Kultar Garcha, GP partner at Hounslow Family Practice, North West London ICB and medical director at Flow Neuroscience, explains that evidence alone isn’t enough to end the mental health postcode lottery.
The clinical and economic case for neurostimulation in moderate to severe depression is now undeniable. A recent evaluation published in BMJ Mental Health demonstrates that rapid transcranial magnetic stimulation (rTMS) brain stimulation therapy offers an incremental cost-effectiveness ratio well below the NICE threshold. For a healthcare system grappling with a mental health crisis, this should be the green light moment.
But as a clinician, I know that evidence alone does not get treatment to patients.
The real hurdle is the delivery. Current neurostimulation models, particularly rTMS, depend on physical infrastructure, face-to-face appointments, and human effort: specialist clinics, trained staff, and high-throughput services. In an NHS where capacity is already stretched to a breaking point, this creates a structural bottleneck. Despite being NICE-approved since 2015, rTMS is currently available in only one in seven NHS Trusts.
A geographic lottery
At this rate, access to this type of care remains a geographic lottery.
If we want neurostimulation to move beyond small-scale pilots and reach the millions who need it, we must shift our focus to how we deliver it at scale.
This requires a move toward more flexible, decentralised models of care. And this means expanding the conversation to include other neurostimulation approaches that don’t need physical infrastructure. Technologies like home-based transcranial direct current stimulation (tDCS) are no longer fringe alternatives but essential components of a modern service. Supported by NICE guidance and recent trials showing remission rates as high as 57.5%, home-based tDCS removes the clinic as the biggest barrier to access.
In my own practice, I’ve seen what happens when we empower patients to manage their treatment at home under remote clinical supervision. They get fast access, they take greater ownership of their recovery, and – perhaps most importantly for the NHS – it frees up clinic-based treatments for the cases that truly require it. These are not trivial considerations when designing services that need to reach patients at scale.
The economic argument for neurostimulation has been won. The next battle is for the delivery model.
If we continue to tether innovation to overstretched clinics, we will continue to fail the patients who need these treatments most. It is time to embrace a hybrid approach that combines the power of the clinic with the reach of the home.
