By Dr Nashid Alam, Consultant Physician, George Elliot Hospital
and Dr Mark Bowman, ST6 Geriatrics, Antrim Area Hospital
Parkinson’s Advanced MasterClass 34A, November 2018
The Northern trust has a population of approximately 500,000 people. The estimated PD patient prevalence is around 750 for Northern Trust. In addition to this, non-PD related tremor disorder has a prevalence of 1500 patients for the whole trust. Historically the service for the PD patients and patients with tremor disorders was very fragmented. It was run by isolated general geriatricians with an interest in Parkinson’s disease or by neurologists. Due to the planned retirement of several geriatricians over last 3-4 years the service became even more fragmented. The waiting time to see a ‘new patient’ referral increased up to one year. In addition to prolonged ‘new patient’ waiting times, most other set standards for the care of PD patients were not being met and practise was not in line with current guidelines. For example the RCP, NICE and PD UK mandates that all PD and other parkinsonian disorders are managed in specialist clinics. Specialists include neurologists and geriatricians with interest in PD with patients being reviewed six monthly which was certainly unachievable under the existing service provision. It was also apparent that patients were being randomly allocated at general geriatric clinics. They were being evaluated amidst other patients whose main complaints were of falls and stroke etc with no focused care. With upcoming planned retirements and reconfigurations it was felt there was a need for urgent change.
The need for change:
It was felt that the ideal way forward would be a streamlined joined up clinic for those with Parkinson’s Disease and tremor disorders involving properly trained geriatricians who have a passion and interest to look after this subgroup of patients. This would happen at least once monthly (with a plan for future expansion) with input from PD nurse specialist, Trainee StRs and pharmacists with future hope for transforming into a a one-stop service involving MDT in the same setting.
Those involved also felt there was a need to develop a PD clinic proforma for such clinics. This should be based on the standards of care set out by the PD audit to deliver consistency and uniformity in the care being delivered amongst various consultants and trainees in the clinic. This would also aim to provide meaningful measurable data on yearly Audits. It was highlighted that this would change according to need and can be easily modified from feedback from users and feedback from individual service reports from the national PD audits.
Regular meetings between the senior management team and our PD clinical lead explaining the rationale for changes outlined above resulted in a positive outcome and acceptance from SMT that setting up a combined PD clinic as a first step was the way forward. Three geriatricians converted one of their clinics and relocated to Ballymena site which was somewhat midway between two acute Hospital sites of Northern trust. Extra nursing support was obtained to aid the clinic.
Our PD lead was using a PD proforma consistently for all new pd patients. It was agreed that such a proforma should be widely available in the clinic. Other speciality clinics were relocated to make room to setup this pd clinic and to run it on the third Tuesday of every month with 9 new and 12 review patients. This template would be then delivered between three consultants and a trainee Str. The case was made for a Parkinson’s nurse specialist to be available for most clinics.
Although early days and some teething issues we have set forth in the right direction and so far have been running the clinic smoothly with no significant issues.
2017 UK Parkinson’s audit data and recommendations were reflected on as below
Regular Audit of service being provided against national performance.
Expansion of service in frequency and involving other trust sites dependent upon demand.
Ultimate aim to set up a one stop shop of PD service to patients including MDT.
Regular participation at national Audit and fine tuning the PD proforma according to need.