A woman spends almost four years on a waiting list for ADHD medication titration, the careful process of finding the right dose. Then, without warning or explanation, South London and Maudsley NHS Foundation Trust removes her from that list, leaving her without specialist monitoring support for around six months. Nobody tells her why. Nobody restores continuity. She is simply gone from a system that had, in its own slow way, been keeping a promise to her.

The Parliamentary and Health Service Ombudsman has now published a report warning that complaints about autism and ADHD services in England have more than tripled in five years, alongside years-long waits and patients paying thousands of pounds for private care. Complaints rose from 410 in 2021-22 to 1,257 in 2025-26, an increase exceeding 200 per cent, tracking a surge in referrals and in the numbers left waiting. Open NHS referrals now run to roughly 562,000, with more than 60 per cent of adults and children facing waits beyond a year. Ombudsman Paula Sussex is blunt about where responsibility sits. She describes a system that forces people to fight through complexity and confusion to get support, and her report, drawn from a review of 3,000 complaints, identifies commissioning itself as the point of failure rather than demand alone.

That distinction matters more than it might first appear, because it lands directly athwart the terms of a debate the government is about to settle. Professor Peter Fonagy's independent review into mental health, ADHD and autism services, commissioned after Lord Darzi's investigation flagged the same rising demand, produced an interim report in March that argued underlying prevalence has stayed broadly stable even as diagnosis and referral rates have climbed sharply. Critics in the neurodiversity sector read that framing as a step toward treating the surge as a problem of overdiagnosis, something to be managed by tightening thresholds rather than expanding capacity. The ombudsman's report, arriving as the final Fonagy findings approach publication, offers an inconvenient counterweight. Whatever the truth about prevalence, patients are being failed by a structure that cannot honour rights it has already promised them.

The clearest example is the statutory Right to Choose, which allows patients to select from eligible NHS-funded providers, including independent ones, for services such as ADHD assessment. The ombudsman found recurring uncertainty about how this right applies, with patients sometimes told wrongly that they could not exercise it. This is not a marginal administrative quirk. Several integrated care boards restricted or discouraged Right to Choose referrals after a national overspend on private ADHD providers ran far beyond projections, even though NHS England maintains the pathway cannot be blocked on cost grounds. Guidance issued to GPs, preferred-provider lists and quiet discouragement have achieved informally what policy will not permit formally. In one case documented by the ombudsman, a patient named Rich was refused a Right to Choose referral by his integrated care board and instead directed toward a local ADHD service that did not yet exist, delaying his NHS treatment by five months and eventually costing him almost four thousand pounds in private care.

This is where the argument sharpens beyond relevance into consequence. If the final Fonagy report concentrates on clinical thresholds and the language of medicalisation without addressing how integrated care boards are quietly rationing an entitlement patients already hold, its recommendations will improve the diagnostic front door while leaving the fragmented, rights-blind machinery behind it untouched. A tighter definition of who qualifies for assessment does nothing for a patient whose GP has been told, wrongly, that no referral is available at all.

The ombudsman's own office now carries a six-month backlog because of the volume of complaints it receives, which is itself a quiet indictment of how far downstream these failures travel before anyone with authority notices. The government has confirmed Professor Fonagy's final report will be published later this summer and will shape the national approach to ADHD, autism and mental health conditions. It will be judged on whether it treats commissioning discipline as inseparable from clinical policy. A patient does not experience the difference between undercapacity and mismanagement. She experiences being quietly removed from a list, and left to explain to herself why the system that diagnosed her needs cannot be trusted to meet them.