Why does my GP charge me?

Eighth in the How GPs are paid series.

Every practice has had the conversation. A patient is asked to pay £30 for a letter — holiday cancellation, gym membership, “fit to skydive” — and is understandably cross: I thought the NHS was free? Meanwhile the same week, the same practice will have absorbed hours of unpaid work it’s legally forbidden from charging that patient for. The rules here are stranger than either side realises.

The bit that is free, full stop

The law is unambiguous. Under the GMS Contracts Regulations, a practice “must not… demand or accept from any of its patients a fee or other remuneration” for treatment — under the contract or otherwise — or for a prescription. Not for a consultation, not for a jab that’s part of NHS care, not for anything that counts as looking after your health. If you’re registered with the practice, your medical care there cannot be sold to you at any price. Full stop.

The bit that was never NHS work

What practices can charge for is a defined list of exceptions: reports and medicals for employers, insurers and other third parties, certain certificates, travel vaccinations the NHS doesn’t fund, fitness-to-travel letters and the like. The BMA’s summary draws the line neatly: treatment can never be charged for; things that aren’t treatment — paperwork produced so somebody else can make a decision about you — can be. Your travel insurer wants the letter; your travel insurer isn’t paying for it; the NHS certainly isn’t; so you are. The fee isn’t your GP monetising your illness. It’s the only part of the operation where the practice is allowed to behave like the small business it legally is — and it’s a rounding error in the accounts.

The asymmetry nobody notices

Now the strange part. An NHS consultant can see you in an NHS clinic on Tuesday and, entirely within the rules, operate on you privately on Thursday. The consultant contract has explicitly permitted private practice alongside NHS work since 2004, subject to NHS commitments taking precedence; the BMA’s guidance notes consultants don’t even need their employer’s permission, merely to disclose it. Roughly half of England’s consultants did some private work at the last broad estimate, a decade ago; around 13,400 were formally active in private practice in 2025.

A GP has no such option — not for their own patients. A practice may see private patients, but not anyone registered with it; since 2019 it can’t even advertise private services of a GP nature; and the obvious workaround — a separate private company down the corridor — is, in the BMA’s words, likely to fall foul of the regulations. The one doctor in the system with a personal list of patients is the one doctor banned from treating them privately. You can argue that’s exactly as it should be — it stops a GP running down NHS access to sell the queue-jump, a conflict the hospital system has simply chosen to live with. And to be fair to consultants: they’re salaried, they draw no partner profit and no notional rent, and their contract polices the conflict in other ways — the comparison is about the rule, not the people. But notice which profession carries the harder rule, and which gets accused of profiteering.

“Doing a dentist”

Which brings us to the conversation now happening out loud. NHS dentistry showed what the endgame looks like when a profession of independent NHS contractors stops believing the contract adds up: by 2022 nine in ten NHS dental practices weren’t accepting new adult NHS patients. General practice has started asking whether it’s on the same road. The UK’s private-pay GP market is already worth around £1.6 billion, with LaingBuisson estimating that 13% of GP consultations are now paid for privately, up from 3% in 2009 — an estimate whose method they don’t publish, which practitioners in the sector think is high, and which almost certainly counts insurer- and employer-funded digital consultations rather than patients paying at the desk. After the imposed 2026/27 contract, 62% of GPs surveyed said they were more likely to increase private work, and a quarter already do some — for patients not on their own lists: private clinics elsewhere, medico-legal work and the like. And in May, GPC England voted overwhelmingly to ballot the profession on a “Plan B” — explicitly including “a means-tested, subscription-based service, such as those being offered currently by NHS dentists”. The committee’s stated reason: confidence in the viability of GP livelihoods within the NHS is “at an all-time low”.

I’d read that ballot as a symptom, not a plan. Most GPs I know have no appetite for a two-tier front door; the registered list, free at the point of use, is the thing we’re proudest of, and dentistry is a cautionary tale as much as a template — ask anyone who’s tried to find an NHS dentist. But symptoms are information. When the profession that’s banned from going private starts formally studying how it might, the interesting question isn’t whether GPs have become greedy. It’s what happened to the deal that used to make the question unnecessary. Everything earlier in this series — the risk, the workload, the formula — is that answer, in instalments.

If this article was useful, the workshop version is better. Howbeck Healthcare — where I’m a director — runs sessions on how general practice and the primary care marketplace work: one to three hours online with your team, or a half or full day in person, bespoke to your organisation, with guest speakers from our network of senior NHS leaders where needed. Practices, PCNs, pharma, IT and service companies all welcome. Details and contact.

Updated 1 September 2026: scope note added to the LaingBuisson figure after a reader challenge on LinkedIn.

Sources: GMS Contracts Regulations 2015, regs 24–25; BMA — what practices can and cannot charge for; DHSC — Code of Conduct for Private Practice; BMA — consultants and private practice; BBC — consultants’ private work; PHIN — private market update; BMA — private practice and GP contracts; BBC — NHS dentistry access; LaingBuisson — private GP market; Pulse — GPs and private work survey; BMA — GPC England “Plan B” vote. England only, except the private-market figures, which are UK-wide.