The issue: long wait times between diagnosis and starting the titration process
We want to update and reassure patients about changes to the titration service for our adult patients who are (or will be) receiving treatment for ADHD via the NHS. We have run a successful adult ADHD service for several years, but we continue to learn. Despite rapid and constant recruitment of clinicians, one issue we have always struggled with is reducing the time people need to wait to start their ADHD treatment.
There are several reasons for this, but one large issue is that titration is ‘open ended’. That is, we adopted an ethos of taking patients through titration at their own pace, until we optimise their treatment. This is a patient-centred approach for an individual in titration, but it is not the best approach with regards to managing our waiting list, nor is it popular with NHS commissioners, as it makes it impossible for them to budget accurately.
There is also the whole question of whether continuing to tinker with medication actually helps: there is a significant percentage of people for whom the medications available just do not work or who are never going to experience more than a partial response. Clinically, there is a good case for saying that we need to more rapidly identify those patients, and give them a route to accessing better specialist non-pharmacological interventions. With medication, there are cases where one has to say that the response is “good enough.”
We therefore need to re-evaluate what we are doing to improve and streamline our model. We need to work more closely with our NHS partners to reassure them that we want to help them make the most efficient use of the budgets available for ADHD. This is about helping as many people as possible, using finite resources responsibly and effectively.
The (partial) solution:
With this in mind, we are moving to a model where titration will be commissioned in 12-week blocks. That is, when you start titration, you will have 12 weeks to complete titration. However, if a patient and their clinician agree that there is a clinical need to extend beyond 12 weeks, we can seek further additional funding for a further 12-week block.
The decision will always be centred around clinical need, such as the inability to tolerate medication tried so far, as well as medication so far proving ineffective. Non-clinical reasons for needing additional time are unlikely to receive further funding, such as inadequate engagement with the titration process due to other conditions or stresses, or wanting to make minor adjustments to treatment plans that are unlikely to yield significant clinical benefit.
We believe that by working more closely with our patients and our NHS partners in this way, we will be able to help and support more adults with ADHD in a responsible and effective way. We are aware that this approach will not suit everyone, and it might be that we need to recommend discharge for some people, with a plan for re-referral when other conditions have been met to maximise the likelihood of effective treatment. Your clinicians will make recommendations and discuss options with you during your journey with us to keep our care patient centred.
Jon Chanter, CEO, Psychiatry-UK