Psychiatric Bulletin (2005) 29: 465-467. doi: 10.1192/pb.29.12.465
© 2005 The Royal College of Psychiatrists
Psychiatric Bulletin (2005) 29: 465-467
© 2005 The Royal College of Psychiatrists
Service innovations: is there a market for neuropsychiatry? A year in the life of a district-based neuropsychiatry service
Ken Barrett, Consultant Neuropsychiatrist
Haywood Hospital, High Lane, Burslem, Stoke-on-Trent, ST7 6AG, UK,
e-mail:
kenneth.barrett{at}nsch-tr.wmids.nhs.uk
S. Sudharsan, Specialist Registrar in Neuropsychiatry
Haywood Hospital, High Lane, Burslem, Stoke-on-Trent, ST7 6AG, UK
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
This paper describes the clinical activity of a district neuropsychiatry
service over a 1-year period. The data presented are drawn from a clinical
database with individuals classified according to the following diagnostic
groups: acquired brain injury, early-onset dementia, Huntington’s
disease, epilepsy, other neurological disorders, developmental disorders and
non-organic disorders. Information is presented on out-patient case-load, new
out-patient referrals, general hospital referrals and in-patient
admissions.
RESULTS
The total out-patient case-load was 451;189 new out-patient and 99 liaison
referrals were seen and 90 individuals were admitted. Acquired brain injury
was the most common neurological diagnosis in all groups.
CLINICAL IMPLICATIONS
The demand for this service indicates that there is a market for
neuropsychiatry, even at a district level, and particularly in the management
of the sequelae of acquired brain injury.
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Introduction
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Neuropsychiatry as a sub-specialty was formally recognised by the Royal
College of Psychiatrists in 2001 with the creation of a College special
interest group. The group has drawn together clinicians working in many
different settings and although some specialise in single diagnostic groups
such as epilepsy or brain injury, others manage a wide range of neurological
diagnoses. What is the demand for such services and what do they do? The first
person to address this was Alwyn Lishman who, in a presentation to the British
Neuropsychiatry Association, described the range of referrals to his service
at the Maudsley Hospital, a national and international centre
(Lishman, 1992). More recently,
Leonard et al (2002)
described a monthly outreach clinic at the Maudsley Hospital. Scheepers et
al (1995) reported 6
months of out-patient referrals and admissions to the Burden Neurological
Hospital in Bristol. The Burden was established over a half a century ago and
has an international reputation for neurophysiology research. The clinical
service is regional rather than district and manages a wide range of
disorders. However, epilepsy and movement disorders predominate, reflecting
the interest of the local clinicians.
What is the demand for local neuropsychiatric services? This paper attempts
to answer this question. It describes the activity of a busy and comprehensive
district neuropsychiatry service over a 1-year period.
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Service origins and composition
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The North Staffordshire Neuropsychiatry Service is unusual in the range of
disorders covered and in the fact that it was established over a decade ago.
North Staffordshire has a population of approximately half a million and is a
sub-regional centre for neurology, neurosurgery, rehabilitation medicine and a
range of other specialties. This is a mixed urban and rural district and
approximately 300 000 people live in the conurbation of Stoke-on-Trent and
Newcastle-under-Lyme.
The North Staffordshire Neuropsychiatry Service began as a monthly special
interest clinic in January 1987. The service grew steadily from those modest
origins, and at the time of writing employs 1.5 consultants and over 30 nurses
(including community nurses) and has dedicated sessions from speech and
language therapists, physiotherapists and occupational therapists. There are
25 beds, including a 10-bed assessment unit and a 15-bed rehabilitation and
planned short-stay unit. There is a well-established neuropsychology service
in the district, including specialists in acquired brain injury.
It is beyond the scope of this paper to describe in detail how the service
evolved to its present size, but some key stages will be noted. The beds
within the service were initially within a large mental hospital. Two wards
were dedicated to people with neuropsychiatric disorders and these were
re-located within the same trust following the closure of that hospital. A
5-year grant from the Department of Health in the early 1990s, to assist with
the development of brain injury services, was another key factor. Local demand
for the service led to increased waiting times for clinics.
In 2001, a major rebuilding scheme was completed and the old mental
hospital was closed. This new service included a ten-bed acute neuropsychiatry
unit adjacent to the general hospital but on a mental health campus. The
service was established before general psychiatry services were split into
sectors based on geography. This has meant that many individuals who
traditionally remain on acute psychiatry wards (e.g. people with brain injury,
Huntington’s disease and early-onset dementia) have their own specialist
provision.
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Method
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Diagnostic groupings
The neuropsychiatry service maintains a clinical database for audit
purposes. This includes diagnostic categories, age, gender, date of referral
and source of referral. Diagnostic categories include: acquired brain injury
(including all single insult causes – trauma, haemorrhage, infection
etc.), Huntington’s disease, early-onset dementia (differentiated from
Huntington’s disease since severe cognitive impairment is usually a late
feature of that disorder), epilepsy, developmental disorders, other
neurological disorders (including Parkinson’s disease, multiple
sclerosis etc.) and non-organic disorders. Psychiatric syndromes treated by
the service are to be the subject of a separate inquiry but it is worth noting
that several such syndromes may develop in a single individual over time,
particularly during recovery from brain injury or in the course of brain
degeneration.
Data covering a 1-year period (1 October 2001 to 30 September 2002) are
presented. The types of contact included are new out-patient referrals,
general hospital/liaison consultations and hospital admissions. A breakdown of
the total out-patient case-load of the service is also included. Age
distribution of in-patient referrals, source of referral for admission and
source of referral of the total out-patient case-load were not recorded.
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Results
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New out-patient referrals, in-patient referrals, out-patient case-load and
hospital admissions are shown in Table
1. In-patients with acquired brain injury are listed according to
cause of injury in Table 2.
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Discussion
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This paper describes the work of a busy, well-established district
neuropsychiatry service. Although the service is not directly comparable to
the Bristol service described by Scheepers et al
(1995) there are some common
features. The highly specialist nature of these services might lead one to
consider them tertiary, but a high proportion of referrals are from primary
care (46.3% in North Staffordshire, 77% in Bristol). The relatively high
proportion of referrals with acquired brain injury reflects the fact that this
is the most established component of the service and in some respects the most
innovative. Early referral and admission following brain injury generally
obviates the need for major tranquillisers to quell difficult behaviour in
this group, a common practice on neurosurgical units. It is perhaps relevant
that over the past decade only one patient with brain injury from this
district has required referral to a private sector brain injury behavioural
unit, a rare case of hyperphagia and personality change following surgery for
craniopharyngioma.
People with Huntington’s disease associated with psychiatric disorder
have been managed by the service since the 1980s but a more comprehensive
approach was adopted in the mid 1990s. This has included pre-symptomatic
genetic testing, which has revealed a high prevalence of the disorder in North
Staffordshire (over 10 in 100 000).
Data on the source of admissions were not retained but most were transfers
from other wards, particularly individuals with brain injury. The relatively
large number of admissions reflects the demand for the service and its
importance in ‘freeing’ acute neurosurgery, neurology and medical
beds. The latter was important in our commissioners’ decision to provide
continuing funds when our Department of Health brain injury grant came to an
end.
Most of the funding for the service now comes from the four primary care
trusts that serve North Staffordshire; when the service began in the late
1980s there was a single health authority for the district. Although the
majority of patients managed by the service live in North Staffordshire,
approximately 15% are from outside the district, mostly from adjacent primary
care trusts. The number of out-of-district referrals has increased yearly,
particularly those with acquired brain injury and Huntington’s
disease.
A significant number of individuals did not have brain disease but
presented with neurological symptoms as part of a dissociative or somatisation
disorder. Referrals of those with neurodevelopmental problems have steadily
increased, and this has recently led to the creation of a joint consultant
appointment with the local learning disabilities service.
In conclusion, the title of this paper posed the question: is there a
market out there for neuropsychiatry? This field trial indicates that the
answer is ‘yes’.
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Acknowledgments
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This paper is based on a presentation to the British Neuropsychiatry
Association in February 2003.
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References
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LEONARD, F., MAJID, S., SIVAKUMARK, K., et al
(2002) Service innovations: a neuropsychiatry outreach clinic.
Psychiatric Bulletin,
26, 99
–101.[Abstract/Free Full Text]
LISHMAN, W. A. (1992) What is neuropsychiatry?
Journal of Neurology, Neurosurgery and Psychiatry,
44, 209
–213.
SCHEEPERS, B. D. M., BIRD, J. M. & ROGERS, D. G.
(1995) Neuropsychiatry: a different approach or a different
clientele? Psychiatric Bulletin,
19, 77
–81.[Abstract/Free Full Text]
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Abstract
Introduction
