After the ADHD Invoice, GPs and Waiters Carry the Cost

NHS boards now pay £300 to £3,000 for similar ADHD and autism assessments, the NHS Alliance says, as Right to Choose invoices outrun local waiting lists.

The Alliance, which represents health managers, calls the current system a “bad deal” for patients and taxpayers. The gap after that invoice is who treats the diagnosis, and who is still waiting on the local list.

A £300 to £3,000 Invoice for the Same Assessment

Managers told the Alliance they are caught between long delays and a bill they cannot cap. Unlike hip and knee operations, ADHD and autism work has no set national tariff that private and NHS providers must keep to, so similar assessments arrive at wildly different prices.

One board saw costs rise 10-fold in a year, to £1.5 million a month. Another watched annual spend jump from £4 million to £30 million over two years. In Cheshire and Merseyside, spending on adult ADHD went from £11 million in 2023-24 to a projected £51 million this year.

WHAT BOARDS TOLD THE ALLIANCE

Right to Choose is the legal route that lets a GP refer someone to any qualifying NHS-contracted provider in England, including independent clinics, so they can skip a local queue. The Alliance says that influx cut some of the longest waits for adults and children, and that it also sent spending “out of control.” Rebecca Gray of the Alliance said managers understand the anguish of those waits.

But in working to meeting demand they face soaring costs that are running out of control.

Rebecca Gray, NHS Alliance

Mel Merritt of the National Autistic Society said spending is rising on short-term solutions after years of thin long-term investment, and that people still face “unacceptable” delays.

Diagnosis-Only Clinics Do Not Need CQC Registration

Boards also said they cannot keep up with quality checks as provider lists swell. A large part of that gap is written into the rules, not invented by a new clinic last month.

The Care Quality Commission’s own scope guidance, updated on 26 March 2026, is blunt at the top of the page: if you only offer diagnosis of ADHD and autism with no treatment, you do not need to register with CQC. Diagnosis does not count as a diagnostic-and-screening procedure because it does not use equipment to measure physiological data, and CQC does not treat that diagnosis as “treatment” either.

Health minister Stephen Kinnock confirmed the same split in a written answer on 7 April 2025. Independent providers who diagnose and treat ADHD fall inside the 2014 regulated-activities rules. Independent providers who only diagnose, with no treatment, “are not within scope of CQC registration, as the regulations currently stand.”

That is the hidden architecture behind the Alliance’s safety warning. An assessment-only firm can invoice an integrated care board under Right to Choose, hand the patient a report, and leave the regulator’s inspection net. The GP and the local mental health team inherit the next step.

Autism researcher Paul Whiteley wrote that the issue is there is no mandatory price or tariff, and that not every provider is offering the same quality of service. Those two gaps travel together. A cheap assessment that later has to be redone is not cheap, and a dear assessment that a GP will not trust is not finished care.

Why Guide Prices Have Not Capped the Bill

NHS England did publish prices. They are guides, and boards do not have to keep to them. The 2026/27 NHS Payment Scheme, in force from 1 April 2026, set non-mandatory guide prices for assessments after a consultation that drew a very large number of responses from individuals. Several of those guides were raised in the final scheme.

2026/27 GUIDE PRICES (NON-MANDATORY)

The guidance says those figures are averages for a mixed caseload, and that an integrated care board may need to amend them. It also tells commissioners that reports from independent Right to Choose providers should be accepted by NHS titration services unless there is a clear clinical reason not to, so people are not assessed twice.

The charged range boards described, £300 to £3,000, sits both below and far above those guides. A tariff for hips does not work like that. Until the guides become a price that must be paid, the invoice remains a local argument with 48 vendors on one board’s books.

GPs Can Refuse the Prescribing Handover

The assessment is the line item everyone can see. The next cost often lands on general practice, which never chose the clinic and does not have to take the drug chart.

NICE guidance says that after titration and dose stabilisation, GPs may carry on prescribing and monitoring under locally agreed shared care. May is the word that matters. Shared care is a voluntary arrangement. A practice can refuse if it is unhappy with the quality of the assessment, if local medical committee advice steers it away from out-of-area specialists, or if it has a blanket policy on private or Right to Choose ADHD drugs, including for children.

NHS England’s own payment guidance prices that refusal. Where a GP has not accepted shared care, the specialist provider may charge the board an annual fee for ongoing medication and review. For children, the published example for a quarterly review without shared care is £130, built as a £100 review plus £30 of prescribing. The ICB keeps paying the clinic. The GP stays out. The patient is diagnosed and still shopping for a prescriber.

WHERE THE PATH SPLITS AFTER DIAGNOSIS

• Assessment only: The clinic issues a report, invoices the board, and needs no CQC registration if it offers no treatment.
• Titration with the same provider: Dose-finding, physical monitoring and first prescriptions stay with the specialist, at a £400 adult guide price.
• Shared care accepted: The GP takes repeat prescribing and monitoring, and the specialist steps back to advice and an annual review.
• Shared care refused: The specialist keeps prescribing, the board pays an ongoing fee, and the local NHS clinic may still insist on its own reassessment.
• Never left the local list: People who do not use Right to Choose, or whose GPs will not refer that way, remain in the queue the policy was meant to bypass.

That last split is the one boards are not putting on the invoice slide. Paying a private firm hundreds of pounds a year to issue a stable stimulant script, while a GP practice down the road could do the same job under a protocol, is how a “cheaper” assessment becomes a long private tail. Several local medical committees have already advised practices to be wary of new ADHD shared-care deals. Some integrated care boards say they have no policy that lets NHS prescribers share care with non-NHS private clinics at all.

505,815 Open ADHD Referrals, and Local Lists Still Grow

Right to Choose was built to empty those lists. It has not. NHS Digital figures compiled for parliament show 505,815 open ADHD referrals in England at the end of March 2026, of which 338,695 (67%) were adults and 167,120 (33%) were children and young people aged 0 to 17.

A further 177,244 people aged 5 to 24 may have been waiting through community health services that do not break the list down by age, which takes the possible total to 683,059. In March 2026 there were 24,480 new ADHD referrals, 9,785 of them for children.

THE ADHD QUEUE, MARCH 2026

• Under 13 weeks: About 10.9% of adults and 11.4% of children had been waiting less than 13 weeks, the target window for first contact.
• Over a year: About 63.1% of adults and 65% of children had been waiting more than a year.
• Who may have ADHD: NHS Digital estimated around 2.5 million people in England as of May 2026, including people without a recorded diagnosis, of whom about 616,000 (24.7%) were aged 0 to 17.
• Autism pathway: NHS England Digital counted 270,701 people with an open suspected-autism referral in March 2026, and 242,708 of them (89.7%) had already been open at least 13 weeks; only 9,071 (3.7%) of that long-wait group had had a first appointment inside 13 weeks.

The cost argument treats each extra assessment as a leak. People still on those lists are living the other bill: years without a decision, and no medication, workplace adjustments or school support that a diagnosis would unlock. Devon Partnership NHS Trust’s adult service, in a June 2026 update, listed 5,051 people waiting for an ADHD diagnostic assessment, with waits of over five years, and 1,211 more waiting for treatment after being diagnosed elsewhere. Its autism list stood at 2,991, and for new autism referrals it was still seeing people first referred in April 2019.

NHS Digital has estimated 2.5 million people in England may have ADHD, using NICE prevalence. The independent review chaired by Professor Peter Fonagy cites NICE estimates of around 5% in children and young people and 2% to 3% in adults, and says recorded diagnosis still lags expected prevalence in some adult groups, including people in contact with the criminal justice system. A queue of this size can be both too expensive for boards and too small for the population NICE describes.

Professor Fonagy’s Review Leaves Overdiagnosis Open

Health secretary Wes Streeting commissioned the review on 4 December 2025, after a public row about whether mental health, ADHD and autism are being over-diagnosed. Professor Fonagy, a clinical psychologist and national clinical adviser on children and young people’s mental health, chairs it, with Professor Sir Simon Wessely and Professor Gillian Baird as vice-chairs. An interim report went out on 31 March 2026. The government has said the final findings will be published soon and that it will act on them with a “new national approach” for autism, ADHD and mental health.

The interim report does not pick a side in that row. It records that referrals, waits and recorded ADHD diagnoses have risen fast, especially among adolescent and young adult females, with incidence among women aged 20 to 24 more than doubling against pre-pandemic trends. It also records that population surveys of ADHD symptoms look much more stable than the administrative numbers.

NHS England monitoring in that report shows the number of children waiting for an ADHD assessment rose from around 21,000 in April 2019 to around 270,000 by December 2025. Among children and young people, the share of diagnoses followed by medication has roughly halved since the pandemic, which the review says may mean a changing mix of cases rather than a simple surge in stimulant use.

Underdiagnosis, misdiagnosis and overdiagnosis are not mutually exclusive possibilities. Nor are they merely abstract concerns. They shape whether people receive support, what form that support takes, how quickly it is available, and whether systems are able to direct resources where they are most needed.

Independent review into mental health conditions, ADHD and autism, interim report, Department of Health and Social Care

That paragraph is the fight the Alliance warning does not settle. If a slice of new diagnoses is poorly done, paying £3,000 a time is waste twice, once in cash and again when a GP or a local clinic throws the report out. If a slice is catching people who were always there, then closing the only fast door, Right to Choose, just returns them to a five-year Devon-style list. The review’s next phase is supposed to test quality and consistency of assessments. Until that lands, boards are trying to cap a demand they cannot yet describe.

Activity Caps Are Already Cutting Right to Choose

While the review writes, commissioners have started rationing the legal route rather than waiting for a tariff. Several integrated care boards have put Indicative Activity Plans on Right to Choose ADHD and autism providers, limiting how many assessments they will pay for in a year. NHS South West London said those plans for each of its Right to Choose ADHD providers began on 1 July 2026. Other boards describe the same tool in their 2026/27 contracts, citing the duty to hit financial balance.

Patients still have a legal right to choose a provider for a first outpatient appointment, including remote ADHD and autism assessments, if the provider holds a qualifying NHS standard contract. That right arrived in 2014 as part of parity with physical health. It was never a dedicated neurodiversity budget. GPs still decide whether a referral is clinically appropriate, and a cap on activity is how a right becomes a waiting list with a different logo on the letterhead.

THE PATH FROM CHOICE TO THIS INVOICE

1. 2014: Patients in England gain a legal right to choose provider and team for mental health, learning disability and autism first outpatient appointments.
2. 2014 regulations, restated 26 March 2026: CQC guidance keeps diagnosis-only ADHD and autism outside registration when no treatment is offered.
3. April 2019: About 21,000 children and young people are waiting for an ADHD assessment.
4. After 2020: Recorded ADHD diagnoses accelerate, especially in young women, while survey measures of symptoms stay flatter.
5. 4 December 2025: Wes Streeting launches the Fonagy review, with findings then expected in summer 2026.
6. 31 March 2026: The interim report is published; by December 2025 about 270,000 children are waiting for ADHD assessment.
7. 1 April 2026: Non-mandatory guide prices for ADHD and autism pathways take effect in the NHS Payment Scheme.
8. 1 July 2026: South West London and other boards apply Indicative Activity Plans to Right to Choose ADHD providers.
9. 28 August 2026: The NHS Alliance warns that autism and ADHD care risks descending into chaos as costs and provider lists expand.

The Alliance wants a national tariff and a national specification for what a decent assessment looks like. NHS England’s payment guidance already points that way as a longer-term goal, and it is still only a guide. Tightening CQC’s net around diagnosis-only clinics, and making shared care a commissioned duty rather than a GP favour, would hit the part of the chaos that never appears on the assessment invoice.

Devon’s adult autism service is still seeing people referred in April 2019. Boards are arguing about this year’s invoices while those names remain on the local list.

Disclaimer: This article is news reporting and analysis of NHS ADHD and autism assessment policy in England, and it is for information only. It is not medical advice, a diagnosis, or a guide to whether any person should seek an assessment, start or stop medication, or use Right to Choose. Readers who are worried about symptoms, waiting times, shared care or prescriptions should speak to their GP or another qualified clinician, and should not change treatment on the basis of this piece. Figures, waiting-list counts, prices and review timetables reflect the official sources cited as of 2 September 2026 and may change as new NHS Digital releases and the Fonagy review’s final report appear.