How can we overcome the crisis in adult ADHD services?

Adult attention-deficit hyperactivity disorder (ADHD) in the UK is facing a critical challenge with escalating waiting times for assessments and treatments. This issue was exacerbated by the Covid-19 pandemic, highlighting the need for substantial intervention to bridge the widening gap between resource demand and capacity. Despite the growth in specialist ADHD services, many regions still struggle with limited access as resources allocated to these services have failed to keep pace with ever-growing demand, leading to substantial variations in waiting times. Addressing the root causes of this crisis and finding solutions for a more efficient and patient-centred approach is paramount.

The current state of adult ADHD services

In the mid-1990s there were only a few specialist adult ADHD services in the UK, often constrained by limited resources. Although the publication of the 2008 National Institute for Health and Care Excellence (NICE) guidelines led to a significant increase in specialist services, demand has outstripped capacity significantly. Freedom of Information requests in 2018 revealed alarming variations in waiting times, ranging from four weeks to nearly four years.

Misleading statistics and lack of national strategy

Traditional waiting time statistics may be misleading as they can underestimate the years people are waiting, while headline figures focus on the individual at the front of the queue, rather than the more relevant perspective from the 'back of the queue.' The escalating problem of ADHD waiting times has continued largely unchecked due to a lack of national targets, political focus and routinely collected national data. 

Government response and the NHS Constitution

The government's response to the ADHD waiting time crisis suggests that local commissioning organisations, rather than central government, should resolve the issue in the absence of specified NICE targets. While the NHS Constitution for England guarantees patients the right to start consultant-led treatment within 18 weeks, this timeframe is not deemed applicable to ADHD. NHS England's Elective Recovery Plan, aimed at reducing waits for non-urgent hospital treatment, makes no mention of mental health services.

Rise of independent providers

Underfunding of NHS adult ADHD services has led to a growth in independent providers, offering an alternative route for patients facing long waits. While this increased capacity is welcomed by many patients, it introduces additional challenges such as navigating a complex and fragmented system and determining the quality and reliability of services. The lack of specific guidance from NICE on what constitutes quality assessment and treatment impacts the required consistency between providers. Resources have been diverted from NHS services and there has been duplication and wastage resulting from NHS services needing to make reassessments where there is a lack of confidence in previous assessments carried out elsewhere. Patients have also been left without medication when GPs have felt unable to continue ADHD medication because of a lack of confidence in the diagnosis.

Addressing ADHD waiting times

The extraordinarily long waiting times for ADHD services are particularly concerning given the effectiveness of available treatments, and that timely access to treatment is crucial for preventing negative consequences, including accidents, comorbidity, and increased mortality. The human (which spans from the individual and their family to the wider public) and financial costs of untreated ADHD highlight the compelling case for increased investment in services.

The road ahead: exploring existing options

A range of solutions exists to address the crisis in adult ADHD services. However, financial and workforce challenges are key barriers and a multi-pronged approach is likely to deliver the most substantial improvements. The options available to move forwards are:

1. The status quo: However, maintaining the current system is not sustainable, as waiting lists are likely to grow, further burdening specialist services and compromising patient care.
2. Enhanced funding: While substantial funding could address the demand-capacity gap and tackle backlogs, the fiscal environment makes this option challenging.
3. Improved system efficiency: Refining the diagnostic and treatment pathway, including leveraging technology, can improve efficiency, but it requires careful implementation and may not be sufficient on its own.
4. Alter the service provision model: Shifting a portion of the workload from specialist services to primary or secondary care could enhance efficiency, but this requires significant funding, training and implementation time.
5. Clinical prioritisation: Limiting access to the most severely affected patients is controversial, ethically challenging, and may not be a practical solution. It also risks potentially disadvantaging specific patient groups with the greatest needs.

Recommendations for positive change

The following recommendations would improve the current state of adult ADHD services in the long term:

1. Agreed standards: Establish agreed standards on diagnostic assessments and reports to improve consistency and management across providers.
2. National target: Introduce a national target for ADHD waiting times to better define and focus attention on the impact of waits and stimulate positive change.
3. National strategy: Develop a national strategy for ADHD to raise awareness of the problem and support commissioning decisions.
4. Additional funding: Urgently allocate additional funding to enable adult ADHD services to better meet demand.

Adult ADHD services in the UK are at a critical juncture and demand immediate action. While the challenges are substantial, a combination of efficient administrative systems, alternative service models and routine data collection for political focus can lead to positive changes. Additional funding and a shift in how we approach ADHD treatment is also needed. The introduction of a national target for starting assessments within three months could also help keep ADHD treatment at the forefront of health policy, ensuring timely and effective care for those in need.