Challenges we see in the system
ADHD and autism pathways rely heavily on specialist assessment and treatment. Workforce shortages and global medication supply issues add further strain, placing sustained pressure on the health system. Several stakeholders told us that clinical guidance envisages specialist teams focusing on complex cases only. To achieve this, the wider mental health and primary care workforce needs support to develop its capabilities to assess and manage ADHD and autism where appropriate.
These challenges are made worse by financial pressures on ICBs, organisational change and mergers (outlined in the NHS Implementation of ICB Mergers Phase 1 and the Strategic Commissioning Framework). Our casework shows this is affecting patient choice, experience and outcomes.
Patients are entitled to, and can reasonably expect, consistent access and provision across the NHS, while ICBs must commission services based on local need with limited capacity and funding. Our analysis suggests there are opportunities to reduce duplication and pressure through clearer alignment between legislation, policy, regulation, clinical guidance, commissioning levers and patient-facing information. The diagram on the next page shows the core tensions between national frameworks and local commissioning and delivery.
Core tensions between national frameworks and local commissioning and delivery
Tensions between Right to Choose and ICB discretion
| Right to Choose | ICB discretion |
| The NHS Constitution (2009), Constitution Handbook (2025) and NHS England website state that when a patient is referred for non-urgent, specialist care, they have the right to choose any NHS-funded provider offering that service. This creates a clear expectation for patients (and often referring GPs) that they can select where their ADHD or autism assessment (and initial treatment) takes place. | The Health and Care Act 2022 gives ICBs responsibility to commission services based on local population need and available resources, while also promoting the NHS Constitution and enabling patient choice. In practice, this means ICBs must balance competing duties, manage finite capacity and funding, and exercise discretion over which providers and pathways they commission. |
| Patient expectation: choice is nationally guaranteed and works consistently everywhere. | Potential impact: local commissioning decisions can, even unintentionally, limit the national promise of patient choice. |
Tensions between shared care and GP discretion
| Shared care | GP discretion |
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National clinical guidance (NICE 2018) states that ADHD medication should be started by specialists and then safely transferred to GP care once treatment is stable. National policy encourages long-term prescribing to move into primary care to keep care closer to home and reduce pressure on specialist services. This is also a core shift in the 10 Year Plan, from hospital to community. |
GMC prescribing standards require GPs to take responsibility only for care they feel clinically competent and safe to provide. Accepting shared care arrangements, including prescribing ADHD medication, therefore remains a clinical judgement rather than an obligation. |
| Patient expectation: GPs will continue prescriptions after diagnosis and stabilisation. | Potential impact: even where national guidance expects shared care, patients may not receive ongoing prescriptions if GPs judge arrangements unsafe or unsupported locally. |
The NHS gives people a right to choose their care provider, but our casework suggests this is not always supported by the way services are commissioned, funded and overseen in practice. We have identified a number of tensions between national policy and local implementation, which make it harder for patients and families to navigate the system, and for clinicians and commissioners to make effective local decisions that lead to positive patient outcomes.
We have explained below the main system challenges we see in our casework and the impact they have on patients. If we address these challenges, patients will be able to make informed decisions about the care they can expect to receive from the NHS and independent sector, at a time of high demand and pressure on the system.
- There is limited clear and up-to-date patient information on NHS referral pathways, Right to Choose and shared care arrangements. This can leave patients and carers uncertain about what options are available and what to expect at each stage.
- There is fragmented data on demand, referrals, waiting times and patient need, despite improvements such as the neurodevelopmental data hub. It is also unclear which waiting time standards apply to ADHD and autism services. These gaps cause issues with service planning and make it difficult for patients, families and GPs to understand why access and waiting times differ between areas. Inconsistencies in how providers capture and share waiting time data, at ICB and national level, add to this issue.
- The ADHD and autism provider market has expanded rapidly with many independent providers entering the system in response to growing demand. While this additional capacity has helped improve access for patients, it has also created new challenges for ICBs in quality assurance, oversight of provider performance and maintaining transparency of provider capacity and resilience. Recent work by the Independent Healthcare Providers Network has highlighted the importance of stronger national coordination between the NHS and independent sector, supported by clearer service standards, data collection and oversight arrangements.
- NICE ADHD guideline (NG87) is informed by guidance from regulatory bodies (such as the General Medical Council’s (GMC) Good Medical Practice and the Nursing and Midwifery Council’s Code) and allows diagnosis by an ‘appropriately qualified healthcare professional with training and expertise in ADHD’. However, it does not name a single national accreditation, training standard or professional background for assessors. The ADHD taskforce recently recommended that relevant Royal Colleges work with NHS England, the Department of Health and Social Care (DHSC) and professional bodies relevant to mental health nursing and psychology to identify and co-develop core competencies and curricula for training and continuing professional development (CPD) in recognising and supporting ADHD.
- NICE guidance (HTG729) was developed in 2024 to evaluate the use of digital technology in ADHD assessments. Based on the available evidence, NICE recommended that one digital technology (QbTest) could support assessments for 6- to 17-years-olds, but concluded that there was not enough evidence to support its use in adults and younger children and more research was needed. These evidence gaps make it harder for commissioners and policymakers to make informed decisions as new digital technologies and AI-enabled technologies enter the market.
- Shared care prescribing arrangements for ADHD medication are informed by GMC’s guidance in prescribing and managing medicines and devices. However, Shared Care Protocols are not in place everywhere and GPs’ confidence to prescribe varies, contributing to inconsistencies in prescribing, ongoing care arrangements and access to medication. This could be addressed through the Single National Formulary, which is being developed as part of the 10 Year Health Plan for England.
- The Health and Care Act (2022), the Strategic Commissioning Framework (2025) and the Health Bill (2026) expect ICBs to commission for local population need. This is at the same time as ensuring patient safety, upholding the NHS Constitution and supporting patient choice. These objectives are difficult to bring together with the challenges of demand, ICB mergers and workforce cuts.
- Contracting and funding arrangements can show up tensions between patient choice, financial control and service sustainability, especially where demand is greater than planned capacity. Processes in the NHS Standard Contract and the NHS Provider Selection Regime, such as implied contracts, direct award processes, indicative activity plans and activity management plans, can influence how quickly and consistently patient choice is carried out across the country.
- NHS-funded ADHD and autism service providers are not consistently visible through national systems, such as the NHS Electronic Referral Service (e-RS).The NHS Standard Contract guidanceonly requires them to make ‘reasonable endeavours’ to register and list services. This reduces transparency about available providers, services, and referral activity, which may make it harder for people to navigate the system and make informed choices.
- Although diagnosis and screening are regulated activities by law, CQC guidance based on current regulations says diagnostic-only providers of ADHD and autism assessments are not required to register with CQC. This creates a regulatory gap, risks variations in quality and affects the confidence of commissioners, clinicians and patients in assessments.
- While NHS England regional teams can escalate issues locally and nationally, mechanisms to support ICBs in raising concerns, such as engagement with independent providers or contract management, are not applied consistently. As a result, opportunities for system-wide learning, improvement and coordination may be missed. This raises the question of whether there should be greater responsibility at a national or regional level to collate intelligence on provider performance and emerging risks in the market.