England has found a cheaper way to answer a demand it cannot meet: it has started putting a number on how long you must wait before you are allowed to be assessed. Four NHS integrated care boards (ICBs) covering large regions have imposed a minimum wait of at least two years before a person with suspected ADHD or autism can be assessed, and 15 boards between them — covering 19 million people — now ration neurodivergence assessments in some form.
The mechanism is the part worth understanding, because it is not a queue. A queue is a list that moves. A minimum wait is a floor: it does not matter whether a clinician is free next month, because the system has decided that a person referred today is not entitled to be seen before a fixed date. And because the wait applies to referrals made to independent providers, it also shuts the exit that existed for people who could use their legal right to choose a non-NHS provider. The right to choose still exists in statute. It has been rationed by the calendar.
The published numbers are concrete. West Yorkshire ICB, which commissions care for 2.4 million people across Leeds, Bradford, Kirklees, Calderdale and Wakefield, imposed a two-year minimum from referral for ADHD or autism assessment with an independent provider after its bill for such assessments rose from £7m in 2023-24 to £21m last year. North East and North Cumbria ICB tells patients that funded private providers are working to an “approximately 78-week minimum waiting time for an initial assessment.” Somerset ICB operates a 52-week minimum; Devon’s is 14 weeks: the same country, different doors, different waits. Kent and Medway has also adopted a minimum wait, and Hampshire and the Isle of Wight has restricted assessment to patients meeting its priority criteria this month. Not all of the 15 boards use the same instrument — some cap the annual number of assessments they will pay for, others restrict assessment to the most severe presentations — but they are all variations on limiting who gets through.
The scale of the queue being managed
These measures are being applied to 960,000 people in England waiting for an ADHD assessment and another 295,000 waiting for one for autism. Roughly half of NHS-funded ADHD assessments and a third of autism assessments are now carried out by private clinics, because so many patients exercise a legal right to choose non-NHS care. A minimum wait converts that route from an escape hatch into an extension of the same queue, and pushes anyone who can afford it toward paying several thousand pounds privately — with the harder question being what happens to the people who cannot.
The policy advice is blunt about the cost. “A minimum wait is heartless and dangerous. It is institutionalised cruelty,” said Henry Shelford, chief executive of ADHD UK, who called the direction “the health service denying people care they need, and care that is available.” From Finally Seen, which tracks the restrictions: “A two-year minimum wait is not a waiting list. It is a locked door with a date on it.” Mel Merritt of the National Autistic Society made the non-medical case: for a child, the wait means “years of wasted school” while assessment is pending, followed by further waits for the plan of support and adjustments that the diagnosis is supposed to unlock.
The boards are not pretending otherwise. Rebecca Gray of the NHS Alliance’s mental health network described local leaders as “keenly aware of the deep frustration caused by long delays,” and then named the constraint: “the need to balance budgets and the pressures of soaring demand have — in some places — led to ‘minimum waits’ or even the closure of some waiting lists.” Sean Phillips of the Independent Healthcare Providers Network argued the obvious remedy — let private clinics offer every appointment they have available while more than a million people wait.
The review that was meant to explain all this
The disclosures land just before a 700-page government-commissioned review of rising mental illness, ADHD and autism diagnoses, led by Prof Peter Fonagy, which was due on Thursday and was postponed to early next month. Sources who have seen it describe a picture of demand outpacing access and patients increasingly reliant on private providers, plus serious concerns about the consistency and quality of assessments and about the “financial incentives associated with assessment activity.” It also documents the trend the whole argument is about: the share of seven- to 18-year-old boys with an autism diagnosis rising from 0.2% in 2000 to 4.7% in 2025, and ADHD diagnoses among the same group rising nearly 13-fold, from 0.4% to 5.1%.
Two readings of those figures are available, and the article does not settle between them. Either diagnosis is capturing people who were always there and never counted, or the category has widened while the support attached to it stayed fixed. Both readings produce the same immediate problem: a diagnosis has become the gate to adjustments at school, accommodations at work, and medication — which means rationing the assessment rations everything behind it. The Guardian’s earlier reporting on the Fonagy review covered a proposal to triage by need instead of diagnosing on demand. The picture now is of boards that have stopped waiting for the argument to conclude and begun rationing access themselves, at the point where it is easiest to do quietly: the calendar. The same approach has already been documented by the BMJ in physical care, where 17 of 36 ICBs introduced minimum waits of 12 to 16 weeks for hip, knee and cataract surgery in a system that is supposed to treat 92% of planned patients within 18 weeks. Neurodivergence assessment is where the practice is newest; it is unlikely to be where it stops.
Read the full story at The Guardian.