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Private providers are profiting from the expansion of ADHD and autism diagnosis The private market is reversing the social gradient of diagnosis

Agreement: I Agree Body: Dear Editor, The four responses to Fisher and Frith so far debate whether the diagnoses are valid, whether the real money is in treatment, whether diagnosis should exist at all, and how to audit it.[1] None asks who, under the present arrangement, actually gets diagnosed. That question matters, because the "expansion" the authors describe is not spreading evenly. In England, neurodevelopmental diagnosis has historically followed deprivation. Childhood ADHD is consistently more common in low-income families,[2] and in a census of seven million pupils, those with a recorded autism diagnosis were 61% more likely to be socially disadvantaged (adjusted prevalence ratio 1.61).[3] Whatever one believes about elastic criteria, need has been concentrated among those least able to pay. Access is now rationed by queue. At the end of November 2025 there were 526 965 open NHS referrals for ADHD assessment, and over 60% of adults and children had waited more than a year.[4] A private assessment costs a four-figure sum. Those who can pay leave the queue; those who cannot stay in it. Right to Choose was meant to narrow this gap, but it is now the referral route that many GPs are being advised to warn patients away from. The second tier is treatment. A national survey of health professionals found that GP practices reported prescribing ADHD medication for 90% of patients with an NHS diagnosis but only 49% of those diagnosed privately.[5] The 2025 UK LMC Conference resolved that any shared care arrangement with a private provider "is unsafe, not enduring, and widens health inequalities," and refusal of new shared care formed part of BMA collective action in 2026.[6] Fisher and Frith ask clinicians to push back against the expansion of diagnosis. In primary care, that push-back is already happening, and it does not fall on providers; it falls on patients. Nor does it fall evenly. A patient with means can pay for an assessment and then pay a private prescriber indefinitely. A patient who scraped together the assessment fee cannot, and ends up with a diagnosis that opens no door. A patient with neither waits years. The result is a three-tier system: diagnosis and continuing treatment for the affluent, a diagnosis without treatment for those in the middle, and a waiting list for the group in which prevalence has always been highest. Area-level data already show deprivation and ethnicity shaping where ADHD prescribing has risen fastest in England.[7] Concluding that the whole increase reflects marketing, rather than examining who is being left out of it, risks a policy response that tightens the gate precisely where need is greatest. The authors' remedies—CQC regulation and curbs on advertising—are sound but incomplete. Three additions would protect equity rather than erode it. First, a single assessment standard applied to NHS and private providers alike, so that a diagnosis meeting that standard is portable regardless of who made it and cannot be refused on provenance alone. Second, NHS England should publish ADHD and autism diagnosis and prescribing rates by deprivation decile as a routine equity indicator, so that the social gradient can be watched as it shifts. Third, funded shared care, so that the decision to treat does not depend on a practice's willingness to absorb unpaid work. Private providers may well be profiting. But the people paying most are not those buying assessments. They are the ones who cannot. References 1. Fisher N, Frith U. Private providers are profiting from the expansion of ADHD and autism diagnosis. BMJ 2026;395:e101196. doi:10.1136/bmj-2026-101196 2. Russell G, Ford T, Rosenberg R, Kelly S. The association of attention deficit hyperactivity disorder with socioeconomic disadvantage: alternative explanations and evidence. J Child Psychol Psychiatry 2014;55:436-45. doi:10.1111/jcpp.12170 3. Roman-Urrestarazu A, van Kessel R, Allison C, Matthews FE, Brayne C, Baron-Cohen S. Association of race/ethnicity and social disadvantage with autism prevalence in 7 million school children in England. JAMA Pediatr 2021;175:e210054. doi:10.1001/jamapediatrics.2021.0054 4..House of Commons Library. ADHD statistics (England). December 2025. https://commonslibrary.parliament.uk/faq-adhd-statistics-england/ 5. Price A, Smith JR, Mughal F, et al. Support for primary care prescribing for adult ADHD in England: national survey. Br J Gen Pract 2024. doi:10.3399/BJGP.2023.0595 6. North West London LMCs. Guidance for practices: Right to Choose and shared care. 2026. https://nwlmcs.org/files/download/documents/Guidance%20for%20Practices%2... 7. Alshahrani A, et al. Socioeconomic status and prescribing of ADHD medications: a study of ICB-level data in England. BMJ Ment Health 2025;28:e301384. doi:10.1136/bmjment-2024-301384 No competing Interests: Yes The following competing Interests: Electronic Publication Date: Friday, November 6, 2026 - 15:50 AI use: No, I have not used AI Highwire Comment Subject: Workflow State: Released Full Title: Private providers are profiting from the expansion of ADHD and autism diagnosis The private market is reversing the social gradient of diagnosis Highwire Comment Response to: Check this box if you would like your letter to appear anonymously:: Last Name: Song First name and middle initial: Zhenyu Email: szheny@swmu.edu.cn Address: No. 182, Chunhui Road, Longmata District, Luzhou City, Sichuan Province Occupation: Medical Doctor Other Authors: Yanyan Zhang Affiliation: Department of Radiology, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University BMJ: Additional Article Info: Rapid response

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