Neuropsychiatry in the UK: planning the service provision for the 21st century

Some believe that Cartesian dualism of mind and body in the19th century and the rise of psychoanalysis by the turn ofthe 20th century was what led to the separation of neurologyand psychiatry. More recently, conceptualisations of the mind/brainparadigm have helped rediscover the relationship between the mind and the brain, bringing renewed synergy between neurologyand psychiatry (Cunningham et al, 2006). However, divisionis still apparent in current service planning and provisionin the UK for individuals whose presentation lies in the no-man’s-landbetween these two historical domains.

Increasing recognition of the complex interface between neurologyand psychiatry (Lishman, 1998) is reflected in recent callsto integrate neurological and psychiatric practice and training(Eisenberg, 2002; Mitchell & Agrawal, 2005). Despite improvementsin the care of individuals with mental illness in the community,supported by the National Service Framework and its emphasison comprehensive mental health services (Department of Health, 1999), current provision of neuropsychiatry services remains patchyand grossly inadequate (Agrawal et al, 2008, this issue).A series of recent National Health Service (NHS) reforms withprogressive separation of purchaser and provider function andthe advent of local commissioning seems to have had a detrimentaleffect on development of specialist services like neuropsychiatry.The majority of neuropsychiatry services in the UK have existedfor more than a decade and a significant minority have beenforced to downsize in recent years (Agrawal et al, 2008, thisissue). This has occurred at a time when psychiatric and neuroscience services have seen unprecedented growth in the NHS.

There is a growing awareness that unrecognised and untreated neuropsychiatric problems cause distress to individuals withvarious chronic neurological conditions, affecting their qualityof life and placing excessive burdens on their carers. Theseunmet needs have been highlighted in a plethora of nationaldocuments from various sources (NHS Health Advisory Service, 1997;British Society of Rehabilitation Medicine, 2003; Royal College of Physicians, 2004),including National Institute for Health and Clinical Excellence(NICE) guidelines for neurological conditions. The National Service Framework for Long-Term Conditions (Department of Health, 2005) has also stressed person-centred care planning and puts emphasison holistic, integrated and interdisciplinary care. It hadbeen argued that it would finally go some way towards raisingawareness of the most significant unmet (neuropsychiatric)needs in the NHS (Agrawal & Mitchell, 2005). However,such an effect has been limited at best. More emphasis is requiredon planning and developing patient-centred multidisciplinarycare to meet neuropsychiatric needs.

Neuropsychiatry service planning and delivery was the focusof a meeting organised by the Special Interest Group in Neuropsychiatryat the Royal College of Psychiatrists. A wide range of stakeholdersattended, including representatives from the Department ofHealth. There was a consensus that while the predominant focusof commissioning of mental health services in recent yearswas on accessible community psychiatric services, commissioning of specialist mental health services like neuropsychiatry hadsuffered. This paper summarises the outcome of this meetingand subsequent deliberations of the working group.

Neuropsychiatric needs in the population

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Neuropsychiatric needs in the...

There is no comprehensive population-based epidemiological studyof incidence and prevalence of neuropsychiatric illnesses.Estimating neuropsychiatric needs in the population has beencomplicated by difficulties in case definition and case ascertainment.Neuropsychiatry consists of wide-ranging symptoms and syndromes,many of which are not adequately classified by the currentclassificatory systems, making it a difficult area to study.Nevertheless, there is an emerging wealth of data from two separate streams, which indirectly highlight the extent of need.

First, there have been a number of scientifically robust studieslooking into the prevalence of neuropsychiatric problems invarious neurological populations. It has been shown that neurologypatients have high levels of neuropsychiatric problems. Datafrom Scandinavia (Fink et al, 2003) suggest that prevalenceof current mental disorders in new neurological patients is55.1% (64.6% in out-patients and 38.6% in in-patients); the lifetime prevalence was over two-thirds. These figures havebeen replicated in a number of different populations, withdifferent methodology. In Edinburgh, general neurology out-patientswere shown to have a prevalence of 47% for anxiety and depressivedisorders and an additional 30% had other symptoms not explainedby an organic disease (Carson et al, 2000). Bridges & Goldberg (1984) estimated the prevalence of psychiatric illnesses inneurological in-patients at 39%. A recent and robust replicationputs the prevalence of neuropsychiatric illnesses in a tertiarycare neurology in-patient unit in South West London as 55% (Jefferies et al, 2007).These studies have shown that neurologists have a low rate ofrecognition for neuropsychiatric illnesses and referral ratesfor such individuals are even lower. It has been argued thatthis is at least partly caused by lack of specialised and accessibleservices.

The second stream of epidemiological data comes from studieslooking into the prevalence of neuropsychiatric problems invarious neurological disorders. The prevalence of diagnosablepsychiatric problems in community patients a year after a headinjury was 18%; this increases significantly (to about 40%) if the focus includes all the neurobehavioural problems (Deb et al, 1999). Taking the incidence and prevalence of head injuries into account,this alone would indicate potential neuropsychiatric problemsin up to 80 per 100 000 population. Most of the major neurologicalillnesses, including epilepsy (with significant psychopathologyin 30–40% of individuals), Parkinson’s disease(with significant psychopathology in 40% of individuals), multiple sclerosis, stroke, Huntington’s disease, etc., similarlyhave been shown to have high neuropsychiatric comorbidity (Chemerinski & Robinson, 2000;Marsh, 2000; Feinstein, 2007). It has been argued that suchcomorbidity requires specialist assessment and treatment from a team which is well integrated with the neuroscience services.

Furthermore, general psychiatric services encounter organicsymptoms in a significant proportion of individuals (about10%), some of whom may require a neuropsychiatric opinion.There are further specialised areas dealing with developmentalneuropsychiatric disorders, including memory and sleep disorders which fall within the remit of neuropsychiatric services atmany centres.

Substantial epidemiological work is required to elucidate theextent of neuropsychiatric need, but the emerging data fromdifferent perspectives and in different populations placesit as significant. Much of this remains currently unmet.

Demand for neuropsychiatry services

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Demand for neuropsychiatry...

A good way to estimate the demand of a service is to look atthe rates of referrals and assessment in a defined population.This has been independently studied by two audits. The NorthStaffordshire neuropsychiatry service audit showed that theannual rate of new out-patient referral was 38 per 100 000 populationand the rate of new in-patient referral was about 20 per 100000 population (Barrett & Sudharsan, 2005).

Very similar rates of referrals have been found in a much largeraudit in South East England. The South London, Kent, Surrey& Sussex neuropsychiatry services audit (Fleminger et al, 2006)covered a population of 6.8 million. A referral rate of 30per 100 000 population was reported from the local catchmentarea of the service. A review of a sample of these referralsfound that the vast majority were appropriate. The furthergeographically the individuals referred were from the neuropsychiatricservices, the lower the referral rate, highlighting the unmetneed.

There is now an emerging consensus that a realistic rate ofreferrals to a neuropsychiatry service would be about 20–30per 100 000 population; a referral rate lower than this wouldindicate an unmet need.

Benefits of neuropsychiatry services

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Benefits of neuropsychiatry...

Lack of adequate and accessible neuropsychiatry services canresult in gaps in service provision causing delays in referrals,prolonged admissions and inappropriately placed patients. Anaccumulating wealth of data identifies neuropsychiatric issuesas key in the patients’ quality of life and contributingto carers’ burden and distress (Global Parkinson’s Disease Survey Steering Committee, 2002; Aarsland et al, 1999; Chipchase & Lincoln, 2001). Hence,overall disability burden to society (World Health Organization, 2001)and the cost to the national economy are immense. Additional financial burden is placed on economy directly through inappropriate placements, social care needs, lengthy admissions, and indirectlythrough loss of productivity. Some of this cost can be reducedby early and appropriate neuropsychiatric interventions.

Planning neuropsychiatry service provision

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Planning neuropsychiatry service...

An ideal future neuropsychiatry service should be accessible,contain an appropriate skill-mix and be adequately staffedto meet local needs and demands. It should be available locallyand be closely allied to both mental health services and neurosciencesservices. It should be acceptable to all the stakeholders andtake both the patients’ and carers’ perspective into account.

Given the current state of neuropsychiatry service provisionand the limited availability of trained professionals, theneed to provide services locally may require future servicesbased on a ‘hub and spoke’ model. This could meana central, regionally-based neuropsychiatry service (possiblyclosely allied to a regional neurosciences centre) acting asa hub, working closely with local psychiatrists with a specialinterest in neuropsychiatry (spoke). These local psychiatristsmay include general psychiatrists, old age psychiatrists, liaisonpsychiatrists, learning disabilities psychiatrists, etc., whomay run a local special interest clinic in neuropsychiatrywith a ready access to tertiary advice and opinion. Establishmentof outreach clinics run by neuropsychiatrists could serve asa spoke in some places. One such clinic which has been successfulin reducing the unmet need has been reported by Leonard etal (2002). It is envisaged that both local special interestclinics and outreach clinics (spoke) will be closely alliedto the regional neuropsychiatry service (hub) for clinical, educational, research and administrative purposes.

Service model and team composition
There cannot be a single model for either the clinical compositionor the approach of a neuropsychiatry service. Several factorsincluding clinical expertise, clinical demand and configurationof neurosciences services will determine the local clinicalapproach and the model adapted for neuropsychiatry serviceprovision.

However, based on the estimated epidemiological need and clinicaldemand for the service it is possible to estimate the expectedrate of referral. This can inform commissioners and cliniciansas to the optimal size and professional mix of a team and helpin the business planning process. At present there are no suchguidelines to help with service development.

Neuropsychiatry service provision can be divided between out-patient service, in-patient beds and specialised clinics. The followingis the consensus recommendation of the working group.

Out-patient neuropsychiatry service
For illustrative purposes, this paper uses a population of 1million for describing the composition of out-patient neuropsychiatryservices. In practice, some existing services cover a smallerpopulation and some services cover a much larger population,based on the local factors. In such cases staffing levels canbe extrapolated on a pro rata basis. It is envisaged that theout-patient service may include an outreach or peripatetic clinic.

Based on the expected rate of referral of 20–30 per 100000 per year, 200–300 new referrals will be expectedfrom a population of 1 million. The range of professionalsand staffing levels required to meet this demand is outlinedin Table 1 (these are minimum numbers based on what has beenfound to be adequate provision of liaison psychiatry, old agepsychiatry and other mental health services). In addition tothe core professional groups included, adequate access to additionalclinical staff, like occupational therapists, physiotherapists, social workers, speech and language therapists, etc., willbe required (about 1 whole time equivalent each). In some servicesthese clinicians may be integral parts of the team.

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Table 1. Proposed composition of out-patient neuropsychiatry service (for an illustrative population of 1 million)

In-patient neuropsychiatry services
Most neuropsychiatry services would require dedicated neuropsychiatry in-patient beds, staffed by an appropriate mix of medical andpsychiatric nursing staff. The number of beds required maydepend on whether the focus of a service is mainly assessmentor comprehensive management including neurorehabilitative approaches.For a population of 1 million the appropriate number of bedsis estimated between 5 and 10. Such beds need not necessarily be within a psychiatric or dedicated neuropsychiatric unit,but could possibly be shared with clinical neurosciences. Thein-patient neuropsychiatry units may also be able to offersome day-patient facilities as required. Additional numbersof a whole range of professionals will be required for the in-patient beds in addition to the out-patient staff as outlined in Table 1.

Specialised clinics
A number of existing regional neuropsychiatric services runspecialised clinics/services covering various neuropsychiatricareas (examples in Box 1). They provide input often in relationto specialist clinics in regional neuroscience centres or braininjury rehabilitation centres. Some of these services havedeveloped in relation to clinical interest and expertise of local clinicians or the research interest of that centre. Thesespecialised clinics/services may require some additional resources.

Referral pathways
Referral pathways to neuropsychiatry vary considerably fromservice to service. Some of the services are seen as regionaland tertiary, only accepting individuals referred from eitherpsychiatrists or neurologists. Many other neuropsychiatry servicesalso accept those referred from primary care. Fleminger etal (2006) showed that the vast majority of referrals wereappropriate, irrespective of the source of referral. Consideringthat some of the current unmet need is related to the barriersin accessing services, referral pathways to neuropsychiatryservices in future should be based on clinical criteria ratherthan the source of a referral.

Commissioning
The organisational issues behind the currently patchy and inadequate services and the resulting gaps in service provision need tobe looked at urgently. There is lack of clarity in currentcommissioning arrangements for neuropsychiatry. This is madeworse by the fact that neuropsychiatry services often fallin the grey area between neurosciences services and mental health services. This problem is apparent in a huge variability offunding sources in the existing services (Agrawal et al, 2008,this issue).

Box 1. Some neuropsychiatric conditions treated in specialist neuropsychiatric clinics

Brain injury rehabilitation

Epilepsy

Memorydisorders

Functional neurological syndromes

Developmentalneuropsychiatry

Sleep disorders

There is urgent need for much closer liaison between mentalhealth and neurosciences services for joint business planningof neuropsychiatry services. Primary care trusts in the futurewill need to work together to commission neuropsychiatry services,many of which will be regional, and clear guidelines will berequired for commissioners and clinicians alike.

Conclusion

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Conclusion

Neuropsychiatry service provision in the UK remains insufficientand haphazard. Organisational issues, lack of clear driversand ambiguities about ownership have been some of the factorsbehind this. Recognition of the impact of untreated neuropsychiatricproblems in neurological settings has led to growing callsto provide for this unmet need. Yet, over the past decade there has been a lack of appropriate expansion of neuropsychiatryservices and some existing services have been forced to downsize.

With emerging data on neuropsychiatric need and demand, it ispossible to estimate the expected rate of referrals to neuropsychiatryservices. This paper has outlined the resources required inorder to meet this demand in the 21st century. The gap betweenthe existing level of service provision and what could be consideredadequate is vast. To bridge this gap, a close working relationshipwill have to be established between mental health and neuroscienceproviders and commissioners. There is a constant trickle of trained neuropsychiatrists emerging from a number of existingcentres. The recent development of a new College core curriculumfor neuropsychiatry is an important first step that has nowbeen taken. A clear training pathway will now need to be establishedto allow more trainees to pursue neuropsychiatric trainingin order to meet the clinical demand. Given that there is along way to go, the journey must start now.

References

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