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

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?