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The Minister of State, Department of Health (Mr Simon Burns)
I congratulate the right hon. Member for Wolverhampton South East (Mr McFadden) on introducing a particularly interesting and sensitive subject. He made his points very fairly and very well. In passing, I should, I suppose, declare an interest because a member of my family has for a number of years been on Ritalin and, contrary to the observations of the hon. Member for Newport West (Paul Flynn), the benefits to that person’s education have been immense—the decision was taken on clinical advice, not on the advice of parents.
I am pleased that the right hon. Gentleman has welcomed the announcement by the Minister with responsibility for social care, my hon. Friend the Member for Sutton and Cheam (Paul Burstow), of £32 million to help with children’s mental health. The right hon. Gentleman asked whether that was new money. It comes from within the £400 million that was identified by the Treasury in the spending review last year.
The right hon. Member for Birkenhead (Mr Field) asked about the link between disability allowance, and other entitlements, and children on Ritalin. The entitlement is based not on having a specific health condition diagnosis or treatment, but on what help is needed with personal care as a result of the disability. Nevertheless, I will certainly draw his comments to the attention of my right hon. Friend the Secretary of State for Work and Pensions, whose Department will hopefully get back to him.
Let me set out some of the background to this issue. According to NICE, between 3% and 9% of school-aged children and young people in the UK meet the broad criteria for mild to moderate attention deficit and hyperactivity disorder, and between 1% and 2% suffer from severe ADHD. Methylphenidate, commonly known as Ritalin, and similar drugs are used to treat a range of mental health conditions, including ADHD. The NICE guidelines, published in 2008, recommend that medication should always form part of a holistic package of care, which might include talking therapies. I fully appreciate the concerns raised by the right hon. Member for Wolverhampton South East about the increase in the number of prescriptions for Ritalin and similar drugs. We need better to understand the reason for that. It is always wrong for doctors to prescribe medication inappropriately, and medication should not be the sole response to an individual’s condition.
I fully appreciate the concerns of those worried about the growth in prescriptions for Ritalin. We do, however, need to acknowledge the fact that too many young people and their families are not getting the support they need. The NICE clinical guidelines on ADHD said, at the time of their publication in 2008, that a minority—fewer than 50%—of all individuals who should be receiving medication and/or specialist care were in receipt of such care. If left untreated, mental health problems can lead to low attainment in school, antisocial behaviour, drink and drug misuse, worklessness and even criminality in adult life. Getting things right for children and their families—through a broad range of support to promote good mental health from the start of life, through the school years and into adulthood—can make a real difference to young lives.
The costs of doing nothing are simply too great. Across hospital and primary care, the prescribing of drugs for ADHD increased by around 12.5% between 2007 and 2010, the latest four years for which data are available, and by around 6% in 2010 alone. Prescribing in primary care alone increased by 22% in that four-year period, reflecting a significant shift in prescribing activity from a hospital setting and into primary care. Looking back further, one sees that prescribing in primary care has tripled in the past 10 years. Some variation in the prescribing of ADHD drugs around the country must be expected in the light of the distribution of specialist services, which might be more likely both to diagnose children with ADHD and to support GPs in taking responsibility from hospital teams for repeat prescriptions; the different local patterns of prescribing across primary care and specialist settings; and demographic factors, such as deprivation, which might be correlated with ADHD.
We do not, however, have good-quality data on the number of children and young people assessed with ADHD, against which prescribing patterns could be compared. If we had, it would be possible to gain a true measure of variations in clinical practice. Prescribing data are not routinely collected by age, but we do need better to understand the position. In the shorter term, we are investigating whether further helpful information can be derived from prescribing research databases. As a result, the data we do have must be interpreted with care and in the context of all the evidence that suggests under-diagnosis and under-treatment of this distressing behavioural disorder.
Mr McFadden
The point about age is important. The NICE guidelines on children under six could not be clearer. The Minister acknowledges that the Government do not know—I will leave aside whether that is a good state of affairs—how many children are prescribed these drugs. His Department has a research budget, so, rather than trawling other research projects, why can it not commit to research to find out from professionals how many children under six have been prescribed such drugs?
Mr Burns
The right hon. Gentleman anticipates my remarks on the NICE guidelines, and I hope that once he has heard them the situation will be clearer.
The 2008 NICE clinical guidelines on the treatment of ADHD are clear that medication is an appropriate treatment for severe ADHD, but that it should be initiated only by a specialist and should form part of a holistic care package that may include talking therapies. The guidelines do not recommend drug treatment for pre-school children, and health care professionals are expected to take the guidelines fully into account when exercising their clinical judgment. They do, however, have the right to prescribe the drugs if they feel it is clinically justified and in keeping with specialist consensus, given the individual circumstances of the child and in consultation with the parent or guardian. Such prescribing can include so-called off licence prescriptions, which means a prescription of medication outside its licensed age indications.
The right hon. Gentleman has asked the Department of Health to conduct a review of the prescription of drugs for the treatment of ADHD, working with families, teachers, medical and mental health professionals. It is, however, for NICE, as an independent organisation, and not for the Department of Health, to review the evidence and to provide national clinical guidance. Between 30 August and 12 September, NICE consulted stakeholders on whether to update its 2008 clinical guidelines. The review is a thorough assessment of the ways in which evidence on ADHD, including pharmacological treatments, has since developed. It will announce a final decision on its review shortly.
In June 2007, the UK led a European review of the risks and benefits of Ritalin and sought advice from independent scientific advisory groups on the available evidence. As a result of that review, the prescribing guidance for patients has been updated to ensure that it contains clear, comprehensive information about the effects of Ritalin and the importance of monitoring children and adolescents throughout their treatment. The safety of Ritalin remains under close review. In addition, the findings of research continue to inform the field and a number of bodies may commission such research, including the National Institute for Health Research. The Government are committed to improving mental health outcomes and have laid down important principles for the future in the strategy, “No health without mental health”, published earlier this year.
The emotional well-being and mental health of children and young people are vital to them as individuals, to their families and to wider society. A principle of the Government's mental health outcomes strategy is the importance of prevention and early evidence-based intervention. Half of those with lifelong mental health problems first experience symptoms before the age of 14, and three quarters of them before their mid-20s. Indeed, today, the Minister with responsibility for social care, my hon. Friend the Member for Sutton and Cheam, has announced £32 million of funding to improve access to psychological therapies for children and young people over the next four years.
Psychological therapies can in some cases form part of the holistic package of care that NICE recommended for children and young people with ADHD. It is important that a range of clinicians—paediatricians and GPs as well as child and adolescent mental health service professionals—are well informed on the diagnosis and treatment of mental health problems in children and young people. I am pleased to tell the right hon. Gentleman that the chief medical officer and the NHS medical director plan to write to clinicians to remind them of the full range of NICE guidelines on conditions—including ADHD—that affect children's mental health. They will highlight the opportunities to support rigorous use of evidence-based treatment through the improving access to psychological therapies programme. High-quality, evidence-based treatment is central to our programme to transform mental health services for children.
The right hon. Gentleman referred to DSM-V. This point goes much wider than ADHD alone and touches on the appropriateness of diagnostic categories that are the subject of international professional consensus through the American Psychiatric Association and through the World Health Organisation. The Association of Educational Psychologists and other concerned professional organisations might wish to make their representations on this issue through the American Psychiatric Association and the World Health Organisation.
The right hon. Gentleman asked what the Government’s response would be, but it is not the responsibility of the Department of Health to respond. The professional bodies respond and reach a broad, scientific consensus on the way forward.
I fully appreciate the concerns of those worried by the increasing number of prescriptions for Ritalin and similar drugs. We are investigating whether further helpful information can be derived from prescribing research databases. It is of course for NICE, not the Department, to review the broader evidence and to consider the case for updating the existing clinical guidelines. That is what it has been doing and we await its conclusion. Furthermore, the NICE clinical guidelines on ADHD state that drug treatment for children and young people with ADHD
“should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.”
The NICE guidelines do not replace the clinical judgment needed to treat individual cases, but health care professionals are expected to consider fully the guidelines alongside professional consensus when exercising their clinical judgment.