After waiting more than a year to see an NHS specialist, Sam's assessment for ADHD took less than two hours. It happened over video, involved a short checklist and brief history, and ended with a swift decision.
Authors
- Oladayo Bifarin
Senior Lecturer School of Nursing and Advanced Practice, Liverpool John Moores University
- Dan W Joyce
Professor of Connected Mental Health, Department of Primary Care and Mental Health, University of Liverpool
Within weeks, Sam had a diagnosis, a prescription and a discharge letter back to the GP. But when symptoms worsened and medication side-effects appeared a few months later, no one seemed sure who was responsible for follow-up. As we know from our clinical and research work, stories like this are increasingly common in UK mental health and neurodevelopmental services.
Against this backdrop, the UK health secretary, Wes Streeting, has ordered an expert review of ADHD, autism and mental health diagnoses. Much of the public conversation focuses on overdiagnosis to suggest that normal distress is too quickly labelled as medical illness. Media coverage has linked these concerns to rising benefit claims related to depression, anxiety, autism and ADHD.
The debate is not only about clinical accuracy. It is also about who is considered too sick to work and what that means for the state. Some commentators suggest that people pursue diagnoses for advantages such as disability benefits or workplace adjustments. Critics argue that this framing implies people are gaming the system, rather than asking why so many are struggling in the first place.
While the public debate often focuses on individual motives, health services point to structural strain . NHS data shows record demand and severe pressure on mental health teams. Patients and families report long waits, repeated assessments and referrals that are rejected or misdirected, leaving some people lost in the system altogether.
Streeting's recent opinion piece in the Guardian captured this tension. He acknowledged that his earlier remarks on overdiagnosis were divisive, and accepted that many people cannot access support when they need it. At the same time, he pointed to a steep rise in referrals for mental health and neurodevelopmental conditions, and argued that the review must uncover what is driving this.
The Centre for Mental Health, an independent UK charity that researches mental health policy and practice, welcomes the review but stresses that evidence already points to a genuine rise in distress linked to poverty, insecure housing, austerity and the pandemic. In a recent statement , its chief executive, Andy Bell, said there had been a clearly rising trend in mental health needs and that he had seen no evidence that mental health problems were being overdiagnosed.
Others argue the debate is misplaced. Miranda Wolpert, director of mental health at Wellcome, argues that the real challenge is not deciding who counts as mentally ill, but how to match different forms of distress to appropriate support. That support might be clinical therapy or medication, but it might also involve housing help, debt advice or peer support.
Professionals have been warning about system design for years. British psychiatry specialists have raised concerns about an overreliance on generic models and a drift away from specialist expertise. Mental health nurses have voiced similar concerns, warning that increasingly broad nurse training risks diluting skills and weakening continuity of care.
Seen in this context, what is often described as overdiagnosis looks more like the predictable outcome of the system itself. NHS care is structured around a sequence of triage, referral, assessment, diagnosis and treatment. People move through brief assessments and short packages of care before being discharged.
This model rewards speed and immediate certainty. It favours quick assessments, clear diagnostic labels and protocol-driven treatments - for example, offering cognitive behavioural therapy or SSRI medication, a common type of antidepressant, when someone scores above a threshold on a questionnaire. This makes planning and auditing easier, but encourages services to treat each case as a short episode that ends abruptly, rather than an evolving set of needs that may require ongoing support.
Diagnosis becomes the main tool for unlocking help. When this is the only mechanism that gives access to medication, therapy or educational support, diagnosis rates rise not because people are exaggerating distress, but because the system leaves them no other route to assistance.
And once an episode of care ends, responsibility is often unclear. Patients are discharged with short letters and must start again if their needs change. Referrals may be rejected because teams are overwhelmed and must focus on people at immediate risk.
Clinicians in primary care face similar pressures. Distress linked to financial strain, workplace problems or bereavement may be recorded as depression or anxiety, because diagnosis allows GPs to prescribe or refer.
Fragmentation across services deepens the problem. Patients are divided between multiple teams, with each handling only part of their needs. Checklists designed for screening rather than diagnosis can become shortcuts. Guidelines on depression, for example, specifically warn against relying on symptom counts alone.
Workforce strain further undermines continuity. In our experience, nurses, psychologists, occupational therapists and social workers often deliver complex care without consistent supervision. Burnout and vacancies weaken the system's ability to offer stable, ongoing support.
The planned review arrives at a critical moment because its conclusions will shape who receives help and how services are redesigned. Counting diagnoses will not address the underlying issues. Rising rates reflect system pressures more than patient behaviour.
There is a clearer route forward. Research shows that when services are built around separate diagnosis-specific pathways, people can face delays and fragmented care because they are moved between teams that only deal with one part of their needs. Studies instead recommend approaches that focus on a person's distress and support needs, rather than forcing them into rigid diagnostic categories.
Better coordination across different professions would also help teams spot overlapping issues, such as speech and language difficulties in autism or how ADHD medication might interact with antidepressants.
Shifting the focus away from strict criteria for emergency help would make it easier for people to receive support earlier and avoid preventable crises. A review that looks closely at how referrals work, how digital tools are used, how the workforce is trained and supported, and how continuity of care is maintained would give a more accurate picture of the system's weaknesses and what needs to change.
The system is not failing because too many people seek help. It is failing because brief, discrete episodes of care cannot manage long-term, complex needs. Until that changes, debates about overdiagnosis will keep obscuring the real issue: building a mental health system that stays with people, instead of processing them and moving on.
Oladayo Bifarin receives funding from National Institute for Health and Care Research. The views expressed in this article are those of the author(s) and not necessarily those of NIHR or the Department of Health and Social Care.
Dan W Joyce receives funding from the National Institute of Health and Social Care Research (NIHR) and the Wellcome Trust.
