Rethink of adult ADHD services is needed, say researchers

A new approach to providing services to people with ADHD is needed, according to researchers who say that current provision is in crisis.

The researchers, who include academics from the University of Cambridge and the University of Huddersfield as well as clinicians from different health trusts, have published an editorial in the BJPsych Bulletin outlining potential new models for service provision.

“The UK’s services for adult attention-deficit hyperactivity disorder (ADHD) are in crisis, with demand outstripping capacity and waiting times reaching unprecedented lengths,” the authors write. “Recognition of and treatments for ADHD have expanded over the past two decades, increasing clinical demand. This issue has been exacerbated by the COVID-19 pandemic. Despite an increase in specialist services, resource allocation has not kept pace, leading to extended waiting times.”

They note that delays to treatment “carry a human and financial cost, imposing a burden on health, social care and the criminal justice system” and add that a rethink of service procurement and delivery is needed.

ADHD services ‘at a critical juncture’

The authors look at five possible options for dealing with the crisis:

• Maintaining the status quo. They note that without change, waiting lists will continue to grow, exacerbating existing problems. As well as being “detrimental to patients,” they write, this “imposes a significant burden on specialist services.” The pressure of extended waiting times also damages morale within specialist services, “bringing additional challenges of workforce retention and capacity, further exacerbating the problem.”
• Increasing funding. They add that “given the fiscal environment, this option seems unlikely. Furthermore, substantial funding would be required to bridge the gap between demand and capacity and to tackle the backlog.”
• Improving system efficiency. They suggest this could be achieved by “could be achieved by refining every aspect of the diagnostic and treatment pathway, including leveraging technology.“ This could include using artificial intelligence or machine leaning approaches to help establish a diagnosis, but they say these developments would be unlikely to affect the system quickly enough. They also suggest using more sophisticated administrative systems for assessment and treatment to “significantly reduce the administrative burden on specialist teams.” Although promising, the researchers say, efficiency savings are unlikely to significantly alleviate the burden without accompanying efforts.
• Altering the service provision model. The authors suggest that instead of relying on specialist services for assessment and management, primary or secondary care could take up a large proportion of the workload. More complex patients could be assessed and treated by case-holding teams, such as community mental health or perinatal teams, if they are already on the case-load. “This approach would make better use of specialist resources but would require significant funding, training and implementation time,” the authors write.
• Clinical prioritisation. This option involves limiting access to services to those most severely affected by ADHD. The authors acknowledge that this would raise ethical concerns and “would pose significant practical challenges.” A recent pilot to explore the viability of such an approach had been criticised, they write. They also recognise that some patients might exaggerate their symptoms in order to access care.

The authors conclude by saying that adult ADHD services in the UK are “at a critical juncture” and that a combination of increasing demand and insufficient resources means the current system is “struggling to provide adequate care for patients.” While some of the options they have suggested relating to efficiency and alternative service models might provide results, they argue that significant strides “will be made only with additional funding and a shift in how we approach ADHD treatment.”

They suggest that the introduction of a national target for starting diagnostic assessments within three months of referral could stimulate positive change. “Such a target could be integrated into the NICE guidelines, helping to keep ADHD treatment at the forefront of health policy,” they write.