Put the ADHD Hand-Off in Writing

October 28, 2026 | The Psychiatric Record | Prescribing

When an independent provider in England diagnoses ADHD and starts medication, the next step is often a request for the patient's GP to take over prescribing. A government-commissioned review found that this step is failing more often. Its conclusion: "Diagnosis can therefore become the beginning of another wait rather than the start of treatment."

England's final report appeared October 9; New South Wales (NSW) announced almost 300 trained GPs on October 21. New South Wales has moved ADHD medication care toward general practice by rule. England's review recommends a similar move, which its government has not adopted.

Continuation prescribers. Since September 1, 2025, GPs who complete a course accepted by the state and receive a general authority can keep prescribing stimulants for patients aged 6 and older who were previously diagnosed and stabilized. They may make minor dose adjustments and switch between formulations of the same drug type, such as immediate to slow release. A switch to a different medicine requires referral to a specialist, and a patient who has stopped medication may be required to see the treating specialist to restart it. The authority does not cover daily doses above 50 mg dexamfetamine, 70 mg lisdexamfetamine or 108 mg methylphenidate, children under 6, or a person who is "drug dependent" as NSW defines the term. These are NSW authority limits, not US labeled maximums or dosing recommendations. Regular review of SafeScript NSW, the state's prescription monitoring system, is a condition of the authority.

Endorsed prescribers. The second stage lets a smaller group of GPs diagnose ADHD and start stimulants in newly diagnosed patients aged 6 and older. To apply, a GP must be a fellow or registrar of one of Australia's two general practice colleges, already be a continuation prescriber, and work in an accredited practice or one working toward accreditation.

This is not every GP. NSW Health said on October 21 that a further 300 GPs are expected to begin training in November, and that GPs "will continue to make specialist referrals, and escalate care, as required," backed by $5.7 million for specialist support. From early 2027, the state will fund up to 2,500 free assessments by endorsed GPs.

Co-management. A third, per-patient route also exists. A GP may prescribe for a previously diagnosed patient of any age "under a formal co-management or transfer of care arrangement with a paediatrician, psychiatrist or neurologist," with individual approval from the state health ministry. It is the closest NSW parallel to a written hand-off between US clinicians who are each already authorized to prescribe.

The endorsed-prescriber competency framework does not publish a list of referral triggers. It does designate as a "red flag" competency a pre-medication assessment covering substance misuse or diversion risk, psychiatric history "(particularly psychosis or mania)," and cardiovascular status. The Royal Australian and New Zealand College of Psychiatrists welcomed the expansion but said specialist capacity must be "built in, not bolted on." It noted that ADHD symptoms "often overlap with various psychiatric conditions," including mood, anxiety, autism spectrum, psychotic, trauma-related and substance use disorders, and said it would like "very clear referral and escalation pathways to psychiatrists."

Queensland opened stimulant initiation to all specialist GPs treating adults. From December 1, 2025, according to Queensland Health, "all specialist GPs will be able to initiate, modify, and continue psychostimulants for adults" with ADHD, "within existing maximum dose limits."

England's review, chaired by Professor Peter Fonagy, proposes a similar split. Recommendation 4 would focus specialist capacity "where it adds greatest value, including in cases of diagnostic uncertainty, clinical complexity, complex co-occurring conditions, significant risk and medication initiation." Recommendation 5 calls for a "[s]hift from episodic specialist care for ADHD to long-term management in primary care where required, supported by funded shared-care arrangements held to a consistent national standard so people are not left stranded between services or reliant on private prescriptions once diagnosed."

Written shared-care protocols already exist in parts of England. "GP acceptance of shared-care arrangements for medication initiated by independent providers has fallen to an average of around 62% and continues to decline," the review reports, "because of concerns about assessment quality and the availability of ongoing specialist support." The report does not give a source for that figure, and we did not find one in its technical annex or in the think-tank report it cites in the preceding paragraph.

The government has not adopted the primary care shift. Its October 9 announcement covered regulation of diagnostic assessments, assessment advertising, a national tariff intended from April 2027, and a NICE guidance review. It did not mention primary care or shared care. A written ministerial statement on October 12 said the forthcoming Mental Health Strategy "will respond to the Review's longer-term recommendations."

For a US practice that shares stimulant care with primary care, these systems suggest four questions for a written agreement.

Who starts and stabilizes. NSW limits stimulant initiation to specialists, endorsed GPs and other authorized prescribers. England's review would focus specialist capacity on it. A practice can state that it initiates and titrates, and define when a patient counts as stable.

What the continuing clinician may change and monitor. The NSW continuation role allows minor dose changes and formulation switches within the same drug type, under fixed daily ceilings. A US agreement can set its own limits, such as a dose range and no change of agent. An agreement records clinical boundaries; it does not create prescribing authority or replace any collaborative-practice arrangement state law requires. It can also say who checks blood pressure, heart rate and weight (and growth in children), how often the specialist sees the patient, and how prescription monitoring checks will be handled under state rules.

What sends the patient back. In New South Wales, a change of medicine or a dose above the ceiling requires specialist involvement, and a restart after a break may. A practice can add its own triggers. The conditions RANZCP lists are a reasonable start: new mood, anxiety or psychotic symptoms, emerging substance use, or a trauma-related presentation. New psychotic or manic symptoms or chest pain or fainting on a stimulant need prompt evaluation rather than a routine referral back; an agreement should say who does that. Pregnancy and new cardiovascular findings are our suggestions; the NSW framework treats cardiovascular status as part of the pre-treatment assessment, not as a listed referral trigger.

What happens if the other clinician declines. England's review shows what is at stake when shared care is not reliably accepted. As an editorial default, the agreement should keep responsibility for prescribing decisions with the referring psychiatrist until the receiving clinician explicitly accepts. If a primary care clinician will not take over, the patient needs a stated alternative, such as continued psychiatric prescribing or a referral elsewhere.

A document alone will not fix what England's review describes. GPs there cite assessment quality and specialist backup, and New South Wales paired its rules with training money and specialist support services. A written agreement is where a small practice can make those commitments explicit: what the psychiatrist will still do after the hand-off, and how quickly.

None of the sources reviewed here evaluates either change's effect on diagnostic accuracy, prescribing or safety; NSW's endorsed prescribers have only now finished training. England's recommendation may be changed or dropped in the Mental Health Strategy. Queensland's adult pathway has run for less than a year. The source of the review's 62% figure is not stated. US rules for Schedule II stimulants, state law and payer policy differ from both systems, and this article does not analyze them.

Treating ADHD Alongside Stimulant-Use Disorder (September 16, 2026).

Source note: This commentary summarizes a government-commissioned review, UK government statements, and state health department rules and announcements in New South Wales and Queensland. The review's recommendations are not government policy. The review reports the 62% shared-care acceptance figure without a stated source, and the figure refers to medication started by independent providers. Several NSW and Queensland health department pages block automated retrieval and were read in a browser. NSW prescriber numbers are as reported by NSW Health. None of the sources reviewed here evaluates the NSW or Queensland change's effect on diagnostic accuracy, prescribing or safety. The monitoring, referral and interim-prescribing arrangements suggested for a US agreement are editorial proposals, not statements of US legal duties. The article does not analyze US federal or state controlled-substance law or payer rules.

Educational Disclaimer: The Psychiatric Record provides general educational information for psychiatric and mental-health professionals. Content does not constitute medical, legal, regulatory, compliance, billing, or other professional advice; does not establish a standard of care; and is not a substitute for independent professional judgment. Co-management arrangements for controlled substances depend on federal and state law, payer rules and each clinician's scope. Practices should review specific arrangements with qualified advisors.