FOI 2025/1451

I am making this request under the Freedom of Information Act 2000 in relation to the use of Indicative Activity Plans (IAPs) in connection with Right to Choose (RtC) referrals for Autism and ADHD assessments.

For the purposes of this request, “IAPs” refers to any indicative activity plans, caps, ceilings or similar mechanisms used to control, limit or manage the volume of RtC activity for particular Autism and/or ADHD assessment providers.

1) Please confirm whether your ICB has introduced, applied, discussed or is planning to introduce any IAPs (or equivalent arrangements) that affect, directly or indirectly, the number or flow of RtC referrals for Autism and/or ADHD assessments to specific providers. If so, please identify which providers these arrangements apply to and the date on which they were first introduced or agreed.

2) If such IAPs (or similar mechanisms) have been introduced, proposed or discussed, please provide all documentation relating to their introduction, development and governance. This should include, but not be limited to, meeting agendas, minutes, action notes, internal correspondence (including emails), briefing papers, slide decks, business cases and any other relevant records. Please also provide any documents setting out the legal basis or policy justification for using IAPs in this way, including any legal advice (internal or external), NHS England or DHSC guidance relied upon, and any internal legal or governance papers explaining how these IAPs are considered compatible with the NHS Constitution and with NHS Choice / Right to Choose regulations and guidance. Please further provide any correspondence with NHS England (including regional teams) concerning the permissibility, design or operation of such IAPs in the context of RtC for Autism and ADHD.

3) Please provide copies of any impact assessments carried out in relation to the introduction or operation of IAPs affecting RtC Autism/ADHD providers. This includes Equality Impact Assessments, Quality Impact Assessments or any similar assessments. Please also provide any analysis, reports or reviews showing how these IAPs have affected waiting lists for Autism and ADHD assessments (for example, changes in waiting times, backlog, or access patterns), and any documentation setting out how the ICB has assured itself that these arrangements do not compromise patient safety, do not unlawfully restrict patients’ RtC, and do not worsen health inequalities or inequities of access.

4) There is significant public concern that activity caps or similar mechanisms may be used to constrain RtC access in a way that was not endorsed nationally. I refer in particular to the campaign described here: https://gbr01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fadhduk.co.uk%2Fnhs-right-to-choose-changes%2F&data=05%7C02%7Cnhsgm.foi%40nhs.net%7Cae5b73cbaf1041baf11908de1df5f5c0%7C37c354b285b047f5b22207b48d774ee3%7C0%7C0%7C638981139428655952%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=QWY%2FNdNrMLOvZDKplocyo6s63Jv8mD0iyUhF9LhwucA%3D&reserved=0

which highlights that caps on RtC were not approved as part of the 2025/26 NHS consultation and planning process. In that context, please provide any internal discussion papers, briefing notes or emails which consider this national position and explain how your ICB’s use (or proposed use) of IAPs is considered compatible with the outcome of that consultation and with national RtC policy. Please also provide any documents that consider whether the use of IAPs could in practice operate as a de facto cap or restriction on RtC access for Autism/ADHD, and how that risk has been addressed or mitigated.

Unless otherwise stated, please treat this request as covering the period from the earliest discussions about such IAPs up to the date of your response. I would be grateful to receive the information in electronic form (such as PDF or other commonly used formats). If you believe any part of this request exceeds the appropriate cost limit, please provide as much as you can within the limit and advise how I might refine the request to bring the remainder within scope.

If you withhold any information, please clearly identify the specific exemption(s) you rely on and explain why they apply.

1. NHS Greater Manchester (NHS GM) has introduced Indicative Activity Plans for all right to choose providers working in Greater Manchester, as this is a requirement.

2. Under the Freedom of Information Act 2000 (FOIA), this section of your request is exempt by virtue of the following exemption, Section 12(1). Section 12. — (1) Section 12(1) does not oblige a public authority to comply with a request for information if the authority estimates that the cost of complying with the request would exceed the appropriate limit. The Freedom of Information Act allows Public Authorities to decline to answer FOI requests when we estimate it would cost us more than £450 (equivalent to 18 hours, calculated at £25 per hour) to identify, locate, extract, and then provide the information that has been asked for.

NHS GM consists of the 10 Greater Manchester localities, Bolton, Bury, Heywood, Middleton and Rochdale, Manchester, Oldham, Salford, Stockport, Tameside, Trafford and Wigan (former Clinical Commissioning Groups), and therefore documents are held on various data bases. Furthermore, NHS GM does not have a search engine/functionality to be able to search all documents on those data bases for key words such as Indicative Activity Plans, or IAPs, therefore a manual search would be required.

On this basis, the exemption has been applied, because to search all meeting agendas, minutes, action notes, internal correspondence (including emails), briefing papers, slide decks, business cases and any other relevant records which mention Indicative Activity Plans, or IAPs on all data bases, would exceed the appropriate limit prescribed in the act.

Although we cannot answer your request, we might be able to answer a refined request within the cost limit. Therefore, you may wish to consider reducing the breadth of your request. Please be aware that we cannot guarantee at this stage that a refined request will fall within the cost limit, but NHS GM would do our upmost to assist you.

3. The Quality Impact Assessment and the Equality and Health Impact Assessment are currently progressing through internal governance processes. Once completed, they will be published for public scrutiny.

The release of this information is exempt from disclosure by virtue of section 22 of the Freedom of Information Act 2000 as it is intended for future publication.

Section 22(1) of the Freedom of Information Act 2000 states:

(a)         the information is held by the public authority with a view to its publication, by the authority or any other person, at some future date (whether determined or not),

(b)         the information was already held with a view to such publication at the time when the request for information was made, and

(c)         it is reasonable in all the circumstances that the information should be withheld from disclosure until the date referred to in paragraph (a).

This exemption is subject to the public interest test and for the reasons outlined below, we are satisfied that the exemption applies.

Public interest test

There is an inherent public interest in ensuring that there is openness and transparency to increase confidence in procurement processes and the purchasing decisions made by NHS GM. Furthermore, disclosure of this information would also be consistent with NHS GM’s commitment to proactively publish data that is in the wider public interest.

However, this information is subject to is subject to review, validation and approval, prior to publication. Early release of the requested information could be misrepresentative, and it is in the public interest that this information is true and accurate.

After considering the arguments outlined above, we have decided that, on balance, the public interest is better served at this time in withholding the Quality Impact Assessment and the Equality and Health Impact Assessment under section 22 of the Freedom of Information Act 2000, on the basis that it will be published in the future once finalised, as outlined above.

4. The concern raised through the referenced campaign focuses on a proposed £100,000 cap and suggests that such caps were not endorsed through the 2025/26 NHS consultation and planning process; however, the campaign does not state that caps cannot be introduced where required. NHS GM Integrated Care Board (ICB) is mandated to commission services within a fixed financial envelope and to maintain overall system financial balance. The current annual budget for ADHD and Autism services within NHS GM is £13.8 million, which has already been exceeded in-year, with a projected overspend of approximately £11–12 million. Without intervention or activity-management mechanisms, spending was forecast to exceed £31 million, and no additional funding from NHS England has been made available to meet the increased demand generated through Right to Choose (RtC) activity. For this reason, activity controls, including the use of Individual Approval Processes (IAPs), have been introduced as necessary measures to stabilise the budget and ensure sustainability of services across the system.

The ICB considers the use of IAPs to be compatible with national RtC policy because the RtC entitlement remains available, and patients retain the option to choose an eligible contracted provider where clinically appropriate. The measures implemented are intended to moderate the flow of new referrals rather than remove entitlement or cancel existing referrals. Patients already within the assessment and treatment pathway, including those receiving medication reviews, continue to receive care, and urgent clinical need is prioritised. To address concerns that the use of IAPs could operate as a de facto cap on access, measures include preservation of existing waiting-list positions, completion of assessment and treatment for those already commenced in the system, monitoring of impact to support equitable access, and the time-limited nature of the control, which will be reviewed in line with future funding availability.

In summary, the introduction of IAPs reflects the statutory duty to maintain financial balance and safeguard service continuity rather than a restriction or withdrawal of RtC access.