When people bring complaints to us about NHS services, they describe problems with access, communication, delays, follow-up and continuity of care. They rarely mention commissioning. But in practice, our experiences of the NHS are shaped by how services are designed, contracted and overseen, and the overall effectiveness of the commissioning process.
The main commissioners of NHS services are the integrated care boards (ICBs), which translate national policy into local service delivery. They must balance patient choice, quality and consistency of care against limited resources and workforce, in a changing national system. These are complex and sometimes competing demands. How they strike that balance has a direct impact on the experiences of patients and families.
These tensions are felt deeply in ADHD (attention deficit hyperactivity disorder) and autism services. For many, the experience begins with a wait – often a very long one. For a child at school without a diagnosis, an adult struggling in the workplace, or a family trying to access the right support, the consequences of that wait can be profound.
National research has called for earlier diagnosis, more personalised support and more seamless pathways of care. But the reality for many people remains long waits for assessments, wide variation in access depending on where they live and fragmented service provision. These are not simply capacity problems – they are also symptomatic of a commissioning system that is not able to meet the needs of service users. By investigating complaints in detail, we are able to establish where failures are isolated or part of a wider issue emerging from a system under pressure.
The Government’s independent review into mental health conditions, ADHD and autism, and NHS England’s independent ADHD taskforce report, reflect a growing recognition that the current situation is not sustainable. Our findings and recommendations aim to complement this work, drawing on the experiences of people who have brought complaints to us as a vital source of intelligence.
The issues we see in casework cannot be resolved by ICBs alone. National leadership is needed to improve services. Many of the difficulties people experience arise from a failure to join up policies, guidance, regulation and commissioning arrangements. Commissioning is both part of the problem and central to the solution. These challenges are not unique to ADHD and autism – we see similar dynamics wherever demand has grown rapidly and commissioning arrangements have struggled to keep pace. We will explore these overarching issues in future reports over the coming year.
To address these challenges, we need to work together to find solutions. In developing this report, we spoke with patient and third-sector organisations, policymakers, ICBs and clinical experts. I found these conversations valuable. Their insights have helped to shape our findings and I am hugely grateful for their engagement. An Ombudsman brings a unique perspective: we impartially see the system through the eyes of patients. The people who come to us are not just seeking redress for themselves – their experiences contain important lessons for the whole system, and it is our responsibility to make sure those lessons are heard.
The new strategy I have set for my office is about bringing these insights together, so we can better support practical, system-wide improvement that puts patient voice at its centre. At its core, commissioning must be there to support people to get quality care, wherever they live, when they need it.
Paula Sussex CBE
Parliamentary and Health Service Ombudsman