Recently we have been receiving a large number of requests to prescribe ADHD medications in situations when it has not been possible to do so. Therefore we thought it might be helpful to have a section describing the general approach to specialist medicines.
There are many adults nationally with undiagnosed ADHD. Media and social media coverage of this has led many patients to suspect they have ADHD and to come forward requesting referral for an assessment. We can appreciate why, for these patients, getting clarification and potentially a diagnosis of ADHD is important and potentially life-changing. Unfortunately, as a result of the huge increase in adults with suspected ADHD, the waiting times for assessments on the NHS has become very long (up to 5 years). Waiting times for children are fortunately much less but still significant.
Understandably some patients are reverting to self-funding private assessments. Often this results in a request for us to start prescribing stimulant ADHD medications. Unfortunately in some of this cases this is not possible.
These specialist drug which can only be prescribed under an approved shared care agreement. Until a shared care agreement is in place all prescribing needs to occur in secondary care (within the specialist clinic). Once the patient is stable on medication the specialist/psychiatrist can write to the GP asking if they are able to enter into a shared care agreement through which (supported on an ongoing basis by the specialist) the practice can take over the prescribing.
Due to the long waiting lists on the NHS a large number of providers offering ADHD assessments and treatment have arisen. While many are offering appropriate care and appropriately detailed assessments there have been reports of patients being given an ADHD diagnosis and advised to commence treatment on the basis of inadequate assessments.
In order for the Practice to be able to enter into a Shared Care Agreement the following criteria will need to be met:
- The diagnosis has been made by an appropriate specialist/psychiatrist specialising in ADHD and in accordance with UK criteria (the diagnostic criteria in some countries is different) and that we can be confident that the assessment has been a full / detailed one.
In line with NICE and national Psychiatry guidelines, the specialist should be trained in excluding other causes, such as general or specific learning difficulties; anxiety disorders; depressive disorder; autistic spectrum disorder, personality disorder, conduct disorder, abuse, trauma, oppositional defiant disorder, other neurodevelopmental disorders, neurocognitive disorder, disruptive mood disorder, bipolar disorder, reactive detachment disorder, disruptive mood dysregulation disorder or rarely, medical conditions, such as unsuspected hearing problems or epilepsy.
In practice, the most appropriately qualified specialist to exclude the above listed alternative conditions with overlapping symptoms (and in doing so confirm the ADHD diagnosis) is someone with the level of experience of a consultant psychiatrist specialising also in ADHD. We are finding increasingly, privately and in the NHS, that clinicians are diagnosing and managing ADHD, who are not ADHD specialist psychiatrists, often not psychiatrists, often healthcare professionals other than doctors who are not even supported by a psychiatrist. These health care professionals that may undertake only a 1-2 days formative course/training for ADHD are now making the diagnosis. The diagnosis is essential and without the appropriately qualified specialist having deep knowledge of the above listed conditions needed to be excluded we cannot have confidence in the diagnosis.
There are a number of providers (NHS & Private) who do not use appropriately qualified psychiatric specialists able to diagnose, manage or exclude the above lists of diagnosis, and for such providers we will not be able enter into a shared care agreement. For these reasons it may not of benefit to be assessed by such a service if this leads to an expectation that we would be required to prescribe such controlled medication that may exacerbate any underlying condition.
2. The request to enter into a shared care agreement needs to come directly from the specialist. The specialist must be readily available for both the patient and GP should any issues or queries arise.
Any requests to enter into a shared care agreement should come directly from the specialist to GP.
3. The patient is going to remain under the care of that psychiatrist for the entire period treatment is occurring and that this continuity is not dependent on the patient being able to self-fund or private insurance (which sometimes patient lose access to if a work-scheme and sometimes insurance companies refuse to cover ongoing care). It is obviously not possible to enter into a “shared care” agreement when continuity of care by the specialist is not guaranteed.
4. The specialist is recommending a treatment course in line with the local protocols and is happy sign the local shared-care agreement
We will obviously consider any request to take on prescribing responsibility. In practice, however, these requirements mean that for the vast majority of cases, it will only be possible to routinely enter into (and prescribe under) a shared-care agreement when a patient is under the care of an NHS specialist ADHD team. In a situation in which the four points above are not met it is highly unlikely that it will be able to take over prescribing.
In many cases previously what was portrayed as “shared care” has in fact been a complete transfer of care into primary care, leaving patients unwell and unsupported on potent medications and the practice unsupported and prescribing contrary to local guidelines and, potentially, the best interests of the patient.
For further information on ADHD please visit the NHS website – https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/
As mentioned, we have taken this position after careful consideration to have a clear and consistent approach that is based on quality, safety and equity.