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.

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Figure 3

Pinderfields Hospital, Wakefield.

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!)

Conclusion

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.