Alistair Church

Key take-home messages

  • GPs already manage the great majority of neurological symptoms, and small increases in referral rates could overwhelm specialist services.
  • Advice and guidance can successfully support the management of a meaningful proportion of patients, but it must be timely, clear, educational and properly resourced.
  • Neurologists should use every letter as an opportunity to improve future primary care management.
  • Patients should receive clear written information and be given the tools to understand and manage their symptoms.
  • Secondary care should not shift specialist administration, test interpretation or appropriate onward referrals back to GPs.
  • Improving the interface requires primary and secondary care to behave as parts of one system, rather than as separate services passing patients and responsibility between them.

This was a candid talk from Alistair Church, who works both as a consultant neurologist and as a GP. His experience on both sides of the primary–secondary care divide gave him a distinctive perspective on why the current model is under strain and what neurologists can realistically do to improve it.

His central argument was that the traditional referral model is no longer sustainable. Neurological symptoms are extremely common in primary care, while specialist neurology capacity remains limited. Around 10% of primary care consultations involve neurological symptoms, representing tens of millions of consultations each year, yet only a small proportion of these patients are seen in general neurology clinics.

This means that GPs already manage the overwhelming majority of neurological symptoms successfully. It also means that even a relatively small increase in referral rates could overwhelm secondary care. In the speaker’s own service, referrals have continued to rise despite a substantial expansion in consultant numbers. Simply working harder or appointing more neurologists will not be enough; the way primary and secondary care work together must change.

Why are referrals increasing?

The reasons are complex and should not be reduced to poor referral practice.

Continuity in general practice has declined, making it harder for one clinician to observe symptoms evolving over time. This matters particularly in neurology, where early disease may be subtle and where time itself can be an important diagnostic tool. A patient with early Parkinson’s disease, tremor or functional symptoms may look very different six months after their first presentation.

Alistair also described a wider loss of confidence in managing uncertainty. General practice has traditionally involved observing, reviewing and intervening when necessary, rather than immediately diagnosing every symptom. Increasingly, however, clinicians and patients may feel uncomfortable with this approach.

Patient expectations are also changing. People may arrive with information from Google, social media or artificial intelligence tools, sometimes accompanied by a firm belief about which investigations or referrals they require. Anxiety can be difficult to resolve in a short consultation, and some referrals are driven as much by the need for reassurance as by a strong suspicion of neurological disease.

Reduced access to investigations can also push referrals upwards. In Alistair’s health board, removing direct GP access to MRI led to a substantial increase in referrals to neurology.

What neurologists should understand about general practice

A major theme was the importance of understanding what GPs contribute beyond diagnostic triage.

GPs often know the patient, their family, their work, their living circumstances and the wider context in which symptoms have developed. They may have cared for the same person over many years and can observe subtle changes that are difficult to capture in a single hospital appointment.

This longitudinal knowledge is one of the great strengths of primary care. However, familiarity can also bring risks, including complacency or delayed recognition of a condition that has developed gradually. Alistair didn’t idealise general practice, but argued that its strengths should be recognised and supported.

Advice and guidance should support primary care, not simply reduce waiting lists

Advice and guidance was presented as one of the most practical ways to improve the interface between primary and secondary care.

The available evidence suggests that around 20-30% of referrals may be managed through good-quality specialist advice rather than a face-to-face appointment, although this varies according to the quality of the referral, the condition involved and the clinician’s tolerance of risk.

Alistair strongly supported advice and guidance, but warned against treating it as a mechanism for rejecting referrals or reducing waiting lists. Its purpose should be to help primary care clinicians manage appropriate patients in the community.

For advice and guidance to work, it must be timely, clear and clinically useful. It should explain what the neurologist thinks is happening, what the GP should do next, what warning signs should prompt reconsideration and when formal referral would be appropriate.

It should also be properly resourced. This work cannot simply be added to a consultant’s lunch break or squeezed between clinics. It requires protected time, suitable systems and appropriate governance.

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Every specialist letter is a teaching opportunity

One practical message was that neurologists should use correspondence to strengthen primary care knowledge.

A clear response to one GP may improve the management of many future patients. Alistair described learning from specialist letters himself and later applying that knowledge when seeing similar presentations.

In the discussion after the talk, he gave very direct advice about how neurologists should structure clinic letters. The diagnosis should be placed clearly at the top. Any action required from the GP should be prominent, ideally near the beginning and in bold. Important requests should not be buried in the middle of a long narrative.

Letters should also be copied to patients. Patients frequently forget much of what is said during an outpatient appointment, and written information helps them understand and take greater responsibility for their care.

Patients should be active participants

Alistair repeatedly returned to the need to give patients greater knowledge and control.

Waiting for a neurology appointment is not a neutral period. During a six- or eight-month wait, a patient may become increasingly focused on symptoms, stop working, stop driving or withdraw from normal activity. Anxiety and disability can become more established, even when the underlying condition is benign or manageable.

Earlier advice, reassurance and access to reliable information may therefore prevent harm, even when a specialist appointment is not required.

Digital NHS systems could support this by giving patients access to letters, care plans and trustworthy information. The aim should be to move away from a model in which the patient simply presents symptoms and waits for the health service to “sort them out”.

Neurologists should not transfer specialist work back to GPs

Alistair was particularly clear about behaviours that damage relationships between primary and secondary care.

Neurologists should not ask GPs to explain investigations that the specialist has ordered, manage results outside their competence or undertake administrative tasks that properly belong to secondary care.

Similarly, when a neurologist identifies an urgent need for another specialist opinion that is directly related to the patient’s presentation, they should make that referral themselves rather than asking the patient to return to the GP solely to obtain it.

This does not mean every incidental problem must be managed by the neurologist. However, unnecessary transfer of work creates delays, frustrates patients and adds to pressures in primary care.

What can neurologists do in real life?

Neurologists can redesign parts of their everyday work rather than waiting for major structural reform.

They can provide timely, supportive advice and guidance; use letters to educate both GPs and patients; make diagnoses and required actions immediately visible; direct patients to reliable self-management information; take responsibility for their own investigations and onward referrals; and contribute to local guidelines and educational resources.

Most importantly, they can approach primary care as a clinical partner rather than simply the source of an ever-growing referral queue.

The overall message was collaborative rather than critical. Neurologists cannot solve rising demand simply by seeing more patients. Their wider role must include supporting, educating and communicating with primary care so that patients receive appropriate neurological care without unnecessary delay.

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