Provider exclusion criteria explained

The regulations exclude a short list of people. Providers exclude a longer one, written by each provider, published inconsistently, and applied after the referral arrives.

The short version

NHS South West London ICB states that each provider will have their own inclusion and exclusion criteria.
It gives a moderate to severe learning disability or an addiction as examples of pre-existing needs that can exclude someone from a particular provider.
Age ranges differ between providers and are not set nationally.
A provider declining a referral does not mean the pathway is closed to you.

There are two gates, and only one of them is written in law. The second is where most refusals happen, and it is barely visible until a referral has already been sent.

What an ICB says about the second gate

NHS South West London ICB puts the relationship between the two plainly. Although anyone registered with a GP in England is legally entitled to access Right To Choose, each provider will have their own inclusion and exclusion criteria.

It then gives the concrete version: this may mean that you are not eligible to access an assessment from a particular provider based on certain pre-existing needs, for example having a moderate to severe learning disability or an addiction.

Its advice about what to do is short and worth following. Your GP will be able to tell you which Right To Choose services are appropriate for you or your child and discuss your options.

The kinds of criteria providers apply

Age. ADHD 360 states it can only accept Right to Choose referrals for children aged 8 plus and adults 16 years and older. Psychiatry-UK describes its scheme service as ADHD assessments for adults aged 18 and over.
Co-occurring needs, which is the category the ICB's two examples sit in.
Service scope. A provider may be commissioned for ADHD and not autism, or for children and not adults. NHS Black Country ICB publishes a provider table with separate columns for adult ADHD, adult autism, children's ADHD and children's autism.
Delivery format, where a provider only assesses online and that is not workable for the person being assessed.

Why this is not the same as being ineligible

A provider saying no is a statement about that provider's service, not about your entitlement. The statutory exclusions are narrow and are the only ones that remove the choice itself.

The practical response is to ask, before the referral goes, whether that provider accepts referrals for someone in your situation, and to have a second provider in mind. A referral sent to a provider that will decline it costs you whatever time it takes to find out.

Ask for the criteria in writing

Providers publish their criteria to different standards and in different places. If you cannot find them, ask the provider directly and keep the answer with the date. Your GP practice may also hold a current list from the integrated care board.

Questions people ask about this

Why did a Right to Choose provider reject my referral?

Most likely on its own inclusion and exclusion criteria rather than on the regulations. NHS South West London ICB states that each provider sets its own, giving a moderate to severe learning disability or an addiction as examples of pre-existing needs that can make a provider unsuitable, and age ranges also differ by provider. A refusal by one provider does not close the pathway.

Where do I find a provider's exclusion criteria?

Providers publish them inconsistently, so the reliable routes are asking the provider directly and asking your GP practice, which NHS South West London ICB says will be able to tell you which Right To Choose services are appropriate for you or your child. Keep the answer and the date you were given it.