Challenges facing UK paediatric neurology

Abstract

Paediatric neurology has been an established specialty within the UK since the days of Ronnie Mac Keith, and the numbers of substantive consultants now in post currently reflects that it is a growing one. The evaluation of a neurologically unwell child is one of the greatest challenges for any clinician, and the technology to aid us continues to move forward. Traditionally in the UK, paediatric neurology has been a tertiary-led specialty, with fewer accredited consultants per capita of the population than most other developed countries. In an age with increasing diagnostic resources, with improved technology and investigative techniques, one could argue for further subspecialization within the specialty itself. Neuromuscular disorders, for example, have already justified a national service with dedicated paediatric neurologists and linked specialties; complex epilepsy could also be seen to require this. Further subspecialty clinics are being developed, with calls for national recognition and support. This appears to be an appropriate concentration of expertize and best practice for access to diagnosis and information for families. This also appears to form the basis for the further development of academic paediatric neurology, providing the clinical resource on which to base our continuing research questions. However, changes in paediatric practice across the UK will provide us with challenges in how we deliver our service. Changes in junior doctor training are increasing demands on consultant time, with more ‘hands-on’ delivery than ‘consultation’, and a greater need for teaching. Furthermore, the degree of administration currently required for research means it is not easy for this research to take place alongside a busy clinical practice. There is less time for thinking, writing, and creation of new ideas, with less protected time. There is also renewed discussion about how specialist services should be delivered overall, in recognition of the changing workforce.1,2 Several models have been put forward for consideration. How do we enable appropriate access to specialist opinion and consequent care pathways for children with neurological disorders? There is little question that, with the expectation of consultant-delivered care, an increased specialty consultant workforce is required in the future. The question remains where care should be based, and how it should be delivered with access to appropriate diagnostic services. Modelling the Future talks of major specialist centres where a critical mass of the workforce would be based.1 However, an argument could be made for returning to some specialty delivery at the very least in each district, particularly on reviewing international models of service delivery. This aside, how we define such individuals – as paediatricians ‘with an expertize’ or fully accredited paediatric neurologists – requires some discussion. Possible overlap with neurodisability is being explored, particularly with regard to training. Other European countries have similar training backgrounds to the two specialities, with development of subspecialty depending on the likely emphasis of the ultimate service requirement. However, the range of individuals currently trained and appointed to these posts in the UK remains wide, and further evaluation of this model is required. The idea of paediatricians with an expertize in epilepsy has also been discussed, particularly in relation to recommendations from the guidelines from the National Institute for Clinical Excellence (NICE) for the diagnosis and management of epilepsy in primary and secondary care.3 However, the more this model is considered, the more we remain concerned about how the level of expertize of such an individual would be defined, considering the need to be aware of all the conditions that may present with epilepsy. Such jobs are currently not reviewed by the Royal College of Paediatrics and Child Health Specialty Advisory Committee for paediatric neurology. How do we protect individuals from another situation such as in Leicester, where an investigation of an individual appointed as a paediatrician with an interest in neurology has resulted in suspension for over-diagnosis and over-treatment of epilepsy? Should we not develop more paediatric neurologists with full accreditation for posts within district hospitals, perhaps covering a minimal population, but with time linked into specialist centres, to avoid isolation? This is already a model working well in Hull (linked with Leeds) and Preston (linked with Manchester). Paediatric neurology continues to be an expanding and developing specialty. There is much potential to further the care for children with neurological disorders; it is important that their assessment is accurate from the start and management therefore optimized. We need to plan how we see delivery of care taking place in the future, and for us within the British Paediatric Neurology Association (BPNA), to take charge of that process.