NHS Right to Choose

We are often approached about services being offered to patients under “NHS Right to Choose,” especially regarding organisations that offer this service to patients from outside the Cambridgeshire & Peterborough area, and for conditions that have very long local waits for assessment, such as ADHD, autism and gender care.

The NHS constitution makes clear that “you have the right to make choices about the services commissioned by NHS bodies and to information to support these choices”.  Patients are entitled to choose where they attend for a first appointment as an outpatient when referred for care: both the provider, and the clinical team within that provider.  There are some principles around this choice to bear in mind:

• Patients can choose their referral destination, but the decision to refer remains a clinical one, and a GP can decline to make an NHS referral if they do not feel it is clinically appropriate. Such a decision would of course need discussion with the patient/their carer and be carefully documented.
• The service must be led by a consultant, or a mental health professional.
• The provider must have an NHS contract for the service being referred to, but this does not have to be based here in Cambs.
• This applies to a first referral for a condition, and not if ongoing care has begun.
• It does not apply to emergencies, crisis care, urgent cancer assessments or other urgent care.
• If the referral involves an onward, second referral to another provider, we would consider that the responsibility of the specialist, and not a task to be passed back to the GP.  As such, the specialist would need to respect “Right To Choose” guidance themselves.

Further information about the framework around Right To Choose is available here.

Patients may ask for input into their choices from their doctor, and may note the following from the gov.uk website linked to above:

We’re asking all referrers to ensure they shortlist on average 5 choices from which the patient may choose, where this is practicable, clinically appropriate and preferred by the patient.

Practices may wish to make their own assessment of practicability if met with such requests, and that assessment would reasonably include strong consideration of the extreme pressures being faced by both clinicians and their administrative teams at the present time.  The LMC would support a practice that felt that this “ask” was unsustainable currently.  Our view is that it would be important to ensure that a service was one that met the criteria for Right to Choose and that the referral itself was clinically appropriate, but detailed research around multiple providers is an excessive demand.

Providers may request investigations to be done before they see the patient; this is particularly the case for those who offer their services remotely.  Investigations should be undertaken based on clinical need, as presented to the GP by the patient.  We would expect Right To Choose providers to be aware of the contractual basis under which GPs work and have their own commissioned arrangements for investigations that their services require.

Some providers operating under Right to Choose may insist upon GPs providing specific investigations or referring using a particular online portal or form.  There is no contractual basis for such an arrangement to be directed; whilst it is important for GPs to provide all the necessary referral information that is clinically indicated, this can be via a conventional letter, and it is for the provider to manage how they process that information.

It is also important for practices to remember that the principles in our guidance around shared care apply to these services.  Many will ask practices to take on prescribing medication after assessment.  We would remind all GPs that shared care arrangements require agreement from specialist, patient and GP and the principles around those are well established for patient safety.  We would advise that shared care is dependent on ongoing specialist input, and there is no obligation to take these on if there are concerns about the safety of the arrangement.

A common enquiry made to our office concerns shared care requests made by Right to Choose providers, most commonly relating to ADHD medication.  This can be as a result of uncertainty over whether these providers are offering NHS or private care.  The principles relating to this are as follows:

For 1) and 2), shared care arrangements apply and are funded for patients via the Local Commissioning Agreement.  The ICB has released a list of providers that they have quality assured at the time of writing, but patients can choose to go to any provider who offers a service under the Right to Choose framework (if they hold an NHS contract anywhere, they can offer this).

You can still decline shared care if you feel it is unsafe for that individual patient, and we would recommend any offered agreement is carefully checked to ensure compliance with the established principles.  In particular, if a patient is discharged from the specialist provider, they cannot be said to be receiving shared care.  

For 3), there is no NHS involvement and whilst a private provider offering a privately funded service can ask for shared care to be put into place, the BMA guidance is that this should not be entered into by the practice, and we support that.

The challenge of course is that many providers offer both 2) and 3) to their patients, and others may offer 1) to patients local to them.  In this case you would need to be clear as to the referral route.  Whilst a GP referral may not be needed for a wholly private referral, it is for a referral under Right To Choose. By definition if a patient has self-referred it is not NHS care.

It is also important to remember that Right To Choose (capital letters) is a formal NHS arrangement, but it is not a universal right to choose (small letters) your care pathway outside of its parameters.

The LMC cannot endorse any clinic or consultant, but we would advise appropriate due diligence before making a referral to any colleague, bearing in mind the principles above.  The ICB has compiled a list of Right To Choose providers for ADHD assessments that they feel offer an appropriate standard of care.   This list places no obligation on the GP around care over and above our guidance, but may be helpful if patients enquire about providers.

Practices may also find it helpful to have their own information available to patients outlining the approach taken for these requests, with particular attention to shared care requests.

Please contact office@cambslmc.org should you require any additional advice or support.