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.
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Author's reply
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