In England, patients with a GP referral can select a private provider for assessment and initial treatment funded by the NHS, but the system is plagued by long waiting lists and frequent rejections of private diagnoses. This creates a problematic grey zone where individuals are caught between private and state care, often leaving them without essential support.
The Personal Cost of a Broken System
Sameer Modha understands the ADHD system intimately, having been diagnosed himself along with his two children. While his own diagnosis proceeded relatively smoothly, his experience with his daughter revealed significant flaws. After obtaining a private assessment from a highly experienced former child and adolescent mental health service director, the NHS later rejected this diagnosis, claiming it did not comply with National Institute for Health and Care Excellence guidelines.
Modha describes being "caught between the private and state systems," with GPs often reluctant to engage in shared care arrangements. He eventually had the diagnosis reconfirmed through the NHS after persistent efforts, but continues to struggle with different parts of the system working together effectively.
Structural Failures and Financial Waste
The NHS is increasingly referring patients to private providers that the health service pays for, only to subsequently reject those assessments. This inefficient cycle wastes public money while leaving patients without proper care and mental health trusts overwhelmed. One NHS trust has reported that this churn is clogging its ability to treat patients as people return to services after private assessments stall.
The financial implications are substantial, with the NHS estimated to be overspending approximately £164 million annually on ADHD services. Health Secretary Wes Streeting recently acknowledged the government's failure to manage what he described as an epidemic of autism and ADHD referrals.
Right to Choose Limitations
Under the NHS Right to Choose policy in England, patients with GP referrals can select private providers for assessment and initial treatment funded by the NHS rather than waiting for local NHS services. In theory, care should then transfer back to the NHS through shared-care arrangements, but this frequently fails to occur in practice.
The Midlands Partnership University NHS Foundation Trust has highlighted structural weaknesses in the system, noting limited regulation surrounding private ADHD providers. The trust observed that while providers can establish services and request to diagnose ADHD, their assessments sometimes fail to comply with Nice guidelines.
Regional Strain and Innovative Responses
In NHS Greater Manchester, adult ADHD services face particularly severe pressure. Referrals have increased by more than 400%, from approximately 2,700 in 2022 to over 11,000 in 2024, with more than 25,000 adults now waiting for autism or ADHD assessments. Services originally designed for much lower demand could see waiting times exceeding seven or even ten years without intervention.
NHS Greater Manchester estimates that funding current levels of Right to Choose diagnostic requests alone would cost at least £30 million annually, without sufficient clinicians available to deliver them. Current waiting times already range from eighteen months to more than seven years.
New Approaches to Managing Demand
Recognising that diagnosis has become an unnecessary gateway to support for many people, NHS Greater Manchester is implementing a central triage hub. All adult ADHD referrals will receive an initial face-to-face assessment, with only those meeting agreed clinical thresholds proceeding to full NHS-funded diagnosis.
This innovative model aims to reduce full diagnostic assessments by 70-80%, standardise decision-making, and alleviate pressure on specialist services. Simultaneously, NHS Greater Manchester plans to expand community-based and non-clinical support, enabling people to access help earlier while waiting for specialist care.
Patient Experiences and Provider Perspectives
Patients continue to bear the brunt of system failures. One father reported that after three years, his son's GP practice unexpectedly stopped working with a private provider. Although his son was referred back to NHS services, waiting times exceeding six months guaranteed a treatment gap, with consultants warning of "predictable harms" if treatment ceased.
Modha summarises the impossible choice facing families: "You're damned if you do and damned if you don't – try to get help privately and integrate later, or try to do it all through the NHS and wait two years, by which time your child may be dead."
The Independent Healthcare Providers Network acknowledges that independent providers play an essential role in supporting NHS ADHD services, while recognising shared care as a significant challenge. They emphasise the importance of collaborative solutions between government, NHS commissioners, GP representative bodies, and independent providers to address coordination issues.
Despite concerns about safety, quality, and consistency of care that require robust regulation, the overriding challenge remains a longstanding lack of capacity and unacceptably long waiting times for diagnosis across ADHD services.
