Mainstreaming adult ADHD into primary care in the UK: guidance, practice, and best practice recommendations

Abstract

Background ADHD in adults is a common and debilitating neurodevelopmental mental health condition. Yet, diagnosis, clinical management and monitoring are frequently constrained by scarce resources, low capacity in specialist services and limited awareness or training in both primary and secondary care. As a result, many people with ADHD experience serious barriers in accessing the care they need. Methods Professionals across primary, secondary, and tertiary care met to discuss adult ADHD clinical care in the United Kingdom. Discussions identified constraints in service provision, and service delivery models with potential to improve healthcare access and delivery. The group aimed to provide a roadmap for improving access to ADHD treatment, identifying avenues for improving provision under current constraints, and innovating provision in the longer-term. National Institute for Health and Care Excellence (NICE) guidelines were used as a benchmark in discussions. Results The group identified three interrelated constraints. First, inconsistent interpretation of what constitutes a ‘specialist’ in the context of delivering ADHD care. Second, restriction of service delivery to limited capacity secondary or tertiary care services. Third, financial limitations or conflicts which reduce capacity and render transfer of care between healthcare sectors difficult. The group recommended the development of ADHD specialism within primary care, along with the transfer of routine and straightforward treatment monitoring to primary care services. Longer term, ADHD care pathways should be brought into line with those for other common mental health disorders, including treatment initiation by appropriately qualified clinicians in primary care, and referral to secondary mental health or tertiary services for more complex cases. Long-term plans in the NHS for more joined up and flexible provision, using a primary care network approach, could invest in developing shared ADHD specialist resources. Conclusions The relegation of adult ADHD diagnosis, treatment and monitoring to specialist tertiary and secondary services is at odds with its high prevalence and chronic course. To enable the cost-effective and at-scale access to ADHD treatment that is needed, general adult mental health and primary care must be empowered to play a key role in the delivery of quality services for adults with ADHD.

Attention-deficit hyperactivity disorder diagnoses and prescriptions in UK primary care, 2000–2018: population-based cohort study

“…It has been suggested that some people with ADHD could be diagnosed and managed entirely 38 or partially 39 in primary care. This would be a substantial shift away from the UK's current national guidelines, which state that a diagnosis of ADHD ‘should only be made by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD’.…”

“…14 In addition, these guidelines state that ADHD should only be diagnosed based on a full clinical and psychosocial assessment, full developmental and psychiatric history and observer reports. 14 Few primary care clinicians currently have the training to do so, or the time (a ‘straightforward’ ADHD assessment may take 2 h, 39 whereas the standard appointment in UK primary care is 10 min long 40 ). Novel solutions could involve a hybrid approach, developing the role of primary care practitioners with special expertise in ADHD in management and perhaps even diagnosis.…”

“…Novel solutions could involve a hybrid approach, developing the role of primary care practitioners with special expertise in ADHD in management and perhaps even diagnosis. 39…”

Protocol for the mixed methods, Managing young people (aged 16–25) with Attention deficit hyperactivity disorder in Primary care (MAP) study: mapping current practice and co-producing guidance to improve healthcare in an underserved population

“…The NHS Community Mental Health Framework,24 also sets out a vision for how community services should modernise to offer joined-up-care for those with mental health needs, within ICSs. Recent guidance, stemming from professionals across primary, secondary, and tertiary care in the UK, has recommended the development of an ADHD specialism within primary care, as part of a roadmap for improving access to treatment 25. The evidence base outlined above, and current guidelines,7 highlight the key role primary care services have to play in the provision of healthcare for young people with ADHD, and the potential for supporting an expansion of this role.…”

Private healthcare pressures on GPs: ADHD deserves better

“…Long waiting lists push the dwindling GP workforce to do more work, which is unfunded and unsustainable. The UK Adult ADHD Network has proposed potential solutions to ADHD waiting lists 4…”