FOI 2025/1502

I am extremely concerned about how Indicative Activity Plans (IAPs) and Activity Management Plans (AMPs) are being used for ADHD and autism assessment and titration, particularly where patients exercise their legal Right to Choose (RtC).
The NHS Standard Contract technical guidance is clear that:
• the IAP is indicative only, and providing more or less activity than the IAP is not a breach of contract and does not, in itself, allow the commissioner to withhold payment
• the purposes of the activity provisions include ensuring that where patients have a legal right to choose their provider, that right is always enabled
• any Activity Management Plan “must not in any way restrict patient choice of provider”
Despite this, FOI responses from multiple ICBs across England show IAPs being treated as hard annual caps on the number of ADHD/autism RtC assessments that will be funded, with activity above the IAP either not paid for or only funded in the next financial year. Public information from some providers confirms that IAPs are being used to limit the number of Right to Choose assessments they can complete for each ICB’s patients in a given year.
This approach appears to:
• penalise patients who exercise RtC by putting them into “funding limbo” queues, even where providers have clinical capacity to see them
• create a de facto two-tier system between patients whose ICB has IAP “headroom” and those whose ICB does not
• sit uneasily with the NHS Constitution right to start treatment within 18 weeks of referral, or to be offered alternative providers that can see patients sooner
• potentially conflict with the legal duties on ICBs to reduce inequalities in access and outcomes and to have due regard to the need to avoid discrimination against disabled groups, including neurodivergent people
I am asking you to please:
1. Confirm whether this ICB has set IAPs that effectively cap the number of ADHD and autism assessments or titrations that will be funded for patients using RtC in 2025/26 and 2026/27.
2. Confirm whether any AMPs or other instructions have been issued to providers that restrict their ability to book and treat RtC patients where the IAP has been exceeded, even if they have clinical capacity.
3. Provide a copy of any equality impact assessments or inequality analyses the ICB has carried out in relation to its use of IAPs and AMPs for ADHD and autism services.
4. Explain how the ICB is assuring itself that its use of IAPs and AMPs does not, in practice, restrict patient choice of provider, extend waits for those who exercise RtC, or breach the spirit of the NHS Constitution and patient choice legislation.
5. Set out how the ICB plans to respond to NHS England’s ADHD & Autism Payment Guidance, including whether it intends to treat the proposed guide prices (£800 for adult ADHD assessment, £400 for titration, £900 for CYP ADHD assessment etc.) as de facto caps, and how it will ensure that providers are funded to deliver safe, thorough, person-centred titration rather than rushed, under-resourced medication pathways.

1. Yes. NHS Greater Manchester ICB (NHS GM) has set Indicative Activity Plans (IAPs) for 2025/26 and 2026/27.
These plans form part of our standard activity-management arrangements under the NHS Standard Contract. IAPs are indicative planning tools used to align commissioned activity with available resources.
2. NHS GM holds information relevant to this request. However, this material is considered exempt by virtue of Section 36(2)(i)(ii) and Section 43(2) of the Freedom of Information Act 2000.
Section 36(2)(b)(i) and (ii) – Prejudice to the Effective Conduct of Public Affairs
Section 36 of the Act sets out a qualified exemption from the right where in the reasonable opinion of a qualified person such disclosure would prejudice the effective conduct of public affairs through:
The Minister responsible for the Freedom of Information in the Department of Health has authorised the senior person in charge of the National Health Service bodies to act as ‘Qualified Persons’ and under Section 5 of the National Health Service Act 1977 this is the Chief Executive. Under the Section 36 exemption, the ‘qualified person’ for NHS Greater Manchester (NHS GM) is Mr Colin Scales, Acting Chief Executive.

Mr Scales is of the opinion that the information should be withheld as he considers that it would, or would be likely to prejudice, the effective conduct of public affairs.
Disclosure of the minutes would, or would be likely to:

• inhibit the free and frank provision of advice, and
• inhibit the free and frank exchange of views for the purposes of deliberation.

The meetings in question were held in private and form part of the ICB’s internal governance and operational decision-making processes. They involve candid discussion of financial risk, commissioning pressures, provider performance, and clinical considerations. The ability of staff to discuss these issues openly would be undermined if detailed minutes were routinely disclosed.
The decision to apply this exemption has been made with the reasonable opinion of the qualified person, as required by the Act.

Public Interest Test

Factors favouring disclosure.

Openness and transparency – It is important that NHS GM acknowledges their responsibility to be open, transparent and accountable.

Factors favouring non-disclosure.

AMP documents and related operational instructions rely on free and frank exchange between commissioners and providers. Releasing them would inhibit open discussion, impede future decision-making, and undermine NHS GM’s ability to manage clinical and financial risk transparently with providers.

Balancing Test.

NHS GM consider that the public interest in withholding the information outweighs the public interest in disclosure. While there is public interest in transparency of commissioning decisions, on balance this is outweighed by the public interest in:
• protecting the integrity of contract-management processes,
• ensuring providers can engage candidly with commissioners,
• avoiding commercial harm to the NHS and contracted providers, and
• maintaining the ICB’s ability to manage financial and clinical risk effectively.

For these reasons, the information is withheld.
Section 43(2) – Prejudice to Commercial Interests
Information is exempt information if its disclosure under this Act would, or would be likely to, prejudice the commercial interests of any person (including the public authority holding it).
In this instance, disclosure of the information would be likely to prejudice the commercial interests of the NHS GM. 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
Factors favouring disclosure.

There is an inherent public interest in ensuring that there is openness and transparency in the spending of public money. Transparency is likely to increase confidence in procurement processes and the purchasing decisions made by NHS GM. It also enables the public to understand whether NHS GM was getting value for money from its purchasing decisions.

Factors favouring non-disclosure.

Disclosure of specific Activity Management Plans (AMPs), contractual instructions, and commissioning thresholds would prejudice both NHS GM and providers’ commercial interests. These documents form part of live contract-management and negotiation processes. Publishing them would reveal operational thresholds, financial positions, and commissioning levers that could undermine NHS GM’s ability to negotiate contract terms on behalf of the public, as well as negatively affect providers operating in a competitive market.
Balancing Test.
After considering the arguments outlined above, we have decided to withhold this information.
3. The Equality and Health Impact Assessment (EHIA) and the Quality Impact Assessment (QIA) are currently progressing through internal governance and are not yet finalised.

In line with ICO guidance, draft documents not yet approved for publication are not disclosable, as they do not represent the final or confirmed position of the ICB.
The final versions will be published once governance is complete, at which point they will be publicly accessible.
Section 22 of the Freedom of Information Act (information intended for future publication). Disclosure of a draft would risk misinterpretation of provisional analysis and conclusions that may change prior to final approval.
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
Factors favouring disclosure.
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.
Factors favouring non-disclosure.
However, this information 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.
Balancing Test.
After considering the arguments outlined above, we have decided that, on balance, the public interest is better served at this time in withholding the latest versions of our Equality Impact and Risk Assessments 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. NHS GM does not remove or restrict the patient’s statutory Right to Choose (RtC) a provider for a first outpatient appointment.

Use of IAPs and AMPs does not override the legal right to choice. It is a contractual tool for managing activity against commissioned levels.
However, we recognise that activity management can affect waiting times, including for patients exercising RtC, because NHS GM must ensure activity is delivered within the available commissioning envelope. This is permitted under the NHS Standard Contract, which allows commissioners to manage over-activity or unexpected levels of demand through activity-management processes.
NHS GM assures compliance with choice legislation through:
• maintaining RtC pathways across all eligible providers.
• reviewing any activity-management decisions for compliance with patient choice regulations.
• regular oversight of waits, demand, and clinical risk.
• ensuring any temporary operational mitigations do not prevent patients from exercising choice.

5. NHS GM is reviewing NHS England’s ADHD & Autism Payment Guidance, including the proposed guide prices and emerging national currency model. These amounts are guide prices, not mandatory national tariffs or caps.

Local commissioning decisions will determine how the guide prices are used within local contracts, taking account of safety, quality and the need for person-centred titration.

Regarding funding, the NHS Long Term Plan does not allocate any additional, dedicated national funding specifically tied to these guide prices. They represent a proposed national approach to standardising pricing, not a funded uplift.

The ICB will continue to engage with providers and NHS England as the national payment approach develops and will ensure services remain safe and clinically appropriate within available resources.