Neurology

Ensure that all patients with acute neurological disorders can promptly access neurology services, including through acute neurology clinics. Actions: a) Ensure neurology services are available at all sites admitting patients with acute neurological disorders, either on site or through defined links with another site. If services are not available, appropriate pre-hospital triage should divert patients to sites with these services. b) Develop acute neurology clinics to provide prompt access to patients with acute neurology disorders. The service would cover all urgent referrals, and cancer waiting times would be met for patients referred on suspicion of cancer. The service model would equate to that of a Rapid Diagnostic Centre (RDC) pathway, meaning that one service could be provided for all urgent referrals. Assurance that a service meets the components of the RDC pathway would be necessary for it to receive cancer referrals. c) Embed effective, funded and clinically led electronic triage systems within trusts to ensure that patients are directed appropriately. d) Ensure that the acute neurology clinic is linked into supporting services, such as imaging and other diagnostics, to enable appropriate rapid access to investigations. e) Audit rate of access to the acute neurology clinic if this is only provided at one site within a multi-site trust, to ensure that all sites have equitable access and proportionate usage.

Embed neurology liaison services to allow timely access to neurologist advice at all sites. Actions: a) Provide an electronic, responsive consultant-led liaison neurology service seven days a week at all sites. The electronic responsive system should provide access to neurology advice when neurologists are not on site. b) Introduce a daily, consultant-led proactive liaison neurology service at larger sites to complement the responsive service. c) Monitor liaison neurology services to ensure consistent delivery.

Expand inpatient services to allow more non-elective admissions to be managed under neurology. Actions: a) Develop inpatient neurology services, particularly at those sites with stroke services. b) Explore options to develop inpatient neurology services at larger sites (those with >0.52% of non-elective admissions) or between linked sites. c) Where inpatient beds are not available, cohort patients with neurological conditions onto a limited number of wards to support development of specialist expertise. d) Where inpatient beds are not available, develop virtual neurology MDT meetings involving relevant team members, including neurologists, trainee neurologists and neurotherapists. This will be most effective in conjunction with action 3c.

Implement advice and guidance and a triaging system of outpatient referrals to ensure effective management of referrals, offer earlier management advice, improve clinic waiting times and reduce DNAs. Actions: a) Implement advice and guidance services. Appropriate time within consultant job plans needs to be recognised to support effective use of these systems. b) Triage outpatient referrals using systems such as the NHS Referral Assessment Service (RAS) within the NHS e-Referral Service (e-RS). Appropriate time within job plans needs to be recognised for this activity. c) Introduce strategies to reduce DNA rates (neurology and trust wide) and phone patients who DNA to undertake remote consultations if appropriate.

Establish mechanisms to better understand outpatient activity to support service planning and enable benchmarking between trusts. Actions: a) Establish specified list of core neurological diagnoses that should be routinely coded from clinic letters. b) Use the specified list of core diagnoses to identify cohorts of outpatients and enable review of condition-specific pathways / better comparison of activity. c) Ensure activity is correctly attributed to the specialty and staff group. Outpatient activity for each consultant should be reported routinely in job plan reviews.

Use remote consultations where clinically appropriate, in line with NHS Long Term Plan and Outpatient Transformation Programme ambitions. Actions: a) Continue to use remote consultations for those patients for whom it is beneficial once COVID-19 has passed. Explore using this as a way of accessing tertiary and quaternary opinions.

Explore opportunities to train advanced practitioners, including specialist nurses or physician associates, to perform lumbar punctures and other appropriate procedures in an outpatient setting. Actions: a) Trusts to consider where advanced practitioners may be able to deliver procedures on their sites and arrange for this alongside training as appropriate, sharing experiences with GIRFT. b) GIRFT to disseminate best practice and consider any issues arising with colleagues in NHSE/I and elsewhere as appropriate.

Review and modernise follow-up strategies within the department to best meet patient needs. Actions: a) Consider arranging clinically triggered follow-ups for patients with pending results, personalised patient-initiated follow-ups for patients with disease in remission or with stable disease, as well as the traditional timed follow-up appointments.

Establish specialist clinics for the most common neurological disorders locally at all sites, with network links to regional or national services. Actions: a) Allocate a lead clinician for each of the most common neurological disorders at each site. b) Establish specialist treatment clinics to provide special injection services or other minor procedures, such as botulinum toxin for dystonia, spasticity and chronic migraine, and peripheral nerve blocks for headaches.

Ensure that patients with chronic neurological disorders have access to specialist nurses or other advanced practitioners working as part of an integrated multidisciplinary team, with appropriate administrative support. Actions: a) Integrate specialist nursing and advanced practitioner resource within the neurology service to enhance and maintain specialist skills. Trusts will need to consider any resourcing issues, and are encouraged to work with other providers within their ICS to establish shared arrangements if helpful. GIRFT will consider any resourcing issues with colleagues in NHS England and NHS Improvement at a national level if needed. b) Develop credential proposals for consideration by HEE, with a view to standardising training for advanced practitioners (including specialist nurses) and covering both general neurology and disease-specific support.

Develop pathways for management of patients with seizures and suspected seizures (including non-epileptic attack disorder) within A&E/acute medical units to link into epilepsy services. Actions: a) Ensure patients with suspected seizures are referred for an early assessment in an outpatient department within two weeks (as per NICE guidelines), with linked capacity for radiological and neurophysiological investigations. b) Embed systems that notify epilepsy services that patients with epilepsy have attended A&E or been admitted to hospital.

Support the Department of Health and Social Care co-ordinated response to implementation of the Independent Medicines and Medical Devices Safety Review relating to safe use of sodium valproate in women of child-bearing potential. Actions: a) Carry out an annual review for all women currently taking sodium valproate. b) Continue to follow guidance regarding prescribing of sodium valproate and alternatives. c) Continue to support patients' involvement in the Pregnancy Prevention Programme (PPP), including by ensuring electronic systems are compatible when the PPP moves online. d) Once established, contribute to the registry for all women on anti-epileptic drugs who become pregnant, and women with MS on disease-modifying therapies.

Ensure understanding of efficacy of MS disease-modifying treatments. Actions: a) Explore options to enable funded analysis of follow-up of patients on MS disease-modifying treatments to provide real-world comparisons of drug use and efficacy.

Develop clinically led subspecialty regional networks, starting with epilepsy and MS, with links to local MDTs. Actions: a) Develop epilepsy regional networks involving neurologists and epilepsy advanced practitioner/nurses. b) Local neurology services should run virtual MDTs with team members including neurologist, specialist practitioners, neurophysiologist and neuroradiologist input for patients with epilepsy; this would provide a forum for interaction with epileptologists from regional services. c) Develop regional MS networks to facilitate virtual MDT discussions.

Optimise services provided by neurologists and geriatricians in the management of Parkinson's disease, and avoid duplication of services. Actions: a) Develop local pathways for patients with Parkinson's disease to optimise the skills of neurologists and geriatricians in the management of Parkinson's disease and to avoid duplication of services. Local pathways should take into account access to specialist palliative care in the management of Parkinson's disease.

Ensure regular review of readmission rates for headaches to understand and address variation, to ensure the pathway for these patients is optimised. Actions: a) Review readmission rates for headache, and carry out local audit of any high rates.

Ensure appropriate provision of whole-life management for patients with MND. Actions: a) Audit site of death for patients with MND and use this as an indicator of whole-life management, and compare with data collected via the Office of National Statistics.

Review and improve local provision of treatments for chronic neurological conditions to ensure patients can access care as close to home as feasible. Actions: a) Collaborate with local and national commissioners to optimise local provision of MS disease-modifying treatments. b) Review pathways to ensure that botulinum toxin clinics for dystonia, spasticity and related disorders, and chronic migraine, are available at sites close to patients' homes. Where possible, non-medical staff should be trained to provide botulinum toxin injections for those patients with stable treatments, with appropriate clinical governance. c) Ensure patients receiving long-term treatment with intravenous immunoglobulin can access treatment as close to home as possible, including consideration of treatment at home. d) Collaborate with local and national commissioners to ensure MND services are delivered as close to home as is feasible. This should include simplifying commissioning of respiratory support for patients with MND.

Use neuroscience centre links into subspecialty regional networks as a key interface for accessing and developing research. Actions: a) Identify areas for research as required, alongside co-ordinating services at system level, within and between integrated care systems.

Review the organisation and roles of neurologists and neurology trainees to better meet patient needs and maximise training quality. Actions: a) Ensure posts for neurologists involved in providing links to neuroscience centres are structured to facilitate and support local neurology service delivery. b) Review the distribution of neurology trainees between sites to maximise training opportunities in acute neurology. c) Evaluate the value, in terms of training experience, of trainees being on call for neurology and specify the experiences that trainees should acquire during their training period. d) Introduce a regional consultant on-call rota. e) Facilitate access to funded fellowship schemes to allow neurology registrars to develop subspecialty expertise in shortage areas, notably the most common subspecialty areas: MS, epilepsy, movement disorders and headache.

Establish inpatient neurology services to mirror the sites of acute stroke services and ensure that neurology trainees play a key role in stroke care. Actions: a) Ensure that neurology trainees continue to obtain experience in acute stroke. b) Review trainee numbers for subspecialty training in stroke.

Improve integration of neurology and neurophysiology services, in turn improving prompt patient access to neurophysiology and new technologies. Actions: a) Ensure neurophysiology services are accessible at all large DGHs with inpatient services. b) Deploy new technologies to enhance service delivery including remote reporting of EEGs, home video telemetry services and improved access to prolonged EEG. c) Increase the numbers of trainee healthcare scientist support workers, practitioners, clinical scientists and consultant clinical scientists to support neurophysiology services. d) Enable clinical physiologists to perform more sophisticated peripheral nerve studies within appropriate clinical governance through appropriate training. e) Enable clinical physiologists to report studies, including normal EEGs and some peripheral nerve studies, within an appropriate clinical governance structure. f) Increase the number of consultant clinical neurophysiologists and credentialed neurologists to allow service delivery.

Improve access and links into neuroradiology services, including through the use of digital solutions. Actions: a) Ensure all sites have access to a neuroradiology MDT, either in person or virtually. This would be facilitated by imaging networks. Digital solutions are required to ensure images and reports are accessible. b) Develop neuroradiology services links with all DGH sites, ideally with visits in person, to enhance imaging of the brain and spine. c) Ensure GPs have access to CT and MRI brain scan within appropriate guidelines. This would be enabled by Community Diagnostic Hubs.

Remodel commissioning arrangements for neurology by narrowing the definition of specialised services, ensuring additional neurology centres are developed to provide leadership and advice, and contracts are designed to support more accessible local neurology services. Actions: a) Redefine specialised neurology services as part of the national neurosciences review to include only high-cost activities or activities that can only be provided at limited number of sites by virtue of infrastructure or links. b) Review commissioning and payment arrangements with a view to facilitating development of inpatient neurology services. c) Use MDT and referral models to ensure that regional and national specialist expertise is accessible to local neurology services. d) Develop a national framework for contracts between neuroscience centres and linked trusts to allow for development of the most clinically appropriate neurology services. e) Commission highly specialised supra-regional services in a way that allows and facilitates cross-regional/ICS access to services that are not provided in all regions, so all patients have access to services, regardless of where they live. f) Ensure commissioning and payment arrangements that allow some services to benefit from extended clinic appointments or enhanced staffing requirements. g) Building on all of the actions above; develop, monitor and manage neurology services at system-level, based on whole population need, with national co-ordination for highly specialised services as required.

Consider options for creation of a neurology dashboard, building on routinely collected data, to enable monitoring of key metrics to support continual quality improvement. Actions: a) Consider options to deliver this, including Model Hospital, alongside any other GIRFT or NHS England and NHS Improvement products.

Reduce litigation costs through application of the GIRFT programme's five-point plan. Actions: a) Clinicians and trust management to assess their benchmarked position compared with the national average when reviewing the estimated litigation cost per activity. b) Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. c) Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. d) Claims should be triangulated with learning themes from complaints, inquests and serious incidents (SI)/patient safety incidents (PSI) and where a claim has not already been reviewed as SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. e) Where trusts are outside the top quartile of trusts for litigation costs per activity, GIRFT will be asking national clinical leads and regions to follow up and support trusts in the steps taken to learn from claims.