Movement disorder service - Norfolk and Norwich University Hospital

Hospital type: University Teaching Hospital
Population served: approximately 750,000
Catchment area: Norfolk and Northern Suffolk

Challenge

• Complex care pathway with two parallel secondary care clinics and no clear referral guidelines for GPs
  
• Long waiting time for initial appointment and long follow-up intervals
  
• Not all patients referred to Parkinson's nurse at diagnosis
  
• Parkinson's nurses overstretched by numbers of patients
  
• No clear referral criteria for out-patient primary care rehabilitation services, resulting in piecemeal and independent referrals for patients and carers
  
• GPs' ability to manage patients hampered by lack of knowledge and inexperience
  
• Reducing crisis admissions for patients with Parkinson's into secondary care
  
• Specialist secondary care diagnostic services all provided in one central hospital setting with variability of ease of physical access

Action

A fundamental review of Parkinson's services and the care pathway in Norfolk was carried out.

The findings were used to develop a strategy with the following improvements proposed:

• New specialist diagnostic service encompassing neurology, medicine for the elderly and multi-disciplinary therapy team based in secondary care
  
• New patients referred will be triaged according to presence of co-morbidities: younger patients without significant co-morbidities seen by neurologists; elderly patients with co-morbidities seen by specialist medicine for the elderly team.
  
• If a diagnosis is confirmed, patients deemed suitable for rehabilitation undergo multidisciplinary assessment by therapists and specialist nurse as appropriate.
  
• Development of pathway whereby most patients in the maintenance phase of Parkinson's are managed by community-based Parkinson's teams run by a Parkinson's nurse/community matron/GP with a special interest with regular ongoing access to rehabilitation by therapists, psychologists, counsellor and education courses
  
• Patients who have entered the complex and palliative stages of the condition are followed up more frequently in secondary care.
  
• Regular contact and meetings between community Parkinson's teams and secondary care, with open access for referral back to secondary care if problems arise.

Achievements

In the interim, a new monthly specialist movement disorder clinic commenced in June 2005:

• Clear referral criteria established
  
• Multidisciplinary team (MDT) assessment and team discussion with a single outcome plan including medical and therapy information, copied to patient
  
• Close links between secondary and primary care, and are currently involved with the Primary Care Trust commissioners in further pathway development
  
• Ability to see new patients within 8 weeks of referral
  
• Ability to offer DaTSCAN to our patients has recently been approved and will result in improved diagnostic accuracy in uncertain cases

Clinic consists of:

• 2 slots for patients requiring MDT assessment usually with established diagnoses
  
• 3 additional new patient slots for patients without clear diagnosis
  
• 3 follow-up slots shared between senior neurological nurse and consultant
  
  

For their work to date the Norfolk and Norwich University Hospital were runners-up in the Parkinson's category of the 'Hospital Doctor of the Year' 2006 competition.

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