Adult ADHD diagnostic pathways in the United Kingdom: a structured review and policy case for a national...

Adult attention-deficit hyperactivity disorder (ADHD) diagnostic pathways in England are under sustained pressure. Demand has risen, waiting times have lengthened, service models remain fragmented, workforce capacity is uneven, and access and quality vary markedly between localities. Although the core clinical principles of ADHD diagnosis are relatively well established, the organisational conditions needed to deliver them consistently remain less secure.

To synthesise UK-wide evidence on adult ADHD diagnostic pathways and to develop an evidence-informed policy case for a national commissioning and quality framework for England.

PRISMA-informed structured policy-oriented review of UK-wide evidence on adult ADHD diagnostic pathways, interpreted through a health services and commissioning lens. The review is not a registered systematic review and did not undertake formal risk-of-bias scoring; appraisal was structured and narrative.

A structured literature search was conducted across PubMed/MEDLINE, Scopus, Web of Science, ScienceDirect, SpringerLink, Google Scholar, SciSpace, and ArXiv. Searches were conducted between 2023 and March 2026, focusing on publications from 2010 onwards. Screening and reporting were informed by PRISMA 2020 guidance, adapted for a structured literature review rather than a full systematic review. Eligible sources included peer-reviewed empirical studies, clinical audits, service assessments, mixed-methods studies, qualitative studies, consensus statements, systematic or scoping reviews, and policy documents relevant to adult ADHD diagnostic pathways in UK healthcare settings. Findings were synthesised thematically into pathways and cross-cutting system factors.

Twenty-six sources met the eligibility criteria. The evidence showed marked variation in access routes, referral quality, screening and triage practice, assessment delivery, service configuration, transition arrangements, post-diagnostic interfaces, and supporting infrastructure. Clinical standards for diagnosis were comparatively stable across NICE, the Royal College of Psychiatrists, the UK Adult ADHD Network, and the British Association for Psychopharmacology guidance, yet operational delivery was inconsistent.

England requires a national adult ADHD commissioning and quality framework that defines minimum diagnostic standards, core pathway functions, stratified allocation of expertise, mixed-provider governance, and whole-pathway outcome monitoring. The framework proposed here is conceptual rather than operational: it defines minimum functions, standards, and governance expectations, but it does not yet specify operational criteria for stratification, complexity thresholds, audit mechanisms, or rules for local implementation, which remain matters for the implementation phase.