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Neurology ‘lottery’ as costs vary 10-fold

By Alisdair Stirling

GP commissioning consortia will inherit an ‘idiosyncratic’ postcode lottery for neurology services from PCTs, with tariffs varying almost tenfold across England, new figures reveal.

Information obtained under the Freedom of Information Act suggests the price trusts were paying for new consultant outpatient appointments for neurology in 2009 varied from £67 to £592.

Tariffs for follow-up appointments varied from £64 to £416 and did not appear to reflect whether a provider had secondary or tertiary facilities, neurology beds or neurology on-call, or the volume of patients sent to neurology.

The figures were compiled by Dr Paul Morrish, a consultant neurologist at Gloucester Royal Hospital, and published in a letter to Clinical Medicine, the journal of the Royal College of Physicians.

Dr Morrish said that the Department of Health held no record of the agreed tariffs and that some PCTs had refused to divulge them because of commercial sensitivity. He suggested negotiations may have been ‘muddled by commercial secrecy or a failure to ask questions’ and urged greater transparency so that GP commissioners would know how much a neurology appointment was going to cost their consortium.

Referring to a continuing 11% annual rise in neurology appointments, he said: ‘Unlimited demand and limited supply has meant that, so far, both expensive and cheap neurology services have flourished and there is no evidence that the free market is correcting the lottery of neurology care.’

‘My rationale for publishing this information is to draw attention to neurology´s continuing idiosyncracy and to allow providers and purchasers more informed negotiation.’

Professor Leone Ridsdale, professor of neurology and general practice at the Institute of Psychiatry in London, called for a standardised national tariff for neurology appointments and said great transparency over pricing was needed: ‘A move to a uniform cost would be fair. If you’re going to subscribe to the notion of a free market, you´re going to need free information so that commissioners know where they are.’

‘There would be great disadvantages for neurology patients if commissioning consortia have to start sending them to distant centres to save money. If variations in costs reflect anything, they need to be linked to demonstrably better outcomes for patients,’ she added.

Dr Oliver Bernath, a former consultant neurologist who is advising GP pathfinder consortia through his consultancy Integrated Health Partners, said some of the variation in neurology tariffs might reflect whether imaging was bundled together with consultant appointments.

‘It used to be a mandatory tariff but was changed a few years ago,’ he said, ‘The reason it is so high in some cases is because it assumes the need for a scan – which can be very expensive. So the cheaper tariffs may not be as cheap as they seem, because imaging – and some of the more esoteric blood tests – may have to be paid for on top.’

‘Proactive commissioning consortia faced with an all-inclusive tariff could try to unbundle the tariff, especially if they have access to imaging without going through a consultant,’ he said.

Dr Greg Rogers, a member of the executive council of the Primary Care Neurology Sociaty and a GPSI in epilepsy practising in Margate, Kent, said Dr Morrish´s findings echoed those from the new spend and outcomes tool for PCTs (SPOT) published earlier this month.

‘Quality and price do not always correlate,’ he said. ‘I notice for my PCT, Eastern and Coastal Kent, we have achieved lower spend and better outcomes – low epilepsy mortality rate and other factors – compared to Hastings and Rother PCT, with around the highest spend and worse outcomes. We are using GPSIs for epilepsy and so maybe this accounts for the lower spend with quality maintained.’

Neurology costs vary 10-fold