ADHD: Risks of Online Clinics & Calls for Physical Health Checks

The increasing demand for ADHD diagnoses in England is colliding with concerns about patient safety, as doctors warn that some private clinics are prescribing powerful stimulant medications without adequate physical examinations. The issue, particularly acute in Greater Manchester, has prompted health authorities to overhaul prescribing rules and mandate face-to-face checks for children seeking treatment.

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition typically diagnosed in childhood, characterized by inattention, hyperactivity, and impulsivity. While medication, such as methylphenidate (commonly known as Ritalin), can be effective in managing symptoms, it’s crucial that children undergo a thorough medical evaluation before starting treatment. Stimulants can affect blood pressure and heart rate, and underlying cardiovascular conditions need to be identified beforehand.

Remote Assessments and Rising Clinical Risk

A surge in video-only consultations, fueled by long NHS waiting lists and the “Right to Choose” scheme allowing patients to access private care funded by the National Health Service, is at the heart of the problem. Rashad Nawaz, a consultant paediatrician in Manchester and Liverpool, has raised serious concerns about the practice of diagnosing and medicating children with ADHD solely through video links. He recently wrote to national regulators and health bodies detailing cases of young patients with potential heart conditions who were prescribed stimulants without any in-person assessment.

Dr. Nawaz highlighted the case of one child diagnosed with a ventricular septal defect (VSD), or a hole in the heart, after already being prescribed ADHD medication by a national online provider. He identified three children in the past year with previously unknown heart murmurs, one of whom was already medicated. “None of them had symptoms, but the one with a VSD may do in the future,” Nawaz said. He described the lack of thorough physical assessments as “serious clinical risk and negligent.”

The National Institute for Health and Care Excellence (NICE) guidelines clearly state that a full physical assessment, including a cardiovascular history and a physical examination of the heart, is mandatory before initiating ADHD treatment. However, some private providers appear to be circumventing these guidelines, relying on minimal information – often just blood pressure and weight provided by parents – and a simple health check tick list, rather than a comprehensive physical exam. The Guardian reports that many of these providers do not conduct face-to-face consultations at all.

Greater Manchester’s Response and the ‘Right to Choose’ Scheme

In response to these growing concerns, NHS Greater Manchester has implemented a new “safety first” pathway. Prof. Manisha Kumar, the region’s chief medical officer, emphasized that “children’s safety has to come first.” The new system requires face-to-face assessments and physical health checks before any ADHD medication is prescribed, effectively barring providers from initiating treatment in the region without demonstrating a robust in-person clinical assessment.

The situation is complicated by the “Right to Choose” scheme, which allows NHS patients to opt for private care if waiting times for NHS services are excessive. While intended to improve access, the scheme has inadvertently created a market for private providers, some of whom may lack the necessary infrastructure and expertise to ensure patient safety. Senior clinicians, like Prof. Marios Adamou, an NHS psychiatrist, argue that this reliance on online-only providers has created a “dangerous clinical vacuum.”

Adamou also points out the burden placed on local GPs, who are frequently asked to perform health checks or even initiate treatment on behalf of private services, despite the prescribing clinician retaining full legal and clinical responsibility. This puts GPs in a difficult position, potentially compromising their professional judgment and increasing their liability.

Deskilling and the Need for Paediatric Expertise

Beyond the lack of physical assessments, Dr. Nawaz also warned of a “deskilling” of the workforce, with health professionals trained primarily in adult care increasingly involved in the medical treatment of children. He cited instances of children being prescribed medication via video link despite a family history of congenital heart disease – a critical detail that was absent from the private provider’s report. This highlights the importance of specialized paediatric expertise in diagnosing and managing ADHD in children.

While a University of Southampton study suggests the benefits of ADHD medication outweigh the impact of increases in blood pressure and heart rate, this does not negate the need for careful screening and monitoring. The study itself acknowledges the importance of identifying and managing potential cardiovascular risks.

Addressing the Growing Demand for ADHD Assessments

The current crisis is unfolding against a backdrop of rising demand for ADHD assessments. Greater Manchester Integrated Care reports that waiting lists are expected to exceed 25,000 people without changes to the current system. The organization acknowledges unequal access to services, with the level of support varying depending on location. A public consultation between April and June 2025 revealed significant concerns about long waiting times and the quality of care.

The vision for the future ADHD service in Greater Manchester focuses on faster and fairer access, a wider range of support options (including self-help tools and peer support), and a more sustainable service model capable of managing growing demand within available resources. The changes to ADHD and Autism (ASD) assessments are intended to address these challenges.

What comes next: Ongoing monitoring and service development

The implementation of the new “safety first” pathway in Greater Manchester is a crucial first step, but ongoing monitoring and evaluation will be essential to ensure its effectiveness. Health authorities will need to track the impact of the changes on waiting times, access to care, and patient outcomes. Further research is needed to understand the long-term effects of remote assessments and to develop best practices for delivering safe and effective ADHD care in a rapidly evolving healthcare landscape. The NHS will also need to address the underlying issues driving the demand for private care, such as long waiting lists and limited access to specialist services.