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.

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.

The LMC is not able to endorse (or not) any clinic or consultant, but we would advise appropriate due diligence before making a referral to any colleague, bearing in mind the principles above.  Practices may also find it helpful to have their own information available to patients outlining the approach taken to these requests, with particular attention to shared care requests.

Parent’s Right to NHS Referral for Neurodevelopmental Assessment

We are aware that some schools may be directing parents of children needing assessments for autism/ADHD to them for Right To Choose referrals, rather than referring them to local services themselves.

We have written to the Education team there to advise them that doing so raises some issues for practices. It creates an extra process step for families, and makes a demand on limited GP capacity. We have also advised them that whilst a RtC provider might offer speedier diagnosis, GPs may well not be able to take on any subsequent prescribing requests as many do not meet our recommended standards for shared care agreements. As such, the benefits of the quicker diagnosis do not include more rapid access to medication.

We continue to reflect both locally, and nationally, that the commissioning arrangements for the assessment of these very important conditions is lacking and that this creates very significant difficulties for patients, their families, and their GPs.  Please see attached link to a template letter that practices could use to reply to such requests from Schools which we hope you find helpful.

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