What works and why building a new approach to managing ... · What works and why – building a new approach to managing ADHD services Peter Mason Consultant Psychiatrist Adult ADHD
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What works and why – building a
new approach to managing ADHD
services
Peter Mason
Consultant Psychiatrist
Adult ADHD Service
Cheshire & Wirral Partnership NHS Foundation Trust
Mark
• ADHD diagnosed age
10
• School & parents in
agreement
• Inattentive, disruptive,
restless and impulsive
• Underachieving
• Losing friends
• Under care of CAMHS
• Good response to Equasym XL
• Good insight!
Mark (continued)
• Transition age 18
• Seen 6 months after
18th birthday
• Engineering
apprenticeship
• Good exam results –
GCSEs and BTech
• Continued compliance
with Equasym XL
• GP issuing
prescriptions
Jamie
• ADHD diagnosed age 15
• ADHD suspected from age 7
• Parents convinced
• School sceptical
• Inattentive, disruptive,
restless and impulsive
• Underachieving
• Losing friends
• Good response to Concerta XL
• No real insight
Jamie (continued)
• Dropped out of follow-up age 16
• GP discontinued Concerta XL
• No GCSEs
• Seen in adult clinic age 19
• Forensic history
• Hopeless
• Reluctantly agreed to restart
Concerta XL
Lessons
• Parents vs school
• More years of underachievement & losing friends
• Poor insight
• Allowed to drop out of follow-up
• Prison services?
• Long wait for adult services?
• Hopeless
Key elements of an ADHD service
• Pre-assessment
• Assessment
• Initiating & optimising treatment
• Post-treatment
• Transition
Pomegranate (Shire 2018)
Pre-assessment
• Awareness raising
• Training of teachers (school & adult education)
• Training of GPs and other healthcare providers
• Co morbidity
• Revolving door
• Prisons
• Drug services
• Referral – clear pathways
• Referrals – clear information
• Admin support & triage
Pomegranate (Shire 2018)
Assessment
• Triage
• Multi-disciplinary triage
• Stratification tools – complexity and risk
• Clinicians
• Comprehensive history
• Diagnostic / symptom tools
• Functional impairment tools
• Diagnosis based on all available information
Pomegranate (Shire 2018)
Initiating and optimising treatment
• Compliance (use technology)
• Same clinician where possible
• Repeat symptom and functional impairment tools
• Medication adherence
• Side effects
1. What is going well you for you?
2. What is not going well?
3. What would you like to change?
Pomegranate (Shire 2018)
Post-treatment
• Health checks
• Life skills
• Shared care
• ?discharge
Pomegranate (Shire 2018)
Transition
• GPs role
• Referral to adult services
• Repeat symptoms and functional impairment tools
Obstacles to treatment
• Demand outstrips capacity (waiting lists)
• Prescribing guidelines & shared care
• GP workload
• Expertise in primary care
• Fragmented NHS
Obstacles to treatment
Cumulative referrals & assessments (Wirral)
Obstacles to treatment
• Demand outstrips capacity (waiting lists)
• Prescribing guidelines & shared care
• GP workload
• Expertise in primary care
• Fragmented NHS
NICE guideline [NG87]
Published: March 2018
1.10.1
• A healthcare professional with training and expertise in
managing ADHD should review ADHD medication at least
once a year and discuss with the person with ADHD (and
their families and carers as appropriate) whether
medication should be continued.
Prescribing guidelines
GMMMG
• The patient will not be discharged from out-patient follow-
up while taking [ADHD Drug].
Obstacles to treatment
• Demand outstrips capacity (waiting lists)
• Prescribing guidelines & shared care
• GP workload
• Expertise in primary care
• Fragmented NHS
New integrated model
Consultant psychiatrist &
specialist nurse prescriber
Specialist nurse prescriber
General Practitioner
Primary care based clinics
• 4 hubs
• Each hub has an ADHD specialist nurse prescriber for 1
day a week
• Next door is GP ADHD specialist for the morning
• Every fourth week consultant and third sector join the
clinic for the full day
• Access to EMIS
• Reception staff training
GP Training
• Training manual developed with Shire
• Training based around case based discussions of
increasing complexity
• Clinic based training
• On site supervision / support
Primary care based clinics
Progress
• GP led clinics began in 2 hubs March 2018
• Next 2 hubs go live mid December 2018
• Discharges to primary care increasing
• No evidence yet that new assessments increasing
Snags
• IT problems
• Initial attendance
• Indemnity
• Who defines stability
GP Feedback
• “Didn’t realise ADHD was so easy”
• “Enjoy being able to spend an adequate amount of time
with patients”
• “I now understand why X’s anxiety didn’t get better”
• “When can I start diagnosing and treating?”
Patient feedback
• Mixed feedback so far:
• Some disasters: wrong venue, wrong letter, benefits
• Some successes: patient with “epilepsy”, better venue
Any questions?
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