At the end of March, the government published interim findings of his independent review on mental health conditions, ADHD and autism. Reactions were predictably polarized.
For some, the review appeared to confirm fears that ministers were preparing to question the legitimacy of rising diagnoses. Others argued that it showed a system being gamed by those seeking clinical recognition as a route to increased support and welfare provision.
The review, led by clinical psychologist Professor Peter Fonagy, comes at a time when demand for both mental health and neurodevelopmental services has grown beyond what the NHS can comfortably absorb. Waiting lists for autism and ADHD assessments stretch into years in some parts of the country, while referrals to children’s mental health services remain well above pre-pandemic levels.
At the heart of the review is a politically explosive question: why?
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The findings are nuanced enough to frustrate a significant number on both sides of the debate. Fonagy does not argue that the growing diagnoses are illegal. Instead, the report presents a system in which medical knowledge is increasingly the price of accessing any help.
“When support is strongly tied to diagnostic labels, the demand for diagnosis will increase,” Fonagy wrote. “When early on, available help is limited, difficulties escalate.”
One finding is that children and young people are increasingly driven to follow diagnoses to access support. That language was seized by elements of the right-wing press. “The review does not conclude that children are being ‘pushed’ to seek diagnoses,” said Dr Amanda Roestorf, director of research at Autistica, of the more sensational responses. “It highlights that demand is growing in a system where diagnosis is the main route to support. The real issue is that people are waiting too long. Many are left without help for months or years, which can make things worse.”
This creates a chain reaction throughout the health care system. “We are concerned that people are increasingly being diagnosed in educational settings or self-diagnosing because the system that should be there to help them is overwhelmed,” admitted Dr Lade Smith, president of the Royal College.
of Psychiatrists.
“They need to be able to access support that can prevent their condition from deteriorating at much earlier stages from more appropriate social services, as well as assessments and care.”
Demand has increased significantly across many services at once: CAMHS, adult mental health care, autism pathways and ADHD assessment services. NHS waiting lists have struggled to keep pace. Private diagnostic providers have expanded rapidly through right-to-choose pathways. With diagnoses becoming increasingly linked to access, diagnostic services now carry pressures beyond medicine alone.
The review cites the erosion of previous forms of support. Youth services have disappeared from many communities. Educational psychology services are very extensive. Social care systems remain under great pressure. Schools are increasingly expected to manage complex emotional and behavioral needs with shrinking resources.
Under these conditions, clinical diagnosis can begin to function as a form of institutional recognition: proof that one’s difficulties are serious enough to count.
“The key message is that a whole systems approach is required across society – not just the NHS,” said Dr Sameer Jauhar, a clinical associate professor at Imperial College. “While we have encouraged people to talk about distress and mental health, we need to be clearer about what this actually means and how this can be addressed at individual, family, school and community levels.”
Fonagy’s findings suggest that otherwise we risk creating an increasingly medicalized system in which distress, disability and social difficulties are channeled through health care services because other avenues of support are weakened.
“It is positive that the review emphasizes moving to a model that responds to people’s needs, rather than one that is too reliant on diagnosis to unlock support,” said Alexa Knight, director of policy and impact at the Mental Health Foundation. “This should mean that appropriate support can be provided across the spectrum of distress, rather than dividing people into deserving or undeserving or waiting until issues become more acute.”
But headlines about people being “rushed” to seek diagnosis have created palpable tension, even if they don’t fully reflect the spirit of the report’s findings. “We have been concerned from the beginning that this review could fuel the increasingly polarized debate about autism,” admitted Mel Merritt of the National Autistic Society. “Unfortunately, we are now seeing just that. Too much attention is being paid to questioning people’s motivations for seeking a diagnosis, rather than recognizing the very real distress that people and their families experience.”
The politics surrounding the review have heightened that sense of conflict. Ministers have increasingly linked long-term illness and mental illness to economic inactivity and pressures on the welfare system. Critics fear that debates about “overdiagnosis” can easily slide into arguments about benefit dependency or exaggerated disease.
said Wes Streeting when the review begins that the government needed “an evidence-based understanding” of the rise in mental health diagnoses and claims. But the report comes down to a place where trust in public systems is already fragile.
At the same time, NHS clinicians warn that the current model is becoming unsustainable. Mental health services remain under tremendous pressure, particularly for children and young people. The review suggests that failures in early intervention may push more people onto specialist clinical pathways later.
The report does not recommend blanket restrictions on the diagnosis. Instead, its interim findings point towards early intervention, wider community support and less reliance on specialist medical pathways alone. The implication is that many problems that currently come to the NHS acutely could have been managed earlier elsewhere.
This would require investment beyond psychiatric clinics. This would mean rebuilding youth services, improving school support, expanding community mental health provision and reducing the barriers people face before getting help. It would also require a political will to treat mental illness and neurodevelopmental conditions as social and economic issues as much as clinical ones.
What makes Fonagy’s review so politically combustible is that it taps into a deeper anxiety within modern Britain: many people feel that support only emerges once their discomfort has been medicated. Diagnosis has become not only a clinical process, but a path to legitimacy.
Critics of the review fear that ministers may ultimately focus on reducing demand rather than rebuilding support. Its defenders argue that the report is simply describing a system that has become increasingly reactive and crisis-driven. Both sides agree on one thing: the status quo is failing. And this failure is no longer limited to mental health services. It affects schools, workplaces, welfare policy and the wider debate about who gets help in modern Britain – and who is left to struggle without it.
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