The patient population
The specialty of clinical neurophysiology provides services to patients of all ages from premature babies to older adults. Numerically, the workload is largely outpatient based. Some of the most urgent, complex and expensive studies are performed on inpatients, either in acute settings or in operating theatres.
High-quality outpatient studies require dedicated rooms with environmental control, recording equipment and, above all, well-trained staff who have adequate supervision. These factors largely determine the number and location of sites at which the service can be provided, and therefore the need for patients to travel. Small departments that cover acute services may find it difficult to provide satellite units.
The types of investigations required on patients in intensive care units can often be performed on portable equipment. Providing services to these patients requires access to tests within reasonable timeframes at any time of the week – something which is simply not available in many parts of the UK.
Prevention of disease
Clinical neurophysiology is almost entirely a diagnostic discipline. Its biggest contribution to reducing the burden of disease consists of identifying and quantifying the disease. For example, in carpal tunnel syndrome the results of nerve conduction studies may influence the decision whether to operate. In other cases, a completely different management pathway may be suggested by clinical neurophysiology – it is well recognised that motor neurone disease may present as ulnar neuropathy, for instance.
Recent changes in the management of patients experiencing out-of-hospital cardiac arrest have led to an increase in adult patients with hypoxic ischaemic encephalopathy. Neurophysiology has an increasing role in prognostication within intensive care units (ICU), enabling appropriate end-of-life planning for some patients.
Planning effective services
Models of provision
Commissioning the delivery of clinical neurophysiology services is often challenging, as in order to operate efficiently and ensure high-quality services departments need to achieve a critical mass, which almost invariably necessitates providing services to a number of commissioners.
In a few large neuroscience centres within areas of high population density it is reasonable to centralise services in one hospital. However, for much of the UK this model requires patients to travel significant distances, which is difficult given that many are children or have mobility problems or cannot drive because of epilepsy. In these circumstances a more devolved hub and spoke delivery model is more appropriate.
To ensure high-quality services, departments should ideally have:
- two or more consultants; single-handed consultant posts are undesirable even in the most remote corners of the UK
- a commitment to training a sustainable workforce, ie participation in a specialist registrar training programme and in the case of healthcare scientists to Practitioner Training Programme (PTP), Accredited Scientific Practice (ASP) and Scientist Training Programme (STP) levels
- a facility to allow senior healthcare scientists to progress and train to Higher Specialist Scientific Training (HSST) level. In most cases this will entail secondment to a large neuroscience centre
- sufficient healthcare scientists to deliver the service, train new recruits and to provide a Modernising Scientific Careers (MSC) compliant local career structure to ensure retention
- sufficient secretarial and administrative staff
- full IT integration with online booking and results availability.
Many new services have been planned without the involvement of clinical neurophysiologists. Although other consultants, particularly neurologists, may have a good understanding of the tests provided they may not be aware of patterns of service provision that might best match the resources available locally. Those planning new services can contact the British Society for Clinical Neurophysiology (BSCN) for up-to-date advice.
Hand-held ‘near patient’ devices are available for some nerve conduction studies. The BSCN offers specific advice (opens PDF, 44.10KB) about providing services using hand-held devices.