Neurology: still in first gear
Editor – The Francis and Future Hospital Commission reports add to neurology's woes, eloquently summarised by Richard Langton-Hewer and met with diplomacy by the Association of British Neurologists (ABN) (Clin Med October 2013 pp 440–2 and Clin Med October 2013 pp 443). Part-time consultants, an aging population, the desire for specialist care in the community and the acknowledgement that stroke, dementia, fatigue, pain syndromes and adult learning disability are also neurological illnesses contribute further pressures. For availability of consultant-led neurological expertise in all admitting hospitals 24 hours per day, 7 days per week (which seems appropriate given the rapidity with which neurological knowledge and treatment is advancing) and if neurologists are to take a share in acute medicine, then expansion of neurology is inevitable. An additional 200 consultants would allow, with redistribution, one per 70,000 population (as suggested by the Royal College of Physicians [RCP]/ABN working party in 2011)1 and an additional 800 consultants would bring the rest of the UK into line with the one per 40,000 population in London.2
Prof Langton-Hewer calls for evidence to guide service delivery. The specialty was battered by the National Audit Office (NAO), whose report commented that there was variation (by primary care trust [PCT]) in acute admission with neurological illness that could not be due to chance.3 The method used to justify this statement was to compare emergency admissions for three illnesses (multiple sclerosis, motor neurone disease and Parkinson's disease) with routine admissions for the same conditions. However, the admission figures used by the NAO show no correlation with the availability, by PCT, of new and follow-up appointments or follow-up to new ratio in -neurology.4 Hence, either the availability of neurology appointments has no effect on acute admission or the figures used by the NAO were not representative of anything relevant. With knowledge of the many factors behind acute and chronic neurological admission, the latter seems more likely. Certainly no decision on neurology consultant staffing should be based on such evidence. In addition, illnesses and treatments change so rapidly, even in neurology, that by the time evidence appears it is out of date.
If we acknowledge that neurology consultant expansion must happen, how can we achieve this in austere times? There will be a reduction in bed use, when patients are seen on the day rather than waiting for a visiting neurologist. There may be fewer unnecessary investigations and fewer missed neurological diagnoses. Neurology will need to investigate and manage patients promptly and cost effectively; for example, over £70 million per year could be saved by cost-effective prescribing in a single neurological disease.5 While neurology has never been integrated with general medicine, there would be a responsibility, in time, for neurologists to take part in acute medicine, as the Future Hospital Commission suggests. Equally, general and acute physicians would need to welcome the early involvement and -support the expansion of -neurology.
After many years of ‘making do’, is it fair that neurological patients must wait for more evidence before there is equitably distributed specialist-led acute and chronic care in -neurology? In 1996 the RCP called for a -neurological consultant to be based in every district general hospital6 but, despite the expansion described by the ABN presidents, that is still a long way off. A start for the ABN and RCP would be to block new consultant neurology posts in London.
Footnotes
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- © 2014 Royal College of Physicians
References
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- Royal College of Physicians, Association of British Neurologists
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- Federation of the Royal Colleges of Physicians of the United Kingdom
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- National Audit Office
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- Morrish P
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- Morrish P
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- Royal College of Physicians
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