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
“Neurology for the masses” announced The BMJ’s then editor, Richard Smith, in 1999.1 Old stereotypes may associate neurology with rare syndromes and a fondness for diagnosis not treatment, he went on, but it is also a specialty of common illnesses such as epilepsy and Parkinson’s disease. He might also have mentioned that neurological symptoms include some of the commonest complaints such as headache and fatigue. Sixteen years on and despite a doubling of consultants, a damning parliamentary report,2 thrombolysis for stroke, and an awareness of increasing neurodegenerative disease only people living in select areas, or able to travel, will encounter a neurologist. The Neurological Alliance, a patients’ organisation in England, reports that 31% of patients had to see their primary care doctor five or more times, and 40% waited more than 12 months with symptoms before seeing one.3 The UK is the only developed nation with this problem. We have one neurologist per 90 000 people4; the European average is one per 15 000,5 and in the United States concern has been expressed that one per 19 000 isn’t enough.6
A scarce resource ought to be distributed fairly. Data emerging through the Neurology Intelligence Network show the poor match between need and provision of services.7 London has the lowest prevalence of epilepsy and dementia yet the capital’s residents have a 40% higher chance of being seen in a neurology outpatient clinic than people living elsewhere.7 Even within London, access to specialists is poorly distributed and may not match patient need.
However, it is neurologists’ involvement in acute care (or lack of it) that is most concerning. Neurological disorders are the third commonest cause of acute admission, behind disorders of the heart and lung,8 but of 145 UK district general hospitals surveyed by the Association of British Neurologists, only nine had dedicated neurology beds, 69 relied on a visiting neurology service, and seven had no service at all.9 (The other 60 have a neurology service but no beds.9) A quarter of acute admitting hospitals offered review by a neurologist on one in six days or fewer, and only 11% of patients admitted with a primary diagnosis of epilepsy were managed by a neurologist.7 Neurologists are involved in thrombolysis for stroke in 90% of the 50 hospitals that have adjacent neurology centres and 14% of the 145 hospitals that don’t.
Why is neurology unlike other medical specialties that serve common illnesses? Despite the prevalence of neurological symptoms and conditions, neurology in the UK has always been physically and intellectually discrete from the general hospital and the community. Originating at one hospital in London, the specialty spread slowly to teaching hospitals in the capital and to regional centres. Few and far between, neurologists couldn’t or wouldn’t take on patients with common problems. Stroke, dementia, migraine, and epilepsy were typically managed in primary care or by other secondary care specialties.
The outpatient service changed dramatically in 1997 when waiting time targets were introduced. The regional centres had to respond quickly to overwhelming demand, and those central hubs of a “hub and spoke” service absorbed the bulk of newly appointed consultants. Some hubs now employ 20 or more neurology specialists while the spokes—the district general hospitals and community services—remain underserved; parts of this wonky, hub heavy wheel of provision have no spokes at all.
Why should a local hospital employ a neurologist when these specialists don’t take part in the general medicine rota for acute admissions, may not manage stroke, and could be made redundant by advanced imaging? Neurologists would answer that neurological mismanagement is catastrophic for the patient and medicolegally expensive for the provider; generalists find diagnosis and management of neurological conditions difficult even with advanced imaging; neurological expertise often changes diagnoses and can reduce length of stay; neurological illness is often long term and disabling, and a locally based neurologist could improve care.8 Nevertheless, more evidence that specialists improve outcomes cost effectively would be helpful. Patients might simply argue that they deserve to be treated locally by experts in their condition.2
Time for independent review
To provide a comprehensive and equitable service, the distribution of neurologists should be inverted, with more smaller centres located where need is greatest. The latest five year plan for the NHS states that “The future will see far more care delivered locally but with some services in specialist centres.”10 It is unfortunate for the two million people (nine million if stroke, dementia, migraine, fatigue syndromes, and traumatic brain injury are included) with a neurological condition, particularly those not living near a centre, that neurology has been deemed a specialised service.
The Future Hospital Commission11 can promise “24/7 specialist care in hospital and in or close to the patient’s home, particularly for those with long-term conditions” but as things stand this will not include specialist neurological care. The Shape of Training review proposes extra generalist training for specialists.12 Neurologists taking part in the general medical rota, managing stroke, and providing outreach to the community might be more useful but do specialised commissioning and the professional bodies support that approach? If they do, there are unlikely to be enough neurologists to meet demand.
Professional oversight of the specialty followed by unsupervised market led growth has failed people with neurological symptoms and conditions. Specialised commissioning and the Future Hospital Commission are set to continue the trend. It is time for independent review to determine what neurologists should be doing, how many are needed, and where they should be based. The current situation is not working for patients and their families or for the wider medical community.
Cite this as: BMJ 2015;350:h3284
I thank Brendan McClean for help with interpreting the data.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I advise the Neurology Intelligence Network, am a member of the Association of British Neurologists, and have been asked to give a lecture (unpaid) by the Commissioning Excellence directorate of NHiS, a private company offering commissioning support to healthcare commissioners.
Provenance and peer review: Not commissioned, externally peer reviewed.