The Right to
Choose still
exists — the NHS
has just stopped
funding it

A cap with a quiet name — what an Indicative Activity Plan actually does

Nobody abolished Right to Choose. No minister stood up and announced that the legal route thousands of people used to escape decade-long NHS waiting lists was closing. Instead, in March 2026, NHS England published a payment scheme document aimed at finance and costing teams, and asked Integrated Care Boards to agree something called an Indicative Activity Plan with every independent provider delivering ADHD and autism assessments under the choice framework.

An Indicative Activity Plan sets three things: how many assessments a provider is expected to deliver in the financial year, the maximum time people should wait, and how much funding is available to pay for it. The contractual basis sits in the NHS Standard Contract 2026/27, which grants ICBs the authority to set these plans. A provider can still accept your referral. It can still add you to its waiting list. What it cannot do, once its funded allocation is spent, is assess you.

The 2026/27 payment guidance also introduces guide prices for the first time: £850 for a face-to-face adult ADHD assessment, £700 virtual, £1,150 for an adult autism assessment, £1,350 for a child’s. These are described as non-mandatory. But a benchmark price plus a capped activity volume equals a budget — and a budget, divided by demand, equals a queue. The Directory covered the arrival of the price benchmark when the NHS refused to pay above roughly £2,000 for assessments, creating a two-tier system in the process. The 2026/27 scheme completes that move. On 9 October 2026 the government said NHS England will consult on a national tariff for autism and ADHD services — covering assessment, post-diagnostic support and follow-ups — with new payment arrangements it intends to introduce from April 2027. The price is now standardised, the volume is now capped, and the pathway pays out only on completion — the guidance states plainly that there is no payment for patients who do not complete the pathway to a diagnostic outcome report.

Hold the two halves of the same document side by side, because they do not know about each other. Requirement five of the commissioning standards instructs that service offers must be communicated to patients via primary care at the point of referral, per Patient Choice Guidance: GPs should explain which providers are available and what each can deliver, so patients can make an informed choice. The same scheme then equips ICBs to cap what any of those providers may actually deliver. The choice must be offered; the chosen thing need not exist in any funded sense. And because payment lands only on completion, a provider holding a capped allocation and an uncapped waiting list carries every incentive to keep accepting referrals it cannot progress — the list costs nothing, signals demand for next year’s negotiation, and pays out the moment funding reappears. The queue is not a malfunction of this design. It is the design’s storage format.

It is worth noticing the register the commissioning document itself uses. ADHD is defined as a syndrome of deficits across executive function domains; autism is defined through ICD-11’s persistent deficits in social communication. That is reported here straight, not endorsed — but it tells you which model of the person the money is organised around.

The postcode ledger — Hampshire, Kent, Bristol

What the national guidance permits, local systems are now doing — unevenly, which is the point.

Hampshire and the Isle of Wight. The ICB has implemented Indicative Activity Plans across all Right to Choose providers serving its area. Its own review found that Right to Choose accounts for around 27% of everyone waiting for an assessment, and that people on that pathway have typically waited considerably less time than those queued for local services. The stated remedy is alignment: RTC patients will now only be offered an assessment in 2027 if they meet prioritisation criteria, and the same applies to new referrals through 2026/27. The faster route was not used as a model for the slower one. The faster route was slowed to match.

Kent and Medway. Providers have told patients that new Right to Choose bookings cannot be made until additional funded activity is confirmed. Psicon has informed people already on its list that routine RTC assessment activity is not expected to resume before April 2027 — queue positions protected, queues not moving. Clinical Partners reports the same instruction: referrals remain open, held safely, unbookable.

Bristol, North Somerset and South Gloucestershire. Freedom of Information responses show the mechanism in working order. Letters went to independent providers in June 2025 proposing activity figures for anyone whose forecast spend exceeded £50,000. In September, providers received a priority order the ICB would fund — already-diagnosed patients, prescribing and titration first — with the ICB itself expecting that people waiting for assessments, and all new referrals, would be held on lists for the remainder of the year. An Equality and Health Inequality Impact Assessment was completed. The waits were assessed for their impact on equality, and then implemented anyway.

And where the caps meet pre-existing under-commissioning, the arithmetic turns absurd. The Retreat Clinics in York, commissioned to triage an estimated 60 referrals a month, report receiving four to five times that — and now publish waiting times of 4.5 years for an autism assessment and 5 years for ADHD, with a 21-month delay before a referral is even triaged. Those are the honest numbers of a system whose demand was priced at a fraction of its size and whose overflow valve is now being welded shut.

Leicester, Leicestershire and Rutland has published the same framework in gentler language. Psychiatry-UK, the largest RTC provider, now maintains a postcode checker so you can find out whether your GP’s location has quietly extended your wait beyond March 2027. Compare this with the FOI data on what ICBs were spending before the caps arrived, and the shape of the ledger is clear: the pathway grew because local NHS services could not meet demand, and it is being capped because it succeeded.

A right preserved in form, hollowed in function

The Directory has argued before that formal entitlements can function as alibis — structures that exist so that institutions can point at them while declining to actually resource them. Right to Choose is becoming the cleanest example of that on record. The NHS Choice Framework is untouched. Your GP can still refer you to the provider of your choice. Every element of the legal architecture stands, and every element of the funded architecture underneath it has been removed or metered.

This is the same manoeuvre visible elsewhere in the system. The Ombudsman’s audit of ADHD and autism services found people fighting the system rather than using it. The proposed EHCP reforms would preserve the language of support while removing its legal teeth. Charities have begun charging £2,000 for the assessments the state will not fund. And the waiting lists this rationing feeds are not abstractions: at current throughput some services face backlogs measured in millennia, and the cost of being found late is written in the mortality data.

The justificatory narrative is demand. Referrals have surged; budgets are finite; something must give. The Fonagy Review’s interim report — which the payment guidance itself cites as pending — has already been used to float the idea that diagnosis is “incentivised”. The Directory has examined what is actually driving rising identification, and it is not a fashion. But notice what the rationing logic requires you to accept: that when a statutory right produces more uptake than the budget anticipated, the correct variable to adjust is the uptake.

I wrote about this pathway at length in The Neurodiversity Book, and the argument there was that Right to Choose was never the mechanics of specialist care delivered through another channel — it was the mechanics of invoice processing. No NHS capability gets built, because the pathway exists precisely to make building it unnecessary. Freedom-of-information data across all forty-two English integrated care boards put NHS private spend on these assessments at no less than £512 million, more than doubling in a single year; of the forty-two, only four could say what that money actually bought, and only four could report their waiting times. A system that cannot say what it purchased with half a billion pounds is not commissioning healthcare. It is paying invoices. That was the figure at the time of writing; the rebuilt dataset puts it at at least £523.5m with private and independent ADHD and autism providers across 2023/24, 2024/25 and part of 2025/26.

What I could not know when I wrote that is how the invoice-paying would end. It ends here, and the shape it takes is the one the argument predicted. A loop that closes outside the system — where the response reroutes the demand without touching the condition that produced it — has no completion state. It has only a budget line, and budget lines get capped. The capability that was never built cannot now absorb the people the cap turns away, so they go back to the queue they left, to prove an already-proven condition to whichever provider still has allocation, performing their own deficits a second time because the architecture shifted beneath them. That is not a new failure. It is the same loop, one turn tighter.

And there is a distinction worth holding, because it explains why none of the softening language helps. Look at everything the file grants a person in this system: the adjustment, the extra time, the quiet room, the prioritisation criterion, the dosed molecule. Every one of them is a means of securing participation. Not one of them is a means of not participating. The modern apparatus licenses accommodation; it has never once licensed abstention. So a right framed as choice was always only ever a choice of queue — and a choice of queue is the first thing a commissioner can ration without touching the word.

The criteria nobody holds

Here is the detail that ought to be the headline and will instead end up in a footnote. Hampshire and Isle of Wight ICB, in its own published FAQ, confirms that no formal, standardised prioritisation criteria are held centrally by the Integrated Care Board. Prioritisation of Right to Choose referrals is set by individual providers, and may vary. GP practices with questions are directed to ask the relevant provider.

Sit with that. Assessment for neurodivergence in 2027 is conditional on meeting prioritisation criteria. The body imposing the condition does not hold the criteria. The criteria differ depending on which company holds your referral. There is no published threshold to appeal against, no common standard to fail, no document a patient can read to learn why the person ahead of them was seen and they were not. Rationing is at least an honest word. This is rationing by criteria that exist nowhere in particular — a decision rule distributed across private providers, each solving its own capped budget in its own way, with the ICB pointing at the providers and the providers pointing at the funding envelope. A coroner’s report on a three-year ADHD assessment wait in Cheshire found a gap one step earlier — no NICE recommendation on how expedited assessment requests should be judged.

A system that caps a legal right, delegates the triage of that cap to commercial contractors, and holds no central record of how the triage works has not managed demand. It has laundered a refusal. The right remains on the statute book because removing it would require a decision someone could be held accountable for. What has been built instead is a structure in which the refusal happens everywhere and is decided nowhere — and the only document that names it is a payment scheme written for finance teams, published in March, and read by almost no one it applies to.

Walk the whole loop looking for the person doing this to people and you will not find them. The ICB is legally required to balance its books and has no capacity to commission instead. The provider is holding a list it would rather be working through. The GP is inside a remit that narrows every year. The finance team drafting the activity plan is doing the job the Standard Contract gives it. Every actor is behaving rationally inside their own frame, and the sum of all that local rationality is a machine none of them would have designed and none of them can halt, because halting it is nobody’s job and everybody’s cost. That is not a comfort, and I do not offer it as one. A designed thing has a designer you can argue with. An accreted thing has no address for the complaint — which is exactly why the complaint has to be made in public, in the only register left: naming the structure precisely enough that it can no longer be mistaken for the weather.

Citations

NHS England (2026) — 2026/27 NHS Payment Scheme: ADHD & Autism Diagnostic Assessment Services Payment Guidance — NHS England, PRN02348

NHS Hampshire and Isle of Wight ICB (2026) — Right to Choose — ADHD and Autism Frequently Asked Questions and Key updates: Autism and ADHD Assessment Services — ICB publications

NHS Bristol, North Somerset and South Gloucestershire ICB (2026) — FOI.ICB-2526/259: Indicative Activity Plans under Right to Choose — Freedom of Information response

The Retreat Clinics (2026) — ADHD & Autism Waiting Times — Provider update

Psychiatry-UK (2026) — Initial Assessment & Titration Waiting Times — Provider update

Clinical Partners (2026) — NHS Right to Choose wait times and updates — Provider update