In one integrated care board, the monthly bill for private ADHD and autism assessments reached £1.5 million this year, having sat at a fraction of that figure twelve months earlier. Elsewhere a regional budget grew from £4 million to £30 million in two years. These are not isolated anomalies buried in a finance committee's minutes. Freedom of Information data gathered across all forty-two English integrated care boards shows spending on private neurodevelopmental assessments has passed half a billion pounds since 2023, rising by well over a hundred per cent in a single year in some areas. The number sounds like waste. It is better understood as the visible cost of a policy that solved one problem by quietly creating another.

Right to Choose exists for a defensible reason. NHS neurodevelopmental pathways cannot cope with demand, and the scheme lets patients referred by a GP select an approved provider, NHS or private, funded by the state, rather than sit on a local waiting list that can stretch past a year. Roughly 562,000 referrals are currently open, with more than three in five patients waiting over twelve months for a first appointment. Faced with that backlog, allowing patients to route around it looks like pragmatism. What it has not come with is any of the machinery that normally accompanies NHS-funded care at scale. There is no national tariff for these assessments, unlike the fixed pricing that governs a hip replacement or a cataract operation. Commissioners report paying anywhere between £300 and £3,000 for what is nominally the same clinical product. Providers offering diagnosis alone, without any accompanying treatment, fall outside the Care Quality Commission's registration requirements altogether, a position the regulator itself has confirmed rather than merely tolerated by omission.

The practical consequence lands on individual ICB commissioners, who are now managing contracts with dozens of providers, in some cases nearly fifty, a fourfold rise in two years, without a shared framework for judging whether the money is buying comparable clinical rigour. Health managers describe the position candidly: they are caught between backlogs they are institutionally obliged to reduce and spending they have limited means to constrain or scrutinise. That is not a description of mismanagement so much as a description of a policy operating exactly as designed, minus the oversight that would normally accompany a public spending commitment of this size.

What sharpens the story now is timing. The independent review into mental health, autism and ADHD pathways, chaired by Professor Peter Fonagy, published interim findings in the spring and is due to report in full this summer. Its early conclusions have already proven contentious, not least because they sit awkwardly between two readings of the same data: that diagnostic demand reflects a genuine and long-overlooked need finally being recognised, or that it reflects a system incentivising diagnosis as the only route to support. Ministers have at times leaned toward language of overdiagnosis. Whichever reading prevails will shape how the review's recommendations are received. But neither reading resolves the more basic governance problem sitting underneath it. A national conversation about whether too many or too few people are being diagnosed says nothing about whether the market currently supplying those diagnoses is priced sensibly, regulated adequately, or answerable for its outcomes.

There is a version of reform that treats this review as an opportunity to build the missing scaffolding: a national commissioning framework, a benchmark tariff, and a registration requirement that closes the gap the CQC has openly acknowledged. There is another version in which the review's findings are absorbed into a narrower argument about clinical thresholds and referral criteria, leaving the market itself untouched. The distinction matters more than the headline spending figures suggest, because the spending will keep rising regardless of where the diagnostic threshold eventually settles, for as long as the underlying capacity gap persists. A government that commissioned a market to solve a waiting list problem owes it more than a review of demand. It owes it a review of supply, and of who is left accountable for what that supply actually delivers.