ADHD Access Criteria Policy

Access Criteria for all adult ADHD diagnosis including local providers and Right to Choose for GPs in Thames Valley ICB.

Due to the massive demand for diagnosis of adult ADHD, which has brought the pausing of local adult ADHD services, BOB ICB have drawn up a list of access criteria. These criteria have been drawn up to enable those with the most severe functional disturbance due to ADHD to access formal diagnosis and medication where the addition of medication is likely to have the greatest positive effect. All others will be directed to a community offer of resources which have helped people with ADHD but will not involve medication.

This approach will allow those with the most severe ADHD to be seen on the waiting lists and help open up the local ADHD services to new patients. It will make sure that Right to Choose and local providers see those patients who will benefit most from diagnosis and medication. The criteria will be monitored and modified according to system capacity and usefulness. The access criteria will be applied by GPs to all referrals including local providers and Right to Choose providers. 

The adult ADHD services will accept clients who meet criteria 1, 2, 3 and one of criteria 4.

1. Over the age of 18 years

And

2. Does not have a contraindication to ADHD Medication at the time of referral. (The person starting ADHD medication is responsible for making sure the patient is fit and does not have any contraindications to the medications being used at the time the medication is being started. This is not a GP responsibility)
   • Cardiovascular issues have been ruled out or Where cardiovascular issues have been identified (such as family history of sudden death or cardiomyopathy in younger age group, or history of exertional chest pain or shortness of breath or palpitations) this has been fully investigated and, if seen by cardiologist, there is a statement that from a cardiac perspective, it would be appropriate to prescribe ADHD medication.
   • Existing hypertension has been appropriately investigated. In those age < 45 years authorisation from appropriate specialist has been obtained to use ADHD medication
   • Any other severe physical condition or medication which might interact with ADHD medication or be adversely affected by a potential side effect­appropriate authority from a specialist needed before referral made.
   • No significant substance and alcohol misuse in last 6 months OR is actively engaging with substance misuse agencies

And

3. Clients whose needs are NOT better met by another service.
   • Clients with a learning disability would be seen within a learning disability service for holistic assessment and where appropriate treatment of ADHD.
   • Clients with a long-term mental health condition would be seen within CMHT for holistic assessment and where appropriate treatment of ADHD.

And

4. The client can provide written evidence that they meet one of the criteria below.

Criteria

Safeguarding:

The client or child in their care is open to a safeguarding team, and an ADHD treatment has been identified as a need.

Legal proceeding:

Client is open to Criminal Justice Liaison and Diversion /street triage/ link / probation, and ADHD treatment has been identified as a need. This does not include family law. This does not include medicolegal assessments.

Long-term conditions:

Client has a long-term physical health condition e.g. diabetes, epilepsy, AND they are struggling to manage the care plan for this condition due to ADHD symptoms and ADHD treatment has been identified as a need.

Education: 

The patient is enrolled in an academic I vocational course and difficulties associated with ADHD (such as focus, submitting work, communication) have led to risk of failing/ non completion/exclusion. The student support service (or SEND) has provided evidence that reasonable adjustments have been implemented consistently for a term and treatment is required to access further support ( e.g. medication/funded adjustments available with a confirmed diagnosis).

Employment:

There is a pattern of repeated loss of employment due to symptoms of ADHD or client is at risk of losing current employment due to symptoms of ADHD despite implementation of reasonable adjustments AND treatment is considered essential to access or maintain employment. This could include unpaid employment.

Unpaid carer role:

There is evidence that a client has not been able to fulfil caring responsibilities due to symptoms of ADHD AND treatment is considered essential to continue their role.

Continuity of care:

Clients have an existing and evidenced (child or adult) diagnosis of ADHD approved by an NHS service (based on NICE compliance) or equivalent according to the health system where the diagnosis was made which was consistent with the NHS NICE guidance:

• Meet the above criteria.
• Or there is objective evidence of past behaviour that indicates significant risk of meeting criteria above if medication stopped (e.g. loss of job, discontinued education, imprisonment). 
• Or have previously benefited from ADHD medication and stopped medication on medical advice (e.g. due to pregnancy or health condition) and wish to restart treatment.

Explanatory notes

It is acknowledged that reducing access criteria to adult ADHD services is reliant on other services looking at how they deal with ADHD diagnosis eg in mental health teams and learning disability. For those where there is not on a diagnostic route, the community offer for those without a formal diagnosis will be built to support those where a diagnosis is probable but with non-medication methods of improving functioning. 

For those with co-occurring ADHD and a more serious mental health condition, the recommendation regarding mental health and ADHD is understood as follows: 

• Patients with possibleADHD and Moderate to Severe mental health condition including bipolar disease, psychosis, schizophrenia or specialised MH issues such as eating disorders, perinatal or specialist psychological disorder services should be under general or specialist MH service for an acute presentation or chronic condition with long term care by the AMHT/CMHT if needed. The team looking after them will remain the main provider and ADHD service may give them advice to support the care of the patient. NO referral direct to adult ADHD. 
• Care starts with general mental health services. Aim to treat mental health conditions without delay. Co-working with ADHD services to be explored, for example using email advice. Transfer toADHD waitlist only suitable if patient stable for discharge to primary care.

This committee, which drew up the access criteria, discussed the many purposes of a diagnostic assessment, the benefits of a diagnosis in its own right and being aware that many people with potential ADHD will not be offered a diagnostic assessment in future. The service model will therefore change to an assess to treat model. Only those clients most likely to be suitable for medication will undergo formal diagnostic assessment for the purpose of treatment with medication. This decision was made in the understanding that all clients will be able to access a community support offer without a formal diagnosis of ADHD.