Picture a school office in late autumn. A parent sits across the desk from the special educational needs coordinator, holding a letter that confirms her son's place on an assessment waiting list. He is eleven, falling behind and increasingly unwilling to enter lessons. The school can offer little until the letter becomes a diagnosis, and the diagnosis is two years away. That scene, repeated in every local authority, is the system Peter Fonagy's independent review examined and the government answered on 9 October.

The review's central finding is that diagnosis has become a narrow gateway to help for distress with wide-ranging causes. Mental distress among children and young people has risen substantially, linked to financial insecurity and poorer sleep among other factors, while population prevalence of ADHD and autism appears broadly stable. Referrals have climbed much faster than underlying prevalence. The gap suggests that families queue for a label because the label is the only thing that unlocks support. The government is proposing a needs-based approach, allowing support in schools, colleges and communities to be provided without requiring a formal clinical diagnosis first.

The principle is sound and the politics are shrewd. It addresses a public argument about overdiagnosis that has soured debate and encouraged doubts about whether young people's difficulties are real. It also speaks to a Treasury concern about the number of young people outside education, employment and training. The interim work by Alan Milburn found that 24% of that group named depression or anxiety as their main limiting condition. Framing mental health as labour market policy may help release funding. It carries a risk if success comes to be measured chiefly by employment outcomes.

The operational difficulty is plain. Needs-led support still needs people to deliver it. Mental health support teams are not expected to be available across all schools and colleges until 2029, leaving many pupils without access to these services in the meantime. The £1.8 billion Experts at Hand offer depends on speech and language therapists and educational psychologists, professions with long-standing vacancies. Removing the diagnostic gate does not remove the queue. It relocates rationing to a triage decision made by a school, a community hub or a talking therapy service, and parents will contest that decision when resources run short. NHS leaders should expect disputes over thresholds to replace complaints about waiting times, and should publish their criteria before that happens.

The regulatory proposals address a market that the NHS itself helped create. Long waits and patient choice rules allowed independent providers to be paid from NHS budgets for ADHD and autism assessments, and some now carry a significant share of that work. The government proposes to make all such assessments CQC-regulated, to consult on a national tariff to take effect from April 2027, and to ban direct advertising of NHS-funded assessments. Each step is defensible. Together they raise a delivery question. If the tariff is set too low, providers may withdraw before the NHS has built replacement capacity, and waits would lengthen. Integrated care boards are asked to oversee these services more closely at a time when they are cutting their own running costs. For health-tech firms and independent providers, the tariff offers price certainty and tighter scrutiny in the same package. Charities running digital services see an opening for a national online offer, but any such layer should be evaluated before it is scaled.

A third pressure concerns people with severe illness. The Royal College of Psychiatrists and Rethink Mental Illness both warned that specialist services for psychosis and complex, enduring conditions must not lose out as the front door widens. Mental health spending is forecast to reach a record £16.1 billion this year, yet a broader entry point draws more people in. If new money follows the prevention agenda while community mental health teams stay stretched, those with the greatest need will find the specialist queue unchanged.

The review has ended any serious claim that rising distress is an artefact of overdiagnosis. That is a real gain, and ministers deserve credit for accepting it. The harder test lies in the mental health strategy due later this year. It must say who receives what support, from whom, by when, and who answers when it fails to arrive. Without published thresholds, workforce numbers and local accountability, diagnosis will have been demoted and the waiting list merely renamed.

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