Development of MS pathway in West Suffolk

In December 2020 a new Community Neuro Specialist Team was set up to cover the West Suffolk area ( figure 1). A Neuro Physiotherapist and a Neuro Occupational Therapist were employed to develop and deliver the service. The Neuro Physiotherapist had a background on the rotational inpatient services and had a special interest in Neurological conditions. The Occupational Therapist had a background in both acute and community stroke therapy. She also has spent the last 3 years leading an ESD team and an acute stroke team. They both have valuable transferable skills to implement in the new service and were both keen to participate in this exciting opportunity.

Up until the Community Neuro Therapy service was implemented, all MS patients were seen by general community therapists with a problemsolving approach. Patients were assessed, treated and discharged, there were underdeveloped links between MDT professionals (Specialist nurses, Neurologists, Community therapists, SALT, etc) which led to a disparity of continuity of care for patients.

Initial challenges were faced by the Specialist Therapists, including linking in with existing Community Teams and IT structures which impacted on developing referral processes. It quickly became evident that the Therapists were facing a huge task as there were no existing pathways for patients with MS and other neurological conditions to access therapy in a consistent manner.

The Therapists promptly formed links with Specialist Nurses and the neighbouring Trusts along with charitable organisations which helped the rapid growth of their service.

A 2020 study estimated that MS prevalence is 190 cases per 100,000 population, with 105,800 individuals in England. Based on the population of West Suffolk it is estimated that there are around 358 people with MS. Out of our current caseload of 187 patients, 39 have MS diagnosis. The development of this team has identified a need for the MS pathway to be developed to enhance an MDT approach for the MS patients, in accordance with NICE guidelines.