Managing MSologist deficiency: the MS MDT model

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