scaisnotsochillandcool

Few proverbs fit the modern ADHD crisis better than this: "you can’t wake a person who is pretending to be asleep".

For years, there’s been ongoing mixed messages about GPs and Shared Care Agreements (SCA) for ADHD medication when the diagnosis comes from a private provider.

In this article I'm going to explore what is an SCA, why it's important and some of the reasons we hear from GPs on why they won't enter into one with private providers.

What is an SCA and why is it important?

A Shared Care Agreement (SCA) is in a very simple way a formal arrangement where a GP agrees to take over prescribing medication that was originally started by someone else. There are two different types of organisations that GPs can potentially interact with on a SCA – the NHS (no real issues) and private companies (huge amount of issues).

In the context of ADHD medication, that private practitioner would be a psychiatrist. In theory if you had an SCA, you would pay your psychiatrist, usually every six months, to check and ensure you should still be on medication and that there are no issues then your GP manages the monthly prescriptions.

Why is this important? Without an agreement in place, you'll have to pay a private GP to write a prescription and additionally pay for the medication, which can be expensive.

Now, let's get to how we got here. Today in Northern Ireland (and large parts of Scotland, England and Wales also), you're faced with two choices if you are looking to go through the diagnosis process for ADHD.

Choice 1. Get put on a waiting list, which in NI is around eight years long (and let's just blissfully ignore the lack of funding to do anything with that waiting list, which makes its very existence futile).

Choice 1b. As above but hope you're in an area that finds a small pot of budget to help a tiny number of people. Stick a four-leaf clover in your left pocket, a rabbit's foot in your right and cross your fingers. Wait and hope you're one of that small number of people.

Choice 1c. Some GPs get that waiting lists are currently as useful as sending a strongly worded letter to your printer when it jams, so they tell you that private is probably your only option.

Choice 2. Pay to go private.

The latter choice is something that many people can't afford to do, but for those who can afford it or for those who go into debt to get a private diagnosis, they're then hit with the SCA conundrum where GPs (in the main) either refuse to enter into, or infuriatingly, recently have begun to rescind SCAs they've had with people who are on amber medication.

An amber drug is a medication that exists in healthcare's version of no man's land – not dangerous enough to be heavily restricted, but scary enough that GPs need a specialist's permission slip before they'll touch them with a bargepole.

Now let's get to some of the reasons why GPs either refuse a SCA or have rescinded them recently when it comes to amber medication. In the interests of fairness, I should state two things at this point – firstly, SCA issues for amber medication is not restricted to ADHD meds, and secondly there's no single point of blame within all of this.

Before we go on, the closest I've been to the medical world is dating a trainee nurse for two weeks, whilst I went to university. So the snarkiness below might be something that a GP or someone else can come back with an eloquent reason as to why I'm wrong. I'm happy to hear that. Please feel free to reach out and correct me. I'm taking this from a patient perspective. The frustration that is felt by people who feel like pawns in the middle of a game of Wizard's Chess, where the rules fell alien.

And my 'nonsense rating system' below is my own opinion, just in case sarcasm isn't your first language.

Credentials

GPs state that they're unable to confirm the credentials of private practitioners easily, particularly when they are based outside of Northern Ireland.

As far as I'm aware, it is not the job of a GP to decide whether someone is qualified or not. The General Medical Council (GMC) fulfils that role. Yes, there are horror stories out there including this BBC investigation, but I could equally find a deluge of horrendous stories like this about GPs.

If we're going to deal in 'What Ifs' all the time coupled with Chicken Little syndrome then GPs might as well bunker down in their bedroom in the comfort of a tinfoil onesie.

It took me less than 60 seconds to find out the following information about the psychiatrist I currently work with: when he gained his qualification; his GMC registration date; the designated body for his revalidation and the responsible officer; his specialisms on the Specialist Register and the fact that he's a trainer recognised by the GMC. The specialist register, if you're interested, is "a list of doctors who are eligible to take up appointment in any fixed term, honorary or substantive consultant post in the NHS".

None of this is private. This is all on the GMC website that anyone can look at. If my math is correct it takes, in an ideal world, at least a decade to become a consultant psychiatrist (medical degree, foundation training and core psychiatry training).

But GP practices across the land are making decisions that essentially say: "let’s assume all private practitioners are rogue alchemists, peddling snake oil from the shadows, forging ADHD diagnoses in candlelit basements while cackling like deranged Victorian hypnotists. Better to barricade the doors and screech that the sky is falling every time a private practitioner appears, as if they rode in on a broomstick and a falsified medical degree".
Nonsense scale rating: 13.31/10

Correspondence

Apparently correspondence from private practitioners can lack detail or clarity to assure the GP that reviews are happening "as stipulated". GPs often also claim that when issues arise the process for contacting private doctors is not in line with that in the NHS which "raises significant safety concerns".

I'd be interested to hear the data on this. Any GPs out there who have had a scale of SCAs where they can confidently say the majority of interactions with private have ended like this? I'd love to hear from you.

Because the answer, right now, is to throw the baby out with the bath water. We'll just not deal with private companies then because of the small number who don't provide adequate details and ignore those people really in need?
Nonsense scale rating: 11.3/10

Regular review

This one is a killer. This is a f**king killer. GPs claim that patients being able to get regular reviews, which are an important and vital part of continuing on medication, can be challenging because they must pay each time they see the consultant and thus they don't happen as often as they should. Like the point on correspondence above, is there any evidence to prove that this is widespread? Have you thought about putting in simple guidelines on SCA within your own practice? You must have a consultant appointment every X months and your private provider must provide adequate details or SCA will be rescinded. That doesn't sound too complicated, does it?

And, as someone who has gone through this process, I can GUARANTEE you that it's cheaper to pay a psychiatrist every six months for a consultation than to pay a private GP to write a prescription 13 times a year and to pay for medication the same number of times.
Nonsense scale rating: 14.9/10

Before we get to the final one, let me check in with you, dear reader, to let you know that I'm not currently having a stroke. Yes, I'm angry at the system, but the headline for this article is, in fact, purposely like that. Mostly that's because I'm listening to a lot of Alessi Rose songs (not within my control) and I may have heard the song below – iamsochillandcool – about 730,000 times now.

Dollar, dollar bill, y'all

GPs can claim all of these nonsensical reasons for not entering into SCAs. In some ways they don't even need to because there is no legal obligation on a GP to enter into one with a private company. And I get it. A GP ultimately is the one writing a prescription for an amber drug and so they need to be comfortable as anything goes wrong will in some ways come back to them.

But The Moment has seen GP letters that have circulated recently to patients who had previously been on SCAs for ADHD medication and one in particular at least in amongst all the noise gives what feels like the real reason to me.

That letter states: "There is no funding or resource allocated to Primary Care to cover the work private practitioners generate. Time spent dealing with these issues directly impacts on our ability to provide the NHS the care we are actually funded for".

So there it is in writing, the reason I'd bet on if Paddy Power took money on such things. GPs aren't paid for the time they spend doing this. I'm a cynical person by nature, so someone please convince me that I'm wrong in this actually being the reason. The sky isn't falling, but the acorn is made of tightly wound dollar bills (how else am I going to reference Wu-Tang Clan in this?).

The letter goes on to state that increasing numbers of SCA requests from the private sector is such that it impacts on the ability to provide NHS care for the "rest of our patients".

Let's be analytical for a moment and accept that multiple things can be true at the same time:

1. GPs shouldn't be taking all of the blame. It just so happens they’re the single point where this calamitous world collides – like a multi-car pileup in heavy fog, with no one quite sure how to apportion blame among the nine cars, two trucks, and one very unlucky motorcycle. This is a complex web that includes many levels of government, in particular, the Department for Health. It's fundamental to a GP that they need to ensure their practice is financially stable. Not being paid for work is challenging. And no one should be expected to work for free.
2. The parade of excuses for not entering into SCAs is infuriating to patients who need help. It's like a politician giving fifteen different reasons why they missed a crucial vote, when we've all seen the pictures of them on a beach in the Seychelles sipping a piña colada - the truth gets buried under an avalanche of excuses, but we can still see it sticking out. For the main, we feel like we're being constantly gaslit by GPs. If lack of funding to deliver on this is the issue, tell people that. Don't hide behind reasons that to lay people feel ridiculous.
3. The language used makes us, the people with ADHD, feel like a burden. That we're somehow the problem, taking away from others' medical needs. It's a special kind of gut punch when healthcare professionals frame us as part of the strain on the system rather than patients who deserve care – especially when many of us have already spent decades feeling like we don't quite fit in anywhere.
4. Private practitioners aren't "generating the work". The lack of a service is driving people towards private companies. To suggest otherwise is like blaming someone for calling a plumber when their pipes burst because the water company won't fix the leak. We're not creating extra work – we're desperately trying to patch the holes in a system that's already failing us.

Government must act, and act now

Taking a societal lens to this, the lack of an ADHD pathway for adults is illogical. It's like a car mechanic saying, "You know what? We don't fix brakes anymore. Too much hassle. Instead, we'll just wait until the car crashes and buy you a new one. That's bound to be cheaper and more efficient". It's not just absurd – it's dangerous. And just like ignoring faulty brakes, not dealing with the ADHD crisis is costing the government far more than fixing a broken system.

There's a huge number of studies that focus on ADHD and suicide. This NHS Berkshire post states that adults with ADHD are five times more likely to attempt suicide and one in four women with ADHD have made attempts on their life.

A 2019 report by Deloitte on ADHD in Australia found that the cost of lost productivity due to ADHD was around $10.19bn meaning that if individuals had earlier access to diagnosis and treatment a significant portion of these costs could be mitigated.

The same report showed 65% of people with ADHD have at least one other condition and children with ADHD are 28% more likely to have an accident that requires hospital care, contributing to increased hospital costs.

Additionally it stated that the prevalence of ADHD in incarcerated populations is estimated to be 25.5% internationally (with variance by country) and that the cost of crime in Australia due to ADHD, including the cost to the justice system, was estimated to be $307m in 2019.

Not only are people with ADHD wildly overrepresented in prisons, but there is evidence that shows an annual incremental cost of inmates with ADHD of more than £590 compared to inmates without ADHD, which is based on a Scottish study.

So while GPs tell us reasons that don't quite hold water, and the Department of Health ponders a strategy but won't tell the public about its approach, we're all paying a much higher price – financially and societally. The cost of not treating ADHD properly isn't just measured in pounds and pence, but in lost potential, increased strain on our justice system, and unnecessary suffering.

And that brings us full circle to our opening proverb. Because when it comes to addressing the ADHD crisis, you can't wake those who are pretending to be asleep – even if their snoring is potentially costing us billions.