The waiting list is often described as if it were the problem itself: a long queue that simply needs to move faster. The independent review published by the government on Friday 9 October offers a more uncomfortable diagnosis of the system. Many people wait too long for an assessment, then discover that help was organised around obtaining a label when some support could have begun much earlier. Others need specialist diagnosis and treatment but struggle to reach it.
The review of mental health conditions, ADHD and autism, chaired by clinical psychologist Professor Peter Fonagy, calls for a “needs-led plus diagnosis” approach. That distinction matters. Its authors do not propose abolishing diagnosis or treating autism and ADHD as interchangeable with ordinary stress. They say support at school, work and in the community should respond to a person's difficulties while a clinical assessment remains available when it is needed. The government says a fuller response will come in a mental health strategy in the coming months.
What the report actually found
The report separates mental ill health from neurodevelopmental conditions. It says common mental health conditions have become substantially more prevalent, especially among young people. The share of 16-to-24-year-olds meeting criteria for a common mental disorder rose from about one in six in 1993 to one in four in 2024, according to the data it cites. That is a real rise in distress, the authors say, rather than awareness alone creating an illusion.
ADHD and autism present a different evidence problem. Recorded diagnoses and assessment referrals have climbed sharply, but the report says population prevalence appears broadly stable or may have risen modestly. It also stresses the weakness of the available estimates: England lacks current population surveys that could give a confident answer, particularly for adults. A rise in recorded cases therefore cannot be read as proof that the underlying conditions have suddenly become vastly more common. Nor is it proof that people seeking help are inventing difficulties.
For ADHD, monthly assessment referrals rose from roughly 5,000 in 2019 to 17,000 in 2024, the review says. Open referrals exceeded 560,000 by the end of 2025. For autism, it records more than 254,000 open referrals in December 2025, with more than 90% waiting over 13 weeks. These are people in different pathways, so the numbers should not be bundled into a claim about one identical queue. Together, they show demand running well beyond what the current arrangement can handle.
The review discusses underdiagnosis, misdiagnosis and overdiagnosis. It is explicit that the available figures do not establish overdiagnosis at scale. Historic failures to recognise ADHD and autism in girls and women are part of the picture. Better recognition can bring previously missed people into view, even while providers still need robust assessment standards. A headline that reduces the whole report to “too many diagnoses” misses its central finding: there are people with real needs waiting for help, and the system makes too much of that help conditional on a diagnostic decision.
What “support before diagnosis” could mean
In practical terms, a pupil struggling to participate at school may need an adjustment, a trusted adult or targeted support while an assessment is pending. An adult may need help to stay in work or manage day-to-day difficulties before a clinic has settled the clinical question. The review argues that support should follow functional needs before, during and after assessment. It also says diagnosis remains essential for many people, including when it guides treatment or access to medication.
That is an appealing principle, but Friday's publication is a report and a government pledge, not a new service that every family can book this morning. Ministers say they want more early help in schools and communities and have asked NHS leaders to examine easier access to advice, assessment and treatment. The government also points to existing spending and school support programmes. Whether people actually feel a difference will depend on local staff, capacity, clear eligibility rules and whether support is still available after a diagnosis. The paperwork cannot comfort somebody who is still being passed between services.
The review asks policymakers to measure more than completed assessments and shorter lists. A person may leave one queue and enter another without gaining help. The proposed test is whether people can participate more fully in education, work, family and community life. That does not make clinical outcomes irrelevant. It forces services to ask whether a referral led to a useful change rather than a tidier spreadsheet.
The private assessment question
The government also wants stronger oversight of ADHD and autism assessments, including work towards making diagnostic assessments subject to Care Quality Commission regulation whether patients are NHS-funded or pay privately. It plans to examine advertising practices, and NHS England intends to consult on a national tariff for NHS-funded assessment and follow-up. Those are proposals and intended actions. A tariff has not already taken effect because a press release mentioned one.
There is a genuine tension here. Independent providers can add capacity when NHS waits are unacceptable, but inconsistent commissioning and quality control can leave patients unsure what will happen after an assessment. The answer cannot be to assume every private diagnosis is suspect, or to presume that paying for one guarantees comprehensive care. Standards, follow-up and information for patients matter as much as the speed of an appointment. The government's stated aim is to make assessment reliable across providers and ensure public money buys appropriate care.
The National Autistic Society published a response on 9 October. Its involvement is a reminder that any redesign needs the people using these services, including those with high support needs, at the table. The review itself warns that better recognition must not make people who need intensive lifelong support less visible. A broad needs-led offer will only be a gain if specialist pathways remain reachable and properly staffed.
For readers following wider NHS changes, OutOut's earlier report on the government's medical-AI safety blueprint shows a similar gap between accepting recommendations and making them work inside services. In this case, the next milestones are the promised mental health strategy, the detail of CQC regulation and the NHS tariff consultation. The question for families will be simpler: can somebody get useful help before a years-long wait has done more damage?
The OutOut verdict
Britain has developed a peculiar customer journey for distress: join a queue to prove why you should have been helped sooner. Fonagy's review identifies that trap without pretending a diagnosis is disposable. Ministers now have a chance to open more doors to support, protect specialist care and test assessments to consistent standards. The roast can wait until the delivery plan arrives. A promise to shorten a queue is easy to applaud; the harder achievement is making sure there is care at the other end of it.
