When NHS services commission external support for neurodevelopmental (ND) pathways, one question comes up more than any other: what happens with complex cases?
This is a reasonable concern. ADHD and Autism frequently co-occur and this combined presentation (AuDHD) can present differently. Alongside this, complexity may arise from previous adverse childhood experiences (ACEs), trauma related presentation and several other differential factors. External providers are not always equipped to manage this complexity. When a provider reaches the limits of what they can deliver, cases get returned. The individual goes back to the beginning, the wait starts again, and the pressure lands on your team.
This is not an edge case. It is one of the most common ways that an external ND partnership fails to deliver on its promise.
At Healios, our approach to this is built around a collaborative multidisciplinary team of highly experienced, registered clinicians. Here is what that looks like in practice, and what it means for the people on your waiting list.
Why complex ND cases get returned
The volume of referrals into NHS neurodevelopmental services has grown dramatically. Some services are now receiving more than 260 referrals a month, far exceeding their capacity, with waiting times in some areas exceeding six years. In that context, bringing in external support is a necessity, not a preference.
But external support only helps if it can actually absorb the cases being referred and offer meaningful support to families. Many providers operate with a narrow clinical scope. They can manage straightforward presentations, but when someone presents with co-occurring conditions, anxiety, emotional dysregulation, risk or a profile that does not fit neatly into a single diagnostic category, the case is returned to the local team.
The treatment approach for someone with ADHD and/or autism differs significantly when they also have an anxiety disorder, for example, and comorbidities can exacerbate symptoms and impair functioning in ways that require a comprehensive treatment plan addressing all presenting needs simultaneously. A provider without the clinical range to do that cannot formulate and conclude those assessments.
“The cases that get returned most often are not the most severe. They are the ones that don’t fit a single category. Someone with ADHD and anxiety, or autism and emotional dysregulation, needs a team around them, not a single clinician making decisions in isolation.”
Charlotte Clee, Head of Assessment Services, Healios
What a collaborative MDT makes possible
At Healios, complex cases are supported by a multidisciplinary team rather than a single clinician working in isolation. When a case requires input beyond the initial clinicians, that resource exists within the same service, with clear processes for how and when it is brought in.
This matters for several reasons.
Firstly, it means fewer cases need to be returned to the local team. The clinical range of an MDT covers presentations that a single-discipline provider cannot manage alone. Someone with co-occurring conditions, or with emotional and behavioural needs sitting alongside their neurodevelopmental profile, can continue to be supported within the pathway rather than being returned to your team.
Second, it means clinical risk is managed more robustly. NHS England guidance on neighbourhood MDT models reflects the same principle: complex cases benefit from regular team discussion and the ability to bring in additional clinical perspectives at any point, not just at referral. Our MDT operates on that basis. Cases can be brought for discussion whenever a clinician identifies a need for additional input, with experienced senior clinicians and Clinical Leads contributing and supporting, alongside robust clinical supervision.
Most importantly, this approach creates better outcomes for individuals and their families. When the clinical team around someone can communicate and coordinate, care feels more joined up. The individual and their family experience continuity rather than fragmentation.
“When our MDT discusses a complex case, the young person benefits from the combined thinking of everyone in that room. That is what keeps cases moving and what stops families being told to start again somewhere else.”
Charlotte Clee, Head of Assessment Services, Healios
What this means for your waiting list
Every case that gets returned by an external provider creates work and additional stress for the client/family. The case has to be triaged again, allocated again, and the young person has to re-engage with a process they may already have found difficult. For a service already managing significant demand, that is a cost you cannot afford.
A provider with a genuine MDT model reduces that risk significantly. Cases that would otherwise return are kept moving. Clinical capacity is used more efficiently. And the people who most need support, those with the most complex presentations, are not the ones who fall through the gaps.
The question worth asking
When you are evaluating an external ND provider, ask directly: what happens when a case is more complex than expected? Who gets involved? How quickly? What is the process? Do they have a robust safeguarding team and adequate senior clinical input?
Good answers are specific. They describe a functioning team and a clear process, not a general commitment to quality.
That is the standard a collaborative MDT should be held to. And it is the standard we work to meet in every NHS partnership we enter.
If you would like to understand more about how Healios supports complex ND cases, or to discuss what that might look like for your service, we would welcome a conversation.