Executive summary

Patient choice is a long-standing NHS right, but our research shows it is not being consistently delivered in practice.
Polling of more than 800 GPs found that:

• Almost two thirds of GPs (62%) said offering patients a choice of provider is “important but difficult to deliver consistently”.
• Only around one third (36%) routinely discuss or offer patients a choice of provider when making a referral.
• Referral management systems, limited consultation time, complex pathways and poor access to information are creating significant barriers to choice.
• Just 10% of GPs believe patient choice currently works well in practice.

This report calls for a renewed national focus on patient choice, including clearer accountability, simpler referral pathways, better information for clinicians and patients, and stronger measures to ensure choice is routinely embedded throughout the patient pathway.

Introduction

In 2022, IHPN, alongside the Patients Association, published its “Time to Choose” report which looked at patient choice in the NHS from the perspective of patients and the public. This included the benefits of choice for patients, with analysis on the variations in NHS waiting times across a range of specialties and regions, and how exercising their “right to choose” an alternative provider could enable patients to cut their wait for care by over three months. The report also looked at public’s perception of patient choice and the support they need to make informed choices, as well as a number of recommendations for the NHS on how to improve awareness of choice and support people to exercise their rights.

Four years on and while the Government and NHS have made patient choice a key part of their work to reduce waiting lists – it’s still the case that less than one quarter of people report being offered a choice of provider when referred by their GP for treatment, with four in ten people being unaware of their legal right to choose a hospital or clinic for a first NHS outpatient appointment.

To help broaden the discussion and debate on patient choice, this report will look at the issue from a different angle – namely how GPs – who play a key role in facilitating choice – understand and implement these rights. We have undertaken polling of over 800 GPs to look at how they help patients to exercise their choice rights, as well as the practical/administrative barriers they face in doing so. This report sets out a number of recommendations around how GPs can be better supported to ensure the full benefits of choice can be realised by both patients and the wider healthcare system.

What is patient choice?

Patient choice has been a central principle of the NHS in England for more than two decades. At its core, patient choice is about giving people greater control over where and how they receive care, supported by clear information about their options. Advocates of choice have argued that it can improve patient experience, reduce waiting times and create incentives for providers to improve quality and responsiveness.

Today, these rights are set out in the NHS Choice Framework and accompanying NHS England guidance. In 2014, these Regulations were amended so patients gained a legal right to choose a provider of certain outpatient mental health services and in some circumstances, a specific clinical team led by a named clinician. In most cases, patients referred for planned consultant-led care have the legal right to choose which provider delivers their treatment, including NHS hospitals and independent sector providers delivering NHS-funded services. Patients can also choose the clinical team responsible for their care and, if they have been waiting over 18 weeks, can request to move to another provider. NHS England guidance emphasises that all parts of the NHS have a responsibility to ensure patients are aware of and able to exercise these rights.

More recently, NHS England has renewed its focus on patient choice as part of wider elective recovery and reform programmes. Guidance published in 2023 reinforced that patient choice is both a legal right and an important operational tool for improving access and reducing variation in waiting times. Likewise, the NHS 10 Year Plan for Health places patient choice and control at the heart of the future NHS. Proposed measures include enabling patients to choose their preferred provider through the NHS App, introducing a new Patient Choice Charter, and trialling ‘patient power payments’, giving patients a greater say in whether providers receive the full payment for their care.

At the same time, however, reforms to how GPs refer patients to secondary care, such as through an expansion of Advice and Guidance alongside broader reforms to how the NHS delivers outpatient care, as well as money-saving policies such as minimum waiting times for treatment, are reshaping how patients access specialist care, raising important questions about how choice is communicated and exercised in practice.

In this context, patient choice remains highly relevant to debates about NHS performance, patient empowerment and the effective use of available healthcare capacity. While the principle of choice is well established in policy and law, important questions remain about how consistently it is offered, understood and utilised across the NHS.

What is Right to Choose?

Right to Choose gives patients in England the legal right, in certain circumstances, to choose the provider that delivers their NHS-funded care. This means patients may be able to:

• Choose between different NHS and independent providers.
• Take waiting times, quality and location into account.
• Access treatment sooner by selecting a provider with available capacity

How choice benefits patients

Our research from 2025 highlighted the significant benefits that patient choice can bring for individuals accessing care. The research found that when patients are offered meaningful choice over where they receive treatment, they are more likely to access care more quickly, select providers that best meet their personal needs and circumstances, and feel more empowered and engaged in decisions about their health. Choice can also help reduce inequalities by ensuring that all patients, not just those who are more confident navigating the system, are aware of the options available to them. At a time of continued pressure on NHS waiting lists, enabling patients to choose from a wider range of NHS and independent sector providers can improve access to timely care, reduce anxiety associated with long waits, and support better overall patient experience and outcomes.

Overall, our analysis of NHS waiting times across the country found that patients in England can cut months off their wait for care by exercising their right to choose a different provider for their NHS treatment. Across England, patients need to travel on average just under 13 miles – typically under 30 minutes by car – to cut over two and a half months off their waiting time.

Utilising the independent sector is part of the solution to an increasingly overstretched NHS

• 1 in 5 of all operations in the NHS are delivered by the independent sector
• In 2024, independent sector providers treated 1.6million NHS patients, removing them from NHS waiting lists
• Half of the top 10 providers for hip and knee adjusted health gains are from the independent sector
• 92% of independent hospitals are rated “good” or “outstanding” by the Care Quality Commission (CQC)
• On average, patients treated at independent hospitals can expect to wait four weeks less than patients on a waiting list at an NHS provider.

How patient choice is managed

Integrated Care Boards (ICBs) are responsible for ensuring that patient choice is implemented effectively across their local health systems, including maintaining referral pathways, ensuring appropriate providers are available on e-Referral Service (e-RS) systems, and supporting compliance with the NHS Choice Framework. In practice, however, it is usually GPs and primary care professionals who enable patients to exercise their right to choose at the point of referral, discussing the available provider options and supporting patients to make informed decisions about their care.

NHS England’s Patient Choice Enforcement Guidance sets out how the system is intended to monitor and enforce compliance with patient choice requirements. The guidance allows providers to raise concerns where they believe patients are being unfairly denied choice, including where referral pathways, administrative processes or local commissioning arrangements restrict access to certain providers. NHS England has historically held oversight powers to investigate breaches and direct ICBs to take corrective action where necessary. As documented in an impact assessment, published alongside the Health Bill, NHS England has never used these powers. Despite the existence of this framework, there remains very limited national data on how consistently patient choice is being offered, exercised or restricted in practice. There is currently no routine, transparent national reporting on whether patients are informed of their rights, how often alternative providers are offered, or the extent to which referral management processes – including the introduction of single points of access for care pathways – may inhibit choice.

These concerns are becoming increasingly important in light of the recent publication of the NHS Modernisation Bill, which proposes transferring many of NHS England’s functions and powers directly to the Secretary of State for Health and Social Care. While the long-term implications are still emerging, there are concerns that patient choice could become more vulnerable to political direction and operational pressures if clear national safeguards, accountability mechanisms and transparent reporting arrangements are not maintained and strengthened. The Bill also introduces new powers relating to the balance of provision across different provider types, but it remains unclear how these powers will be exercised by the current Secretary of State or by future governments, and what impact this could have on patient choice in practice. At the same time, the absence of robust data on the operation of patient choice means there is currently limited visibility over whether patients’ legal rights are being consistently upheld across the NHS.

The view from general practice

To better understand how GPs view patient choice in the NHS and support its implementation, we commissioned medeConnect Healthcare Insight to poll over 800 GPs to understand their attitudes and behaviour around all aspects of patient choice.

Overall, the research has found that while most GPs support the principle of offering patients a choice of provider and recognise it as an important part of delivering good care, there is widespread concern that the system does not make this easy to deliver, with structural, operational and system barriers within referral pathways and local commissioning arrangements having a material impact on how patient choice is experienced in practice.

Key findings from the polling show that:

GPs broadly support the principle of patient choice:

• Nearly 56% of GPs agreed that offering patients a choice of provider is an important part of delivering good care, with just 18% of GPs disagreeing.
• However, support for patient choice varies by region – London GPs were most likely to view choice as important (cited by 66% of GPs in the capital), whereas in the South West, just 48% agreed this was the case.  

However, despite overall support for patient choice, in practice it is being inconsistently offered to patients by GPs:

• Only around one third (36%) of GPs said they “always” or “often” discuss with or offer patients a choice of provider when making a referral for an elective procedure. This includes even in scenarios where: waiting time targets are breached (36%); or when they prompted by systems including the e-referral services (38%)
• However, over two thirds of GPs (68%) say they discuss the choices available when a patient specifically asks about alternative providers; with over half (53%) saying they offer choice when referral times are long; or when they are familiar with multiple providers (51%).

GPs are unclear about the expectations/requirements of them around patient choice:

• Almost 4 in 10 GPs (38%) say a lack of clarity about expectations or requirements on choice make it more difficult to have conversations with patients around their options, with almost 7 in 10 (68%) saying there are unclear expectations for GPs in this area.
• Only 22% of GPs said discussions about choice were “often or always” recorded in e-RS or other systems, with 30% saying they are “never” or “rarely” recorded.

A lack of choice being offered to patients is largely due to the practical barriers GPs face in operationalising choice:

• While 27% of GPs state that a patient’s preference not to choose is a key barrier to discussing choice, around two thirds of GPs (68%) cited local referral pathways (e.g. single point of access systems); limited time during consultations (67%); the complexity of referral pathways (66%); or lack of clear or accessible information on e.g waiting times or providers (64%) as the major impediments to facilitating choice.
• A further one third of GPs also stated that “local policies discourage” their ability to have conversations with patients around choice.
• Just 3% of GPs say they do not experience significant barriers in offering or discussing a choice of provider with patients.

There are a number of practical improvements that would make GPs more likely to offer choice of provider to patients:

• Almost 3/4 of GPs (74%) said that better access to up-to-date provider information would support them to offer more choice to their patients, with 79% citing simpler or more intuitive referral systems as something that would help.
• More time with patients would also help in facilitating choice (72%), with a similar proportion stating that clearer guidance from the NHS/ICBs would help, and a further 60% wanting to see greater support from practice staff (e.g. care coordinators)
• Less than half (48%) identified that financial or contractual incentives would support them to offer more choice.

Overall when asked to give their overall reflection on how choice works:

• Almost two thirds (62%) said offering patients a choice of provider is “important but difficult to deliver consistently”.
• Just 10% said choice “works well in practice”, with 20% saying that choice is “not important in most cases”.

How GPs can be better supported to facilitate patient choice

This polling – the first of its kind – paints a picture of a patient choice system that is supported in principle but inconsistently delivered in practice.

While GPs broadly recognise the importance of offering patients a choice of provider – particularly in the context of long waits and increasing pressure on NHS services – they also describe a system that is operationally complex, administratively burdensome and often shaped by local pathway constraints.

The findings suggest that improving patient choice will require more than reaffirming policy rights but rather clearer operational expectations; better visibility of provider options and waiting times; simpler referral pathways; improved recording and accountability; and greater consistency across local systems.

Without these changes, there is a risk that patient choice continues to exist more strongly in policy than in everyday patient experience.

To help GPs to better support patients to understand the choices available to them and make the best possible decision around their care, we are making the following recommendations to ensure choice is fully embedded in the patient pathway:

A system wide commitment to choice

• Strengthen NHS regulations to require effective provision and oversight of patient choice. This should include the requirement for commissioners to produce supporting information for providers and patients to support patient choice.
• Publish the Choice Charter – committed to in the 10 Year Plan, the charter should make choice visible, understandable and enforceable for every NHS patient.
• Measure and publish patient choice. Introduce questions on patient choice into the annual GP Patient Survey, as well as exploring mandating the tracking of choice data through the eRS system, and set clear improvement milestones to ensure the majority of patients are offered choice
• Support for GPs in being able to offer choice by redesigning referral systems in consultation with GPs, in order to reduce complexity and minimise administrative friction.

Better visibility of provider options and waiting times

• NHS England to look into how GPs currently facilitate patient choice through the e-referral system, including reenergising the NHS Capacity Alerts Project and implementing it across the country to support GPs and help them recognise where the shortest waits are.

NHS e-referral service (eRS) Capacity Alerts programme

The NHS e-referral service (eRS) capacity alerts programme aims to help support GPs to facilitate choice. A red ‘Limited Capacity’ flag is used on eRS for clinics where waiting times were very long, with a prompt for GPs to discuss long waiting times at these services with their patients. A green box was also created at the top of the referral system listing local clinics which had spare capacity. As a result of these simple measures, there was a 20-38% reduction in referrals to services with the longest waits and a 14% increase in referrals to services with green alerts when this approach was piloted in east London in 2016.

Simpler referral pathways

• Ensure that where NHS Single Point of Access (SPOA) systems and other local referral management processes are in place, clear guidelines are published – and made available to all primary and secondary care providers operating within the system – detailing how those processes interact with patient choice, and at which stage of each patient pathway patients should be offered a choice of provider.
• Ensure patient choice is offered during the new NHS Online pathway including for diagnostic tests and any hands-on clinical services.
• Ensure patient choice is embedded in all new care pathways. Where services are moved from consultant-led or hospital-based care into community settings, patients should continue to be offered a choice of provider unless there is a clear clinical reason not to do so. Choice should be designed into new pathways from the outset rather than lost through service redesign.
• Strengthen the Independent Patient Choice and Procurement Panel’s powers – with an explicit remit to investigate representations and evidence relating to reported breaches of patient choice regulations.

Raising public awareness of choice to support conversations with GPs

• A national campaign to promote choice to patients with more accessible information provided directly to patients on the choices available to them – in both digital and non-digital forms.
• Ensure the NHS App is a genuine “Manage my booking” service where patients can log in and understand the different options of where they can receive their care and waiting times for all providers, including independent providers.      

Conclusion

Patient choice is one of the NHS’s most established rights and remains a key part of the Government’s vision for a more personalised, responsive and efficient health service. Yet this research suggests there remains a significant gap between policy and practice.

GPs overwhelmingly support the principle of choice, but too often face practical barriers that make it difficult to deliver consistently. As a result, many patients are not being made aware of the options available to them or given the opportunity to benefit from shorter waits and more convenient care.

At a time when the NHS is seeking to reduce waiting lists, make better use of available capacity and empower patients to take greater control of their care, patient choice should not be seen as an optional extra. It should be a routine and visible part of every patient pathway.

Making choice a reality will require renewed national leadership, better information, simpler referral processes and stronger accountability. If these changes can be achieved, patient choice has the potential to improve access to care, enhance patient experience and help ensure that NHS resources are used to their fullest effect.