GP services are more complicated than you might imagine. This is a summary of how general practice works, looking at the key points around services to patients.
GPs are asked to provide certain essential services (this is called ‘commissioned’) to the population. Some of these services are the same across England – they are referred to as General Medical Services – GMS. Every GP practice has to provide these.
Additional services are also part of the GMS contract, and it is assumed that all GPs will do them. However, practices can ‘opt-out’ if they wish.
GPs may choose to offer enhanced services (ES). These may be decided nationally (DES) or locally (LES). Practices can choose whether or not they sign up to these. The benefits are more services for patients and extra funding, but the downside is that it is extra work in an already overstretched service. Unlike additional services, practices choose to sign up to offer them. There is no expectation that they will do.
Some of the things that GPs are asked to do are not covered by any NHS contract. These are therefore considered to be non-NHS work. Because this is essentially private work, practices are not under any obligation to do it as it’s not part of any contract. It also means that, if they choose to do it, they can charge for the work in the same way that a solicitor might charge for their services.
The information here is a brief summary of key points. If you want more details on what is and isn’t in the contracts, then the visit the Department of Health and Social Care website. They have published statutory guidance on Primary Medical Services – both the GMS contract and Directed Enhanced Services.
Frequently Asked Questions
What are the Essential Services?
Essential Services are those which are described in the current NHS GMS Contract. The services have to be provided for the management of patients by the practice within core hours (0800-1830) in a way that is appropriate to meet the reasonable needs of the patients. These services are for patients who are or believe themselves to be ill. The services must be delivered in a way determined by the practice, in discussion with the patient. The term ‘management of patients’ includes offering a consultation (this includes digital, online, telephone, face to face) and if appropriate, examination, tests, treatment or referral. GP practices are also expected to offer health advice and health promotion.
Essential services also include contraceptive services (but not sexual health), and a maternal 6-8 week check.
For precise wording and full details, please see the GMS contract, which is available online.
Essential services also include contraceptive services (but not sexual health), and a maternal 6-8 week check.
For precise wording and full details, please see the GMS contract, which is available online.
What are the Additional Services?
Additional Services comprise of cervical screening (smears), NHS vaccines & immunisations, child health surveillance (e.g. 6-8 week baby check) and antenatal care.
Some practices will opt-out of offering one or more of these, for a variety of reasons (see below).
For precise wording and full details, please see the GMS contract, which is available online.
Some practices will opt-out of offering one or more of these, for a variety of reasons (see below).
For precise wording and full details, please see the GMS contract, which is available online.
What are the Enhanced Services?
The Enhanced Services available across England vary considerably by area – this is because many of them are decided at a more local level. The organisation that decides on the Local Enhanced Services is referred to as the Integrated Care Board. In Portchester, ours is the Hampshire and Isle of Wight ICB. These are individual sign-up services rather than the opt-out arrangement that exists with Additional Services.
Patient-facing Enhanced Services which are available in Hampshire include (not exhaustive): ECGs, blood tests, spirometry (breathing tests), learning disabilities health checks, minor surgery, joint injections, leg ulcer treatment, post-operative wound care (e.g. removing stitches/staples), ring pessaries for prolapse, shared-care prescribing and monitoring for certain medications.
Patient-facing Enhanced Services which are available in Hampshire include (not exhaustive): ECGs, blood tests, spirometry (breathing tests), learning disabilities health checks, minor surgery, joint injections, leg ulcer treatment, post-operative wound care (e.g. removing stitches/staples), ring pessaries for prolapse, shared-care prescribing and monitoring for certain medications.
Why doesn’t every practice offer every service?
There are a variety of reasons for this. The most common one is that practices are so busy that they don’t have capacity to take on extra work. For other practices, the local population don’t have enough need for the service to make it worthwhile to set up. Sometimes it is down to funding – if the amount of money provided for a service doesn’t cover the costs to that practice of providing it, then it is unlikely that it will be taken on. In some areas the staff don’t have the particular training or experience (this is typically true of minor surgery, ring pessaries and joint injections). Although it is possible to gain this training, it is a significant undertaking in terms of time and cost, so not necessarily viable.
Every decision to take on, or not take on, a service is done with very careful consideration. GPs want to be able to provide as much as they can for patients, but have to make sure they don’t do it at the expense of the essential services.
Every decision to take on, or not take on, a service is done with very careful consideration. GPs want to be able to provide as much as they can for patients, but have to make sure they don’t do it at the expense of the essential services.
What happens if my practice doesn’t provide a particular service?
If a practice hasn’t signed up to provide an enhanced service, then an alternative will be provided. The main difference is that it is unlikely take place at your local practice; typically it is provided by ‘secondary care’ (e.g. hospital trusts or private companies). Where a patient needs an enhanced service that is not provided by the practice then we will refer you to the appropriate alternative. The decision on who provides the alternative service is made either by the government or the ICB – the practice doesn’t have any influence over this.
What is non-NHS work?
Any work that is not part of any NHS contract is non-NHS (private) work. The most common types of private work are medical reports and medical examinations, such as for driving or adoption, or for insurance companies. We are usually able to complete these as requested, as they are fairly standard.
Other requests for private work include things like letters, completion of various certificates or reports and other ad-hoc documents. Depending on the nature of the request, we may or may not be able to carry out the work.
Please note that we do not issue diazepam for fear of flying, complete firearms licenses, or sign any forms stating that people are ‘fit to’ do any activity, such as sports or charity events.
Other requests for private work include things like letters, completion of various certificates or reports and other ad-hoc documents. Depending on the nature of the request, we may or may not be able to carry out the work.
Please note that we do not issue diazepam for fear of flying, complete firearms licenses, or sign any forms stating that people are ‘fit to’ do any activity, such as sports or charity events.
Why do I have to pay?
The contracts above define what we are commissioned to do, and pay for the services that we are contracted to provide. If we are going to do things beyond this, then they need to have funding to support the time and costs associated with them. Each individual request may seem quick or small, but bear in mind that we look after over 10,000 patients and get many such requests each month. The time rapidly adds up.
We do our best to keep fees as low as we can. However, this work carries medicolegal liability and, along with rising costs to running the practice, we have to charge. The fees set are broadly in line with those you might expect from a similarly qualified professional such as a solicitor.
As an alternative, you may wish to seek the services of a private GP to do the work for you. Please note that they do not have access to your medical records, however.
Fees for Non NHS Work
We do our best to keep fees as low as we can. However, this work carries medicolegal liability and, along with rising costs to running the practice, we have to charge. The fees set are broadly in line with those you might expect from a similarly qualified professional such as a solicitor.
As an alternative, you may wish to seek the services of a private GP to do the work for you. Please note that they do not have access to your medical records, however.
Fees for Non NHS Work
Why won’t you do what I have asked for?
There is no obligation for your GP practice to do any private work. Where we are able to help then we will. However there are times or circumstances when we cannot. There are a variety of reasons for this, including time constraints or the nature of the work not being covered by our medical indemnity (the insurance that GPs have in the event that something goes wrong). As above, you may wish to seek the services of a private GP to do the work for you.
Is there any other work that you cannot do?
The NHS is a complicated organisation, and funding only comes through contracts. Without the money for the work, we cannot provide the service.
There are some circumstances in which no-one is contracted to do a particular activity. This may be because it is not deemed essential (e.g. the NHS can no longer afford to remove many non-cancerous skin lesions or routinely do some types of surgery), or it may be because there is just not a contract that covers the situation. Whilst there may be an assumption that general practice will the fill the gap, the reality is that this is not the case. This can feel very uncomfortable for both doctors and patients, but it is not something that your practice can resolve. If you feel there is a gap in commissioning of a service, then you need to contact the ICB.
Some situations arise relatively often, and it is important that people realise where they may find gaps. Here are some examples.
– If you go for a procedure abroad, and the aftercare isn’t something that is usually provided by primary care if the procedure was done in the NHS, then we cannot provide the service. A common example of this is weight loss surgery done abroad. Sometimes people are unaware of the need for post-operative monitoring and expect that this is carried out by their GP, but this is not so. In the NHS, this aftercare sits within the hospital for around 2 years post-operatively. However, hospitals are also not commissioned to provide monitoring for people who have surgery abroad. Therefore, you will need to pay for this from a private provider.
– Medication requests from private healthcare providers are another area which can be a problem. If a GP receives a request for a prescription from a private consultation, they are not obliged to issue it. We may decline if there are reasons we do not feel it is appropriate, we don’t have enough information, or we are unfamiliar with its use. The consultant will be able to issue you a private prescription, however, but you will have to pay. Likewise, we cannot issue prescriptions based on the recommendations of a dentist, or convert dental prescriptions to NHS prescriptions.
– We are sometimes asked to issue prescriptions before procedures, such as for diazepam if someone is fearful of having scan or going to the dentist. These medications are not without risk. If you are told to contact your GP for this, then unfortunately you are being misinformed. If they feel the medication is needed, then it is their duty to prescribe it, as they are the ones who will need to monitor the effects. You will need to contact them again,
– ‘Shared care’ is an arrangement where primary care issues NHS prescriptions for a medication, but secondary care (hospitals) continue overall management of the condition. GPs may feel it is unsafe to issue NHS prescriptions under a shared care agreement with a private consultant due to lack of assurances that the care will indeed be shared. In this instance, either your prescriptions will need to be issued by the consultant, or your care will need to be transferred to the NHS, with prescriptions continued privately until this transfer is complete. Shared care is considered to be an enhanced service, and not all practices have opted in to shared care. Where shared care does not exist, the ICB have arranged alternative provision, but this will require transfer into the NHS services, via a usual referral process and subsequent waiting time.
There are some circumstances in which no-one is contracted to do a particular activity. This may be because it is not deemed essential (e.g. the NHS can no longer afford to remove many non-cancerous skin lesions or routinely do some types of surgery), or it may be because there is just not a contract that covers the situation. Whilst there may be an assumption that general practice will the fill the gap, the reality is that this is not the case. This can feel very uncomfortable for both doctors and patients, but it is not something that your practice can resolve. If you feel there is a gap in commissioning of a service, then you need to contact the ICB.
Some situations arise relatively often, and it is important that people realise where they may find gaps. Here are some examples.
– If you go for a procedure abroad, and the aftercare isn’t something that is usually provided by primary care if the procedure was done in the NHS, then we cannot provide the service. A common example of this is weight loss surgery done abroad. Sometimes people are unaware of the need for post-operative monitoring and expect that this is carried out by their GP, but this is not so. In the NHS, this aftercare sits within the hospital for around 2 years post-operatively. However, hospitals are also not commissioned to provide monitoring for people who have surgery abroad. Therefore, you will need to pay for this from a private provider.
– Medication requests from private healthcare providers are another area which can be a problem. If a GP receives a request for a prescription from a private consultation, they are not obliged to issue it. We may decline if there are reasons we do not feel it is appropriate, we don’t have enough information, or we are unfamiliar with its use. The consultant will be able to issue you a private prescription, however, but you will have to pay. Likewise, we cannot issue prescriptions based on the recommendations of a dentist, or convert dental prescriptions to NHS prescriptions.
– We are sometimes asked to issue prescriptions before procedures, such as for diazepam if someone is fearful of having scan or going to the dentist. These medications are not without risk. If you are told to contact your GP for this, then unfortunately you are being misinformed. If they feel the medication is needed, then it is their duty to prescribe it, as they are the ones who will need to monitor the effects. You will need to contact them again,
– ‘Shared care’ is an arrangement where primary care issues NHS prescriptions for a medication, but secondary care (hospitals) continue overall management of the condition. GPs may feel it is unsafe to issue NHS prescriptions under a shared care agreement with a private consultant due to lack of assurances that the care will indeed be shared. In this instance, either your prescriptions will need to be issued by the consultant, or your care will need to be transferred to the NHS, with prescriptions continued privately until this transfer is complete. Shared care is considered to be an enhanced service, and not all practices have opted in to shared care. Where shared care does not exist, the ICB have arranged alternative provision, but this will require transfer into the NHS services, via a usual referral process and subsequent waiting time.
ADHD Medication and Right to Choose
ADHD medications need a mention of their own. Due to the long waiting times for assessments, people sometimes ask for a referral under the ‘right to choose’ scheme. This means that they are able to choose who they are referred to, from a group of organisations. It is important that patients make sure that the provider they choose is one who prescribes medication, as your we will not be able to prescribe on their behalf.
If you choose to have a private assessment with a provider who is not under the right to choose programme, you will not be able to get any NHS prescriptions. In this situation, if you want NHS prescriptions for ADHD treatment then we will be happy to refer you into the NHS system. However, you will start at the back of the waiting list, even if you already have an ADHD diagnosis and the referral is just for medication.
You might find this flow chart helpful when deciding whether to use a Right to Choose provider.
If you choose to have a private assessment with a provider who is not under the right to choose programme, you will not be able to get any NHS prescriptions. In this situation, if you want NHS prescriptions for ADHD treatment then we will be happy to refer you into the NHS system. However, you will start at the back of the waiting list, even if you already have an ADHD diagnosis and the referral is just for medication.
You might find this flow chart helpful when deciding whether to use a Right to Choose provider.
Who do I contact if I’m not happy with your decision?
We understand that it can be frustrating if you cannot get the care that you feel you need or want. We are committed to providing you with the best care that we can, and sometimes this means that we have to decline to take on additional work. If you feel that you are not being provided with NHS care that you are entitled to, and your questions are not answered here, please contact the practice in the first instance. Your complaint will be handled in line with the NHS Complaints Policy.
If the concern is regarding an NHS service that the practice is not contracted to provide, then please contact the ICB.
Complaints regarding a private service provided to you by the practice should also be directed to us in the first instance, but the NHS Complaints Policy does not apply.
If the concern is regarding an NHS service that the practice is not contracted to provide, then please contact the ICB.
Complaints regarding a private service provided to you by the practice should also be directed to us in the first instance, but the NHS Complaints Policy does not apply.
Other organisations
If you have concerns about services from another NHS or private provider, please contact them directly. Local organisations providing NHS services are listed below. Unfortunately we cannot assist with any complaints regarding waiting times, service delivery, follow-ups, appointment timing, or any other issues regarding services provided by any other provider – you will need to contact them directly.
– Portsmouth Hospitals NHS Trust (Queen Alexandra Hospital): 02392 286000 – ask for the extension number of the secretary for the speciality you are under. Alternatively, you may wish to contact the Patient Advice and Liaison Service (PALS).
– Southern Health NHS Foundation Trust (soon to be Hampshire and Isle of Wight Healthcare NHS Foundation Trust) have contact details here. They encompass adult mental health services, physiotherapy, community nursing services and more.
– For Hampshire Child and Adolescent Mental Health Services (CAMHS), including ADHD and autism, see here.
– For Hampshire adult ADHD services see the details for PHL.
– For Hampshire adult autism services see the details for The Owl Centre.
– Portsmouth Hospitals NHS Trust (Queen Alexandra Hospital): 02392 286000 – ask for the extension number of the secretary for the speciality you are under. Alternatively, you may wish to contact the Patient Advice and Liaison Service (PALS).
– Southern Health NHS Foundation Trust (soon to be Hampshire and Isle of Wight Healthcare NHS Foundation Trust) have contact details here. They encompass adult mental health services, physiotherapy, community nursing services and more.
– For Hampshire Child and Adolescent Mental Health Services (CAMHS), including ADHD and autism, see here.
– For Hampshire adult ADHD services see the details for PHL.
– For Hampshire adult autism services see the details for The Owl Centre.