The National Health Service in England is grappling with a financial crisis driven by the rising cost of assessing and treating autism and attention deficit hyperactivity disorder. Health managers say demand for diagnosis has grown so quickly that spending in some areas is now running out of control, with local budgets absorbing shocks that were never planned for. The surge has accelerated sharply since the coronavirus pandemic, as referral numbers climbed and waiting lists lengthened across the country.

The scale of the financial strain varies by region, but the pattern is consistent. In one area, monthly spending on autism and ADHD assessments rose roughly tenfold, from around £146,000 to £1.5 million. In another, the annual cost of adult ADHD services is projected to nearly quadruple within a single financial year, climbing from £11 million to more than £50 million. These are not gradual increases absorbed within existing plans. Integrated care boards have had to respond in real time, and the response has often meant freezing other waiting lists or reconsidering funding for services unconnected to neurodevelopmental conditions. Managers describe a system where money intended for one area of care is being diverted to cover overspends elsewhere, with little warning and less control.

Much of the pressure stems from the interaction between two separate factors: patients' right to choose any qualified provider for their assessment, and a shortage of capacity within NHS trusts themselves. Waiting times for NHS-run assessments have grown so long in many areas that patients have turned to the right to choose routes in large numbers, seeking care from independent providers instead. That shift has drawn a wave of new businesses into the market. In some local areas, the number of providers submitting invoices for autism and ADHD assessments has jumped from around a dozen to nearly 50, and in certain regions to as many as 80.

This expansion has occurred without a national price cap, and the result is a wide spread in what is charged for broadly comparable services. Assessments that ought to be similar in scope and clinical content have been invoiced anywhere between £300 and £3,000, depending on the provider and the region commissioning the work. Health leaders say this inconsistency makes it difficult for ICBs to plan or budget with any confidence, since the same clinical need can carry a wildly different price tag depending on where a patient happens to live and which provider they choose.

Quality and continuity of care have also come under scrutiny. Some smaller providers have built business models around initial assessments, which tend to be well remunerated, while offering little in the way of ongoing management or follow-up support once a diagnosis is made. Health leaders argue this leaves patients with a diagnosis but no clear pathway for the care that should follow, shifting the burden of long-term support back onto an NHS system that is already stretched.

Directors of mental health networks representing NHS managers describe a position caught between two competing pressures. On one side sits the moral case for reducing waiting lists that leave patients and families without support for years at a time. On the other sits the fiscal reality of running services within fixed budgets that were not designed to absorb costs of this magnitude. Their conclusion is that the current fragmented arrangement serves neither taxpayers nor patients well, producing inconsistent care at unpredictable and often inflated cost.

To address this, health leadership bodies are calling for a mandatory national tariff for autism and ADHD assessments, removing the wide pricing discrepancies that have emerged under the right to choose model. They are also pressing for a standardised national service specification, one that would require any NHS-funded provider, regardless of size, to deliver consistent clinical standards and to provide proper aftercare rather than assessment alone. Without such changes, health leaders warn, the financial and clinical pressures now visible in individual regions are likely to spread further across the system.

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