How nurses are rethinking ADHD care in the NHS
The revolutionary ADHD care pathway redesign at North Staffordshire Child and Adolescent Mental Health Services (CAMHS) has helped forge a new pathway using QbTest that is evidence-based and utilizes the role of nurse practitioners to support caseloads. This has helped save clinicians time and improve the quality of care patients receive.
Those involved in the redesign include:
- Rachel Bullock, advanced clinical practitioner and independent nurse prescriber
- Sue Ford, RMN, BSc independent nurse prescriber and ADHD lead North Staffordshire community CAHMs
- Ann Cox, nurse consultant, clinical academic, MPFT
The challenge at North Staffordshire CAHMS
Ann Cox Previously, there was little capacity in any of the nurse or medic teams – we were struggling to get patients through the various care pathways. What we found was that children with ADHD were the biggest weight on our caseload because there was no formalised pathway.
At the time, the whole process was medic-led which meant we were reliant on a consultant psychiatrist at the end to make a diagnostic decision. Patients were waiting approximately 18 months and sometimes longer to reach a diagnostic decision which created a bottleneck. We wanted to release some of that medic time by restructuring the ADHD care pathway.
We had a mixture of ideas and ways to do ADHD assessments. We had some children that would only have had a Conners Rating Scale completed (or it was out of date), sometimes there was no neurodevelopmental assessment, or a school observation had been completed but was now out-of-date because they’d been on the waiting list for so long.
I’d previously introduced and used QbTest at Derbyshire CAMHS and so it made it easier to evaluate it for use in our current ADHD care pathway. Having an objective measure is far more helpful to explain ADHD symptoms to parents and families than just having a subjective assessment.
Realigning caseloads to roles
Ann Cox It was the perfect storm in terms of us being able to change this pathway. A fundamental challenge was realigning caseloads to roles, ensuring children were being seen by the right practitioner. Our team of psychiatrists had a lot of ADHD cases that were settled and were stable on or off medication, that could have been moved to nurse prescribers like us.
We took on that challenge, to take these cases off the psychiatrists’ caseload – to allow them to have the capacity to deal with the mental health presentations that were more severe, enduring, and risky. These were children that would have otherwise had to have waited for care due to the backlog of ADHD cases.
Adding objective data to the ADHD care pathway
Since adopting QbTest, the 18 month waiting lists are now 12 weeks. The team are now able to provide an ADHD diagnosis and initiate medication and titrate. That would normally be costed to a consultant psychiatrist – now it is less expensive with their team of nurse prescribers who can do it. Secondly, the cost of the prescription now sits with the GP.
Their new pathway is evidence-based – they’re no longer reliant solely on questionnaires and seeing the child for 20 minutes to come to a conclusion.
In their previous way of working, some children were stable on an ADHD medication on the same dose for over two years in some cases and were seeing a psychiatrist every month.
The team were concerned about the message that gave to a young person that they needed to come into a mental health service to see a psychiatrist every month as well as the unnecessary use of resources and clinical time. The only patients that now go to a psychiatrist for diagnosis are complex.
Relationship with primary care
Sue Ford Our relationship with primary care has developed significantly. We made an offer on the shared care plan that if there were six or more patients at any one GP surgery, we would go out and run a dedicated clinic at the GP surgery.
We also connect with South Stoke CAMHS, linking them with the primary care centres and pharmacists, which helps ensure that each child is getting the relevant monitoring that they need in order for the GPs to continue to prescribe.
Rachel Bullock Having those relationships with pharmacists in the primary care networks has been helpful and I think it’s giving GPs more confidence too, that we’re working together to try and make sure that we can keep patients where they need to be.
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