This week the BBC released a panorama episode entitled ‘Private ADHD Clinics Exposed’, in which it went undercover to find that three private clinics in the UK are giving out ADHD prescriptions based on a short and potentially unreliable online assessment delivered by a non-psychiatrist. Is there a wider issue that there is a perverse incentive in private health care to over diagnose and over prescribe?
Lawyers for one of the three clinics featured in the episode say that ADHD is “under-identified, under-diagnosed and under-treated,” and that it has “no incentive (…) to over diagnose”.
But is that true generally? It is true that private clinics and private clinicians who are not selling medication are not getting paid per prescription or diagnosis they hand out, but the fact that these clinics are diagnosing the vast majority of those that come to them based on a short and one could therefore assume potentially unreliable assessment does suggest they have some bias in favour of doing so. And given that there are many people who don’t have ADHD who take drugs such as Ritalin to help them concentrate, an obvious explanation for why that might be is that they see these people as potential customers.
Is this fair? Dr. Michelle Tempest, partner at UK-based health care consultancy Candesic, cautions that for some conditions there is genuine uncertainty over when exactly someone should be diagnosed and prescribed, and that it’s the job of regulators to figure that out, which can take time.
“For some conditions there is no black and white. Even for cardiology in America they used to do far more PCIs (percutaneous coronary interventions) than in the UK. It took years of real world evidence and longitudinal data to better understand that PCI was not always the best first line option. As health care develops there always are these grey areas. You have to rely on professional integrity and collect data over time.”
Where there is genuine uncertainty, a bias in favour of under-prescribing can also be a problem. An interesting example is medicinal cannabis, which doctors have been allowed to prescribe in the UK since 2018. But to date, hardly any prescriptions have been handed out by NHS doctors, despite there being solid evidence that it can help symptoms for people who have chronic pain, multiple sclerosis or chemotherapy-induced nausea and vomiting.
With cannabis being the most popular illegal recreational drug in the world, there is clearly a risk of medicinal cannabis prescriptions being abused, and private clinics profiteering from this. This can be clearly seen in the US states which have legalised medicinal but not recreational cannabis. Perhaps NHS clinicians in the UK are right to err on the side of caution.
But if being too cautious means that even most people who do actually have a medical need for it not getting prescribed, that is clearly also an issue. And if private clinics are willing to step in and take on the risk, reputational or otherwise, of prescribing to these patients, that can also be a good thing.
“With cannabis and ketamine, a GP is probably not going to be prescribing it every day,” says Tempest. “But you have start-up companies like Clerkenwell Health, which have been set up to help expedite trials into this sector. A clinic which is a specialist in cannabis is much more likely to prescribe it. They have their own data to back up what they’re doing.”
Ultimately, it is up to regulators to clarify when exactly someone should be diagnosed with a particular condition and prescribed a particular medicine. The problem is they often have to do this before the medical and scientific community has reached a solid level of consensus and certainty on an issue. And where there is uncertainty, there is always room for bias to come into play.
Might there instead be a way to remove any potential perverse incentive that would bias private clinicians towards over diagnosing and prescribing? It’s hard to see how, short of banning private health care entirely. For-profit companies have an incentive to give their customers what they want, and sometimes what patients want is a particular diagnosis or prescription.
But perhaps it’s less of an issue in health care systems where private providers are more embedded into the wider system. In countries which have Bismarckian systems, such as Germany, there isn’t a clear distinction in the outpatient sector between public and private provision: all or almost all outpatient clinics and clinicians are effectively private.
This contrasts with the UK, where you have the default option of the NHS, which is expected to always be held to the highest standards despite its tight budget, and a small and more free-wheeling private sector that is seen as peripheral and often doesn’t receive the same level of scrutiny. This is perhaps the real issue.We would welcome your thoughts on this story. Email your views to Martin De Benito Gellner or call 0207 183 3779.