British neurology is under pressure to meet new demands in our outpatient and inpatient work. The two are closely linked and the Association of British Neurologists (ABN) is working hard to influence changes in both areas.
Outpatient neurology, open access MRI and real efficiency
Cancer targets have infiltrated all areas of medicine, including neurology. In particular, headache is seen as a potential area of change. The potential ‘solution’ of direct access MRI scanning for GPs for all new headache patients (trialled locally in some areas already) won’t solve any problems, will create new ones and at the end of it all, won’t get rid of the patient’s headache. Instead of more scans, the ABN suggests increasing partnership with primary care, working to increase awareness and utilisation of current headache management guidelines such as BASH (The British Association for the Study of Headache), Map of Medicine, and other locally produced guidelines.
Eliminating cancer as the underlying cause is only a very small part of neurological practice, and can usually be done clinically in the case of headache. Headache makes up a huge chunk of neurology referrall, and, as an isolated symptom, is almost never the consequence of a brain tumour. With the large number of patients with migraine and other headaches, many scans would be requested if direct access was implemented. Given the limited number of MRI scanners available, this will compromise the availability of scans in patients for whom the scan will have a greater role in diagnosis and management.
Given that migraine occurs in 5% to 10% of the population (at least), and may resist treatment for over a month and sometimes much longer, it would be unnecessary and costly to arrange MRI brain scans on everyone with chronic migraine. Patients with chronic migraine rarely require an MRI scan. Furthermore, a scan does not cure their headache, and up to 6% will have an incidental or false positive finding such as a small aneurysm. This creates unnecessary and enormous anxiety, as well as potentially leading to more investigations with added costs and occasional risks, and even to surgery with very serious risks. This figure does not include the findings of VOMITs, UBOs, and with increasing age, white matter hyperintensities and microbleeds. Incidental findings generate a huge need for specialist referrals to settle anxiety, and explain findings. Indiscriminate MRI scanning would be enormously expensive over and above the cost of the scan itself.
Access to scanning is not the most important issue for patients with headache, and will not solve their pain. Education and empowerment of GPs to treat migraine earlier and more could have a significant impact on improving their care.
Making a difference at the coal-face
A joint report from the ABN and Royal College of Physicians (RCP) “Local adult neurology services for the next decade” has just been launched and is available on the RCP website. It is staggering that the UK is one of the few places in the world where neurologists are not acutely involved in neurological emergencies. They are common, making up 10% of emergency medical admissions (and many more with stroke). Services for patients admitted to hospital with an acute neurological illness are particularly concerning because they are rarely provided by neurologists, in contrast to those for stroke and other acute medical specialties, which may result in patients not receiving the best possible care available. Neurology remains a shortage specialty, with appointments mainly to the regional neurosciences centres and an inequality of more than three to one in numbers of neurologists in different parts of the UK.
Neurology services in the UK are organised around large regional neurosciences centres with an emphasis on research and academic excellence. These are crucial and should not be threatened, or we will lose the heart of what is needed to maintain excellence. They have produced world class research and new treatments for patients. But district general hospital services remain under-resourced because of a lack of local neurologists, in contrast to the USA and Europe with more neurologists per head of the population (1:40,000 versus 1:125,000). The lack of local neurologists in the DGH has resulted in poor local services exacerbated by an increase in outpatient demand driven by waiting time targets, inadequate resources and sometimes poorly structured services networked across health providers.
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Long-term care of neurology patients also require big improvements. Patients need a range of neurology services at different stages of their illness – acute admission, outpatient care and long-term care. However, these are currently badly integrated, leaving many patients unable to access the right specialist at the right time and often far from home. They include such a variety of conditions that more than one model is needed for good care. For the patient, and their families, they need to be able to move between services, without fights or delays in provisions.
To solve these problems, the report recommends better integrated primary, secondary and tertiary resources to achieve a neurology network that is easily accessible, provides local care where appropriate and, as needed, at the regional neurosciences centre. The report proposes changes to cover acute neurology services, outpatient care, care for patients with long-term neurological conditions, the relationship between local services and the regional centres, commissioning, workforce planning and training.
What can we do?
We don’t want the new report to grow dusty on the shelf. It is clear that both large and small scale changesare needed to improve acute and long-term care of neurology patients.
Improvements have been, and can be, made at local level and we really would like to hear about more of these, as models of good care.
The neurological charities support our calls for improvements in services for patients, both acutely and in the long term, and it is clear that central changes are needed. It is also clear that some of the changes will require more money. The resources required for direct access MRI would be much better spent on implementation of the RCP-ABN report, and we are making this crucial point to the Department of Health.
