could be a complaint to the Family Health Services Authority (FHSA), with a possible finding of breach of the terms of service, a complaint to the General Medical Council’s (GMC’s) Professional Conduct Committee or, ultimately, criminal proceedings. GPs who are in any doubt about whether they may or may not charge a fee for something that may be construed as treatment should consult their local British Medical Association (BMA) office or their medical defence organisation.

How much to charge

Providing GPs meet the terms of their NHS contract, there is no limit to the amount that they may earn from private practice. However, if income from private work exceeds 10% of gross practice receipts, FHSA allowances for premises and staff used will be proportionately abated. This is covered in paragraph 52.19 of the Statement of Fees and Allowances (SFA).

Fees for almost all the services that GPs may provide privately are negotiated or considered by the Private Practice and Professional Fees Committee of the BMA. This includes fees for local and central government departments, and reports and certificates for patients or third parties. The level of fees varies according to the work involved, but is largely calculated on a time-banded basis, except where it is governed by statute or represents the outcome of negotiations with a government department or other national body. Copies of the BMA guidance notes on fees for part-time medical services can be obtained by members of the BMA from their local offices.

For ease of reference, the fees are grouped into four broad categories, as given below.

Category A

These are fees prescribed by statute or statutory instrument, including fees for giving emergency treatment at road traffic accidents and certain specified work in connection with the Access to Medical Records Act and the Data Protection Act.

Category B

Category B comprises fees negotiated nationally (UK) with government departments and other employers. Until 1993, all government departments set their fees in line with the so-called ‘Treasury general schedule’. This schedule was agreed between representatives of various government departments, including the Treasury, and representatives of the BMA in 1981. The agreement provided for annual uprating of the fees in line with the recommendations of the Doctors’ and Dentists’ Review Body (DDRB) and also for a triennial review of the baselines. Owing to refusal of the Treasury to take part, the triennial reviews never occurred, and in 1993 a new agreement was reached with the Treasury, which provided for a much shortened and simplified fee structure, together with significant increases in most of the fees. Although this new schedule was accepted by some government departments (e.g. the Driver and Vehicle Licensing Authority [DVLA], the Criminal Injuries Compensation Board and the Ministry of Defence), other government departments, such as the Department of Health (DoH), the Department of Social Security (DSS) and the Lord Chancellor’s Department, all refused to implement the new Treasury schedule. Although some of them have applied a modest increase to the fee scales payable in 1993, the BMA has refused to agree these fees as providing a satisfactory level of remuneration, and there is no longer any national agreement between these government departments and the BMA on an appropriate scale of fees for providing the services that these departments request.

Category C

Category C covers fees negotiated nationally with other representative bodies. This includes fees for life assurance reports negotiated with the Association of British Insurers, and work for the provident associations and the ambulance associations. The agreement is binding only on members of the national body with whom the BMA has reached agreement, but in practice, it means that the agr...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• List of contributors
• The Business Side of General Practice: Editorial Board
• Foreword
• Preface
• 1 Everyday work for GPs outside the NHS contract
• 2 Work for central and local government
• 3 Private GP services
• 4 Opportunities in insurance work
• 5 Working as a locum or deputy in general practice
• 6 Police surgeon (forensic medical examiner) work
• 7 The role of the part-time prison medical officer
• 8 Working for schools and colleges
• 9 Pharmaceutical trials
• 10 Part-time occupational health work
• 11 Sports medicine
• 12 Surgical work in general practice
• 13 Doctors, solicitors and the courts: a guide to accepting and receiving instructions
• 14 Medico-legal fees: dealing with solicitors and courts
• 15 Opportunities in medical journalism
• 16 Opportunities in medical education
• Index