ADHD Checklist

All the points below need to be met and adhered to be considered for any ADHD Shared Care agreement:

There are no contraindications to the medications
The Diagnosis is by a UK based specialist following UK Diagnostic Criteria
The Diagnosis is made by an appropriate specialist or psychiatrist specialising in ADHD who is qualified to exclude other Diagnoses
The Shared Care Agreement Request comes directly in writing from the specialist
All the relevant information has been received (including all clinic letters, a full diagnostic assessment and responses to queries in a timely fashion)
Baseline tests are done by the specialist
The prescribed dose is in line with licensed doses or the local NHS formulary
The Patient is on a stable dose of medication
Follow-up and monitoring is in line with licensed doses or local NHS formulary
Continuity of Care: we need assurance that your care will continue, especially when self-funding or with a private insurance. This includes managing changes due to any medication shortages that need to be managed by a specialist.

For further clarification of the above points, please see below detailed explanatory notes:

Contraindications

Due to the risk of harm, most psychostimulant ADHD medications are contraindicated in the following conditions:

glaucoma
phaeochromocytoma
hyperthyroidism
diagnosis or history of severe depression
anorexia nervosa/anorexic disorders
suicidal tendencies
psychotic symptoms
severe mood disorders
mania
schizophrenia
psychopathic/borderline personality disorder
severe hypertension
heart failure
arterial occlusive disease
angina
haemodynamically significant congenital heart disease
cardiomyopathies
myocardial infarction
potentially life-threatening arrhythmias
pre-existing cerebrovascular disorders
cerebral aneurysm
vascular abnormalities including vasculitis or stroke.

Diagnosis

The Diagnosis and any baseline tests must be made by an appropriately qualified specialist, such as a consultant psychiatrist with extensive knowledge of ADHD, and in accordance with UK criteria. The diagnostic criteria and treatment varies from country to country.

In line with NICE and national psychiatry guidelines, the specialist should be trained in excluding other causes, such as general or specific learning difficulties; anxiety disorders; depressive disorder; autistic spectrum disorder, personality disorder, conduct disorder, abuse, trauma, oppositional defiant disorder, other neurodevelopments disorders, neurocognitive disorder, disruptive mood disorder, bipolar disorder, reactive detachment disorder, disruptive mood dysregulation disorder or rarely, medical conditions, such as unsuspected hearing problems or epilepsy (please see the National Institute for Health and Care Excellence website).

In practice, the most appropriately qualified specialist to exclude any alternative conditions with overlapping symptoms (and in doing so confirm the ADHD diagnosis) is someone with the level of experience of a consultant psychiatrist specialising in ADHD. We are finding that ADHD is increasingly being diagnosed by clinicians who are not ADHD specialist psychiatrists, often not psychiatrists and are often healthcare professionals other than doctors who are not supported by a psychiatrist. Healthcare professionals that may undertake only 1-2 days training for ADHD are now making the diagnosis. This is the case with some private providers including those commissioned by the NHS. An accurate diagnosis is essential and we cannot have confidence in a diagnosis unless this is made by an appropriately qualified specialist having deep knowledge of the above listed conditions that need to be excluded.

There are a number of providers (NHS & Private) who do not use appropriately qualified psychiatric specialists that are able to diagnose, manage or exclude an alternative diagnosis. We will not be able to enter into a shared care agreement with any such provider. For these reasons it may not be of benefit to be assessed by such a service if this leads to an expectation that we would be required to prescribe controlled medication that may worsen any underlying condition, especially if you are self funding this.

Patients are free to obtain a private assessment. Private assessments tend to lean towards over-diagnosis. If a private provider feels a diagnosis of ADHD is likely then it may well be worth waiting for a confirmatory assessment via a recognised specialist in ADHD on the NHS in case there are any subsequent queries relating to the diagnosis and we are unable to offer treatment.

In such a case, once a confirmatory assessment through the NHS ADHD service has occurred we may well be able to enter into a shared-care agreement under which we can prescribe. Until we can take on prescribing, however, it would need to be done by the private provider.

The request to enter into a shared care agreement needs to come directly from the specialist. The specialist must be readily available for both the patient and GP should any issues or queries arise.

Patients should never be used as a conduit for informing the GP that prescribing is to be transferred. Any requests to enter into a shared care agreement should come directly and in writing from the specialist to the GP. There need to be clear lines of direct communication. These specialist medications can only be managed safely under shared care if with receive the required timely support.

Relevant information (clinic letters and full diagnostic assessment)

As a part of any shared care agreement there is an expectation that we will be kept up to date in a timely fashion. This includes receiving any relevant information such as clinic letters and a full diagnostic assessment as well as responses to any queries or advice we may have.

Stabilisation

A stable patient is one who has been prescribed the medication at the same dose usually for at least 3 months and is being monitored to demonstrate the treatment has been optimised and the response is consistent.

This includes the stabilisation of other conditions, particularly mental health conditions that may be worsened by the introduction of the psychostimulant ADHD medication. This might involve adjusting both ADHD medication as well as any other medication when treating ADHD.

If medication is stopped and restarted, or a dose adjustment is made, or alternative drugs are used for example due to unavailability of usual drugs then the Shared Care Guideline ceases to be valid. The psychiatrist would need to prescribe and supervise until a stable dose has been achieved and the GP has been informed and is able to reconsider taking over prescribing again.

Please note that Shared care agreements may not be suitable for Patients who are very complex. Anyone with significant other conditions requiring regular specialist input or if a medication dosage above the usual licensed doses is needed are not suitable for prescribing under a shared care agreement.

The specialist is recommending a treatment course including monitoring and follow-ups in line with the local protocols and is happy sign the local shared-care agreement (which many private specialists are not).

We will consider any request to take on prescribing responsibility. In a situation in which the monitoring and follow-up are not met it is highly unlikely that we will be able to take over prescribing.

When monitoring and follow-up is not available, this would effectively be a complete transfer of care into primary care, leaving patients and the practice clincians unsupported. It is not in the best interests of patients, or clinically safe to take on or continue prescribing in such scenarios.

Continuity of Care

The patient must remain under the care of the specialist for the entire duration of treatment. This continuity of care should not depend on self-funding or private insurance.

Medication Supply Issues

If medication shortages occur, we can only switch to bioequivalent formulations (as per national guidelines). If other changes to medication or dosage are required, the patient must be re-assessed and stabilised before shared care can continue.

Other Considerations

If you have had a private assessment and are not able to fund the required follow-up to enable stabilisation and ongoing monitoring, or even the prescription costs, then you may choose to wait for an NHS assessment. In this case we will not be able to prescribe by entering into a shared care agreement until you have been assessed by the NHS service.

Stimulant medicines used for ADHD are costly and the private provider may state that a consultation (and associated fee) is required for each prescription. This amounts to a significant financial commitment. For many patients, this is not a viable option and we strongly encourage our patients to view a private assessment as a screening process rather than something that will expedite treatment.

Patients that have had assessments abroad (whether private or through the relevant state healthcare system) requesting medication will likely need to been seen through a NHS ADHD service with ongoing input before we can take over prescribing via a shared care agreement. We will consider any request to take over prescribing if the criteria stated above are met. We strongly recommend patients registering from abroad ensure they have adequate supplies of their medication (or a mechanism to obtain more medication) pending transfer into a NHS ADHD specialist clinic.

Please note that a diagnosis must be made by a suitably qualified clinician and to UK diagnostic criteria.

We have taken this position after careful consideration to enable a clear and consistent approach that is based on quality, safety and equity.

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