Chapter 8: When can fees be charged to a patient by a GP Practice?

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When can fees be charged to a patient by a GP Practice?

 

 

This chapter contains:

 

1.     Introduction.

2.     The general prohibition on an NHS GP Practice charging fees to patients.

3.     Medical certificates that a GP practice must provide free of charge.

4.     Charges where the GP practice has reasonable doubts as to whether a patient is on the practice list.

5.     Charges permitted by Schedule 5 of the GMS Regulations and Schedule 3 of the PMS Regulations.

6.     Charges for meeting the requirements of other statutory bodies.

7.     Fees for conducting routine medical examinations.

8.     Services provided by a specialist GP for private patients in hospitals or a care home.

9.     Payment for emergency treatment of traffic casualties.

10.     Fees for attending a police station.

11.     Fees for preparing medical reports and issuing medical certificates.

12.     Fees for preparing medico-legal reports.

13.     Fees for preparing reports for seat belt purposes, following a traffic accident, a criminal assault or for fitness to travel.

14.     Eye examinations by GPs.

15.     Dispensing doctors and scheduled drugs.

 

1.             Introduction.

 

1.1          NHS services are generally free at the point of use for patients.  However the NHS has always imposed charges for some healthcare services and there are other functions undertaken by NHS doctors which are outside their NHS duties and hence attract a fee.  It follows that full legal position is somewhat more nuanced.   The general requirement that services should generally be provided free of charge is set out in section 1(4) of the National Health Service Act 2006 (“the NHS Act”) which provides:

 

The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed”

 

1.2          There are a number of areas where Regulations provide that charges may be imposed for NHS services including:

 

a)             Prescriptions;

b)             Dental services;

c)              Optical services;

d)             Contraceptive services;

e)             Hospital services for persons who are not usually ordinarily resident in the UK.

 

1.3          Primary care services provided under a GMS[1] or PMS[2] contract to patients on the practice list or temporary residents are required to be provided free of charge.  The GMS and PMS contracts also provide that GP practices have a contractual obligation to provide a range of other services to patients[3].   However GP practices are (almost all) private sectors businesses that have contracted with NHS England to provide defined primary care services to a defined group of patients and to provide defined level of emergency medical services in limited circumstances.  If a registered patient or temporary resident[4] seeks primary care services from an NHS GP practice outside the terms of the contract held by that practice, the NHS GP practice has no obligation to provide services to that person.  However the GP practice cannot charge for treatment provided outside the GP Practice contract unless the service falls within a limited categories of specific services.

 

2.             The general prohibition on an NHS GP Practice charging fees to patients.

 

2.1          The general prohibition on an NHS GP Practice charging fees for services provided to patients is set out in Regulation 24 of the GMS Regulations[5] which provides:

 

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”

 

There is a like provision in the PMS Regulations. 

 

2.2          The prohibition covers any charge which is made for the provision of treatment or any prescription to a patient, not just treatment that the GP is required to provide under the practice contract.  A GP practice cannot therefore charge a third party, such as an employer or the parent of a child, for medical treatment provided to a patient.

 

2.3          The word “patient” is defined for the purposes of Regulation 24 in Regulation 2 of the GMS Regulations.  It provides as follows:

 

““patient” means—

 

(a)           a registered patient,

 

(b)           a temporary resident,

 

(c)           persons to whom the contractor is required to provide immediately necessary treatment under regulation 15(6) or (8) respectively,

 

(d)           any other person to whom the contractor has agreed to provide services under the contract,

 

(e)           any person for whom the contractor is responsible under regulation 31, and

 

(f)             any person for whom the contractor is responsible under arrangements made with another contractor in accordance with Schedule 7”

 

2.4          Every GP practice which is contracted to the NHS is prohibited from imposing any charge for treatment or drugs to any of the categories of “patient” as defined above.  Most of the categories of “patient are” self evident.  The meanings of “registered patient” and a “temporary resident are set out in Chapter 6 as is the categories of persons to whom a GP is required to provide “immediately necessary treatment”.  Regulation 31 and Schedule 7 refers to GP Practices that have Out of Hours responsibilities which may be owed to a wider class of persons than just the patients of the practice.

 

2.5          The general prohibition on imposing charges for treatment means that a GP with a GMS or PMS contract cannot charge a “patient” for the delivery of any form of medical treatment even if that treatment is not provided as part of NHS funded healthcare.  Thus a GP who provides, for example, osteopathy, acupuncture or homeopathy outside of NHS funded care is prohibited from charging patients (as that term is defined above) for the provision of such a service.  There is nothing to prevent a GP practice from offering such services on a commercial basis to persons who are not patients of the practice and do not otherwise come within the definition of being a “patient” under the GMS or PMS Regulations.  However Regulation 24 provides that a GP practice which holds an NHS contract cannot charge for offering any form of medical treatment (even outside NHS services) to patients of an NHS practice.

 

3.             Medical certificates that a GP practice must provide free of charge.

 

3.1          The GMS and PMS Regulations contain a list of statutory certificates that GP practices are required to provide without charge.  Regulation 21 of the GMS Regulations[6] provides:

 

“(1)     A contract must contain a term which has the effect of requiring the contractor to issue free of charge to a patient or his personal representatives any medical certificate of a description prescribed in column 1 of Schedule 4, which is reasonably required under or for the purposes of the enactments specified in relation to the certificate in column 2 of that Schedule, except where, for the condition to which the certificate relates, the patient—

 

(a)     is being attended by a medical practitioner who is not—

 

(i)     employed or engaged by the contractor,

 

(ii)     in the case of a contract with two or more individuals practising in partnership, one of those individuals; or

 

(iii)     in the case of a contract with a company limited by shares, one of the persons legally or beneficially owning shares in that company; or

 

(b)     is not being treated by or under the supervision of a health care professional.

 

(2)     The exception in paragraph (1)(a) does not apply where the certificate is issued in accordance with regulation 2(1) of the Social Security (Medical Evidence) Regulations 1976 (evidence of incapacity for work, limited capability for work and confinement) or regulation 2(1) of the Statutory Sick Pay (Medical Evidence) Regulations 1985 (medical information)”

 

3.2          This provision is somewhat clumsily worded but it means that a GP must issue one or more statutory certificates without charge where the following apply:

 

a)             The GP is asked to produce the certificate by a patient (as that term is defined as to which see above) or his personal representative;

 

b)             The certificate is of a description prescribed in column 1 of Schedule 4 to the GMS Regulations.  These are listed below;

 

c)              The certificate must be reasonably required under or for the purposes of the enactments specified in relation to the certificate in column 2 of Schedule 4 to the GMS Regulations;

 

d)             The exemption in sub-paragraphs (a) and (b) does not apply (as to which see below); and

 

e)             The exemption in Regulation 21(2) to the exemption in Regulation 21(1)(b) does not apply.

 

3.3          Column 1 of Schedule 4 to the GMS Regulations lists the types of certificates which have to be provided free of charge and column 2 lists the Acts of Parliament under which the certificates have to be provided. 

 

Column 1:  Purpose of certificate

Column 2:  Enactments

To support a claim or to obtain payment either personally or by proxy; to prove incapacity to work or for self-support for the purposes of an award by the Secretary of State; or to enable proxy to draw pensions etc

Naval and Marine Pay and Pensions Act 1865
Air Force (Constitution) Act 1917
Pensions (Navy, Army, Air Force and Mercantile Marine) Act 1939
Personal Injuries (Emergency Provisions) Act 1939
Pensions (Mercantile Marine) Act 1942
Polish Resettlement Act 1947
Social Security Administration Act 1992
Social Security Contributions and Benefits Act 1992
Social Security Act 1998

To establish pregnancy for the purpose of obtaining welfare foods

Section 13 of the Social Security Act 1988 (schemes for distribution etc of welfare foods)

To secure registration of still-birth

Section 11 of the Births and Deaths Registration Act 1953 (special provision as to registration of still-birth)

 To enable payment to be made to an institution or other person in case of mental disorder of persons entitled to payment from public funds

Section 142 of the Mental Health Act 1983 (pay, pensions etc of mentally disordered persons)

To establish unfitness for jury service

Juries Act 1974

To support late application for reinstatement in civil employment or notification of non-availability to take up employment owing to sickness

Reserve Forces (Safeguarding of Employment) Act 1985

To enable a person to be registered as an absent voter on grounds of physical incapacity

Representation of the People Act 1983

To support applications for certificates conferring exemption from charges in respect of drugs, medicines and appliances

National Health Service Act 2006

 To support a claim by or on behalf of a severely mentally impaired person for exemption from liability to pay the Council Tax or eligibility for a discount in respect of the amount of Council Tax payable

Local Government Finance Act 1992

 

 

3.4          The wording of the exemption in sub-paragraph (a) means that none of the above certificates have to be provided free of charge where the medical condition to which the certificate relates is being treated by a doctor or other healthcare professional who is not either a partner of the practice (including a corporate partner) or is employed by the GP practice.  In such a case the Regulations effectively signpost the patient to obtaining the certificate from the doctor or other healthcare professional who is treating the patient.  This could be a private doctor or is more likely to be a consultant in secondary care.  This exception does not apply where the certificate is sought in accordance with regulation 2(1) of the Social Security (Medical Evidence) Regulations 1976 (evidence of incapacity for work, limited capability for work and confinement) or regulation 2(1) of the Statutory Sick Pay (Medical Evidence) Regulations 1985 (medical information).  In such cases the GP practice must issue the certificate free of charge even though the patient is being treated by another doctor or other healthcare professional.

 

3.5          The exemption in sub-paragraph (b) provides that where the medical condition to which the certificate relates is not being treated by a health care professional at all, the GP practice is not required to provide a certificate free of charge.

 

3.6          The BMA reports that it has clarified with the Department of Work and Pensions that it is not obligatory for GPs to fill in the factual reports for the Disability Living Allowance, Attendance Allowance and form DS1500 (Special Rules).  These forms attract a separate fee paid by the DWP.

 

3.7          Once a certificate has been issued to the Department of Work and Pensions (“DWP”), the person to whom the certificate is sent is entitled to come back with follow up questions.  The terms of the GMS and PMS contracts provide that the GP practice must seek the consent of the patient before answering and questions but, if consent is given, no charge can be made by the GP practice for answering questions which follow on from a report that must be provided free of charge.  This is set out in paragraph 80 of Schedule 6 to the GMS Regulations[7] which provides that GMS Contract must contain a term that:

 

(1)     The contractor must, if satisfied that the patient consents—

 

(a)     supply in writing to any person specified in sub-paragraph (3), within such reasonable period as that person may specify, such clinical information as any of the persons mentioned in sub-paragraph (3)(a) to (d) considers relevant about a patient to whom the contractor or a person acting on behalf of the contractor has issued or has refused to issue a medical certificate; and

 

 

(b)     answer any inquiries by any person mentioned in sub-paragraph (3) about—

 

(i)     a prescription form or medical certificate issued or created by, or on behalf of, the contractor, or

 

(ii)     any statement which the contractor or a person acting on behalf of the contractor has made in a report.

 

(2)     For the purposes of being satisfied that a patient consents, a contractor may rely on an assurance in writing from any person mentioned in sub-paragraph (3) that the consent of the patient has been obtained, unless the contractor has reason to believe that the patient does not consent.

 

(3)     For the purposes of sub-paragraph (1) and (2), the persons are—

 

(a)     a medical officer;

 

(b)     a nursing officer;

 

(c)     an occupational therapist;

 

(d)     a physiotherapist; or

 

(e)     an officer of the Department for Work and Pensions who is acting on behalf of, and at the direction of, any person specified in paragraphs (a) to (d).

 

(4)     In this paragraph—

 

(a)     “medical officer” means a medical practitioner who is—

 

(i)     employed or engaged by the Department for Work and Pensions, or

 

(ii)     provided by an organisation under a contract entered into with the Secretary of State for Work and Pensions;

 

(b)     “nursing officer” means a health care professional who is registered on the Nursing and Midwifery Register and—

 

(i)     employed or engaged by the Department for Work and Pensions, or

 

(ii)     provided by an organisation under a contract entered into with the Secretary of State for Work and Pensions;

 

(c)     “occupational therapist” means a health care professional who is registered in the part of the register maintained by the Health Professions Council under article 5 of the Health and Social Work Professions Order 2001 relating to occupational therapists and—

 

(i)     employed or engaged by the Department for Work and Pensions, or

 

(ii)     provided by an organisation under a contract entered into with the Secretary of State for Work and Pensions; and

 

(d)     “physiotherapist” means a health care professional who is registered in the part of the register maintained by the Health Professions Council under article 5 of the [Health and Social Work Professions Order 2001] relating to physiotherapists and—

 

(i)     employed or engaged by the Department for Work and Pensions, or

 

(ii)     provided by an organisation under a contract entered into with the Secretary of State for Work and Pensions”

 

3.8          Paragraph (d)(ii) of Schedule 5 to the GMS Regulations provides that where a GP practice is asked by a commercial, educational or not-for-profit organisation to attend and/or examine (but not otherwise treat) a patient for the purpose of creating any other form of medical report or certificate the GP practice is entitled to charge a reasonable fee.   This seems to cover virtually all types of reports that are requested concerning patients other than the certificates issued under the various statutes listed above.

 

4.             Charges where the GP practice has reasonable doubts as to whether a patient is on the practice list.

 

4.1          Both the PMS and the GMS Regulations contain the following provision to cover someone who presents seeking treatment but where the GP has genuine doubts about whether the GP practice has a duty to provide services to that person under Regulation 24(3).  In such a case the GP practice can impose a charge as follows:

 

“(3) Where a person applies to a contractor for the provision of essential services and claims to be on that contractor’s list of patients, but fails to produce his medical card on request and the contractor has reasonable doubts about that person’s claim, the contractor shall give any necessary treatment and shall be entitled to demand and accept a reasonable fee in accordance with paragraph 1(e) of Schedule 5, subject to the provision for repayment contained in paragraph (4).

 

(4) Where a person from whom a contractor received a fee under paragraph 1(e) of Schedule 5 applies to the Board for a refund within 14 days of payment of the fee (or such longer period not exceeding a month as the Board may allow if it is satisfied that the failure to apply within 14 days was reasonable) and the Board is satisfied that the person was on the contractor’s list of patients when the treatment was given, the Board may recover the amount of the fee from the contractor, by deduction from its remuneration or otherwise, and shall pay that amount to the person who paid the fee”

 

4.2          This Regulation imposes  a duty on the GP to provide “essential services” to the person notwithstanding the fact that the GP practice has “reasonable doubts” that the practice contract requires the GP practice to treat the person.  However, in such a case the GP practice can impose a reasonable charge and recover this sum from the patient.  The exemption is also referred to in paragraph (d) of Schedule 5 to the GMS Regulations (and in like form in the PMS Regulations).

 

4.3          The reasonable fee will, of course, depend on the circumstances and the precise nature of the treatment provided.  The Regulations provide that the individual can then claim the fee back from NHS England if that person can prove they were on the list of patients for the practice at the relevant time.   NHS England will then claim the fee back from the GP practice if the patient was a “patient” of the practice.

 

4.4          The above provision only applies if a GP practice has “reasonable doubts” whether a person is on the practice list or not.  If the GP practice knows (without any reasonable doubt) that the patient is not on the practice list, then there is no duty to provide essential services to that person.  Hence if, for example, a patient has been removed from the practice list because they have moved away, registered with anther GP practice or have been violent, attends the surgery seeking treatment, the GP practice owes no duty to provide essential services to that person (unless there is a medical emergency) and can require the patient to leave the premises.  The person will be a trespasser and thus, if they do not leave, the person may commit a civil wrong.  If there is a suggestion of a breach of the peace the police can be called.

 

5.             Charges permitted by Schedule 5 of the GMS Regulations and Schedule 3 of the PMS Regulations.

 

5.1          The specific circumstances in which GP practices can impose charges on “patients”[8] is set out in Schedule 5 of the GMS Regulations (with like provision in Schedule 3 to the PMS Regulations) which provides as follows:

 

“The contractor may demand or accept a fee or other remuneration—

 

(a)     from any statutory body for services rendered for the purposes of that body's statutory functions;

 

(b)     from any body, employer or school for a routine medical examination of persons for whose welfare the body, employer or school is responsible, or an examination of such persons for the purpose of advising the body, employer or school of any administrative action they might take;

 

(c)     for treatment which is not primary medical services or otherwise required to be provided under the contract and which is given—

 

(i)     pursuant to the provisions of section 65 of the Act (accommodation and services for private patients), or

 

(ii)     in a registered nursing home which is not providing services under that Act,

 

if, in either case, the person administering the treatment is serving on the staff of a hospital providing services under the Act as a specialist providing treatment of the kind the patient requires and if, within 7 days of giving the treatment, the contractor or the person providing the treatment supplies the Board, on a form provided by it for the purpose, with such information about the treatment as it may require;

 

(d)     under section 158 of the Road Traffic Act 1988 (payment for emergency treatment of traffic casualties);

 

(e)     when it treats a patient under regulation 24(3), in which case it shall be entitled to demand and accept a reasonable fee (recoverable in certain circumstances under regulation 24(4)) for any treatment given, if it gives the patient a receipt;

 

(f)     for attending and examining (but not otherwise treating) a patient—

 

(i)     at his request at a police station in connection with possible criminal proceedings against him,

 

(ii)     at the request of a commercial, educational or not-for-profit organisation for the purpose of creating a medical report or certificate,

 

(iii)     for the purpose of creating a medical report required in connection with an actual or potential claim for compensation by the patient;

 

(g)     for treatment consisting of an immunisation for which no remuneration is payable by the Board and which is requested in connection with travel abroad;

 

(h)     for prescribing or providing drugs, medicines or appliances (including a collection of such drugs, medicines or appliances in the form of a travel kit) which a patient requires to have in his possession solely in anticipation of the onset of an ailment or occurrence of an injury while he is outside the United Kingdom but for which he is not requiring treatment when the medicine is prescribed;

 

(i)     for a medical examination—

 

(i)     to enable a decision to be made whether or not it is inadvisable on medical grounds for a person to wear a seat belt, or

 

(ii)     for the purpose of creating a report—

 

(aa)     relating to a road traffic accident or criminal assault, or

 

(bb)     that offers an opinion as to whether a patient is fit to travel;

 

(j)     for testing the sight of a person to whom none of paragraphs (a), (b) or (c) of section 38(1) of the Act (arrangements for general ophthalmic services) applies (including by reason of regulations under section 38(6) of that Act);

 

(k)     where it is a contractor which is authorised or required in accordance with arrangements made with the Board under section 126 (arrangements for pharmaceutical services) and in accordance with regulations made under section 129 (regulations as to pharmaceutical services) of the 2006 Act to provide drugs, medicines or appliances to a patient and provides for that patient, otherwise than by way of dispensing services, any Scheduled drug;

 

(l)     for prescribing or providing drugs or medicines for malaria chemoprophylaxis”

 

5.2          There is a like provision in Regulation 15 of the PMS Regulations[9] with the exceptions set out in Schedule 3 to those Regulations.    The particular circumstances relating to each of these exemptions is set out below.  APMS contractors are likely to have the same restrictions on charging and the same exemptions introduced through a contractual term.

 

6.             Charges for meeting the requirements of other Statutory bodies.

 

6.1          GP practices are under contract to NHS England.  They are obliged to undertake the functions set out in the contract but are not obliged to spend time responding to requests from other statutory bodies including local authorities unless the request is based on another form of statutory authority including, for example, requests under the Freedom of Information Act 2000.  In practice this it can often be difficult for GP practices to set out clear limits on what they are prepared to do because statutory bodies assume that GP practices have a duty to co-operate with them in the discharge of their public functions.

 

6.2          The right to charge for doing work in response to requests by other public bodies includes where a GP is asked to attend a Child Protection Conferences at the request of the local authority for a child who is a practice patient or the GP has seen.  The relevant Guidance from the RCGP provides:

 

“The contribution of GPs to safeguarding children is invaluable and priority should be given to attendance and sending a report wherever possible. GPs may claim a fee for attendance at Child Protection Conferences, under the Collaborative Arrangements for Work for Local Authorities 1974, to defray their expenses. Different arrangements exist in different areas: consult your health authority or Local Medical Committee for details”

 

6.3          The BMA explains that prior to the 2005-06 report, the Doctors and Dentists Review Body (DDRB) used to recommend national fees under the collaborative arrangements for doctors providing work in the field of education, social services and public health to local authorities.  They include a number of services provided in the community health service (particularly sessional work in family planning, see Fees Guidance Schedule 4) which were transferred to the NHS in 1974.  However following concerns from the profession that the existing fee rates were no longer economic and that many doctors had lost confidence in the collaborative arrangements system with a significant number refusing to work within the current fee scales, the DDRB ceased to recommend fees for this work.    The BMA therefore advises individual doctors and GP practices to establish and agree their own fees in advance of undertaking the work.

 

6.4          If a GP practice is asked to undertake work for any other statutory agency, the GP practice is entitled to levy a reasonable fee.  However no fee can be claimed if a GP is required to do something under a different statutory scheme (which may or may not give rise to a right to payment depending on that statutory scheme).  Hence if a GP is summoned to court as a witness of fact by the Crown Prosecution Service no fee is payable because the legal duty to attend arises from the summons.   It is, of course, different if the GP is attending court as an expert where fees can be claimed.

 

7.             Fees for conducting routine medical examinations.

 

7.1          It is not part of the duties of a GP to undertake medical examinations of persons who are not and do not believe themselves to be ill.  Hence the second exemption to the rule against charges in Schedule 5 provides that if an employer, a school or any other body asks a GP to do a medical examination of a well patient “for the purpose of advising the body, employer or school of any administrative action they might take”, a fee can be charged.  The request for such a service is outside the terms of the duty to provide “essential services” under a GMS or PMS contract and yet it is not in the interests of the patient for the GP to refuse to provide such a report.  Hence the Regulations allow the GP practice to charge a fee for this work.

 

7.2          If a patient of the practice asks for a medical examination to provide reassurance to an employer that they can undertake a physical job or a student wants a report to confirm he or she is fit to go on an expedition, the GP practice is entitled to charge a reasonable fee for this service.

 

8.             Services provided by a specialist GP for private patients in hospitals or a care home.

 

8.1          The third circumstance in which a GP practice can charge a fee in Schedule 5 needs a little explanation.  The wording is as follows:

 

“The contractor may demand or accept a fee or other remuneration—

 

 

(c)     for treatment which is not primary medical services or otherwise required to be provided under the contract and which is given—

 

(i)     pursuant to the provisions of section 65 of the Act (accommodation and services for private patients), or

 

(ii)     in a registered nursing home which is not providing services under that Act,

 

if, in either case, the person administering the treatment is serving on the staff of a hospital providing services under the Act as a specialist providing treatment of the kind the patient requires and if, within 7 days of giving the treatment, the contractor or the person providing the treatment supplies the Board, on a form provided by it for the purpose, with such information about the treatment as it may require;

 

8.2          There is no difficulty in a GP practice charging a fee for providing services to a nursing home or receiving remuneration for working in an NHS hospital if the patients who are being treated are not “patients” of the GP practice within the above definition.  However there are only very limited circumstances in which a GP practice can charge for medical services provided in a hospital or care home to practice patients or others who come within the above definition.  In order for the GP practice lawfully to be able to impose a charge under the above exemption:

 

a)             The location requirement must be met.  The services must be provided in either a registered care home or to a private patient in an NHS hospital.  This exemption does not extend to providing services in a private hospital;

 

b)             The services requirement must be met.  The services provided to the patient must not be “primary care services” under this exemption.  The meaning of “primary care services” is explored in chapter 7.  The fact that a general management service for a resident patient in a care home or a private patient in an NHS hospital is provided in the home rather than requiring the patient to come to the surgery does not take the service outside being a primary care service.   Thus charges can only be made if the service provided by the GP Practice is something which cannot properly be described as being a primary care service.  It thus effectively means that the GP is contracted by the care home (or private wing in an NHS hospital) to provide a service that is different to the services that GPs usually provide in the surgery;

 

c)              The person requirement must be met.  The person from the GP practice who is providing the services must be employed by a hospital providing services under the NHS Act as a specialist providing treatment of the kind the patient requires; and

 

d)             The procedural requirement must be met.  Within 7 days of giving the treatment, the contractor or the person providing the treatment must supply the Board with such information about the treatment as the Board may require on a form provided by the Board for this purpose.

 

8.3          This is the provision which is used by some GP practices to charge for providing medical cover to nursing homes.  If the patients at a nursing home are not registered patients of a GP practice (because they are registered with another practice) and do not come within the definition of “patients” as set out above, then there is no prohibition on a GP practice providing medical cover for the care home and charging for that service.  However if the residents are registered patients of the GP practice, the right to charge is strictly limited by the above 4 provisions.  This exemption probably only applies in practice to a partner or salaried doctor in a GP practice who is employed by a local NHS Trust to deliver a specialist skill and, as part of that work, finds himself or herself treating a patient from his or her own practice.  It is thus a very limited exemption.

 

9.             Payment for emergency treatment of traffic casualties.

 

9.1          Section 158 of the Road Traffic Act 1988 provides for very modest payments to any doctor who treats a victim of a road traffic accident.  It provides:

 

“(1)     Subsection (2) below applies where—

 

(a)     medical or surgical treatment or examination is immediately required as a result of bodily injury (including fatal injury) to a person caused by, or arising out of, the use of a motor vehicle on a road or in some other public place, and

 

(b)     the treatment or examination so required (in this Part of this Act referred to as “emergency treatment”) is effected by a legally qualified medical practitioner.

 

(2)     The person who was using the vehicle at the time of the event out of which the bodily injury arose must, on a claim being made in accordance with the provisions of section 159 of this Act, pay to the practitioner (or, where emergency treatment is effected by more than one practitioner, to the practitioner by whom it is first effected)—

 

(a)     a fee of £21.30 in respect of each person in whose case the emergency treatment is effected by him, and

 

(b)     a sum, in respect of any distance in excess of two miles which he must cover in order—

 

(i)     to proceed from the place from which he is summoned to the place where the emergency treatment is carried out by him, and

 

(ii)     to return to the first mentioned place,

equal to 41 pence for every complete mile and additional part of a mile of that distance”

 

9.2          This exemption to the general rules against charging practice patients only applies if a GP attends on a road accident on a road or in some other public place (i.e. not in the doctor’s surgery) and the victim happens to be a “patient” within the meaning of the above definition.  In such a case a GP who administers any treatment to such a patient is allowed to claim a fee of £21.30 from the accident victim and 41p per mile for any travelling over 2 miles.  The fee must be claimed from the patient and it can then be reclaimed from whoever caused the accident in the first place (unless that was the person being so treated of course).

 

9.3          If the person who is treated by the GP is not a “patient” of the practice then the GP can still claim the fee under section 158.  However this arrangement is entirely outside the contract and so there are no relevant restrictions on the GP.

 

10.          Fees for attending a police station.

 

10.1       Many GPs are under contract to the police service to attend police stations in order to provide healthcare services to those who are arrested or otherwise detained by the police.  There will, of course, be occasions where the person who the GP is called upon by the police to treat is a patient of the practice where the GP is a partner or works as a salaried doctor.  Exemption (e)(i) provides that a GP can still claim his fee (usually from the police) in such circumstances.

 

10.2       This exemption would also entitle a GP to claim a fee if he was asked to attend a police station by anyone else to see a patient of the practice (or any other person coming within the above definition of being a “patient”) including for example a solicitor for the patient.

 

11.          Fees for preparing medico-legal reports.

 

11.1       Paragraph (d)(ii) of Schedule 5 to the GMS Regulations provides that where a GP practice is asked to attend and/or examine (but not otherwise treat) a patient for the purpose of creating a medical report required in connection with an actual or potential claim for compensation by the patient, the GP practice is entitled to charge a reasonable fee.  

 

11.2       The fee can be payable by the patient or by the solicitors firm who have made the request, depending on the circumstances.

 

12.          Requests by patients who are about to travel abroad.

 

12.1       Where a patient asked for treatment consisting of an immunisation for which no remuneration is payable by NHS England (because it is not usually provided as part of NHS funded treatment) and which is requested in connection with travel abroad, a fee can be charged.  

 

12.2       Travellers also frequently request a prescription of drugs to prevent them from contracting a condition.  The GP practice can also charge for prescribing or providing drugs, medicines or appliances (including a collection of such drugs, medicines or appliances in the form of a travel kit) which a patient requires to have in his possession solely in anticipation of the onset of an ailment or occurrence of an injury while he is outside the United Kingdom but for which he is not requiring treatment when the medicine is prescribed.

 

12.3       A fee can also be charged for prescribing or providing drugs or medicines for malaria chemoprophylaxis.

 

13.          Fees for preparing reports for seat belt purposes, following a traffic accident, a criminal assault or for fitness to travel.

 

13.1       A fee can be charged where a GP practice is asked to undertake a medical examination to enable a decision to be made whether or not it is inadvisable on medical grounds for a person to wear a seat belt.

 

13.2       A fee can also be charged where a GP practice is asked to undertake a medical examination for the purpose of creating a report relating to a road traffic accident or criminal assault or that offers an opinion as to whether a patient is fit to travel.

 

14.          Eye examinations by GPs.

 

14.1       Part 6 of the NHS Act 2006 places a requirement on NHS England to arrange ophthalmic services for specific classes of people, notably those who are under 16, over 60, who are on state benefits or have defined medical conditions.  These services are generally delivered by opticians and not by GPs.  However, unlike other areas of NHS services, the ophthalmic service is not universal and there are individuals who are not included in NHS provision.  If such persons come to a GP practice then a fee can be charged for undertaking an eye examination.

 

15.          Dispensing doctors and scheduled drugs.

 

15.1       The last exemption in Schedule 5 of the MS Regulations only applies to dispensing GP practices.  It permits dispensing practices to charge a fee to patients if a “scheduled drug” is prescribed to that patient.  A “scheduled drug” means a drug which has been prohibited by the Secretary of State from being prescribed to NHS patients generally or has been prohibited for prescription as part of NHS funded treatment apart from a limited class of patients[10].  This is known as the “black list” or the “black/grey list”.

 

15.2       The list of drugs which cannot be prescribed in general practice in any circumstances is set out at Schedule 1[11] to the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc) Regulations 2004.  It includes substances such as cod liver oil and Allisons Wholemeal Flour.  The Regulations have been amended from time to time to add new substances to the list.  Click here for an up to date list of the substances on the current list.

 

15.3       Regulation 3 of the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc) Regulations 2004 provides:

 

“A drug, medicine or other substance specified in an entry in column 1 of Schedule 2 may not be ordered for a patient in the provision of medical services under a general medical services contract unless—

 

(a)     that patient is a person of a description mentioned in column 2 of that entry; and

 

(b)     that drug, medicine or other substance is prescribed for that patient only for the purpose specified in column 3 of that entry”

 

15.4       Thus substances on the list in Schedule 2 can only be proscribed for the specific conditions set out in the schedule.  Click here for the present text of schedule 2.  Hence, for example, this is the schedule which restricts the circumstances in which Tamiflu can be provided as part of NHS funded treatment.



[1] GMS stands for “General Medical Services”.  It is the default form of agreement for GP practices.  For details of the different types of contracts that a GP practice can hold please see chapter 3.

[2] PMS stands for “Personal Medical Services”, a form of GP Practice contract originally brought in by the National Health Service (Primary Care) Act 1997.  For details please see chapter 3.

[3] Please see chapter 7 for details of the range of services that a GMS or PMS practice is obliged to provide.

[4] Please see chapter 6 for details about how GP practice lists work and the persons to whom a GP is obliged to provide services.

[5] The electronic version of the National Health Service (General Medical Services) Regulations 2004 on the www.legislation.gov.uk website has not yet been updated to show all the changes made by the numerous amending regulations made since the Regulations were introduced in 2004.  The original Regulations are at http://www.legislation.gov.uk/ssi/2004/115/contents/made but the wording quoted in this chapter is the version which is current at 1 January 2014 when this chapter has been written. 

[6] There is a like provision in the PMS Regulations.

[7] There is a similar provision in the PMS Regulations.

[8] As that term is defined in the GMS and PMS Regulations as explained above.

[9] The electronic version of the National Health Service (Personal Medical Services Agreements) Regulations 2004 on the www.legislation.gov.uk website has not yet been updated to show all the changes made by the numerous amending regulations made since the Regulations were introduced in 2004.  The original Regulations are at http://www.legislation.gov.uk/ssi/2004/691/contents/madebut the wording quoted in this chapter is the version which is current at 1 January 2014 when this chapter has been written. 

[10] The GMS Regulations define a Scheduled Drug as (a) a drug, medicine or other substance specified in any directions given by the Secretary of State under section 28U of the Act(38) as being a drug, medicine or other substance which may not be ordered for patients in the provision of medical services under the contract, or (b) except where the conditions in paragraph 42(2) of Schedule 6 are satisfied, a drug, medicine or other substance which is specified in any directions given by the Secretary of State under section 28U of the Act as being a drug, medicine or other substance which can only be ordered for specified patients and specified purposes.

[11] The original Regulations are at http://www.legislation.gov.uk/uksi/2004/629/contents/made.  However

David Lock QC

David Lock QC is a barrister at the Landmark Chambers.

180 Fleet Street
London, EC4A 2HG
DX 1042 (London)

He was called to the Bar in 1985 and was appointed Queens Counsel in 2011.

David Lock QC is Head of the Administrative & Public Law Group and the Judicial Review & high Court Challenges Group at No5 Chambers. - See more at: http://www.no5.com/barristers/barrister-details/137-david-lock-qc/#sthash.PcnGl1Eh.dpuf

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