|
There is something refreshing about Professor Peter Fonagy's review of mental-health services.
It says what experienced professionals, patients and families have been saying for years. That is...
People need help.
Not another waiting list.
Too often, particularly with ADHD and autism, the NHS has created a system in which people wait for an assessment, receive a diagnosis and then discover they have joined another queue for support.
A waiting list, to get onto another waiting list.
Fonagy challenges the assumption that everyone must have a diagnostic label before practical help can begin.
He's right, but... there's an important distinction.
The problem isn't diagnosis. It's making diagnosis the only doorway to help.
For many people, a timely, properly conducted diagnosis can be life-changing.
It can explain years of difficulty, help families understand their children, support adjustments at school or work and give people strategies to live fuller lives.
Diagnosis done well isn't simply a label. It's education, understanding and sometimes the beginning of self-help, and...
... we must be careful.
There is concern among professionals and patient campaigners that enthusiasm for reducing reliance on diagnosis could become something rather different.
An excuse for reducing access to it. The financial pressures are enormous.
NHS spending on independent ADHD assessments and treatment has reportedly risen by 252%. Right-to-Choose has enabled people to escape intolerable NHS waiting lists, but exposed years of inadequate capacity planning.
Commissioners find themselves purchasing services from a rapidly expanding independent sector, with questions about consistency, quality and follow-up.
Some providers deliver excellent care. Others require much closer scrutiny. The CQC have been spectators, but now; working to close a legal loophole that previously allowed diagnosis-only companies to operate without oversight.
It seems to me, people seeking assessments are not the problem.
Nor does rising expenditure prove diagnoses are unnecessary.
Some demand may reflect post-Covid pressures and previously unmet need.
Whether it will eventually settle remains uncertain.
We must be certain that moving away from diagnosis is driven by what is best for patients, not by the discovery that diagnosing them has become expensive.
There is another, rather awkward omission.
England has had an Autism Act since 2009, supported by statutory guidance issued in 2015.
It places responsibilities on NHS bodies and local authorities to provide appropriate autism pathways, including access to diagnosis.
NICE says autism assessments should begin within three months of referral.
Fonagy reports that more than 90% of the 254,000 people awaiting autism assessment had already waited longer than 13 weeks... ouch!
And, remarkably, in its 599 pages, I can't find an explicit reference to the Autism Act or its statutory guidance.
The law hasn't disappeared because a review has overlooked it.
Nor should a sensible move towards earlier, needs-led support become an excuse for allowing diagnostic services to deteriorate further.
Before we redesign the pathway, perhaps we should ask why we haven't delivered the one Parliament already provided for.
There is a practical alternative.
Create properly resourced, NHS-led single points of access.
Offer advice, education, coping strategies and practical support from the beginning.
Some people, and families with children, may decide that the help they receive is sufficient and choose not to pursue formal diagnosis.
Others will need assessment and should receive it promptly.
Independent providers can be part of the pathway, but operating to common standards, with proper accreditation, oversight and continuing care.
Support and diagnosis should be parallel opportunities, not competing alternatives.
Decisions driven by clinical need and informed patient choice, not commissioners' budgets.
There's a management lesson here.
W. Edwards Deming taught us to look at the system rather than blame people struggling within it.
Our arrangements reward activity around assessment while too often failing to provide timely, practical support.
We have created a system that can be very busy without necessarily being very helpful.
Changing that requires investment, properly trained professionals and pathways that don't abandon people once an assessment is completed.
Ministers must resist turning a sensible clinical argument into a convenient savings programme.
Fonagy has opened an important debate.
The test will be what happens next.
The answer is not to diagnose everyone.
Nor is it to stop diagnosing people because the system cannot afford the consequences.
It is to provide help when people need it, diagnosis when appropriate, and continuing support when required.
Diagnosis should open doors.
It should never be the only door.
| 
