The Independent Healthcare Providers Network’s (IHPN) recent The Choice Gap report found that while General Practitioners (GPs) support the principle of patient choice, only 1 in 10 agreed that it works well in practice. Respondents cited a number of barriers preventing patients from having real choice. Similarly, the recently published GP Patient Survey (GPPS) 2026 included new questions on patient choice. The results were poor, with only 31% of those referred for specialist care offered a choice of provider, and only 34% of those referred reporting awareness of their right to choose.

The barriers identified by the IHPN are concerning, not just because all NHS patients have had the legal right to choose their provider since 2014, but because they show the challenges of turning aspiration into reality. To create real change, it is necessary to first remove the obstacles that may prevent it.

The 10 Year Health Plan is, rightly, aspirational in its vision for the future of the NHS and seeks to empower patients by giving them greater choice and a louder voice. These commitments are not new, however – and if patient choice is already being delivered inconsistently, this raises questions about how the plan’s goals can be achieved.

One of the plan’s most eye-catching patient voice commitments was a pilot of Patient Power Payments (PPPs) – but to meaningfully influence financial flows, patients first need to be confident in their ability to enact their legal right to choose, and providers need to be able to consistently offer that choice.

Understanding the choice gap

Two thirds of GPs responding to the IHPN’s poll agreed that offering patients choice was “important but difficult to deliver consistently”, while only one third said that they regularly discuss choice with their patients when making a referral. GPs identified barriers that prevent them enacting patient choice, including referral management systems, limited consultation time, complex pathways, and poor access to information. That NHS staff report complex pathways and poor access to information as barriers should raise alarm bells, not just about how the NHS communicates with patients and service users, but also with its own staff. Access to information is poor for patients too, with four in ten patients unaware of their legal right to choose a hospital or clinic for their first NHS outpatient appointment.

The Choice Gap’s polling points to regional differences in patient choice. GPs in London were the most likely to view choice as important, while GPs in the South West were the least likely to. A simple explanation could be that in a densely populated urban environment, there are more providers to choose from: however, GPs in other areas of the country, like the South East, that are densely populated with access to a range of providers, still report lower scores compared to London GPs when asked about whether they view choice as important. While this polling was of professionals, data from the GPPS shows that patients from different communities or with particular protected characteristics experience choice differently.

Patient Power Payments 

Patient choice has been an aspiration in the health service for a long time, and a legal right for over a decade. While the ambitions of the 10 Year Health Plan are welcome, The Choice Gap’s polling demonstrates that operationalising ambitions can be challenging. This raises questions about the feasibility of PPPs – do we not first need to be facilitating patient choice, before we can expect patients to influence payment? Particularly as PPPs are expected to be used in secondary care – not in primary care where a patient’s right to choose is most likely to be enacted.

Picker has already noted that there is a risk of unintended consequences with PPPs and it is essential that any pilot defines how these risks will be mitigated. Most importantly, there are questions about what information will be provided to both patients, to help them respond, and to staff, to help them to act on feedback. From The Choice Gap’s polling, we already know that poor information is a barrier to staff when it comes to patient choice.

From the patient’s perspective, they will need to know which service they are being asked to rate. Again, the IHPN’s polling shows that pathways are complex for staff, so it is a safe assumption that they are equally, if not almost certainly more complex for patients. In a scenario where a patient has not been offered a choice at referral, could this lead to a patient withholding funds from a secondary care provider for circumstances outside of that provider’s control? Alternatively, is there a risk that for some patients, the idea of diverting funds to an ‘improvement fund’ is seen as inherently desirable?

Translating ambition into reality

Overall, the 10 Year Health Plan’s patient choice and voice ambitions are positive, but they must lead to tangible change for patients if they are to be considered a success. Much of this will be linked to communicating clearly about patient’s rights and advertising initiatives to increase choice and voice clearly to the public, but how these changes are operationalised and how existing barriers will be removed will also be key. Both the IHPN’s The Choice Gap and Picker’s briefing on PPPs outline how technical and operational barriers can be mitigated against and overcome to finally make expanding patient choice and voice a reality.