Why Adult ADHD Care in Ireland Is at a Tipping Point

By Dr Jahan Khan, Consultant Psychiatrist and Clinical Director, Mediconline.ie

MBBS, MRCPsych, MCPsychI. Registered with the Irish Medical Council.

Demand for adult ADHD assessment in Ireland has risen far faster over the past few years than the system has been able to absorb. In more than fifteen years as a consultant psychiatrist in the Irish health service I have not seen a comparable gap between the number of people seeking assessment and the capacity available to carry it out. The result is a large group of adults who raised their concerns with a GP two or three years ago and remain on a list, alongside a private market that has expanded very quickly to fill the space, often without giving patients a clear view of what they are buying.

The pressure on adult ADHD assessment in Ireland is now at a tipping point, and it closely mirrors the bottlenecks that have built up across the NHS. The consequences land on patients, and they land unevenly.

Where adult ADHD care in Ireland currently stands

Until recently there was no public specialist service for adults with ADHD in this country at all. The HSE Model of Care for ADHD in Adults, launched in January 2021, was a genuine step forward. It set out, for the first time, how assessment and treatment for adults should be delivered inside public mental health services.

The difficulty is that the model depends on funded teams being in place, and that rollout is still incomplete. Seven adult ADHD teams have been established, with recruitment under way for further areas. Whether you can access one depends entirely on where you live.

At the time of writing, the service information published for the adult ADHD programme lists dedicated teams covering areas including Sligo, Leitrim and Donegal, Limerick, Clare and north Tipperary, Cork and Kerry, and parts of Dublin and Wicklow. It also lists areas with no dedicated adult ADHD service at all, among them Galway, Roscommon and Mayo, the south east counties of Waterford, Wexford, Carlow, Kilkenny and south Tipperary, and north Dublin. Two adults with identical difficulties, living an hour apart, are therefore on completely different pathways.

There is a second point that gets very little attention. Referral to these teams is intended for moderate to severe ADHD, meaning at least two of the three core symptom domains together with significant impairment in two or more areas of life. That is a reasonable clinical threshold for a service under strain, but it does mean that adults with real and disruptive difficulties can fall outside it and be left with no public option.

There is also no reliable national figure for how long the wait is. Waiting list data is held by individual local mental health services rather than centrally, so no national position is published and there is no straightforward way for a patient to establish where they stand. The figures quoted publicly range from around eighteen months to four years depending on the region. A system in which someone cannot find out what they are waiting for, or how long they are likely to wait for it, is not simply under-resourced. It is opaque, and the opacity does damage of its own.

What patients are running into in the private market

Because the public route is not available to everyone, a large private market has grown very quickly. There is excellent, evidence based work being done in it. There is also a great deal that concerns me, and patients are the ones absorbing the risk. Four issues come up again and again.

Wide price differences with very little explanation

Private assessment fees in Ireland run from roughly six hundred euro to well over three thousand, and it is often impossible to work out from a website what that fee actually buys. Is a written report included? Is it a letter or a full diagnostic report? Is any follow up included, or does the price cover the assessment only? A patient comparing two clinics is frequently not comparing the same thing at all. Our guide sets out what an ADHD assessment costs in Ireland and what should be included.

A diagnosis with nothing after it

This is the one that troubles me most. People are assessed, given a report, and then left on their own. No medication review, no titration, no psychological input, no plan. A diagnosis on its own does not treat anybody. For most adults the diagnosis is the beginning of care, not the end of it, and any service offering assessment should be able to say clearly what happens the following month and the month after that.

Reports that are not accepted

The surge in demand has drawn in providers without the appropriate psychiatric or clinical credentials. I regularly see reports that GPs and public mental health teams will not act on, which leaves the patient having paid for something with no clinical value and needing to start again. In Ireland a formal ADHD diagnosis should come from a psychiatrist or clinical psychologist who is appropriately registered, and the assessment should be built on the recognised diagnostic criteria for adult ADHD. Patients should not need to know that in order to be protected from it.

No published quality benchmark

There is no standard a patient can hold a provider to, and no simple way for them to tell a thorough multidisciplinary assessment from a fifteen minute conversation. They are being asked to make a clinical judgement that they have no way of making.

Delayed recognition, not over-diagnosis 

I want to be very direct about this, because the framing matters. What we are seeing is not too many people seeking care, and it is not a fashion. It is what happens when a condition goes unrecognised in a population for decades and then recognition finally catches up. The people presenting now are, in the main, adults who went undiagnosed for years and should have been identified long ago.

A health system that only stays within budget because a large part of the population cannot get through the door is not a system that is working efficiently. It is a system that has moved the cost onto patients, onto families, onto employers and onto other parts of the health service. That is a structural problem and it needs a structural answer.

What a quality led pathway would look like

Ireland does not have to choose between public and private capacity. It has to decide how to use both without giving up clinical standards. Three things would make the difference.

1. An Irish route to accredited private assessment, publicly funded

England has a mechanism, Right to Choose, that allows a patient facing an excessive wait to be assessed by an approved private provider at public expense. Nothing equivalent exists here. Something along those lines would take pressure off the public teams and end the situation where the ability to pay decides who gets assessed.

It is worth being honest about the English experience, though, because it also shows what to avoid. Where commissioning ran ahead of planning, the result was cost inflation and inconsistent quality, and some areas have since had to restrict access again. The model is right. The implementation is where it succeeds or fails.

2. Commission carefully, and audit credentials before contracts are signed

Public contracts should not be handed out to meet a waiting list target. Any pathway of this kind needs proper service planning, verification of every clinician’s registration and training, and realistic capacity testing before a single referral is sent. Getting this wrong once would set adult ADHD care back years.

3. National service specifications and transparent, capped tariffs

Every participating provider should be working to the same diagnostic standard, with multidisciplinary follow up built into the pathway rather than sold as an extra, and with published, capped fees for assessment and for ongoing care. That single change would remove most of the confusion patients currently face.

What you can do while you are waiting

None of that helps someone who needs an answer this year, so a practical note. If you are considering a private assessment, ask any provider these five questions before you pay anything.

1.   Who carries out the assessment, and what is their registration?

2.   Which structured diagnostic process do you use?

3.   Is a written report included, and will it be accepted by a GP, an employer or a college?

4.   What happens if I am diagnosed, and what does the first year of follow up cost?

5.   What happens if I am not diagnosed?

A provider who cannot answer all five clearly, in writing, is not one I would recommend to a patient of mine.

It is also worth knowing that if you are prescribed medication, the Drugs Payment Scheme caps what a household pays for approved prescribed medicines at eighty euro a month, and that tax relief at twenty per cent is available on qualifying medical expenses through Revenue. Neither removes the cost of a private assessment, but both reduce the cost of staying well afterwards.

Where Mediconline stands

I set out the criticisms above because I think they are fair, so it is only reasonable to say how we answer them ourselves. Our adult ADHD assessment is delivered by Irish trained consultant psychiatrists and psychologists. The initial screening call is free. The fee is published on our site rather than quoted on request, and it covers the full pathway: psychometric testing, a sixty to ninety minute assessment with a psychologist using the DIVA-5, and a forty five minute consultation with a consultant psychiatrist who gives you the outcome directly and sets out a treatment plan. You receive a diagnostic report suitable for your GP, your employer, your college or a DARE application. Follow up appointments and prescription management are available at published prices, so you can see the cost of the first year before you start.

If you would like to talk it through first, the screening call costs nothing and carries no obligation.

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