Managing MSologist deficiency: the MS MDT model


By By Dr Basil Ridha, Royal Sussex County Hospital, Brighton

Background

  • Brighton and Sussex University Hospital NHS Trust (BSUH) is based at 2 main sites :
    • Royal Sussex County Hospital, Brighton
    • Princess Royal Hospital, Haywards Heath
      • Includes Hurstwood Park Neurosciences Centre
    • Provides:
      • Acute service to 0.5 Million (2012)
      • Regional neurosciences service to 1.5 Million (2012)
    • Regional neurosciences service:
      • 16 full time equivalent consultant neurologists
      • Of these 8 bases at BSUH
      • Of these, 2 have special interest in MS
    • Traditionally, all new patients with suspected MS referred to MS clinic and the:
      • Discharged back to referring neurologist if :
        • Patients do not require/qualify for DMT
        • Patients go on glatiramer acetate/ beta interferon
      • Discharged back to referring neurologist if the patient remains stable on a first line oral therapies (Aubagio/Tecfidera) for a year.
      • Remain under MS clinic only if prescribed a high efficacy therapy (Gilenya, Lemtrada, Tysabri)

Challenge

  • One of the 2 neurologists with special interest in MS left the Trust almost 2 years ago.
  • New academic neurologist with special interest in MS appointed with limited clinical commitment capacity.
  • Significant reduction in capacity to follow up existing MS patients and see new referrals.
  • Over time there has been accumulation of backlog of 500 MS patients needing follow up.
  • Patients under MS clinic:
    • Tecfidera 181
    • Copaxone 79-probably 3-4 times that number in whole of Sussex
    • Beta interferons 61-probably 3-4 times that number in whole of Sussex
    • Teriflunomide 70
    • Alemtuzumab 129 (58 second round)
    • Fingolimod 117
    • Tysabri 101
  • About 580 MS patients on oral or infusion DMT
  • So far no replacement appointed to replace the full time neurologist with special interest in MS
  • Remaining MS neurologist and academic neurologist just doing MS clinics, with little general neurology work, to clear backlog of follow ups

Interim solution

  • MDT model:
    • All referrals from general neurologists discussed at weekly MS MDT (tagged to neuroradiology meeting) attended by :
      • Neurologist with special in MS
      • Neuroradiologist
      • 3 hospital based MS Nurse specialists (looking after oral and infusion DMTs)
      • Sometimes community nurses
    • If patient goes on therapy other than infusion treatment or Gilenya, then all care remains under referring neurologist. Otherwise, joint care.
  • MDT model for referrals started in past 6 weeks
  • Over the past 6 weeks, I have referred 5 patients:
    • 3 offered first line MDT :
      • 1 patient gone on Lemtrada
      • 1 patient considering either Tecfidera or Copaxone but undecided
      • 1 patient gone on Aubagio
    • 1 patient felt not eligible as probably PPMS
    • 1 inpatient. Diagnosis still uncertain if highly active MS or NMO. Under joint care for now

Challenges (to the referring general neurologist)

  • Time to attend MS MDT
  • Additional admin time eg liaising with MS therapy nurses
  • Blueteq form
  • Record EDSS yearly when seen in general neurology clinic

Advantages (to the referring general neurologist)

  • Quicker time from diagnosis to therapy
  • Sense of involvement and “personal value”
  • Feel more part of MS team
  • Reskilling in MS emerging therapies
  • Put into practice things learnt from courses- eg MS MasterClass

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