Inadequate neurology services undermine patient care in the UKBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3284 (Published 18 June 2015) Cite this as: BMJ 2015;350:h3284
All rapid responses
Thank you for these responses. My article draws attention to the difficulties, for patients and other doctors, with the current neurology service in England and expresses concern for its future.
The number of new patient appointments provided by CCGs in 2012-3 ranged between 165 and 2531 per 100,000 population with no relationship to the prevalence of neurological illness (1). The National Audit of Seizure management in Hospitals (2) showed that only 18% of those presenting to hospital with seizure (and no prior history) had their fundi examined and 41% their plantar reflexes tested. 63% of those admitted with known epilepsy had not seen a specialist in the preceding year. Such difference between haves and have-nots, whether inpatients or outpatients, is indefensible.
Healthcare needs to change with advances in medicine and a changing population. Centres once made sense and some neurology care, for example assessment for epilepsy surgery, may need to be centre-based but most can be carried out with a tendon hammer, an ophthalmoscope and an image-link, in a district hospital or at a patient’s home. Neurological research also loses out from poorly distributed unrepresentative recruitment of subjects.
Dr Macintyre gives a welcome view from another specialty. It has been a managerial failure and my specialty does indeed carry some blame, but so do faith in market forces, waiting list targets and bizarre tariffs (3). Dr Fletcher and colleagues’ views will be shared by many neurologists but they are as defeatist as mine are utopian. Three or four days per week of neurology (or sometimes none) in many DGHs, or tele-medicine instead, are a far cry from the quality of care that we could offer and our patients might reasonably expect. The NASH audit shows how reliance on specialists descending intermittently from a higher centre may not promote a local culture of neurological excellence. The Association of British Neurologists has an unenviable task in balancing the views within its membership, and those of the patients, the government and the national audit office.
Its support for review shows a profession that has struggled to meet the demands placed upon it and is open to outside opinion. Dr Bateman, National Clinical Director, is optimistic that new commissioning arrangements can encourage CCGs to invest in local neurology services; an external review could provide guidance on how the neurological needs of 211 very different CCGs can be fairly served, given the potential problems described by Fletcher. It isn’t only about manpower. What value extra resources if they go to the wrong place? There are now more than 600 neurologists and 179 stroke physicians in England (4). With existing manpower there could already be 100 well-staffed admitting hospitals with round-the-clock consultant neurological expertise. That would be close to the pattern of local provision envisaged by the RCP and ABN report of 2011 (5).
This isn’t about regional horse-races either. It is instead about how the specialty of neurology can best serve the entire adult population of England. When it does that, it will be better placed to survive and thrive. It has acknowledged its difficulties and can, perhaps with help from outside, begin the difficult process of change.
1. Public Health England. Neurology Intelligence Network. http://www.yhpho.org.uk/resource/view.aspx?RID=213049 (accessed Sept 2015)
2. Dixon PA, Kirkham JJ, Marson AG, Pearson MG. National Audit of Seizure management in Hospitals (NASH): results of the national audit of adult epilepsy in the UK. BMJ Open 2015;5:e007325 doi:10.1136/bmjopen-2014-007325 (accessed Sept 2015)
3. What is happening to English neurology: an update. Clin Med 2011;11:101-102
4. Royal College of Physicians. Census of Consultant Physicians 2013-4. https://www.rcplondon.ac.uk/resources/201314-census-specialty-reports (accessed Sept 2015)
5. Royal College of Physicians of London and the Association of British Neurologists. Local adult
neurology services for the next decade. London: RCP, 2011.
Competing interests: No competing interests
I respond to this article is as a recently retired Glasgow general and respiratory physician who while working was concerned about the issue of poor neurology services. I would for example find myself in the situation of offering out-patient follow up to patients with recurrent convulsion admissions to allow some form of convenient local review.
My perception of the background to this was comparison of the local history of the two specialties of neurology and rheumatology. When I was appointed consultant rheumatology was almost entirely centralised in a specialist unit. Neurology was similar at Glasgow’s Southern General Hospital though with a slightly better outpatient ‘spoke’ service. Both centres had substantial reputations within their specialty. The appointment of a new professor of rheumatology changed that with his clearly stated aim to have a rheumatologist in every hospital in the west of Scotland. That was achieved with increased training numbers and with the result that rheumatology is now on a par with the other main medical specialties. Neurology unfortunately went the other way and actually removed much of the previous outpatient services and concentrated further into the ‘centre of excellence’. Any idea that neurology was part of general medicine in both service provision and training was lost.
Inevitably numbers training in neurology stagnated and neurologists now find themselves with problematic workloads. This has resulted from policy within the specialty and does not come from any general medical or management strategy. In fact the way in which this has happened could be seen as a real failure of managerial control of the NHS. Neurologists historically have only themselves to blame for the current situation and need first to agree amongst themselves how it might be addressed. My guess is that this would have to involve greater integration of neurology into general medical training and junior cover with an associated increase in specialty training posts. It is unlikely to be improved by retaining the priority of centres of excellence separate form general medicine.
Competing interests: No competing interests
We agree with Morrish (BMJ 2015; 350: h3284) that neurology services in the UK are inadequately resourced, understaffed and unable to fully meet current needs. Morrish correctly identifies a shortage of consultants as the main issue. It is clearly his opinion that the solution to these difficulties is to move away from centre based neurology services to a different model of locally based neurology units in DGHs.
While we agree with Morrish that equity of access to a service, local care whenever possible and reducing variability of service are key priorities, we are concerned that his vision of DGH based neurology services will make such outcomes less likely - not help them – and would be neither realisable nor sustainable. If there are not enough neurologists and DGHs compete to recruit them, some DGHs will have some (but not in all cases enough for a truly satisfactory and viable service) and others will have nothing. How will this help? How would this be equitable? The risk is a patchy provision with highly variable and inconsistent facilities, clinical quality, access and clinical governance arrangements, and a generally fragmented service. It is inconceivable that every DGH would have enough neurologists let alone adequate clinical and diagnostic infrastructure. Even if the money was available, the staff are not.
We agree that a purely centre based structure with minimal outreach (as Morrish inaccurately generalises about UK neurology) is also unsatisfactory and inequitable as access to the service would then be related to distance from it.
However, it is not a choice between these two equally undesirable alternatives - one utopian and undeliverable; the other ineffective and unresponsive. A properly run outreach network from a centre committed to care of patients, in linked DGHs and communities, with both centre based and DGH based outpatient and inpatient ward liaison support - plus community based provision by centre based (or managed) medical and specialist nursing staff can provide an equitable, consistent, operationally realistic, deliverable and sustainable service. Both centre- and DGH-provided services can contribute in complementary ways to research and to training and education across the board, hopefully reducing the “neurophobia” so prevalent in non-neurologists. It also enhances seven day care, and the ready and rapid coordination of service with neurosurgery and the neuro-specific diagnostic services; and supports provision of neuropsychology and neuropsychiatry services, surely two of the most neglected and needy services to patients with neurological symptoms and diseases.
Our service is based at Walton in Liverpool; 40% of our activity is based in linked DGHs provided by Walton neurologists. We visit hospitals in Cheshire & Merseyside, North Wales, Lancashire and fly consultants to the Isle of Man each week. Most of the DGHs within our network have 3-4 days of neurology each week. Patients needing local care can get it; those who need highly specialised care can be transferred in to the centre - wherever they are initially seen. Those patients transferred between DGH and centre will be managed by the same consultant team. Many of our linked hospitals have more ward liaison sessions each week than could be provided by two full time DGH based consultants. Furthermore the service is large enough to guarantee continuation in the DGH in the event of sickness or maternity leave.
Our service is certainly not perfect - we are not in DGHs every day but provide the most equitable and realistic service model with currently available (and realistically expected) resources. Until there are enough qualified specialists and all the necessary support for a fully staffed and equipped neurology department in every hospital (which we agree is an idealistic aspiration) a well-managed hub and spoke outreach system with specialised providers operating within dispersed local hospitals or community settings is the only viable model in what will be increasingly financially challenging times. Such a model can of course evolve and improve (for example we are piloting remote ‘tele-neurology’ ward consultations to provide specialist consultations at times when we do not have a neurologist on-site), but to abandon it entirely seems unnecessary.
It is also obvious that different parts of the UK will need different provision - depending on population patterns, transport links and geographical area, and of course the very variable recruitment challenges in different regions. Many of the same considerations of course apply to the viability and sustainability of DGHs themselves, let alone any neurology departments within them. At a time when NHS England are looking for vanguard sites for future models of acute care collaboration, we do wonder if some within British neurology are backing the wrong horse in an inappropriate regional race.
Competing interests: No competing interests
To the Editor
Dr Morrish highlights that the UK has too few neurologists and an inadequate provision of neurology services (1). He draws attention to the enormous variations in access to acute neurological services across the UK that we reported in the Association of British Neurologists’ recent survey (2). Very few district general hospitals (DGH) have inpatient neurology beds, with inpatient neurology being effectively limited to neuroscience and neurology centre. The majority of DGHs depend upon visiting neurologists to assess inpatient ward referrals. Our data showed that many hospitals can access such neurological opinions for only a few days each week – a far cry from the aspiration of a 7-day service across the country. There are considerable logistical difficulties in trying to provide a uniform 7 day referrals service – all the more so since inpatient referrals are not measured or funded in any formal way and are effectively an invisible service.
However, this focus on acute neurological services only tells half the story. Many patients with neurological conditions have chronic disabling conditions (multiple sclerosis, epilepsy, Parkinson’s disease, dementia, neuromuscular disorders) requiring long term predominantly outpatient based management. The limited number of neurologists in the UK (1 per 90,000 versus 1 per 15,000 in the rest of Europe (1)) means that outpatient demand cannot be met and patients with neurological disorders are having to wait. The Neurological Alliance’s recent patient survey highlighted this poor access as a significant concern for patients (3). The current focus on timely assessment of new patients has contributed to the difficulty in providing adequate outpatient follow up for long term patients. This outpatient pressure has contributed to many neurologists having only limited involvement with acute neurology, and to neurology services being focused on addressing outpatient demand. Neurological services for some common neurological disorders—for example, stroke, dementia, epilepsy and movement disorders—have developed in parallel within other specialties to meet this demand. Yet even those areas of the UK with more neurologists still have far fewer per head of population than in the rest of the world. In regions where there are more neurologists, such as London, neurologists have been able to take a bigger role in the care of these common conditions, for example delivering hyperacute stroke services.
Patients with neurological disorders, whether inpatients or outpatients, need timely access to neurological expertise, and as close as feasible to their home. It is essential that improvements in acute neurology services do not compromise outpatient services, most of which already run close to the 18-week target for new patients (in England) and with considerable difficulties for follow up patients.
The Neurological Alliance entitled their report, “The invisible patient”, reflecting the perception that very many patients with neurological disorders do not get the recognition and the services they deserve (3). This contrasts with the recent dramatic focus on patients with cancer and the resultant improvement in their services. We agree with Dr Morrish that the provision of neurology services has been too inadequate for too long, depriving patients with neurological disorders of an equitable and responsive service. We join with him and the Neurological Alliance in calling for a full evidence-based review of services for people with neurological disorders, particularly in response to the National Audit Office’s progress report (4). However, this would apply to both acute and outpatient services, as current evidence suggests that the service falls well short of international provision everywhere.
Immediate Past President Association of British Neurologists
President of the Association of British Neurologists
President Elect of the Association of British Neurologists
Chair of the Services and Standards Committee of the Association of British Neurologists
1) Morrish PK, Inadequate neurology services undermine patient care in the UK, BMJ 2015;350:h3284 doi: 10.1136/bmj.h3284
2) Association of British Neurologists, ABN Acute Neurology Survey, 2014 www.theabn.org/media/Acute%20Neurology%20Survey%20-%20FINAL%20Dec14.pdf
3) The Neurological Alliance, The invisible patient, 2015 www.neural.org.uk/store/assets/files/496/original/Invisible_patients_-_r...
4) National Audit Office. Services for people with neurological conditions. http://www.nao.org.uk/report/services-for-people-with-neurological-condi...
Competing interests: No competing interests
Morrish(1) describes very well the current shortcomings of adult neurology services in England. I share these. Although the professions and charities have championed improvements, these have proved difficult to achieve. The June 2011 RCP/ABN report "local adult neurology services for the next decade"(2) which had widespread support from the professions and charities emphasised the need for and benefits of improved acute care in the DGH and the need to provide better local long term care through collaboration with local commissioners. It was followed by the NAO report(3) and PAC report(4). The recently published review by the NAO(5) highlights the lack of progress.
However the most recent changes in commissioning and 5 year forward view (NHSE) offer real opportunities to remedy these deficiencies in services. The majority of neurology services which were previously commissioned as specialised have now been more appropriately redefined as tier 2 services requiring considerable CCG involvement. In future they will be collaboratively commissioned with CCGs.
This means that CCGs can demand local acute neurology services run by neurologists in certain selected bigger DGHs. This fits very well with the requirement to provide acute stroke care and 7 day working. Neurologists, stroke physicians and elderly care physicians can work in teams to provide the entirety of acute neurology care including stroke. Advances in stroke care with clot retrieval will require earlier neurological assessment. This will allow shared rotas, staff and facilities. This is all supported by the thrust of the 5 year forward view with its emphasis on redesign of emergency care and 7 day working. Realistically it is the only way to achieve it wit current resources and consultant numbers.
The 5 year forward view also emphasises the necessity of integrated care and multidisciplinary working which are essential requirements for patients with neurology long term conditions such as multiple sclerosis, Parkinson's disease, neuromuscular disorders and MND. The RCP in its vision for the future hospital describes the benefits of more specialist care in the community which is ideal for improving the care of these patients. Adult neurology conditions are one of the work streams of the strategic clinical networks who can help coordinate this and other work. They are currently working together with NHSE to develop a commissioning model for community neurology care for long term conditions.
For the first time commissioning structures have been developed and mandated to break down the barriers between tertiary secondary primary and community care which offers a real opportunity to substantially improve neurology services in England. The SCNs, the professions, professional organisations and charities in each region are working hard to use these levers to achieve these aims. There has never been such a good opportunity before and we must not miss the chance.
1 Morrish P.K. BMJ 2015; 350:h3284
2 Local adult neurology services for the next decade report of a working party The RCP June 2011
3 National audit office report services for people with neurological conditions London : the stationery office 2011
4 PAC report 2012 HC Committee of Public Accounts, Services for people with neurological conditions, Seventy-second Report of Session 2010–2012, HC 1759, March 2012.
5 NAO report services for people with neurological conditions : progress review 2015
Competing interests: No competing interests