The inpatient neurology consultation service: value and cost

Editor–The paper by Douglas and colleagues emphasises the importance of neurological advice for the diagnosis and management of hospital inpatients with acute neurological disorders (Clin Med June 2011 pp 215–17). This is usually available in the district general hospital (DGH) attached to the regional neurology centre but not so readily elsewhere. This can create difficulties since the present default model of management of acute medical emergencies is admission to an acute medical unit (AMU) followed by triage to an appropriate specialist consultant physician. Without neurologists in the DGH, who rarely have inpatient beds, there is nobody for patients with acute neurological symptoms to be triaged to.

The recent report Local adult neurology services for the next decade published jointly by the Royal College of Physicians and Association of British Neurologists, draws attention to this inequitable standard of care for patients with acute neurological disorders in many DGHs.¹ It also refers to other evidence² that liaison neurology can halve the length of stay of patients with acute neurological emergencies and result in more accurate diagnosis, confirmed by Douglas et al's paper. One of the major recommendations of the report is that acute neurology services run by neurologists should now be specifically commissioned and provided in the DGH so that patients with acute neurological disorders get earlier access to a neurology opinion and treatment.

Some simple calculations show that rapid access to neurology advice, as well as potentially improving outcomes, would easily pay for the appropriate neurological time by saving costs through reductions in the length of stay and number of admissions. If 120 patients have an average length of stay of four days each, this amounts to 480-bed days per three months at a cost of £72,000 (assuming £150 per bed day). Reducing the length of stay to two days saves £36,000 per three months or £144,000 per year. Halving these estimates to an average length of stay to two and one day respectively, still amounts to £72,000 per year, more than enough to pay for the necessary neurological sessions.

There are therefore sound financial reasons as well as potential improvements in care if patients with acute neurological disorders are seen by the people best able to look after them, ie neurologists. General physicians, specialist physicians themselves, quite rightly in my experience, see no reason why they should continue to manage patients with acute neurological disorders any longer. This is surely the responsibility of neurologists! The case for acute neurology run by neurologists is incontrovertible and DGH trusts should be encouraged to appoint acute neurologists to do this.