Reforming neurology services and the role of CCG commissioning

david batemanDr David Bateman, NCD for Neurological Conditions
David is a full time DGH Neurologist in Sunderland having previously worked as a Consultant in Bath and North Cumbria. He has a long standing interest and success in developing and improving neurological services particularly in conjunction with GPs. David was the chair of the RCP working party which together with the Association of British Neurologists published the recent report “Local adult neurology services for the next decade”. The report provides useful advice for commissioning local services. David has held national office as secretary of the ABN, Chair of the Standards and Services Committee at ABN and has also the Joint Neurosciences Committee at RCP.
E: david.bateman@nhs.net

Despite the controversy about CCG commissioning, it provides a remarkable opportunity to radically improve neurology services. Whereas previously only routine outpatient (OP) neurology appointments have been commissioned, there is now an opportunity to commission a specific urgent and acute neurology service and a NeuroCare service for patients with long term neurological conditions. Acute neurology services should be commissioned for a population of 500,000, given existing arrangements, but it can be smaller for routine outpatient services and long term neurology conditions. This depends on local discussions between the local Neurologists, GPs and CCG neurology leads.

The Royal College of Physicians/Association of British Neurologists (RCP/ABN) report (June 2011)1 highlighted the poor care that patients with acute neurological disorders receive and how this can easily be improved. Frequently these patients do not see a Neurologist on admission leading to possible poor outcomes. Evidence shows that providing liaison neurology, so that these patients are seen earlier, halves length of stay, changes management and reduces unnecessary investigations. The benefit of making such changes is illustrated by PHE figures showing that 70,000 patients were admitted with a final diagnosis of tension headache in England last year, at a probable cost of 21 million pounds. The NASH report2 revealed the poor care provided for patients with acute seizures attending hospital. Also commissioning urgent clinics can reduce admissions for seizures and acute headache which our CCG here in Sunderland have commissioned in preference to some routine appointments. Big improvements in care can be achieved at less cost.

Patients with long term conditions need care plans and organised care which have been shown to improve care and reduce emergency admissions. Groups of CCGs can commission specific services for Parkinson’s disease, multiple sclerosis and epilepsy along similar lines with multidisciplinary clinics done in the community alongside GPs. None of these patients need to be seen in secondary care. This idea is supported by the recent RCP initiative to develop community services with support from the local DGH specialists. It would allow sessional employment of all the necessary clinicians to provide a comprehensive service e.g. designated therapists and specialist nurses would also run clinics alongside. This would revolutionise care and management of patients with long term neurological conditions, with access to the appropriate clinicians in one place at one time! Patients would have local access to therapists. Specialist nurses would spend more time in the community skilling up and supporting practice nurses and community matrons. Local GPs would have their own service to refer to. Local GPs would sit in with the Consultant to learn the necessary skills to eventually run much of these clinics themselves. They also know the social and domestic background of these patients with better access to social care.

Neurology OP services are a classic example of the problems with supply sensitive care. OP numbers have risen exponentially over the past few years with the introduction of targets to the disadvantage of acute and long term care. OP access can be modernised by forming a committee of local Neurologists and GPs to scrutinise referrals and offer initial advice and guidance, if appropriate, instead of an appointment. This enables advice without delay. It can shorten waiting times by 40%. NeuroMail (an email service linking GPs with a Consultant Neurologist) can also be provided to offer advice and guidance for existing or more urgent new problems.

CCG commissioning along these lines would significantly improve care at lower cost. The opportunity must not now be missed!

REFERENCES

1. Royal College of Physicians. Local adult neurology services for the next decade. Report of a working party. London: RCP, 2011.

2. National Audit of Seizure Management in Hospitals (NASH) 2012 http://www.nashstudy.org.uk/