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Services for people with neurological conditions are poor value for money

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d8205 (Published 16 December 2011) Cite this as: BMJ 2011;343:d8205
  1. Jacqui Wise
  1. 1London

Department of Health spending on neurological conditions increased by almost 40% over four years yet there was little to show for it, says a report from the National Audit Office.

The report, which focuses on Parkinson’s disease, multiple sclerosis, and motor neurone disease, says there has been little progress since the national service framework for long term conditions was introduced in 2005. In the UK, two million people are estimated to have neurological conditions, excluding migraine.

“We don’t believe the current spending is value for money,” said David Moon, director of health value for money studies at the National Audit Office and author of the report. Health spending on neurological services increased by 38% in real terms from £2.1bn (€2.5bn; $3.26bn) in 2006-7 to £2.9bn in 2009-10. This was part of local commissioners’ general budget and was not ring fenced by the Department of Health.

The national service framework set out 11 quality requirements that were supposed to be fully implemented by 2015. “Implementation of these quality requirements has been poor and has probably not improved at all since 2005,” said Mr Moon.

The report, Services for People with Neurological Conditions, did find some improvements since the framework was introduced. Access to health services for people with long term neurological conditions has improved. And the number of emergency bed days fell by 12% between 2004-5 and 2007-8. Waiting times for inpatient and outpatient neurology have improved since 2007. And the number of beneficial elective neurological operations being performed has also increased.

But the report says important indicators of the quality of care for people with neurological conditions have worsened. For example, the number of people admitted to hospital as an emergency has increased significantly—up 32% between 2004-5 and 2009-10, compared with a 17% increase for the NHS as a whole. The report points out that people with neurological conditions admitted to hospital as an emergency often receive care from health professionals who have no neurological training.

The number of emergency admissions also varies across primary care trusts. In addition, the number of emergency readmissions after an overnight stay increased for patients with Parkinson’s disease, multiple sclerosis, and motor neurone disease.

The report also highlighted a pattern of patients being referred to hospital for treatment, then discharged, but then referred back to hospital. This was because of the “new to follow-up” ratio performance measure, which the report says is a “perverse performance incentive” that puts pressure on hospitals to discharge patients.

The report identifies several serious problems with current services. For example, after diagnosis many patients did not receive information on their condition, local services, or available support. One of the report’s recommendations is that all neurologists should be required, at the point of diagnosis, to give patients information packs about their condition.

Another problem is that ongoing care is fragmented, with poor coordination between health and social services. The report calls for patients to have a personal care plan for health and social services with one professional in charge of coordinating an individual’s care.

The National Audit Office points out that the framework had none of the levers or incentives necessary to motivate local organisations to implement its 11 quality requirements. In addition, the Department of Health cancelled the midpoint review of the framework, agreed by the previous government. As a result, the report says the Department of Health has no way to measure the effect of additional spending on services or patient outcomes.

Amyas Morse, head of the National Audit Office, said, “It is not clear how lessons will be learnt and there are risks to services which the department must address to ensure that care improves.”

Access to services for patients also varies depending on where a patient lives. For example, the number of specialist nurses per person with multiple sclerosis varies across the country. Mr Moon said: “There are examples of good practice around the country—for example, the use of specialist nurses, which can reduce the number of emergency bed days and readmissions.”

Pam Macfarlane, chief executive of the MS Trust, commented: “The Department of Health needs to take this report very seriously and use the opportunity to look hard at the performance and financial incentives in place on NHS trusts. Such incentives are in place for conditions like stroke and heart attack, which have seen dramatic improvements in the past decade. Similar incentives on NHS trusts are needed for the long term care of neurological conditions like MS [multiple sclerosis] if we are actually to see improved services in future.”

A report published earlier this year by the Royal College of Physicians and the Association of British Neurologists identified similar problems to the National Audit Office. Dr David Bateman, author of that report, Local Adult Neurology Services for the next decade, commented: “Many of the problems identified by the National Audit Office are due to limited availability of local neurologists to see emergency neurology admissions, limited access to outpatient clinics, and lack of coordinated planning and commissioning of neurology services across hospitals, primary care, and social care.”

Services for people with neurological conditions is available at www.nao.org.uk.

Notes

Cite this as: BMJ 2011;343:d8205