In 2008, Clinical Medicine kindly published my analysis of the availability of neurology outpatients by primary care trust (PCT) of residence from 2003 to 2006.1 The information was also given to the Department of Health (DH). I have extended this study to April 2009 and the trends are essentially the same. The number of appointments in neurology has continued to rise (by 11% per year, compared with 3% per year for general medicine) with no apparent ceiling. The follow-up to new appointment ratio has dropped from 1.6 to 1.46 over the same time. The lottery in regional access has not changed (Fig 1).
The number of primary care trusts (PCTs) referring a given number of patients (new appointments in neurology per 1,000 population) in 2003–4, 2006–7 and 2008–9.
I recently approached the DH to ask for the agreed outpatient tariffs between PCTs and providers in secondary care. Neurology is unusual in that there has been no nationally agreed tariff; instead, local tariffs have been negotiated between hospitals and PCTs. The DH held no record of the agreed tariffs. Using freedom of information legislation I then contacted all 152 PCTs to ask to which providers their patients were referred and at what cost. In total, 104 PCTs responded, giving the tariffs for 121 providers in England; other PCTs used the exemption that the information was commercially sensitive. The information that has been made available provides a chaotic picture of service provision and cost per appointment. The cost, to a PCT, of a new consultant outpatient appointment in neurology in England varies from £67 to £592 and the cost of a follow-up appointment from £64 to £416. The average for a new consultant appointment in 2009–10 was £249 (standard deviation (SD) £90), the average follow-up was £153 (SD £56). There is little pattern to the tariffs. The tariffs do not appear to recognise whether a provider has secondary or tertiary facilities (Fig 2), neurology beds or neurology on-call. There is no relationship between the price a PCT pays for its neurology and the number of patients it sends to neurology.
New outpatient tariff for 121 neurology providers in England (four providers have separate tariffs for secondary and tertiary care).
The implications are important for anyone running, or referring a patient to, a neurology service. The free market in healthcare in England appears to have had diverse effects on neurology. The expansion in outpatient numbers is a response to demand but demand has not been limited by an expensive neurology service or transferred to a cheap neurology service. There are watersheds, with three patients seen on one side of a line for the price of one on the other. General practitioners (GPs) may not know the cost of referral. If they do know the cost perhaps they value their local service and see the extra cost as justifiable. Some providers appear to have a monopoly, with PCTs accepting the high cost of their local service rather than, for example, arranging transport to a more distant provider. A limited supply and distribution of neurologists may have facilitated this. The negotiating process may have been muddled by commercial secrecy or a failure to ask questions. For a neurology service seeing 4,000 patients per year a change in new patient tariff from £200 to £250 would provide an extra income of £200,000 per year, enough to provide two more neurology consultants to do the work that is already being done.
This information does not necessarily condemn the introduction of a free market in healthcare but it does pose awkward questions for the DH. How much should a neurology appointment cost a commissioning group, PCT or GP, and why should it be more expensive in some parts of the country than others? Why, given the problem in neurology service provision,1,2 does the DH not know the agreed tariffs across the country? How many neurologists do you need to run a national neurology service?
Unlimited demand and limited supply has meant that, so far, both expensive and cheap neurology services have flourished and there is no evidence that the free market is correcting the national lottery of neurology care. My rationale for publicising this information is to draw attention to neurology's continuing service idiosyncracy and to allow providers and purchasers more informed negotiation. Many of the PCTs requested that I did not publish the information provided and hence no individual PCT or provider name is given.
Footnotes
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- Royal College of Physicians
