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2 Specialties Clinical neurophysiologyas part of the Improving Quality In Physiologicaldiagnostic Services (IQIPS) initiative hosted by theRoyal College of Physicians (RCP). The UKAccreditation Service (UKAS) is expected to use thesestandards to accredit departments formally. Continuingeducation for consultants is through scientifc meetingsof the BSCN. International clinical neurophysiologyconferences and a BSCN advanced course are held everythree to four years. Consultants are expected to keep upto date by personal study, verifed at annual appraisal.The ANS supervises training for scientifc staff, anddelivers a certifcation process in addition to theuniversity education recently introduced underModernising Scientifc Careers. 5Specialty and national guidelines and auditsThe BSCN and the ANS have produced nationalguidelines and standards for the commonly performedneurophysiological procedure. 6 Audit has been locallyand regionally based, but the BSCN and ANS arepiloting national audit in 2011/12.6 Clinical work of consultantsThe working patterns of consultants in clinicalneurophysiology vary according to location andexpertise, but will typically include a mixture ofspecialist procedures and clinical reporting. Themajority of EMG and EEG work is for outpatientsalthough investigations are also required for acutely illinpatients. Consultants working in larger centres willusually provide some specialist investigations such asvideo-telemetry or intra-operative monitoring.Indications of appropriate numbers of investigationsper programmed activity (PA) are given in Table 1.These numbers should be reduced if there is a signifcanttraining component to the clinics/ reporting sessions orif the consultant is required to supervise otherprofessionals such as specialty registrars (StRs) or HCSsat the same time as performing their own clinical work.The BSCN recommends that at least one hour in eachfour-hour EMG/NCS/EEG clinic should be allowed forclinical administration which includes responding toreferrals, the generation of written reports and othercommunications regarding the patients. Someneurophysiologists with neurological expertise mayhold clinical outpatient clinics, eg for epilepsy, but it isunusual for them to be involved in general internalmedicine. On-call commitments vary according to thesize of the department, with some centres being able toprovide a formal out-of-hours service whilst othershaving ad hoc arrangements in place.7 Opportunities for integrated careAs a diagnostic specialty, the majority ofneurophysiology care is integrated with other specialties(including neurology and neurosurgery, paediatrics,rheumatology, orthopaedics and plastic surgery, generalmedicine, and ophthalmology) and within clinicalpathways. MDT meetings are usual for complexdisorders including neurophysiology, such as thesurgical treatment of epilepsy.8 Workforce requirements for the specialtyThe RCP recommends that one consultant clinicalneurophysiologist is required to serve a population ofapproximately 300,000. The latest RCP census 7 records118 consultants in the UK, with 103 in England. Thisworkforce is not uniformly distributed around thecountry and the extremes are London, with oneconsultant to fewer than 300,000 patients, and theNorth West, South East Coast and East Midlands withone to (in excess of) 700,000 patients.The consultant workforce has consistently beeninsuffcient to meet demand for neurophysiologicalinvestigations despite consultant provision improvingin nearly all regions with total numbers doubling overthe last 10 years. Because of the small number ofconsultants and the need to work with others tomaintain continuing professional development (CPD)and clinical standards, neurophysiology is concentratedin neuroscience centres to the detriment of DGHs andthe community. With the current workforce predictionsand numbers of trainees, the RCP recommendation isunlikely to be met in the near future.9 Consultant work programme/specimenjob planConsultant work programmes will vary according tohospital size and the specialist services provided, andthe job plan will have to take into consideration localneeds. The key elements of a job plan are shown inTable1onthenextpage.C○ Royal College of Physicians 2013 69
Consultant physicians working with patientsTable 1 Consultant work programme for clinical neurophysiologyActivity Workload (patients per PA) Programmed activities (PAs)Direct clinical carOutpatient EMG clinics 4–6 (depending on complexity) 2–5Inpatient EMG3–4 studies in the department,fewer if on wardUp to 1Supervision and reporting of HCS NCSclinics8–10 (4–5 per HCS clinic) 0–2Reporting routine EEG 10–15 (depending on complexity) 1–3Performing and reporting specialisedtests eg video-telemetry or visualelectrophysiologyIntra-operative procedures, eg evokedpotential monitoring, intracranialrecording/functional mapping1–5 0–3 (may be more inspecialist centres)0.5–1 0–4Multidisciplinary team meetings Up to 2Total number of direct clinical care PAs7.5 on averageSupporting professional activities (SPAs)CPD/appraisal/revalidation 1.5Teaching/training 0–1Service development, clinicalgovernance, audit0–1Research 0–12.5 on averageOther NHS dutiesExternal dutieseg for deaneries, royal colleges,Department of HealthBy local agreementBy local agreement10 Key points for commissioners1 Clinical neurophysiology provides importantdiagnostic support for a number of specialties.2 These investigations are essential for themanagement of epilepsy and many peripheralnerve disorders, which are common and importantclinical conditions.3 Recent computerisation of recording apparatus hasensured that neurophysiology continues to have adiagnostic role.4 Consultant numbers are insuffcient for the servicedemand and consultants tend to be grouped inneuroscience centres.5 Neurophysiology is essential for managing someneurological emergencies and any move to increaseneurological provision in DGHs must includeneurophysiological support.6 Neurophysiology services are highly dependent ona scientifc workforce that must be continuallydeveloped. Departments should be supervised by aconsultant trained in clinical neurophysiology andhealthcare scientists should be appropriatelyqualifed for the investigations they undertake.7 Geographical distribution of neurophysiologyconsultants and trainees is skewed to London, withunder-provision in some parts of the UK – adistribution that should be addressed.70 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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2 Specialties Acute internal medici
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