Neuropsychiatry in the UK: national survey of existing service provision

AIMS AND METHOD

To elucidate and describe current neuropsychiatry service provisionin the UK. A questionnaire was developed and posted to membersof the Royal College of Psychiatrists who had expressed aninterest in neuropsychiatry. The responses were tabulated andanalysed using descriptive statistics and SPSS version 11.0for Windows. The neuropsychiatry services provided, sourcesof referrals, setting of the services and funding streams aredescribed.

RESULTS

Out of 251 respondents, 70 reported providing a neuropsychiatryservice, 21 having been principally appointed as neuropsychiatrists.

CLINICAL IMPLICATIONS

Neuropsychiatry services in the UK are currently based in afew regional centres, representing a patchy and inadequateservice provision.

Introduction

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Introduction

Increasing recognition of the effect of brain disorder on mentalhealth and insights into the indelible inseparability of mindand body (Yudofsky & Hales, 2002) have contributed toa growing interest in neuropsychiatry. This interest has beenfuelled by the arbitrariness of the historical separation ofneurology and psychiatry, and recognition of the growing overlapbetween the two, with advancement of scientific knowledge.In the UK, early identification and management of cognitive,behavioural and mood symptoms in people with neurological disorders,in the true Meyerian tradition of psychobiology (Lidz, 1966),is now an important quality requirement of the National ServiceFramework for long-term conditions (Agrawal & Mitchell, 2005;Department of Health, 2005).

Yet, the current map of neuropsychiatry service provision inthe UK is still not clear. Traditionally, such services havebeen provided at a few regional or national centres and userswere expected to travel long distances for a neuropsychiatrist’sopinion. This is very much against the ideals of integrated,interdisciplinary and easily accessible neuropsychiatry services(Department of Health, 2005). Geographic distance to accessibleneuropsychiatry services has been found to be associated withunmet need (Fleminger et al, 2006). This highlights the needfor reasonably local neuropsychiatry services with clear referralpathways.

Nationally, there is a dearth of information about neuropsychiatry services, their referral pathways and funding streams. Therehave been a few papers on individual neuropsychiatry servicesor a group of services in the UK (Leonard et al, 2002; Barrett & Sudharsan, 2005; Fleminger et al, 2006), but they do not provide a coherentnational picture.

Hence, the Royal College of Psychiatrists’ Special InterestGroup in Neuropsychiatry decided to survey College memberswho had expressed an interest in neuropsychiatry, to obtaininformation on current neuropsychiatry service provision, includingstaffing levels, services provided, their setting, referralpathways and funding streams. Our aim was to use this informationto inform neuropsychiatry service development in the UK.

Method

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Method

A questionnaire was developed by a working group of the SpecialInterest Group in Neuropsychiatry. This was posted to 508 Collegemembers by the audit department of South West London and StGeorge’s Mental Health Trust on behalf of the Group.An envelope was included for the reply and an additional sheetof paper was enclosed to allow the trainees, who may have feltthey were not responsible for providing any services, to respond.The members were mailed after 4 weeks to encourage responsefrom those who did not answer the initial letter. All the responseswere collated and entered on to an SPSS database and analysedwith the help of the Trust’s audit department.

Results

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Results

A total of 251 members (49.4%) replied to the survey: 161 (64.1%)after the first mailing and a further 90 (35.9%) followingsecond mailing. Some trainees who were not responsible forproviding a neuropsychiatry service answered by telephone,as the questionnaire did not apply to them.

Of the 251 respondents, 70 reported (27.9%) that they were responsiblefor providing some degree of neuropsychiatry service. The rest(n=181), who felt that the survey did not apply to them, includedtrainees (35.1%), members who had an interest in but were notresponsible for providing any neuropsychiatry service (30.4%),and others (32.1%). This latter group included ‘addresseenot known or moved’ or questionnaire returns withoutstating a reason. Only a small proportion of the respondents(2.6%) reported no interest in neuropsychiatry.

In our analysis we focused on 70 respondents who reported beingresponsible for or providing some neuropsychiatry services.The vast majority of these (77%) were National Health Service(NHS) consultants, a small number were academics (16%) anda few (7%) worked in the private sector (Fig. 1).

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Fig. 1. Type of employment (n=70).

Only 21 of these respondents (30%) were principally employedas neuropsychiatrists. The rest had a range of principal employmentsin various psychiatric subspecialties (Fig. 2). However, thegreat majority of these nevertheless provided at least 1–2sessions worth of neuropsychiatry input.

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Fig. 2. Clinical field of principal employment (n=70).

Of those who were principally employed as a neuropsychiatrist (n=21), similar proportions were working in the NHS sectorand had academic jobs as in Fig. 1. Over half (52.4%) of theneuropsychiatrists were working full-time in clinical neuropsychiatry– one in five did 6–9 sessions and about a quarter did 3–5 sessions. Part-time neuropsychiatrists were eitherdoing split clinical jobs with other psychiatric subspecialties(30%) or academic jobs (40%), with the rest not specifying.

A wide range of neuropsychiatry services (defined as those employinga neuropsychiatrist) were offered (Table 1). The most commonof these were out-patient services and specialist clinics.Over half (61.9%) had in-patient beds. Community nursing wasonly rarely available as a part of neuropsychiatry service.Most of the services covered a wide range of neuropsychiatryareas. The most common of these were brain injury, memory andepilepsy clinics (Table 2).

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Table 1. Neuropsychiatry services provided by the 21 neuropsychiatrists¹

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Table 2. Areas covered by neuropsychiatric services provided by the 21 neuropsychiatrists¹

Of the 21 doctors who were principally appointed as neuropsychiatrists, over 70% of the neuropsychiatry services had existed for morethan 10 years, 5% for more than 5 but less than 10 years andthe rest had been developed within the last 5 years. Although52% of the services had expanded in the last 5 years (includingthe ones which were developed in this period), 38% remained unchanged and 10% were forced to reduce in size.

Over half of the services were principally based in teachinghospitals (56%); the rest were based in brain injury rehabilitationunits (14%), regional neurosciences centres (10%), districtgeneral hospitals (10%), and other settings (10%). The sourcesof funding of the services varied widely (Fig. 3). Three-fourthsof the funds was, however, channelled through mental healthtrusts.

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Fig. 3. Sources of funding (n=21 neuropsychiatrists).

The majority of neuropsychiatry services accepted referralsfrom a wide range of sources (Table 3), including psychiatrists,neuroscience clinicians (neurologists, neurosurgeons, neuropsychologists,etc.) and specialist units such as brain injury rehabilitationcentres. Despite the perceived tertiary nature of neuropsychiatry,three-quarters of the services accepted referrals from primarycare.

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Table 3. Referral pathways (N=21 neuropsychiatrists)

Discussion

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Discussion

This is the first national survey of its kind. It focused onthe members of the Royal College of Psychiatrists with interestin neuropsychiatry. Although it is possible that some psychiatristswho provide neuropsychiatry services may not have registeredan interest, for the purpose of the study we assumed it isunlikely that clinicians principally employed as neuropsychiatristswill not have done so. The rate of response to our survey wasconsistent with other postal surveys. A high number of traineesand other clinicians expressing interest in neuropsychiatryreflects the growing interest in this specialty. This needsto be fostered and a clear neuropsychiatry training programmehas to be provided to meet their needs (Mitchell & Agrawal, 2005).

We found that there were 21 consultants who were principallyemployed as a neuropsychiatrist in the UK. This number is consistentwith the number of neuropsychiatrists known to our interestgroup. The majority were based in a few major regional, nationalor teaching hospitals. This confirms the patchy nature of currentneuropsychiatry service provision.

A range of psychiatric consultants currently provide some degreeof neuropsychiatric input, mostly in the form of 1–2special interest clinics a week. Out of the 21 consultantswho were employed as neuropsychiatrists, about half were devotingall their sessions to clinical neuropsychiatry and most ofthe rest devoted 3–9 sessions to clinical work. Theyprovided a wide range of neuropsychiatry services, includinga number of specialist neuropsychiatry clinics. Referrals wereaccepted from primary, secondary or tertiary services. Hence,where the neuropsychiatry services existed, they provided areasonably comprehensive service. However, in-patient neuropsychiatrybeds were not commonly available.

One of the most worrying aspects identified was that of thetwo-thirds of neuropsychiatry services that had existed formore than a decade, a significant proportion had not expandedin recent years and a significant number was forced to reducein size. This occurred at a time when neurological and psychiatricservices went through an unprecedented expansion and the overallnumbers of consultants increased in the UK by over 70% (Departmentof Health, 2004). This could possibly be attributed to thepredominant focus of national service framework for mentalhealth (Department of Health, 1999) on providing comprehensivecommunity services. The wide range of funding sources of existingneuropsychiatry services indicate a lack of coherent fundingand commissioning arrangements. This can again be a factorcontributing to the lack of appropriate neuropsychiatry servicedevelopment in the UK.

In conclusion, neuropsychiatry services in the UK are currentlybased in a few regional centres. This represents a grosslyinadequate service provision. Although some other psychiatricspecialists try and fill in the gap with the help of specialinterest clinics, this can not be a reliable way to meet the population need. Neuropsychiatry service development seemsto have lagged behind other psychiatric and neuroscience servicessignificantly over the past decade. Lack of clarity of fundingstreams, commissioning arrangements, and appropriate guidelinesabout what would constitute an adequate neuropsychiatry servicecould be contributing to this limited and currently inequitable service provision.

Acknowledgments

We thank the Audit Department of the South West London and St George’s Mental Health Trust at Springfield Hospitalwhich provided substantial help and support. In particular,we thank Ms Liz Collins, Ms Jane Dunnell and Ms Grace Chew.

References

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