Liaison neurology (consulting with inpatient ward referrals) is the main way that most patients admitted with neurological disease will access neurology services. Most liaison neurology services are responsive, seeing referrals on request, but they also can be proactive, with a regular neurology presence in the acute medical unit. Fewer than half of hospitals in England have electronic systems, yet these can facilitate the process—allowing electronic responses to advise on investigations before seeing the patient, and arranging follow-up after—as well as prioritising referrals and documenting the process. In this time of COVID-19, there are additional benefits in providing prompt remote advice. Improving the way liaison neurology is delivered can improve patient outcomes and save money by shortening admissions. This hidden work of the neurologists needs to be recorded and recognised.
- SOMATISATION DISORDER
- CLINICAL NEUROLOGY
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Getting It Right First Time is an initiative within the National Health Service (NHS) in England that looks at variations in service delivery, aiming to use an analysis of this variation, together with examples of best practice, to improve patient care.1 The considerable variation in liaison neurology services in England suggests opportunities for significant improvement. Many of these opportunities for improvement will applicable to neurology services internationally.
Acute neurology is an important part of the acute medical service. In England in 2018–2019, there were 3 092 052 non-elective admissions under all medical specialties2 of whom 242 085 were discharged with a primary diagnosis of neurological diagnoses, excluding stroke.3 Thus, primarily neurological disorders, excluding stroke, accounted for 7.8% of non-elective admissions. This can be regarded as a minimum estimate of neurological disorders, as many patients with coexisting neurological disorders will be admitted with primarily non-neurological diagnoses (eg, a patient with epilepsy admitted with a chest infection).
Most previous studies looking at admission rates over limited periods at individual hospitals in the UK and internationally4–6 have found that about 10% of acute medical admissions have neurological problems once stroke is excluded. Those reporting higher rates have considered symptoms at presentation.7
Liaison neurology: what is it and why is it important?
Liaison neurology has no strict definition, but the term has been used to describe the consultation service where neurologists are asked to see inpatients under general medicine and other specialties as inpatient referrals. While a few services offer dedicated neurology beds for all patients with neurological disease and stroke,8 most patients in the UK and across the world9–20 who are admitted with neurological disorders are cared for by general physicians. Thus, the main way for inpatients to access specialist neurological opinion is by referral through a liaison neurology service.
A neurological referral service can have a significant clinical impact. Following neurological liaison assessment, 21–63%9 14–16 19 21 have a change in diagnosis and 21–88%9 1213151618 have a change in management plans—with reduced length of stay16 20 and reduced inpatient care costs.17 20
In 2011, The Royal College of Physicians (London) and the Association of British Neurologists (ABN) recommended daily neurology consultant ward rounds at all sites admitting neurology patients.22 In 2017, the ABN quality standards suggested that advice should be available at all times for patients admitted with a neurological emergency, or within 4 hours for an acute neurological admission, and that patients should be able to see a neurologist within 24 hours.23 These standards are challenging, and achieving such a timely response requires an effective referral system.
What happens now?
Liaison neurology services vary between hospitals. The systems used have developed according to local custom, the type of neurology service available (and hence the staff available) and the infrastructure within the hospital.
Neurology services in hospitals across England vary and have been divided into five categories.1
Neuroscience centres have neurology and neurosurgery inpatient beds and neurology trainees.
Neurology centres have neurology inpatient beds and neurology trainees.
District general hospitals (DGHs) with a neurology service have neurologists based at that site.
DGHs with visiting neurologists have regularly visiting neurologists, who are based elsewhere.
DGHs without a neurology service have no regularly visiting neurologists.
Figure 1 shows the numbers of patients admitted to each type of site with primarily neurological disorders.
Two-thirds of patients with primarily neurological diagnoses are admitted to hospital sites without neurology inpatient beds and thus with no junior neurological rota. Within this, one-third (of the total) are admitted to sites where the neurological services are provided by neurologists who visit from another site and who, by definition, are based elsewhere. This highlights the need for an efficient liaison service with a system that allows advice to be provided at a distance.
Liaison neurology services have two elements.
1. A proactive service, where neurologists are either based at or regularly attend the acute medical unit. In about 60% of neuroscience or neurology centres, neurologists regularly visit the acute medical unit; occasionally, they are based in the unit.20 However, in a significant number of these centres (21–27%), neurologists do not visit the acute medical unit regularly.
Neurologists ‘usually’ or ‘almost always’ visit the acute medical unit at 38% of DGHs with neurologists based there (40% ‘rarely’ or ‘almost never’ do), whereas at DGHs with visiting neurologists, 26% ‘usually’ or ‘almost always’ have neurologists attend the acute medical unit (47% ‘rarely’ or ‘almost never’ do).
Daily or two times per day, visits to the acute medical unit would provide one mechanism to meet the ABN standards and to achieve prompt review and early diagnosis and management. These data illustrate that this is possible even in smaller hospitals, though it requires this activity to be appropriately resourced. Most other major medical specialties undertake such acute medical unit visits. Why should neurological patients not benefit from them too?22
2. A responsive service, where neurologists respond to referrals from other specialties. The way these referrals are made varies considerably. These include the following:
Contacting the neurologist by bleep or phone to make a referral in person.
Calling the neurology secretary and leaving a message (or an answerphone message out of hours).
Using a paper letter or referral form (these are often coloured—‘a yellow slip’ or ‘red top’).
Faxing an internal referral (which usually requires phone calls to the secretary to find the number and to make sure it has arrived).
Using an electronic system, as part of an electronic patient record.
Using a bespoke system electronic system, such as an email-based system.
All these approaches are currently being used in England (figure 2). Fewer than half of sites reported using an electronic system. Sites that have a trainee rota tend to use these doctors as the first point of call either in person or by phone.
Some referral systems that seemingly fit into the classification above are much more convoluted. For example, at one site, the referrer must type the referral into the electronic paper record and then print the referral out and then fax it to the neurology secretary who then gives the fax to the consultant when they visit the hospital.
What does a referral system need to do?
All referral systems have some features in common. They all provide core information about the referral: who the patient is, including age and hospital number or other identifier; where they are; key points in the patient’s medical background and the question being asked. Beyond this, the different methods each have different strengths and limitations that relate to the following: the quality of the clinical information in the referral; the timeliness of the delivery of the referral; the security and efficiency of the system; the opportunity for discussion and response; the ease, reliability and timeliness of response; the opportunity for audit and follow-up; and the opportunity for education. All these issues are common to other medical and surgical specialties. However, given that most inpatients with neurological disorders depend on this mechanism as the main way to access neurological services, the issue is of greater importance to neurology patients.
The huge advantage of referrals made to the neurologist in person or directly on the phone is that they allow the referring doctor to provide full information and immediate discussion of the issues, the opportunity of immediate advice if applicable and an opportunity for education. This is the mechanism for emergency advice. It requires access to a neurologist who can be interrupted and is thus often delegated to trainees, a service available in a minority of sites (figure 2). However, this system has disadvantages: the referrals are dealt with as they are made, with the same mechanism being used for simple, complicated, non-urgent and urgent referrals, which makes it more difficult to prioritise them efficiently; the referrals are not trackable or linked to the patient record and the referral process is usually carried out by trainees; this is time-consuming for both the referrer, who has to track down the neurologist, and the provider team, who has to do the tracking; and there is no inbuilt system to follow up the referrals.
Referrals that depend on leaving messages with a secretary or on an answerphone introduce an inevitable delay and provide no opportunity for discussion or immediate advice and the risk of being lost. With a message left on an answerphone, the referrer cannot be confident that the referral has been received and will be acted on.
The fax has been widely used within the UK as a secure mechanism of communication within hospitals and between hospitals and general practitioners. However, fax tends to be a one-way form of communication. In addition, faxes are becoming obsolete; one site was running an ‘axe the fax’ campaign to encourage more sustainable systems.
Electronic referral systems, whether they are part of the electronic record or bespoke (eg, the email-based system described in box 1 can provide an easy to set up service), provide a legible, trackable, auditable train of information, are delivered promptly and facilitate easy response, either to seek further information if needed or to provide immediate advice. The referring team knows that the referral has been made and can confidently await a response. An electronic referral system allows physicians at sites that depend on visiting neurologists to make neurological referrals and get advice when a neurologist is not on site. Additionally, the visiting neurologist will be aware of the referral, where the patient is within the hospital, and can prioritise accordingly—for example, to see someone before rather than after the clinic.
An email-based referral system
A simple and effective electronic referral system can be developed within an email system.
A referral address is created and set up as a subdirectory within the email accounts of all those consultants and registrars who would see referrals (and usually their secretaries). This allows neurology staff to open and see all emails making referrals.
In its simplest form, the referral could just be made to the email address. However, it is relatively simple to set up a page within the hospital intranet to include a standardised referral form. It is worth engaging with members referring teams in designing the referral form, balancing space for free text with some prompts to provide relevant information, and to encourage the referrer to think about the question they are asking.
The system can be set up to send copies of the responses automatically to the referring consultant as well as the referring doctor. The referrals and responses can be archived and linked to the patient record.
The neurology department will need a rota to cover referrals and a system put in place to ensure the referrals are cleared daily or two times per day.
When reading a referral, the consultant has several options:
If advice is all that is needed, they can email back (requesting a copy be printed off and put in the notes). They can request investigations be arranged or treatment started before the patient is seen.
If the patient needs to be seen, our practice is to write an opinion in the notes (of variable legibility) and then add a brief (and legible) note by email with an automatic copy to the consultant. This response ensures that the team knows the patient has been seen and highlights any specific actions that need to be prioritised—and again is printed off in the notes. The email response is archived, which can help in follow-up.
If the patient needs follow-up or specialist nurse involvement, then this can be requested by forwarding emails to secretary or nurse.
For some departments within the hospital, for example, the acute medical units where trainees work on shifts, that department can set up a shared email address to receive the responses to referrals so that this information is not lost if one trainee is away after making a referral.
Within the National Health Service, the email system, nhs.net, provides a confidential email system within which to share patient information. The referral and responses are part of the patient record, so the emails need to be copied into the record, either printed off or copied electronically into the patient record.
Electronic systems simplify referrals for the referring team. It is easy to make a referral and that referral is acknowledged. In most, there is a simple built-in mechanism to reply to provide advice and organise follow-up. Simple questions can be asked as there is the option for easy reply. In the current COVID-19 pandemic, this mechanism facilitates provision of advice at a distance. In addition, and rather against our expectation, our experience suggests that electronic referrals provide more complete clinical details. Writing referrals can also be seen as being a useful way for junior doctors to learn a skill they will need for the rest of their career—how to make an effective referral—and the response provides good educational feedback.
The few studies that have compared these mechanisms find that electronic referral systems are beneficial, reducing response time and user approval.13 The public might be puzzled by the notion that we need studies to demonstrate the benefits of electronic communication over the answerphone or the fax.
There is a concern that making referrals easier and more efficient will increase the demand for service. The number of referrals is increasing with time: one site found a 2.5 increase in demand over a decade18; early publications on liaison neurology reported seven referrals a week in 1996 in a neuroscience centre9; more recent reports 35 a week in a similarly sized DGH.21 While improving referral systems will probably increase demand for this service,13 maintaining an inefficient system to limit referrals is a poor justification and clearly is not in the best interest of patients. Ensuring that the neurologist’s response to any referral is also sent to the supervising consultant will encourage their trainees to think before referring .
Liaison neurology services and ward referrals are an increasing part of neurologists’ workload across the world13 17 ,19 and have been described as ‘hidden work’ of neurologists.13 These activities are not as appreciated externally as they should be; for example, they do not attract a tariff within the NHS. The lack of recognition, lack of monitoring and funding contribute to the difficulties in developing this service when there is widespread unmet need.
Having an electronic referral system does not prevent referrers from making urgent referrals in person—they can call a neurologist directly to request urgent advice as well as putting in an e-referral. However, an electronic system means fewer phone calls so that these more urgent referrals can be easily identified and dealt with more promptly.
Getting liaison neurology activity recognised
Liaison neurology is not measured in many healthcare systems including the NHS and does not attract specific funding despite being an increasingly important part of most neurology services. Recording this activity is a necessary step towards achieving the required recognition—an additional argument for an electronic referral system. Demonstrating the demand for the service and showing the benefits through an audit of the electronic system will allow service development. The amount of neurologists’ time needed will be subject to significant local variation; however, as an indicator, a recent study in a medium-sized hospital found that liaison neurology required 2.4–3.6 hours of neurology time per day on average, going up on occasion to 7.5 hours.18
Liaison neurology is an important service for patients with neurological disease. It prompts changes in diagnosis and management in a significant number of patients, leading to earlier diagnosis and treatment, and shorter admissions, all of which are likely to improve patient outcomes.
Proactive liaison neurology, with regular visits to the acute medical unit, is possible at every type of hospital, but requires recognition and funding.
The mechanism for making inpatient referrals varies considerably across England, a variation that is likely to be mirrored in other countries. A range of systems have evolved but only about half of hospital sites use electronic referral systems at present. Introducing an electronic system could improve specialist neurology access for inpatients. If the hospital infrastructure does not have an electronic notes system that enables this, a straightforward e-referral system can be built onto an internal email system to improve efficiency and effectiveness and enhance patient care.
Most patients with acute neurological disorders (8% of non-elective medical admissions) access neurological advice via a liaison neurology service; this advice frequently changes the diagnosis and management, and shortens length of stay.
A proactive liaison service, where neurologists regularly attend the medical admission unit, is available at most centres with neurology inpatient beds and some other sites, and is clearly feasible with appropriate resources.
A responsive liaison service depends on effective referral systems, which vary considerably: 20% use fax and fewer than half of hospitals in England use electronic referral systems.
Electronic systems for specialist inpatient referrals would improve speed of access, responsiveness and trackability of responses and thus improve care of neurology inpatients.
Fuller GN, Connolly M, Mummery C, Williams A, GIRFT Neurology Methodology and Initial Summary of Regional Data, 2019 https://gettingitrightfirsttime.co.uk/wp-content/uploads/2017/07/GIRFT-neurology-methodology-090919-FINAL.pdf accessed May 2020.
Royal College of Physicians. Local adult neurology services for the next decade. Report of a working party. London: RCP, 2011.
Broderick, N, Farrell, C & Tubridy, N. Should we call the neurologist? The value and cost of a growing neurology consultation service. Ir J Med Sci 185, 611–616 (2016).
I am grateful to my colleagues at Gloucester Royal Hospital for the development of our electronic referral system and for all welcome and interest from all the centres I have visited.
Funding This work is supported by the Getting It Right First Time team of Madeleine Connolly, Anne Osborne, Tim Gustafson, Nick Dunkley and Anthony James. The GIRFT/ABN Census was developed in collaboration with Cath Mummery at the Association of British Neurologists.
Competing interests GNF is a co-editor of Practical Neurology.
Patient consent for publication Not required.
Provenance and peer review Commissioned; externally peer reviewed by Niall Turbridy, Dublin, Republic of Ireland.
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