ADHD assessments, Right to Choose, and the impact on NHS ADHD services

There has been an important recent analysis from the LSE looking at what is happening to ADHD assessment funding in England under the “Right to Choose” system.

The headline figures are stark. NHS spending on private ADHD assessments has more than tripled in just three years, rising from around £36 million to over £120 million. Some private providers are reportedly making profit margins of over 30%, which means that a significant proportion of NHS money is not going into patient care at all.

The argument in the LSE piece is not that people should not have access to timely assessment. Of course they should. The argument is that the current model is an expensive sticking plaster that actively undermines the NHS’s ability to build sustainable ADHD services.

Local NHS systems, through Integrated Care Boards, are legally required to fund these private referrals, even when budgets are already under extreme pressure. There is very little local control over this spend, even when it means money is being pulled away from other already stretched services. Over time, this creates a system that is paying more and more, getting less and less, and building nothing lasting.

Why outsourcing ADHD assessments does not increase NHS capacity

One of the least discussed consequences of this model is that it does not create new clinicians. It simply redistributes a finite workforce.

Private providers can often offer higher pay, more flexible remote work, and far less administrative burden. At the same time, NHS ADHD services are under enormous pressure, with long waiting lists, complex caseloads, and high levels of risk and responsibility. It is entirely predictable that clinicians reduce their NHS hours or leave altogether to work in the private sector, because it is easier and less stressful. This is not a moral failing, it is a system incentive.

The result is a vicious circle. NHS services become more understaffed and overwhelmed, working conditions become more pressured, more clinicians leave or reduce their NHS work, and capacity falls further. The system then responds by outsourcing even more work, which further weakens the NHS service it is supposed to be supporting.

The NHS ADHD pathway is broken, not just the assessment stage

Much of the public discussion focuses only on access to assessment. But ADHD is not a “one appointment and done” condition.

A proper ADHD pathway is not just a diagnostic appointment. It includes assessment, medication titration where appropriate, medical follow up and monitoring, psychological and practical support, and help with work, education, and daily life. It also includes support while people are waiting.

At the moment, most of the money and attention is being poured into one narrow part of the pathway, the diagnostic appointment, while the rest of the pathway remains fragmented, underfunded, or in many places simply unavailable.

This is one of the reasons NHS services feel so overwhelmed. They are left holding the most complex, risky, and long term work, while the system keeps paying for more and more assessments that then feed into services that do not have the capacity to absorb them.

How NHS funding for ADHD could be used more effectively

This is the part that often gets missed in the debate.

The hundreds of millions currently being spent on outsourced assessments could be used to build something far more humane, effective, and sustainable within the NHS.

Building properly staffed NHS ADHD teams

Instead of paying per assessment to private companies, that money could be used to build and stabilise NHS services. This means recruiting and retaining psychiatrists, nurses, psychologists, and allied professionals, funding permanent posts rather than short term firefighting, and creating stable multidisciplinary teams.

Stable teams build expertise over time. They supervise and train others. They develop better pathways and safer ways of holding risk and complexity. This is how real capacity is created, not by repeatedly buying in activity from outside.

Providing ADHD support from the point of referral

At the moment, many people are referred for an ADHD assessment and then left in limbo for years. That waiting period is not neutral. People are often struggling with work, relationships, mental health, and basic day to day functioning long before they ever reach an assessment appointment. Many are already burnt out by the time they are finally seen.

Support during this phase could include structured psychoeducation about ADHD, group sessions focused on energy, time, and stress management, and practical strategies for daily life and work. It could also include support to help people understand their strengths as well as their difficulties.

This is exactly the kind of work that can be offered by psychologists, specialist nurses, and properly trained ADHD coaches working within, or alongside, NHS services. None of this requires a diagnosis to be helpful, and all of it can reduce deterioration while people are waiting.

Improving post diagnostic support for adults with ADHD

For many people, diagnosis is not the end of the journey. It is the beginning.

A good pathway would include structured post diagnostic education, support to understand how ADHD shows up in that person’s life, and help to make realistic, sustainable changes at work and at home. It would also include coaching or therapy input focused on daily functioning, not just symptom reduction, and appropriate support for common coexisting difficulties such as anxiety, depression, trauma, or burnout.

At the moment, many people are diagnosed and then effectively sent away with very little follow up, especially if they do not go down the medication route, or once titration is complete. That is not good medicine, and it is not a good use of the diagnosis either.

Fixing ADHD medication titration and follow up in the NHS

Medication can be life changing for some people, but it requires time, careful titration, monitoring, and follow up. NHS services are often completely overwhelmed here, which leads to long delays and fragmented care.

Investing in NHS teams would allow this to be done safely and properly, rather than pushing more and more people into a system that cannot keep up.

How a better NHS ADHD pathway would reduce long term demand

A good ADHD service does not just process people. It reduces future crisis, burnout, job loss, and mental health deterioration.

People who are properly supported are more likely to stay in work, less likely to reach crisis point, and less likely to develop severe secondary mental health problems. Over time, this reduces pressure on the wider system. That is what a preventive, adult, and mature healthcare system looks like.

Why the ADHD assessment crisis is not a patient problem

It is important to be very clear about this. People are not wrong to seek assessment. They are not wrong to use Right to Choose. They are responding rationally to a broken system.

This is a commissioning and system design problem.

The current model is expensive, inefficient, and actively undermines the NHS’s ability to build a sustainable ADHD pathway.

What needs to change to fix NHS ADHD services

The LSE article is right to highlight that this model is draining money out of the NHS without building anything lasting.

If we genuinely want to fix ADHD pathways, we have to stop relying on endless outsourcing and start investing that money into NHS staff, NHS teams, and whole pathways, not just assessments. That means building support before diagnosis, after diagnosis, and in between, rather than continuing to pour money into a system that fragments care and weakens the services it depends on.

This is not about ideology. It is about building a system that actually works, for patients, for clinicians, and for the NHS in the long term.