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19-21 Broad Street | St Helier Jersey | JE2 3RR
Deputy Doublet
Chair, Health and Social Security Scrutiny Panel BY EMAIL
03 September 2024
Dear Chair,
Re: Review of Prescription of Medication for ADHD
Thank you for your request for evidence in relation to the above review. Please find below my response to your questions.
- At our public hearings on both 14th March and 6th June of this year, you informed us that discussions were being had around closing the waiting list for ADHD diagnosis due to the number of people waiting to be seen. Has any decision been made on this?
No decision has been made to close the waiting list for (adult) ADHD diagnosis. This action was being considered - and has been implemented by various services both public and private in other jurisdictions – as a result of the ever-growing waiting list and associated length of wait. However, on reflection – and partially in response to feedback - we concluded that we should fully undertake the work looking at the current waiting list and potential actions to reduce this (see below) before further considering this option.
- We note that the number of people waiting to be seen increased from 736 in March to 817 in June with an additional 140 children waiting to transition. Can you confirm the numbers as of today?
As at the end of August, the number of adults on the ADHD assessment waiting list is 778.
This number has reduced from 817 in June because of the work that is being undertaken on the waiting list. The number of children & young people waiting to transition into adult services remains the same.
- At our public hearing on 6th June, you informed us that you had successfully recruited a very senior and experienced nurse 2 days a week' who would look to review the waiting list. Has this recruitment made an impact on the waiting list? Could you also give an update on the recruitment status overall?
Yes, as described above this work has been focussing on reviewing and cleansing the waiting list.
The senior nurse, who has specific expertise in this area, is seconded from the education department on a part time basis and this arrangement is working well. We are now exploring the potential to further enhance the on-going use of the senior nurse – for example, by supporting her to train as a non-medical prescriber.
What else is being done to help alleviate the level of demand vs the capacity available?
In addition to the review of the waiting list, there are several other actions that are being implemented and/ or explored to alleviate the current demand. These include:
• The introduction of a new self-assessment questionnaire as part of the pre-diagnostic assessment pathway. This will help with the diagnostic assessment, potentially reducing time and also ensuring higher quality patient reported information.
• A further capacity and demand review being led by the Clinical Lead for mental health services
• Planned implementation of ADHD training for staff across mental health services, to support with initial mental health screening and potentially reduce unnecessary referral for ADHD assessment
• The planned implementation of a programme of psychological support interventions for people on the waiting list (this will be in place by the end of November)
• Current discussion with a potential private provider partner, who has expressed an interest in developing both an assessment and prescribing service on island. This is at an early stage, but alleviates the concerns that have existed to date around outsourcing only the ADHD assessments to a private provider which would then result in an increased (and potentially unmanageable) repeat prescribing demand.
• On-going discussions with primary care colleagues regarding the potential for shared
care prescribing.
In addition, we have been approached by a potential private partner to explore the use of a pilot electronic self-assessment that is being used elsewhere, which again may significantly reduce inappropriate referral and support diagnostic assessment but is also linked to associated on-line resources for the patient around self-help. This is a very recent approach and is currently being considered / discussed.
- We note that medication can only be prescribed by a specialist which is causing a huge backlog and adding to the waiting times for medication. At our public hearing on 14th March, you informed us that the Primary Care Board was due to meet to discuss delegation of this responsibility to GP's. Could you provide an update to this?
Various on-going discussions have been held with Primary Care partners in relation to potential shared care arrangements. Draft shared care protocols have been developed, and the Pharmaceutical Benefit Advisory Committee (PBAC) have met to consider the inclusion of ADHD medication on the Prescribed List. However, whilst PBAC were supportive of this in principle, they were unable to recommend this until the international shortages of these medicines is resolved, and agreement has been reached on the shared care protocols / ADHD pathway. This was discussed recently again at the joint meeting between HCS and the Primary Care Board representatives in August; there appears to be some ongoing clinical disagreement (including amongst GPs) about the way forward for shared care, which we have committed to seek to resolve.
- We are aware from various sources that there is a global shortage of ADHD
medication due to increased global demand and manufacturing problems. How has this impacted upon Jersey, if at all, and what is being done to mitigate this problem?
The global shortage of ADHD products, initially identified in a National Patient Safety Alert in 2023, results from a variety of factors – with manufacturing issues and the rapid rise in demand being the most significant.
Jersey obtains medicines from the UK supply chain for a number of reasons, including compliance with appropriate regulatory controls to ensure patient safety. This means that we are subject to the same shortages as are faced by the UK.
Prescribing available medicines to treat ADHD contains an overview of the current supply position and is regularly updated as the national stock situation continues to evolve.
The impact in Jersey has been similar to the impacts across the UK and other parts of the world. The shortage has meant that over the last 12 months we have been unable to initiate some new patients onto ADHD treatments, both for some specific medicines or where that additional demand would otherwise mean that current patients would not be able to continue their treatment. It remains the case that we cannot initiate new patients on some products, such as modified release methylphenidate tablets.
However, close and on-going collaboration between Jersey CAMHS/ adult mental health prescribers and the hospital pharmacy - particularly our medicines information pharmacist and our pharmacy procurement manager - has minimised that impact. There has also been intensive work between pharmacy and prescribers to modify prescriptions to ensure that patients can continue intended treatment. This has occasionally required changes to alternative products, requiring re-titration to maintain treatment effect. This work continues, as the shortages of products continues and is likely to remain a problem for some months yet. Finally, to maintain supplies for those who need it, all ADHD prescriptions are limited to 1 month treatment at a time.
- As part of our evidence gathering, we have received a number of written submissions from members of the public on the waiting list who have little choice other than to seek private care. We note that funding for ADHD comes from the budget of Health and Community Services as opposed to the Health Insurance Fund (HIF) (which is managed by the Minister for Social Security). If this method of funding were to change, could the cost of private care appointments and/or medication be subsidised by Government for those on a waiting list for assessment of a condition?
There have been no plans developed to subsidise the cost of private care (consultation or prescribing). This would not be consistent with the planned use of the HIF, and would potentially further contribute to (or widen) health inequalities – as well as potentially setting a precent across other areas of HCS.
- Could you provide a list of ADHD medications and the cost of each under private prescription?
The Deputy Medical Director is currently leading a review of charges for Private Patient Prescriptions.
The cost of a private patient prescription will depend on where it is dispensed - there is no 
set tariff across community pharmacies. Hospital policy currently states BNF price plus 25%, with a minimum charge of £7.50 applied.
The actual cost of treatment will vary depending on the combination of tablets required to achieve the treatment dose, and, resulting from the supply issues, variation in costs applied by suppliers. This may cause purchase costs to rise above standard BNF costs
Items available on the hospital formulary can be found here
I hope that this information is of use to the Panel. Please do not hesitate to contact me should you require any clarification or any further information.
Yours sincerely,
Deputy Tom Binet
Minister for Health and Social Services E t.binet@gov.je