Wednesday briefing: Over-budget and under-regulated – the NHS’s ADHD crisis

Original article by Martin Belam

Good morning. Hundreds of thousands of people are seeking attention deficit hyperactivity disorder (ADHD) diagnoses in England – but the system designed to help them has turned into a fragmented marketplace that is costing the NHS far more than planned. A Guardian investigation has found services are on track to overspend their budgets by £164m this year.

The months-long investigation found growing demand is being pushed into an under-regulated – and highly profitable – private sector that, in some cases, is leaving patients dangerously unsupported. It has also landed in the middle of a rancorous political debate about whether ADHD is being overdiagnosed – an argument that ignores the very real struggles that are driving people to seek help in the first place.

For today’s newsletter I spoke to Sarah Marsh, the Guardian’s consumer affairs correspondent, who worked on the reporting, to find out how the investigation came about, what it found about the way NHS England is struggling to help people to get, or deal with, an ADHD diagnosis, and where she hopes the findings can make a difference. Before that, here are the headlines.

Five big stories

1. Iran | China has threatened to retaliate against Donald Trump after the US president said he would impose 25% tariffs on countries that trade with Iran

2. UK politics | A vast new Chinese embassy complex in east London is almost certain to be formally approved next week despite worries about security risks and the effect on Hong Kong and Uyghur exiles in the capital.

3. Pollution | High-profile studies reporting the presence of microplastics throughout the human body have been thrown into doubt by scientists who say the discoveries are probably the result of contamination and false positives.

4. Social media | Keir Starmer has told MPs that he is open to the idea of an Australian-style ban on social media for young people after becoming concerned about the amount of time children and teenagers are spending on their phones

5. Asylum | A Palestinian citizen of Israel has been granted asylum in the UK on the basis of a “well-founded fear of persecution”, despite a former home secretary’s personal interference in the case to try to block the claim.

In depth: How the system meant to deliver ADHD care in England got broken

ADHD is usually associated with difficulty sustaining attention, hyperactivity and impulsivity – but as anyone who has tried to navigate the diagnostic maze will know, the labels are often less revealing than the lived experience. In an opinion piece for the Guardian, Gabor Maté – diagnosed in his early 50s – wrote that his diagnosis “seemed to explain many of my behaviour patterns, thought processes, childish emotional reactions, my workaholism and other addictive tendencies, the sudden eruptions of bad temper and complete irrationality … my propensity to bump into doorways, hit my head on shelves, drop objects.”

Sarah, who has written about her own ADHD diagnosis before, says the crucial point is that people are not seeking help on a whim. They are seeking it because they are struggling – and a system that can’t offer timely support is pushing them into a patchwork of private assessments, paperwork and uncertainty.

Sarah’s investigation began in August, after David Rowland, director of the Centre for Health and the Public Interest, started scrutinising NHS spending on ADHD diagnosis and services. “That part of gathering data took months, because obviously with freedom of information requests you have to go back and forth,” says Sarah. “Alongside that, we did a separate investigation talking to people who worked for the private clinics, to get a sense of what the issues are. And we also had a callout on the website to gather case studies.

“We wanted to find out if the money was being well spent – if patients were being looked after, and if they were being given a clear pathway for getting the help they needed.”

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The spending gap

Rowland’s work found a widening gap between what NHS England budgeted for ADHD services and what it is now likely to spend. Analysis of data from 32 of England’s 42 integrated care boards (ICBs) suggests spending is projected to reach £314m by April 2026, more than double the annual budget of £150m – leaving an estimated £164m overspend that local health bodies may have to offset elsewhere.

It also found that a growing slice of this spending is flowing to private providers, as people turn to “right to choose” to bypass long waiting lists. Nineteen ICBs also provided data on how much of their ADHD budget went on private companies, which showed that spending on private ADHD services more than tripled over three years, rising from £16.3m in 2022-23 to £58m last year. Campaigners and clinicians raised concerns about an under-regulated market, which includes providers that aren’t registered with the Care Quality Commission carrying out NHS-funded assessments.

Sarah says the investigation found that private companies – “often private equity-backed firms” – are making “huge” money from the current system, and “there is little criteria for what private companies need to do to get greenlit to provide the service”.

Part of the problem, she adds, is that while there are guidelines, there is still no single national framework setting out what a good ADHD assessment looks like – or the qualifications required to diagnose it. Some clinics use quality standards from bodies such as the UK Adult ADHD Network, but the absence of a consistent baseline leaves patients and GPs stuck arguing over whether an assessment is good enough.

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Quality control

“One thing I would say,” Sarah tells me, “is that there are people who have positive experiences as well as negative experiences of private services. There’s always going to be a huge range of quality.”

But across dozens of accounts, the same problems kept surfacing. “A lot of the same stuff came up time and time again,” she says: people getting a private diagnosis and then being unable to secure a shared-care agreement with their GP (whereby the GP takes on long-term care and prescription of medication); assessments that felt rushed or superficial; and patients who were left not knowing where to go once the report had landed in their inbox.

“For a lot of people, it’s the bit after diagnosis that falls apart,” Sarah says. “They might have spent months waiting and hundreds or thousands of pounds on an assessment, only to find their GP won’t accept it, or the clinic won’t respond, or their medication isn’t reviewed properly. So they’re left stuck – still unwell, still waiting, but now in a system that doesn’t seem to belong to anyone.”

For some families, those administrative and clinical gaps have had devastating consequences – as the Guardian’s reporting on the tragic death of Ryan White shows – turning what was meant to be a route into care into a prolonged period of isolation and risk.

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A political football

The diagnosis of neurodiverse conditions and making accommodations for them has become increasingly politically charged. In November, Reform UK deputy leader Richard Tice described children wearing ear defenders in school as “insane” and claimed there was a “crisis of overdiagnosis” of neurodiverse conditions (positions he later attempted to row back on).

The health secretary, Wes Streeting, has ordered a clinical review into the diagnosis of mental health conditions, autism and ADHD, saying that he knew from “personal experience how devastating it can be for people who face poor mental health, have ADHD or autism and can’t get a diagnosis or the right support. I also know, from speaking to clinicians, how the diagnosis of these conditions is sharply rising.”

Response was polarised. In the Times, Hadley Freeman demanded that Streeting “must stand up” to what she called “the ADHD activists” [£]. In contrast, John Harris, who has written a memoir about how music helped him connect with his autistic son, wrote for us that Streeting should not be on “the right’s callous overdiagnosis bandwagon”.

Sarah is wary of how the “overdiagnosis” debate obscures the reality of what’s really happening. “What I would say from researching this is you’ve got people that need help,” she tells me. “Whether ADHD is the right diagnosis or a misdiagnosis is kind of by the by. They’re not seeking help because they want a diagnosis. They’re not spending thousands of pounds on private treatment for no reason. They’re seeking help because they are struggling.”

She suggests that Streeting’s review needs to start there – and ask why so many people have reached the point where they are desperate enough to pay, wait and fight their way through a system that too often fails to join up.

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What will happen now?

“The big thing that struck me,” Sarah says, “is that you’ve got a system that is just not functioning well, and the people really affected are the patients. They essentially can’t get treated because the NHS waiting list is so long. Then, if they get help privately, there is this disjointed system which is letting them down. It just feels like somebody needs to look at the system and say, ‘Is this money being spent effectively?’ And it doesn’t seem to be.

“The next question is: ‘How can we make it better?’ And I think, hopefully, our investigation raises that question – and puts some pressure on to answer it.”

The people trapped in a broken system must be hoping that too.

What else we’ve been reading

• Women are going feral for Heated Rivalry, the gay hockey TV drama that has taken the world by storm. But what does it say about female sexual desire? Julia Carrie Wong investigates. Aamna Mohdin, newsletters team

• The revolution will be computerised – in this piece for the Electronic Frontier Foundation, Cooper Quintin details the tools, tips and tricks that hackers are using to fight back against ICE in the US. Martin

• It has almost been 10 years since Brexit. While much coverage of the anniversary will focus on the political earthquake it brought, Anneke Schmidt’s moving piece on the impact on her personal life is well worth a read. Aamna

• Photographer Tristram Kenton was granted access to a new space-themed immersive multiplayer stealth game from the Punchdrunk theatre company in London, and it looks fantastic. Martin

• If you want to understand what’s happening in the US right now, don’t just focus on Trump, writes Arwa Mahdawi. Pay close attention to his deputy chief of staff, Stephen Miller, who has a frightening vision for the future. Aamna

Sport

Football | Manchester City closed in on a place in the Carabao Cup final after two second-half goals gave Pep Guardiola’s side a 2-0 first-leg victory against Newcastle.

Tennis | Emma Raducanu offered an impressive demonstration of her resilience at the Hobart International as she rallied from an overnight second-set deficit in her rain-delayed first-round match to defeat Camila Osorio of Colombia 6-3, 7-6 (2).

Football | Xabi Alonso has left his job as coach of Real Madrid, only seven months after arriving for his first day at the club’s Valdebebas training ground.

The front pages

The Guardian’s top story is “‘Help is on its way’: Trump calls on Iran’s protesters to remain defiant”. Likewise the Telegraph has “Trump: Help is on the way” and the Financial Times says “Help is on its way, Trump tells Iranians”. In the Metro a North Sea catastrophe has its court sequel: “Russian captain ‘did nothing’ to avoid US tanker”.

“The rail deal” – the Mirror celebrates Labour’s “northern powerhouse pledge”. The i paper’s rendition is “Labour promises new rail links for the north – but not until 2030s”. The Times runs with “New Starmer U-turn over compulsory IDs”. The Express leads on “Elderly living in poverty ‘could exceed 2 million’”.

Today in Focus

Is Marco Rubio playing Trump?

How far will Rubio go to achieve his own objectives? With Lauren Gambino

Cartoon of the day | Ella Baron

The Upside

A bit of good news to remind you that the world’s not all bad

Jacarandas is a Colombian abortion helpline that uses eye-catching illustrations to appeal to young women and teenagers. Established after abortion was decriminalised in the country in 2022, the all-women team provides a WhatsApp service offering advice on abortion and sexual rights, as well as legal support for those who have been denied their right to free abortions or had bad experiences with providers.

The playful communication approach is working: Jacarandas is the most-followed Spanish-speaking abortion account on social media, with almost 400,000 followers on TikTok and 312,000 on Instagram. Since it started, it has received messages from more than 26,300 people, and provided advice to about 700 users a month in 2025. Although abortion is legal up to 24 weeks in Colombia, 93% of Jacarandas users have an abortion before 12 weeks.

Sign up here for a weekly roundup of The Upside, sent to you every Sunday

Bored at work?

And finally, the Guardian’s puzzles are here to keep you entertained throughout the day. And if you took up the challenge of the King William’s College 2025 quiz over the holiday period, the answers are now available here.

• Quick crossword

• Cryptic crossword

• Wordiply