Understanding "Right to Choose" for ADHD and Autism Assessments: A Guide for GPs
As a General Practitioner (GP), it is important to be aware of your patients' legal right to choose where they receive their NHS treatment, particularly for conditions like Attention Deficit Hyperactivity Disorder(ADHD) and autism assessments. This "Right to Choose" (RTC) is part of the NHS Constitution for England and aims to give patients greater control over their healthcare.
What is the Right to Choose (RTC)?
The national NHS Right to Choose (RTC) Framework allows patients to select their NHS-funded healthcare provider when referred by a GP or another professional for their first appointment. This right applies to suitable physical or mental health services. It means patients can choose any qualified provider in England, including NHS organisations, private, and independent providers, as long as they are commissioned by the NHS to offer the required service. The NHS Constitution specifically states that patients have the right to choose the provider and team they are referred to from all those who have a contract to provide the service.
When Does the Right to Choose Apply for ADHD/Autism Assessments?
For your patient to exercise their Right to Choose for an ADHD or autism assessment, the following conditions must typically be met:
- The patient is receiving an NHS referral for their first outpatient appointment.
- The referral is made by a GP. (For other needs, a dentist or optometrist can also refer).
- The service and team are led by a consultant or a mental healthcare professional.
- The chosen provider holds a commissioning contract with any Integrated Care Board (ICB) or NHS England for the required service. This means the provider must be commissioned by the NHS in England.
- The referral is clinically appropriate. This is a clinical judgement about what is in the patient's best clinical interests, guided by published National Institute for Health and Care Excellence (NICE) guidelines and specifications.
When Does the Right to Choose NOT Apply?
There are specific circumstances where the Right to Choose does not apply:
- The patient has self-referred.
- The patient needs urgent or emergency (crisis) treatment.
- The patient is already receiving mental health care following an elective referral for the same condition. However, if there's a second referral after a previous NHS diagnosis, it must be supported by new evidence or symptoms not previously considered.
- The organisation or clinical team chosen does not provide the right care for their condition.
- The patient is a member of the armed forces.
- The patient is a prisoner or on temporary release from prison.
- The patient is detained under the Mental Health Act 1983.
- The patient is detained in a secure hospital setting or "other prescribed accommodation" (e.g., court, secure children’s home, immigration removal centre).
- The service is commissioned by a local authority outside a joint commissioning agreement, or is delivered through primary care.
Your Role as a GP in Facilitating Choice
As the referring GP, you play a central role in enabling patient choice.
- Discuss Options: You should have a conversation with your patient to discuss their options for hospital or service choice, considering their preferences regarding waiting times, quality of service, location, or previous experience. You should be able to offer a range of clinically appropriate providers.
- Clinical Appropriateness: It is your responsibility to decide what is clinically appropriate when offering choices. You should consider the patient's personal circumstances, any co-morbidities (such as depression, anxiety, or dyslexia often seen with ADHD), continuity of care, and whether the patient would benefit from advocacy services.
- Information Sharing: You should discuss how the patient would be able to travel to and from the provider if they choose one outside their local area. While providers of community services are not obligated to travel to the patient, patient travel costs may be refundable for eligible low-income individuals.
- NHS e-Referral Service (e-RS): This system is a primary means for referring patients to outpatient services, including mental health services. It allows you to view available providers, send referral information electronically, and enables patients to book appointments. You can create a shortlist of options for the patient to choose from.
Information to Help Patients Choose
Patients can find information to help them choose on the NHS website (www.nhs.uk). This includes details on quality of care, waiting times, parking, and travel. Providers are contractually required to publish relevant services and appointment slots on e-RS and make service information available on NHS Choices.
What Happens After the Assessment?
If an ADHD diagnosis is made, the specialist will discuss what it means and the next steps, including available help and support. Management options include lifestyle changes, workplace adjustments (e.g., quiet workspace, written instructions, help with task planning), and medicines.
Regarding medication for ADHD:
- ADHD medicines (like methylphenidate or lisdexamfetamine) must be started and monitored by an ADHD specialist.
- Initial costs for medication are covered under RTC.
- After the titration period, the RTC provider will send a Shared Care Protocol (SCP) to the patient's GP for them to consider taking over regular prescribing.
- If your practice takes over prescribing, the RTC provider must continue to provide annual (or more frequent) reviews and monitoring.
- It is important to note that not all RTC providers can start drug therapy or prescribe medication, with some only offering assessment or diagnosis. If they don't, the patient might need to remain with a private provider longer-term or seek a new assessment if the provider no longer offers care.
Addressing Waiting Times and Potential Changes
Referrals for autism and ADHD assessments have significantly increased, leading to long waiting times. Right to Choose allows patients to be referred to independent providers with NHS contracts, which often have shorter waiting lists.
If your patient is likely to wait longer than the maximum waiting time for treatment, they have the legal right to ask for their appointment to be moved to a different provider that can see them sooner. Research suggests that exercising choice can potentially reduce waiting times by up to three months.
What if Choice is Not Offered or There Are Concerns?
You should always offer choice at the point of referral. If you or your patient feel that choice has not been offered, the patient can speak to you initially. If the issue persists, they can complain to their local ICB, who are responsible for ensuring patients are given choices. Ultimately, complaints can be taken to the independent Parliamentary and Health Service Ombudsman.
If you do not feel a service is appropriate, you can explain this to the patient. Ultimately, it is their choice. A referral for Right to Choose does not mean that you are obliged to accept to share care with that provider.
For more detailed information, you can direct patients to the Department of Health, or NHS England Guide to Right to Choose, for specific guidance on ADHD/autism assessments.
