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

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition associated with persistent difficulties in attention regulation, impulsivity, and activity level (), with consequences that may extend across education, employment, relationships, mental health, and everyday functioning throughout the lifespan (). Although ADHD was historically framed mainly as a childhood disorder, it commonly persists into adulthood (). In England, recognition of adult ADHD has increased substantially over the past decade, driven by greater public awareness, improved understanding of lifespan persistence, refinements in diagnostic frameworks, and the growing numbers of young people moving out of child services (–). This growth in recognition has brought longstanding weaknesses in service provision into sharper view (). Adult ADHD pathways in England have developed unevenly and often reflect local commissioning history rather than coherent national design. Some areas offer specialist adult ADHD clinics, and elsewhere, pathways depend on community mental health teams, broader neurodevelopmental services, mixed-provider arrangements, or combinations of NHS and independent-sector provision. Referral thresholds, access routes, waiting times, diagnostic processes, and post-diagnostic arrangements vary considerably between areas and, at times, within the same integrated care board footprint (). As a result, access and pathway quality may be shaped as much by geography and local service configuration as by clinical need. The policy issue is therefore broader than just waiting times. Delays matter clinically and psychologically, but they are only one visible expression of a wider pathway problem. Across the existing literature, the core difficulties include rising demand, uneven service configuration, inconsistent pathway functions, limited specialist capacity, weak transition arrangements, and variable post-diagnostic provision. These features point to systemic misalignment between need, demand, supply, and commissioned pathway design. In that context, long waits, large lists, and recourse to alternative routes of care become predictable consequences rather than isolated failures ().