Self-funded patients and the blurred NHS/private boundaries: a case-by-case study
The number of patients paying for private care to jump the queue has exploded in the previous few years and this has left a number of medicolegal grey areas for GPs. The Medical Defense Society takes a look at a few of the more common scenarios GPs may face
This is part of the Pulse Partners series. This article has been paid for by the Medical Defense Society, with editorial input by Pulse. The opinions in this article do not necessarily reflect the views of Pulse.
With sustained pressure on NHS services and long waits for appointments, patients are increasingly seeking faster access to healthcare, and many are prepared to pay for it. Self-funded, pay-as-you-go care is now an established feature of healthcare delivery, but it brings significant challenges for GPs.
A 2025 YouGov survey found that one in seven Britons had used private healthcare in the previous year, and around half of those (54%) paid out of pocket rather than using private medical insurance. Many patients move back and forth between NHS and private services, selectively paying for appointments, tests or treatments while still receiving care from an NHS GP.
For patients, this flexibility may feel empowering. For general practice, it increasingly blurs the traditional boundaries between NHS and private care. At Medical Defense Society, we see how this creates daily clinical, contractual, ethical and medico-legal dilemmas for GPs, often without sufficient clarity or support. We hear from GPs who encounter these issues when patients attend one or two private consultations and then return to NHS care with expectations about follow-up.
A 2023 survey by Pulse highlighted GPs’ concerns about the growing, unfunded workload arising from requests by private providers for patient information, prescriptions, investigations, referrals and ongoing monitoring of privately initiated medicines. Managing correspondence from multiple private companies adds layers of administrative complexity, often without clear contractual responsibility.
This creates medicolegal issues. Some of this is addressed in 2009 Department of Health guidance entitled NHS patients who wish to pay for additional private care. This set out key principles designed to preserve equity and protect NHS resources; that there should be as clear a separation as possible between NHS and private care; that private and NHS care should be distinct in terms of funding, legal status, liability and accountability; NHS should never contribute towards the patient’s costs of private healthcare, with the patient (or their insurance) fully funding the care; and that patients remain entitled to NHS services on the basis of clinical need, even for the same condition for which they are seeing a private provider about.
The guidance was published before the huge increase in self-funded care that we see today. Perhaps more pertinent is the BMA’s guidance for handling private provider requests, titled General practice responsibility in responding to private healthcare.
The BMA guidance sets out useful parameters. GPs will have different approaches when dealing with patients who are using private healthcare. We will take a look at three different cases that GPs will commonly encounter, and the medicolegal and contractual issues around approaches taken by three GPs in each case: Dr A, who refuses to engage with any requests from private provider; Dr B, who is amenable to fulfilling all requests from private providers; and Dr C, who takes the most common approach doing what she considers to be ‘reasonable’ based on the circumstances of the case.
Case 1: Shared care arrangements for adult ADHD
Adult patient has received a diagnosis of ADHD from a private provider that has not been commissioned through the NHS (eg, this hasn’t been commissioned through ‘Right to choose’). Provider requests that the GP enter into a shared care arrangement with the private provider for ongoing provision and monitoring of medication in the NHS.
Dr A refuses to engage. She says that she does not have the requisite expertise to manage and monitor specilised medication. Moreover, she has a distrust of the private provider in this case, concerned they are making a diagnosis that is in their own best interests. Dr B agrees to all the requests by the private provider. He feels that, while not a specialist, the arrangement with the private provider seems strong enough and he is happy to give the patient what they need. Dr C is uncomfortable with the specialised medicine, but comes to an arrangement with the private provider around responsibilities that she believes is clinically safe and covers her from a medicolegal point of view.
Confusion around the boundaries commonly arises in treatment areas where NHS access is limited or eligibility criteria are tightly defined. For example, with patients facing long waits for attention deficit hyperactivity disorder (ADHD) services on the NHS, rising numbers are seeking initial diagnosis and treatment in the private sector and then requesting follow-up in the NHS.
While NICE guidance for ADHD states that this care should be provided under Shared Care Protocol arrangements with primary care, the BMA cautions that Shared Care is an NHS service and is not recommended with private providers. Nevertheless, the advice adds: ‘Shared care may be appropriate where private providers are providing commissioned NHS services and where appropriate shared care arrangements are in place.’
The BMA is clear that GPs have no obligation to enter into a shared care agreement and may decline for any reason, including on clinical safety or capacity grounds. In this scenario, the GP would need to explain carefully to the patient why shared care is not possible and clarify the options for ongoing care, which may be a complete transfer to the NHS or continuation with the private provider.
In this case, patients can be understandably distressed to learn that Dr A may be unable, or unwilling, to take on these responsibilities. If a patient from the outset advises their GP that they are going private then this is an opportunity for the GP to explain to the patient setting down parameters what the GPs role will be and what the private provider role will be. Having such conversations reduces the risk of straining the GP-patient relationship and leaving clinicians exposed to complaints or allegations of unfairness which Dr A may well be expecting. But Dr A is well within her rights to not enter into the arrangement.
Case 2: Tests ahead of fertility treatment
A couple who have been trying to get pregnant for six years have had one unsuccessful round of IVF through the NHS. They have now paid for private fertility treatment. As money is tight for them, the private provider suggests they get whatever tests they can through the NHS. Dr A refuses, stating that all tests related to their private infertility management should be arranged privately. Dr B agrees to arrange whatever tests are possible. Dr C is open to arranging tests that she would have done as part of her NHS work.
In support of Dr A’s approach, the BMA reminds GPs that complying with such requests would be outside the scope of NHS GMS contracts.
But there is scope for the GP to support the couple. The BMA guidance states that a GP should only proceed if they are the responsible doctor, if they judge the pre-treatment fertility investigations to be clinically appropriate, and if they are competent to interpret the results and manage the patient’s subsequent care. If any of these requirements is not met, they should advise the patient and private provider to make alternative arrangements. However, this can be a challenging situation when the private provider has set the patient’s expections early on.
In this case, Dr C has correctly identified that some of the tests suggested by the private provider are not recommended by the NHS, and are usually only provided by private providers as add ons. However, there are some tests that are approved as aiding fertility treatment. As Dr C is the responsible doctor, the tests are locally funded by the NHS and the GP considers herself competent to interpret the results and manage subsequent care outside of the fertility treatment, she is able to book the tests and is covered from a medicolegal standpoint.
Case 3: Request for information around tirzepatide
A patient seeking to lose weight wants to purchase tirzepatide privately from an online provider but needs information from his GP. However, it becomes apparent to Drs A, B and C that the patient’s medical history does not tally with the information the patient gave to the online provider.
To safely prescribe in accordance with Good Medical Practice and the General Pharmaceutical Council guidance for online services, prescribers must independently verify the patient’s medical history, including body mass index. This commonly leads to a request for the information from the NHS GP. With the patient’s consent, the GP may comply with the request.
However, in this case if the patient does not consent, the GP should prioritise clinical safety and professional transparency. The GP must first address the medical risks directly with the patient, warning them that providing inaccurate history to obtain Tirzepatide could lead to severe adverse effects. If the patient refuses to allow the GP to share the correct medical data with the private provider, the GP should still notify that provider of a general clinical ‘safety concerns’ without disclosing specific details. This approach fulfils the GP’s duty of care while shifting the legal and clinical responsibility for the prescription back to the private prescriber, who is ultimately accountable for verifying the patient’s suitability for the medication.
Such a situation creates potential difficulties for the GP’s relationship with the patient. For many GPs, the volume of these requests often adds to existing workload concerns. We recommend referring to the BMA advice in Focus on Tirzepatide (Mounjaro) for Weight Management in General Practice, which urges providers to encourage patients to share their on-line medical records directly.
Mitigating the risks
For GPs, the threat of complaints and litigation remains ever-present when their patients receive care across the divide between NHS and private practice. There are medicolegal risks involved, and these vary on a case-by-case basis.
But there are some key principles for GPs when faced with requests from private providers; they should never work outside of their competence and expertise; they are indemnified only for work within their core GMS responsibilities, unless there are specific local arrangements (ie, a local enhanced service); and that patients who have had private treatment are eligible for NHS care for the same condition if clinically appropriate.
If GPs are providing care outside their core contract, they will not be covered by the state indemnity schemes. They remain responsible for ensuring they have adequate and appropriate protection for the full scope of their practice, including any private work. Confusion about indemnity cover is common, particularly when care straddles NHS and private settings, so expert guidance is crucial.
It is important to remember that indemnity follows the funding and contractual responsibility, not the physical setting. Self-funded care is usually treated as private work for indemnity purposes, whereas state-backed cover applies to core NHS services, even if the patient has previously been treated privately for the same condition. Clear contracts and a clear understanding of who owes the duty of care are essential. We advise GPs to contact their indemnity provider for clarification if in doubt.
Self-funded care is not inherently problematic in general practice. Problems arise when NHS and private services are not properly separated in terms of funding, legal status, accountability and liability. We suggest that GP practices establish a policy to uphold the distinction between settings, particularly regarding more contentious issues such as managing requests from private providers, and to ensure consistency between the various clinicians in the practice.
Many of the difficulties described here could be avoided if expectations were set clearly from the start, in private consultations and in general practice. Patients need to understand what paying privately does, and does not, mean for their ongoing NHS care.
With GPs under intense pressure, working in an increasingly complex landscape, the risks are evident. Clear policies, transparent communication and timely medico-legal support remain the most effective safeguards we have.
