7.1 Service and configuration - Australian ADHD Clinical Practice Guideline

7. Considerations – Service & Policy

7.1 Services and Configuration

Clinical Questions

1. What referral pathways should be established?
2. Which agencies should be involved in the support of ADHD?
3. How should services be configured? What should services provide and to whom?
4. How should services for those with ADHD in Australia be funded?
5. What are shared care models and are they effective?

Clinical practice gaps, uncertainties and need for guidance

Existing care for people with attention deficit hyperactivity disorder (ADHD) is fragmented. A multimodal, multi-professional and multi-agency approach is recognised as optimal care, particularly when there are co-occurring conditions with significant impacts on a person’s functioning and quality of life. However, in reality, this is rarely available.

Most public sector mental health services do not provide ADHD services, resulting in an over-reliance on private sector care and services. Existing services are often difficult to access due to long waiting lists and out-of-pocket costs. To improve care, clearer referral pathways (for example, from GPs to other specialists and back again) and increased service capacity are needed. Guidance is needed as to which agencies should be involved to provide holistic treatment and support of ADHD, and the configuration of these services, including shared care.

Summary of narrative review

The NICE ADHD guideline recommends that health professionals, with training and expertise in ADHD, should be involved in the diagnosis, assessment and ongoing treatment and support of children, adolescents and adults with ADHD as well as overseeing continuity of care (NICE, 2018). Communication and ongoing feedback between health professionals and education and social care providers is also highlighted. The importance of psychological services for people with ADHD as well as programs that provide group and individual parenting interventions as well as support groups for people with ADHD and websites are also noted.

Equity in the delivery of services for people with ADHD remains a major issue in Australia, with the majority of public health services electing not to diagnose and treat ADHD, especially in adults. This leads to the majority of people on low incomes, adults especially, not being able to access essential services.

Improvements are being made to the equitable provision of medications for ADHD, but some medications are still not available on the PBS for adults who have not been diagnosed in childhood. ADHD is not on the list of eligible conditions for entry to the NDIS. Although this does not exclude those with significant impairment from accessing the scheme, it has meant that no meaningful communication has been possible to educate the NDIS in the needs of those who are disabled by ADHD.

Service configuration recommendations within the NICE guideline (NICE, 2018) highlight the importance of giving the person with ADHD and/or their carer the option of being involved in treatment decisions and planning. Shared care protocols for medication monitoring between primary and secondary health care professionals are also recommended. Integration and better organisation between child health services and mental health services with the formation of multidisciplinary specialist ADHD teams is a further recommendation.

In addition, local multi-agency teams with representatives from paediatrics, mental health, education, social, forensic services and parent groups are needed as well as provide training and a directory of information regarding ADHD services. There is a need for models of care within the Australian context, particularly shared care.

Recommendations

Clinical considerations for implementation of the recommendations

The implementation of these recommendations will have implications at the policy level regarding funding of ADHD treatment in Australia, through to how services are configured. An economic evaluation will be required to fully understand the implications of these recommendations which is beyond the scope of this guideline development which has a clinical focus. Further work relating to service and policy development for people with ADHD is warranted.

See Technical Report, sections 11.4 and 12.5 for further details.