The UK government recently published the Independent Review into Prevalence and Support for Mental Health Conditions, ADHD and Autism, chaired by Professor Peter Fonagy. The final report runs to almost 600 pages and directly addresses the extraordinary growth in demand for neurodevelopmental assessment and support.
It describes a system under immense pressure and raises legitimate questions about assessment quality, commissioning, medicalisation and the rapid expansion of independent provision. At the same time, I believe the debate needs to recognise something equally important: high-quality independent services and the NHS Right to Choose framework have become a significant part of how people access care when local pathways cannot meet demand.
Key findings: validating the distress
Real distress, real demand
The review rejects simplistic explanations for rising demand. It distinguishes between population prevalence, recorded diagnoses, demand for assessment and unmet need, while recognising substantial increases in psychological distress and service pressure.
The waiting-list crisis
The scale of the backlog is stark. The review reports that the number of children and young people with open referrals waiting for an ADHD assessment rose from roughly 21,000 in April 2019 to around 270,000 by December 2025. Whatever view one takes on diagnosis, that is evidence of a system unable to respond promptly to people seeking help.
Diagnosis as a gateway
The final report says diagnosis has increasingly been perceived as a requirement to access help in education, employment and parts of the welfare system. Its broader recommendation is that support should respond to identified need rather than requiring diagnosis to be the only gateway.
The “label” debate
The review also discusses the potential risks of medicalisation. That deserves serious consideration. But from a clinical perspective, a well-founded diagnosis can also be validating: it can help an adult understand longstanding difficulties, distinguish ADHD from other explanations and make informed choices about treatment and support.
A diagnosis should never be treated as the whole person. But neither should we dismiss the value of a careful diagnosis when it explains a lifelong pattern of impairment.
A clinician’s analysis: the role of independent care and Right to Choose
The final report is critical of inconsistent oversight and quality assurance in parts of independent provision. Those concerns should not be brushed aside. Poor-quality assessment harms patients and damages trust in the entire sector.
But independent provision is not, in itself, the problem. The report itself notes that independent providers are often used successfully to cover gaps or reduce waiting lists, and that they now carry out more than half of NHS-funded ADHD assessments. That makes quality assurance and good commissioning more important — not the disappearance of independent capacity.
What Right to Choose actually means
For eligible NHS referrals in England, patient choice can allow a person to choose a clinically appropriate provider for a first outpatient mental-health appointment. It is not a right to choose any private clinic. The provider must hold a qualifying NHS Standard Contract for the relevant service, and the referring clinician must consider the referral and provider clinically appropriate.
Used properly, this framework can widen access beyond a person's local service and reduce the impact of postcode variation. It also makes it vital that commissioners and providers are transparent about contracts, quality, governance and outcomes.
What the proposed changes could mean for ADHD care
1. Expanded CQC regulation
The government has said it intends to make all ADHD and autism diagnostic assessments a CQC-regulated activity. The CQC has confirmed it has been asked to regulate all diagnostic assessment services once new regulations are in place. At present, the CQC regulates services that provide both diagnosis and treatment, while diagnostic-only provision falls outside parts of the current legislative scope.
As clinicians, we should welcome proportionate regulation that helps patients distinguish robust services from poor ones and creates consistent expectations around safety, governance and quality.
2. Advertising scrutiny
The Fonagy Review recommends banning direct-to-public advertising of NHS-funded ADHD and autism assessments. Separately, the government has said it will ask the Advertising Standards Authority to review advertising practices around ADHD and autism services more broadly. These are important distinctions: the recommendation is not the same as a blanket ban on all private ADHD advertising.
Whatever regulatory approach follows, advertising should be factual, balanced and careful not to imply that common difficulties automatically equal ADHD or that paying for an assessment guarantees a diagnosis.
3. A possible national tariff
NHS England is expected to consult on a national set of prices for NHS-funded autism and ADHD services, including assessment, follow-up and post-diagnostic support. Done well, a tariff could improve consistency and transparency. Done badly, it could incentivise volume over quality. Clinical standards must therefore sit alongside any price framework.
4. Moving toward needs-led support
The review recommends moving from a diagnosis-dependent system towards “needs-led plus diagnosis” support. The principle is sensible: people should not have to wait years for basic help while they await a diagnostic decision. But this cannot become a mechanism for denying access to specialist assessment where diagnosis is clinically important or where treatment decisions depend on it.
The bottom line
The Fonagy Review is an important acknowledgement that the current model is under severe strain. It also raises concerns that the independent sector must take seriously: variable quality, weak oversight in some pathways and the need for better transparency.
My view is that the answer is not to demonise private care or patient choice. It is to make every pathway — NHS, independent and NHS-funded independent provision — clinically robust, properly governed and transparent. High-quality independent providers can be part of the capacity solution, while stronger regulation can help ensure patients receive the standard of assessment they deserve.
For adults seeking answers after years of difficulty, timely access matters. So does accuracy. We should insist on both.
Sources and further reading
- Department of Health and Social Care — Independent review into mental health conditions, ADHD and autism: final report (9 October 2026; updated 21 October 2026)
- Final report executive summary
- Government response — earlier support, regulation, advertising review and tariff proposals (9 October 2026)
- Care Quality Commission — CQC to regulate autism and ADHD diagnostic assessments (9 October 2026)
- NHS England — Patient choice guidance