Recommendations
Recommendation 1: New national commissioning guidance and an implementation framework on ADHD and autism are developed to support ICBs to make commissioning decisions that improve patient experience and access to care.
It is important that ICBs understand how their responsibilities in different areas fit together so they can make commissioning decisions that meet the needs of local populations, against a backdrop of rising demand and fewer resources. National commissioning guidance would help provide the foundations for a future Modern Service Framework. However, national guidance should be complemented by practical support from NHS England and DHSC. This should promote cross-system learning and strengthen commissioning capabilities and local expertise through the Strategic Commissioning Development Programme. These measures should build on national improvement support, data and lived experience to help areas develop accessible, joined-up pathways that respond to local need while enabling patients, carers and professionals to better understand and use their right to choose.
We recommend that NHS England and DHSC publish national commissioning guidance to set out how patients’ right to choose, commissioning responsibilities and local contract arrangements should operate together within ADHD and autism pathways in ICBs. This should support improvement on strategic issues that affect multiple NHS regions so commissioners can plan, procure and oversee services that reflect population need, patient choice, clinical quality and sustainable use of resources.
We recommend that through the Strategic Commissioning Development Programme, NHS England and DHSC support ICBs to build local strategic commissioning capabilities across ADHD and autism pathways. This should include strengthening local strategic commissioning expertise, supporting the sharing and application of good practice and facilitating peer learning across ICBs.
This should support ICBs to:
- use learning from complaints so that patient experiences and feedback inform the design of pathways
- prioritise resources to meet local population need and support the design of sustainable services
- provide information and support to help patients navigate pathways, managing expectations around choice of provider and waiting times for assessment
- strengthen data capabilities and reporting so ICBs have visibility of provider performance to help shape market planning and procurement.
Recommendation 2: The evidence base for digital diagnostic technologies is developed and strengthened to support future updates to NICE guidance on ADHD and autism assessments.
Digital technologies are playing an increasing role in ADHD and autism assessments and could offer opportunities to improve access and consistency. However, as the market continues to rapidly expand and becomes more fragmented, data collection and evidence generation on digital technologies is expected to become more challenging across manufacturers and providers. This will make it harder to assess the safety, diagnostic accuracy and effectiveness of technologies at a population level and across different NHS settings.
While manufacturers are responsible for generating evidence to meet the regulatory requirements for health technologies, a more coordinated approach bringing together DHSC, NHS England, the Medicines and Healthcare products Regulatory Agency (MHRA), NICE, researchers, providers and manufacturers could help strengthen the evidence base on digital diagnostic technologies. Improving how evidence is generated, collected and evaluated in clinical settings could lead to a better understanding of efficacy and impact on patient outcomes. This would provide greater assurance for patients, clinicians and commissioners, and ensure that NICE has the evidence needed to determine whether emerging technologies are clinically and cost effective for use in NHS-funded services.
We recommend that DHSC and NHS England establish a process to strengthen the evidence base around the use of digital and AI technologies in the assessment of ADHD and autism, in addition to manufacturers generating appropriate evidence. This could include commissioning new research and evaluating the findings of independent reviews.
We recommend that NICE use this expanded evidence base, when available, to assess the clinical and cost-effectiveness of digital and AI diagnostic technologies and update its guidance.
Recommendation 3: Health and Social Care Act regulations are updated so that the Care Quality Commission (CQC) can improve oversight and accountability mechanisms for NHS-funded providers that only deliver ADHD and/or autism assessments.
Although diagnostic and screening procedures are regulated activities, the wording of current regulations means that diagnosis of ADHD and autism does not currently fall into scope of CQC registration and inspection. As such, diagnostic-only providers of ADHD and autism assessments are not required to register with CQC. This creates varying levels of confidence for commissioners, clinicians and patients. We believe this regulatory gap should be addressed urgently. Improved quality assurance and oversight mechanisms will help increase the visibility, transparency and monitoring of NHS-funded providers and referral pathways.
We recommend that the Government considers seeking revisions to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to bring diagnosis of ADHD and autism into scope of CQC registration and inspection.