Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
Yorkshire, it is said, is ‘a country within a county’. It boasts the famous limestone scenery of the Yorkshire dales, the popular historic city of York, beautiful coastline including traditional fishing ports such as Whitby and the stereotypically taciturn Yorkshire people. West Yorkshire accounts for half its population (figure 1). Leeds, now a thriving commercial centre, is the largest city with a population of 800,000. Wakefield was once a powerful hub of the coal industry. Although it lies within the ‘rhubarb triangle’, a neurologist with a diagnostic dilemma requesting a serum rhubarb test is likely to receive short shrift by our laboratory!
Pinderfields Hospital in Wakefield (figure 2) was built on the grounds of the West Yorkshire Lunatic asylum (1818-1995) and thus has an illustrious history of neuroscience research. One of the founding fathers of epileptology and neurological localisation, Sir David Ferrier, did much of his experimental work here. Along with the asylum director Sir James Crichton-Browne, John Hughlings-Jackson (of ‘Jacksonian march’ fame and born only a short cycle ride from the author's house) and Sir John Bucknill founded the journal The Medical Reports of the West-Riding Lunatic Asylum which later evolved into the journal Brain. Nearby is the town of Pontefract, famous (some would say!) due to the production of Pontefract cakes. These discs of liquorice are seen by locals as a tonic for various ailments, but we have come across cases of over-indulgence resulting in generalised weakness (resulting from hypokalaemia) and severe hypertension due to the active ingredient glycyrrhizic acid.
In West Yorkshire there is no hub-and-spoke model of neurological services, rather each trust employs its own neurologists to work locally. We all meet once a week to discuss cases and exchange ideas.
Much has been written on the need for neurologists to leave their clinics and involve themselves in the care of acute patients with neurological problems. With limited numbers of neurologists in the UK, we compare poorly with colleagues elsewhere in the world in our ability (and willingness) to get involved with the care of those with acute neurological problems, often to the detriment of our patients. Neurologists' provision of acute neurological services is one of many important strands within the recent Association of British Neurologists/Royal College of Physicians report, ‘Local adult neurology services for the next decade’.1 In the (at times) wild west of Yorkshire, we have developed two different approaches to the challenge of acute neurology, the Lone Ranger in Leeds and the Magnificent Seven in Wakefield.
The Lone Ranger (ED)
I was employed in 2004 to take on the considerable unmet need of neurology patients admitted under medicine at the Leeds General Infirmary. It was intended that I would move to a more traditional consultant role after a couple of years, but 7 years later that does not appeal. Why is that? In short, because I enjoy what I do, but that may need some explaining.
Leeds Teaching Hospitals is the largest NHS Trust in the UK. Although stroke is now admitted directly, most neurological admissions are through the acute medical unit (AMU). The commonest reasons for admission are epileptic seizures, migraine with aura and functional weakness but the spectrum of presentations is broad. I provide a ward liaison service three times a week. Referrals are left in my folder after the three consultant rounds on the acute floor (admissions unit, short stay ward and elderly admissions unit). On the other days of the week, the physicians decide either to call the deputy (referrals registrar) or to ask the patient to return to see me another day in my acute clinic. As well as the unpredictable nature of what will be referred, I enjoy the opportunities for teaching the juniors that the rounds provide. I also train acute medicine registrars and often discuss cases with the referring consultant after assessing the patient.
My provision of a less than comprehensive service would seem to be an obvious weakness, but I strongly suspect it is also a strength. Through working closely with the physicians, we avoid the trap of learned helplessness, whereby the physicians would simply leave all the neurology to the neurologist. Instead, I have seen the quality of referrals to my acute clinics improve and the ‘missed’ cases, not picked up by the physicians, have dropped off markedly. As an example, patients with spinal cord pathology seemed to be missed on a monthly basis during my first year in post; now it is about one a year. As well as improving the quality of care on the AMU, the length of stay for neurological patients has fallen considerably (8 days in 2004/5 to 2 days in 2009/10), and so the model works well for the management too.
I provide two acute clinics per week, ensuring rapid access primarily for internal referrals but also seeing the urgent 2-week wait referrals for suspected first fits and central nervous system cancer. The clinic also allows follow-up for the more challenging cases seen in the AMU. In particular, patients with non-epileptic attacks and functional weakness prove tricky – many are the days I wish the Lone Ranger was indeed accompanied by his sidekick Tonto (the liaison psychiatrist).
The Magnificent Seven (RD et al)
To be accurate, we are five not seven but in Wakefield (Mid-Yorkshire NHS Trust/Pinderfields Hospital (figure 3), a district general hospital serving around 550 000 people) we share the acute work, taking turns as ‘Neurologist of the Week’ (NOTW). The NOTW role includes twice weekly ward rounds, seeing inpatient referrals, dropping in to the neurology ward to support the junior doctors, in-reach to the AMU and an acute neurology clinic. This runs every afternoon, with the NOTW booking suitable cases mostly at short notice. The NOTW does not do routine outpatient clinics. The system provides a mechanism to see urgent outpatients, such as multiple sclerosis relapses and suspected central nervous system cancer. At present we have only minor involement with the acute stroke and transient ischaemic attack service due to the extra workload this brings. The NOTW is supported by one or two neurology registrars. This provides an excellent training opportunity for neurology registrars and offers an inbuilt means of completing work-based assessments.
We have operated the NOTW service for over a year and have found it both challenging and rewarding. Our audits show gradually increasing case numbers seen and calls received. Feedback from referrers both within the trust and from local general practitioners suggests that the service is well received. Although difficult to measure, our perception is that we both prevent and significantly shorten admissions. We have some concerns that the system is open to abuse, since referrers have such rapid access to outpatient opinions – the NOTW system risks of becoming a victim of its own success! At times, the role is stressful and busy, bringing back long-suppressed memories of house jobs. A huge range of neurological disorders, common and rare, can be seen in close succession. By Friday evening, it is certainly time to put the feet up with glass of wine!
The system has had a knock-on effect on related services such as radiology and neurophysiology that require foresight and planning. Adequate secretarial support is crucial. Instigating our NOTW system required prolonged discussions with hospital managers who took much convincing that the system would not detrimentally affect all-important targets (this has not been the case so far!)
We have highlighted two innovative ways of running a consultant-led acute neurology service. Each has their pros and cons; we will leave the reader to decide whether the former out-weigh the latter.
The authors would like to thank our fellow consultant neurologists for their support in developing and running our acute neurology services.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.