Until recently, most of my ADD / ADHD patients who did well on a trial of medication, were then able to obtain further NHS prescriptions from their GP.
My website highlights the 2009 NICE (National Institute for Health and Clinical Excellence) ADHD guidelines, because the guidelines are strongly in favour of diagnosis and treatment choice. When NICE was set up as a state-funded body in 1999 there was a commitment, which was made legally stronger in 2005, that the NHS would be provided with enough money to follow its recommendations.
Last year, the new Government’s Conservative Health Secretary, Andrew Lansley, abolished this legal commitment for GP’s to follow NICE guidelines.
Under financial pressure to reduce prescribing, GP’s look at adult ADD / ADHD, and see that no medication is licensed. Unless the GP has direct experience of treatment benefits, this relatively new diagnosis inevitably becomes a target for cost reduction.
The fact is, medication licensing is really about the claims that a pharmaceutical company can make for its product, rather than what clinicians can prescribe (and the NICE guidelines are more relevant to that). But such distinctions make little difference to GP’s, especially when fully licensed ADD / ADHD treatment in children and teenagers is still often opposed by prominent NHS academic psychiatrists.
My own experience is that ADD / ADHD medication, together with counselling and psychotherapy which takes diagnosis properly into account, can improve interpersonal and work functioning enormously. If patients do have to fund diagnosis and treatment themselves, it is likely to be well worth it, as long as they have moderate or severe ADD / ADHD. Treatment could even be cost-effective if the ADD / ADHD is milder: what price can you put on better relationships?
Drafted by 2nd July 2011, published at DrNMblog.wordpress.com on 6th October 2011
Psychotherapy has been in the news recently, with the announcement that a further 400 million pounds will be made available through the so-called IAPT (Improving Access to Psychological Therapies) programme.
But although the government has stated the money is “new”, a senior IAPT adviser has been sacked, apparently for saying that is “a lie” (1). Certainly, savings are to be made elsewhere in the NHS mental health budget.
Somewhat lost in the discussion has been a shift away from the idea that IAPT is just about CBT (cognitive-behavioural therapy). In theory, IAPT has for years accepted that Interpersonal Therapy (IPT), and couples therapy, are just as valid for problems such as depression and anxiety.
At a seminar on IAPT eighteen months ago, a regional manager told me that it was proving difficult to recruit therapists for these approaches. That seems to be changing, and the British Psychoanalytic Council’s recent comments appear to be positive about psychodynamic therapies gaining significant funding alongside CBT (2).
In my view that is a good thing. Since the early 1990’s, I have been sceptical of the established NHS wisdom that psychodynamic treatments had been demonstrated to be generally inferior.
Yesterday I attended the second annual meeting of UKAAN (UK Adult ADHD Network), which is led by academics and funded by a leading pharmaceutical company (1).
It was very interesting to hear how local NHS adult services, all English, were coping with increased referrals of patients. What seems clear is that many people are screened out, often by so-called “gateway workers”, who tell patients that they do not “meet the criteria”.
When the NICE guidelines came out, I wondered if patients with ADD / ADHD would often be found to not “meet the criteria” on the basis that their condition was “only” mild. However, it looks as though a lot of mild and moderate ADD / ADHD is simply being diagnosed as “no ADD / ADHD”.
I have already seen many people with moderate-to-severe disorders, who should fall within the NICE guidelines, but have been told that they should stop “medicalising their past failures” and just get on with their lives.
The President of UKAAN, Professor Phil Asherson, told the meeting that in many areas services are being closed. This means that people who have been on waiting lists for months may end up being told that they will not be seeing a specialist after all.
I will be suggesting to ADDISS and AADD-UK that they consider telling their members and supporters about the reality of all this in greater detail and that, for those who can afford it, paying to see an independent specialist may be the best option for at least the next 2-3 years (2).
(1) There appeared to be no promotional activity at all within the meeting itself.
(2) “2-3 years” is based on the wide perception of how long the most intense NHS spending restraint may last.
The BBC’s recent bad news, about Panorama’s flawed ADD / ADHD programmes (1), seems to have been buried by the general pre-election media coverage. I have been assured that the BBC Trust’s delayed decision (itself still a subject of the complaints process) was not deliberate “news management” timing; but myself and ADDISS did find it interesting last year that the initial recognition of a problem with the 2007 programme was made public in early August (2), a traditionally quiet time when press releases often don’t get followed up.
Therefore it may take some months to discover the changes, if any, to the way mental health and behavioural disorder issues are now dealt with by the BBC.
For me, the problem with the 2007 programme (3) was not just the one-sided presentation of research on medication. It was the avoidance of any exploration of why Craig, the teenager whose ADHD and perhaps other problems caused him to end up in Court, was not receiving any input from local NHS services. No local professionals or managers were questioned (they were in the 2000 programme), and the interview with NICE’s Dr Tim Kendall was extremely limited.
By making the overall issue about medication, rather than local services, the 2007 programme in effect promoted the Department of Health’s policy that specialist mental health services are focused on “severe and enduring” problems, and can therefore exclude moderate and mild ones. This policy has now been in place for nearly two decades and has undoubtedly removed billions of pounds from the DOH’s “frontline services” balance sheet. However, many ADD / ADHD specialists believe that failure to intervene earlier, in these less severe disorders, results in substantial financial costs later in terms of underemployment, prison places, and adult mental health problems. Dr Kendall might have been asked some difficult questions on NICE’s narrow money-orientated evaluation process, but that didn’t happen.
Perhaps Panorama has unbroadcasted material which would throw light on all this. A fuller review of the reasons for the “unfair and not open-minded” programme might also include emails and other communications from and to the Department of Health (4).
(1) See my previous blog post (5th March)
(3) The BBC Trust ordered the programme to be removed from the BBC website. Today, weeks later, I was still able to view it at http://www.bbc.co.uk/accessibility/win/hearing/alt/panorama/sub_3.shtml . It has also been placed on YouTube as “A Panorama report on the life of a young child hooked on medication prescribed for his so called ADHD condition. “
(4) I remain open to a range of explanations for the problems with the programmes; and I am not suggesting that Panorama deliberately colluded with the Department of Health, to be misleading.