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White marble sculpture of a human head lying on its side, partially wrapped in bandage-like strips, evoking restraint, silence, and psychological distress.

Heaven

Is it, or isn’t it…

… that is the question.

Whether ’tis a sickness in the mind, to suffer
The slings and arrows of outrageous fortune,
Or to take arms against this sea of troubles
And by opposing, end them and… cut their benefits.

With apologies to Hamlet.

Is it or isn’t it… Streeting’s mental health review; is it a genuine attempt to look into the ‘sea of troubles’ so many people seem to be in, or is it just a crude attempt to find a way to cut the benefits bill?

He’s asked for a review into the ‘over-diagnosis’ of mental-health conditions, including ADHD.

Serious business? Or political theatre?

On the face of it, he’s asked serious people to look at a serious problem.

Despite the headlines, the UK isn’t drowning in ADHD or autism diagnoses. Actually, it’s missing a lot. ‘Over-diagnosis’ is a convenient myth…

… not the reality.

Diagnoses are rising, claims for benefits are up. Ministers want to know why. Fair enough… don’t we all, but…

… the politics behind it is unmistakable. The Treasury is twitchy, welfare spending is climbing, suddenly over-diagnosis becomes a ‘thing’.

Before we rush to conclusions, we need to understand what’s really going on. It looks to me…

… the UK doesn’t have an epidemic of ADHD…

… we have an epidemic of diagnostic inconsistency.

Across the country, diagnosis rates vary wildly. Not because children in Surrey behave differently from children in Sunderland…

… it’s because the NHS delivers what it has the capacity to deliver.

Areas with specialist clinics, trained assessors and shorter waiting lists ‘find’ more ADHD.
Areas with four-year waits, patchy CAMHS, reluctant GPs and no post-diagnostic support ‘find’ less.

That’s not over-diagnosis. That’s rationing by delay.

Add in schools with different levels of SEND expertise, deprivation that suppresses referrals and families who can or cannot afford to go private, plus…

… GP judgment, commissioning decisions and coding inconsistency. What do you get?

A postcode lottery dressed up as epidemiology.

The facts tell their own story; the underlying prevalence of ADHD across high-income countries is remarkably similar… around 5–7%… however, diagnosis rates vary hugely.

In the UK, only about 1.3% of people have a formal diagnosis. In the United States, it’s pushing 10%. Canada sits at 7.5%. Sweden at 3%.

Same condition;
Different systems.
Different thresholds.
Different cultures.

No one seriously argues that British children have less ADHD… we simply diagnose less.

Autism shows the same pattern. The UK, around 1-in-68. The U.S. is closer to 1-in-44. Lower-income countries report lower rates not because the condition is rarer but because the data is poorer and services are thinner.

Which brings us back to the review.

If it focuses on the clinical reality;

system variation,
service gaps,
commissioning decisions,
inconsistent pathways…

… it could do real good… finally standardise what should have been standard years ago.

If it leans into the political narrative…

… diagnoses are being handed out like sweets and benefits must be cut…

… it’ll do real harm… because the evidence doesn’t show a country drowning in over-diagnosis…

… it shows a country that struggles to diagnose at all.

Diagnosis rates aren’t a sign of moral decline or benefits culture. They’re a sign of the NHS delivering in some places, failing in others and leaving people to navigate the gaps.

If the review wants to be useful, it should stop counting labels and start counting the structural reasons people fall between the cracks.

In truth, the review can only show the problem isn’t too many diagnoses…

… paradoxically, it’s too few, in the wrong places, for the wrong reasons.

As ever in the NHS, the variation isn’t the anomaly. It’s the system.

We can probably write the Street-view, now;

ADHD, autism and other mental-health conditions are being diagnosed more frequently
Much of this reflects greater awareness, better access in some regions
Evolve proper diagnostic criteria rather than unsupported narrative of over-diagnosis
Highlight regional and socioeconomic disparities, long waiting lists
Gaps in service provision,
Claims that diagnoses are being handed out indiscriminately won’t be supported by the evidence, and…

… the review will probably recommend a review, to review training (they always do) and systemic factors that shape who gets assessed and who doesn’t…

… but the great brains producing the report might do well to remember the words of Hamlet’s manipulative uncle…

… ‘words without thoughts never to heaven go.’

News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.

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