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New regulatory authority requires all consultants within the private sector to give more information to those who might be referred to them. This information is supposed to be provided in advance of any consultation. It must be pointed out that with a neurological practice any delay in seeing a neurologist could under some circumstances be problematic but we have no choice but to follow what is the required regulation.
If insured, speak to your insurance company. They should give an authorisation number. Always check the amount of cover you have. Blood tests are far more expensive than people realise. Fees will be a maximum of £300.00 for new patient consultations and £200.00 for follow up consultations. The centre charges fees according to the tests carried out.
Invoices are usually sent directly to the insurer when we there is such an arrangement. Even if you are insured you are still responsible for the payment of professional and clinic fees. Although the insurers may settle directly on your behalf, it is always your responsibility to make sure that has taken place.
I hope you are as surprised as we are that a number of people perceive that there is no need to settle fees. This is both frustrating and basically wrong. Like any professional practice, we do take every action in order to have fees settled. Personally, we would much rather focus on medical matters but all of our practices’ depend on fees being settled.
A neurologist deals with all matters in relation to the nervous system. This includes the brain, spinal cord, peripheral nerves, muscle and spine. Our practice also focuses on the management of pain. We frequently see people who other specialists have not been able to assist fully. We are usually able to help by our knowledge of how the nervous system works in generating symptoms.
When this is combined with our knowledge of the rehabilitation process an appropriate treatment programme is recommended. It is our view that almost no one sits in a position where they cannot get fundamental improvement from whatever symptom or problem they present.
When you attend you will be asked to register and give details of your insurer if that is the case or to confirm that you understand if self-paying that you will be responsible for all fees. That might include any fees for the investigation carried out by the clinic on our behalf. As expected, these days paperwork needs to be completed. The clinic may ask for a credit card. Practices will be invoicing professional fees quite separate from the clinic
The initial part of the consultation will involve questions about your background. This is simple demographic data which helps always with the neurological assessment.
A full history will then be obtained focusing initially on what are the main symptoms.
Most neurological examinations are not unpleasant, certainly not painful and usually people do not have to undress other than remove their shoes and socks. If the muscles need to be examined then a greater degree of undressing in needed. Any person can always ask for a chaperone if they feel more comfortable.
At the end of the consultation we will discuss with you our thoughts about what might be going on. Sometimes it is possible to give a precise or near precise diagnosis but equally often it is necessary to undertake investigations. Forms will be written in your name. The tests can be carried out locally or you can choose to have the tests done at any private facility you wish. It is not possible to take forms within the private sector to the NHS and expect the NHS to carry out the tests. If you are NHS entitled, we can never quite understand why that should be given that we have worked effectively within the NHS for many years but these are the rules. At any time you can choose to go back to your GP and get an NHS referral. The NHS remains free at the point of delivery to all NHS entitled people.
A range of investigations can be arranged by any consultant. In neurological practice these will involve blood tests, scanning, ultrasound tests and investigations known as neurophysiology. Occasionally admission is required in order to look at the spinal fluid by a test called a lumbar puncture.
The blood test form requires that you go round to the blood taking area of the hospital. Blood tests cost far more than people realise in the private sector.
The phlebotomist will usually invite you to sit down. There will be an explanation. A cuff is put around the arm in order to make a vein stand out, usually at the level of the elbow or in the forearm. With modern disposable needles blood taking is not usually painful. If you have any tendency towards fainting as a consequence of having a blood test then let the phlebotomist know (person taking the blood) they will want to do the test with you lying down. Under those circumstances you should remain lying for a short period after the test and then only sit up slowly to make sure that there is no residual faint feeling.
Occasionally blood tests must be done in the fasting state and if that is the situation then you will be informed of that.
Occasionally neurologists will order urine tests which will involve either a small sample of urine being collected or a 24hr collection undertaken when the laboratory will tell you exactly what to do.
Neurologists do MRI scans, CT brain scans and ultrasound tests usually looking at blood vessels of the neck.
MRI brain scanning is by far the most sensitive test that we have. It doesn’t involve x-irradiation. It doesn’t hurt at all. The machine makes quite a lot of noise and it is claustrophobic. If you suffer from claustrophobia than it is worthwhile mentioning and there are Three upright scan centres in central London which are not claustrophobic at all. There is a half open scanner in Hendon but a plate still comes down towards the top of you which some people do still find disconcerting.
Each facility charges its own rate for scanning. Sometimes an injection has to be done during the scans. If that is the case there will be a need to do a test of kidney function first. That is usually a blood test.
If an injection is required this will be fully explained. A little cannula, that is a needle in the arm, called a butterfly drop will be placed and the dye given. This often gives a warm feeling but again unless you are very unlucky to have an allergy to the dye which is very rare it is unlikely to be a problem. MR scanning takes about 20 minutes for each section and you will be taken out of the scanner after each section if you are worried. The radiographer can talk to you throughout the scan and will let you know what is happening. Having been scanned myself I actually prefer it when the machine is making a lot of noise rather than when it goes silent as one doesn’t quite know when the next phase is coming but the radiographers will always tell you.
The costs of MR scanning are different between hospitals. There is an extra fee for the gadolinium enhancement. If you are not insured then it is worth knowing about the Vista Diagnostic units in Central London and Ealing as they charge a lesser rate. Their scanners are good scanners. Their films are reported by neuroradiologists. I must emphasise that there is no vested interest in any scan unit to encourage me to refer you in any particular direction. Many people uninsured prefer the convenience of being at the local hospital. Others are content to travel in order to save the cost.
A single scan will cost in the order of £500.00 at the local hospitals and £250.00 at the Vista Unit though prices do vary according to the extent of the scanning and the time when the scans are being carried out.
CT scanning in an x-irradiation test. There are specific rules and guidelines with regard to x-irradiation. CT scanning is very quick. It isn’t as sensitive as MR scanning but it is used in certain circumstances. The most common of these is if an individual has a pacemaker or metal fragments in the eye such that MR scanning would be dangerous. CT scanning can be done with modern day coronary artery stents and with joint replacements. Usually heart valves are safe as well in the modern era. CT brain scanning can be undertaken in all these individuals.
No scanning is done without reason in the first three months of pregnancy. For some reason CT scanning is preferred in those first three months but if a CT brain scan for instance needs to be done in pregnancy it is likely that an MRI scan will follow and there will be extensive discussion about that. In simple terms it just isn’t known if MRI scanning is safe in early pregnancy whereas it is known that CT brain scanning with LED shielding is safe.
Ultrasound scanning literally involves the radiologist skilled in ultrasound waving a pen like object over the artery and listening to the sound it makes.
All of the specialist radiologists will send a report to myself. I will also look at many of the films though would always require the imaging of ultrasound to be reported. It is usually best to leave 48 hrs after any scan to make sure that the reports and films are available. If the scans are done outside of the hospital network then 72hrs is preferred as it just takes a little longer to get the films and report available.
Neurophysiology testing includes electroencephalography (EEG), evoked potential testing (EP’s), nerve conduction studies (NCS) and electromyography (EMG). NCS and EMG’s are carried out by a consultant neurophysiologist. For the record I am an accredited neurophysiologist who reports on all neurophysiology but elected not to do NCS and EMG after I got my clinical consultant neurology post. There are other specialists who do only these tests who are just better at it.
An EEG requires electrodes to be placed on the scalp. No hair has to be removed. Evoked potential testing looks at the way the nervous system conducts electrical impulses. The visual pathway and sensory pathways are tested by placing electrodes appropriately. None of these tests are painful. EEG does require you to look at flashing lights and to hyperventilate which some people do find disturbing but it is not harmful in the slightest. An EEG with triggering activities may actually produce a seizure which could be disconcerting but that in a way is all part of the testing process when a diagnosis might be uncertain in any case.
Nerve conduction studies and EMG testing involve a specific appointment as do all of the tests and the consultant neurophysiologist will explain in detail what they will be doing.
Each hospital has its own schedule of neurophysiology testing charges and the websites where these notes are being forwarded will have details of all of those charges.
If there is any disorder of memory or a change of personality then consultant neurologists’ will frequently ask a consultant neuropsychologist who is a colleague not medically qualified but trained to look at every aspect of cognitive functioning including memory. This testing actually takes about 4 hours. Often it is misunderstood by insurers as representing a psychiatric assessment. There is actually nothing wrong with a psychiatric assessment but neuropsychology testing is quite different. The neuropsychologist would give a full explanation as to what happens during the testing process.
Vestibular function tests that is measuring the balance mechanism are also undertaken. We can use The London Balance Clinic in Harrow. The tests take about one hour. A questionnaire needs to be completed and the technologist doing the tests will explain carefully. There is nothing unpleasant. Video head impulse testing is the more modern testing technique and we find it gives excellent results.
Examination of the spinal fluid is done for a number of reasons. The test needs to be carried out as a day case. You will be invited to make an appointment that suits your timetable. You will be admitted to hospital. After the nursing procedures have been carried out the test can be done at the bed side or under x-ray. The test will be explained carefully. The only side-effect that we have ever had in 40 years of doing lumbar punctures is the condition known as post lumbar puncture headaches. This is a headache which you get the day after the procedure. It is characterised by headache on standing up which goes away on lying down. 10% of people after the lumbar puncture get this problem. Usually it settles down spontaneously with simple analgesia, fluids and the taking of caffeine. Every now and again someone will get it worse and then a short course of steroids or even three days of bed rest with intravenous fluids may be required but that is very uncommon.
The spinal fluid samples are taken off after the pressure is measured and these will go to the laboratory.
The hospital makes all of the charges for the inpatient admission and the spinal fluid testing. This can be remarkably expensive and may actually generate a charge of about £1,800.00 to £2,000.00 for the investigation and an £800.00 inpatient day case stay though these figures would need to be checked with the hospitals concerned. They are only an estimate and cannot be used in any way to criticise as obviously they can change at any time according to circumstances.
Please read all of the information about every medication you might take. We will usually give a first script. The GP will normally follow this up. We do need to charge a fee of £15 (for administration purposes) if you want us to provide further treatment. A follow up at least every 6 months is mandatory as it will be for your GP.
There have been a number of high profile medico-legal cases where doctors regrettably have been criticised over the consenting process for procedures. Fortunately neurologists do not undertake surgical procedures but we do organise tests and so some discussion about consent is reasonable.
It must be assumed that the fact that any person is coming to see a doctor is because they have a problem and would like some help or at least an understanding as to what is going on. In all of the years that I have practiced medicine we have never come across a doctor or nurse who wants to do anything other than help the people that they are seeing or providing care. We all know the case of Dr Harold Shipman and there are like every other areas of life occasional bad eggs. Judges get verdicts wrong, solicitors make mistakes and most businesses perceive that they are doing well if they achieve a 90% success rate. In medicine it would seem that nothing less than 100% is acceptable. The time available to doctors is being increasingly consumed by the massive increase in administration, bureaucracy, paper work, annual appraisal and five yearly revalidation. In the private sector the insurers are asking for more and more information sometimes just in relation to a single consultation. Doctors have no more time being doctors than other people. Most doctors already work far more than the hours that would usually be regarded as acceptable under the European Working Time Regulations.
The internet provides a wonderful resource for information. There are support groups for more or less every condition once diagnosed. Likewise, symptoms are analysed in depth but be cautious about always thinking the worst. For instance, headache is usually benign and not a sign of something sinister. Always ask any doctor about your worries. A very good question to ask, “What would you do if it was yourself or close family member needing to make the decision?”
The consultation process as discussed above assumes consent. It assumes that a letter can be written to the referring doctor and a copy going to yourself. If that is not acceptable for any reason than you must let me know. The GDPR (General Data Protection Regulations) come into force on 25th May 2018. These regulations will add a huge burden on medical practise, but it means we need to have your consent to hold information, e mail, write letters, telephone or share information with other professionals. If you do not want any of this to happen then you are entitled to say so. Safe medical practise however does involve letting your GP and sometimes other doctors or professionals (e.g. physiotherapists) know about your condition.
If any tests are ordered on you then again it is entirely your choice whether you have these carried out or not. You can ask for an estimate of likely costs. This will be discussed anyway. You can also ask as to the likelihood of the tests being abnormal. Be assured I would not do a test if I was 100% certain that it would be normal. The insurers do actually have a quite a lot of difficulty with this thinking at the moment. If we miss a diagnosis, then given the current climate in the UK then a single mistake can actually lead to the end of a 40 year career. The final decision on any testing or treating process will be for you alone and not the doctor. If you refuse any test or treatment there is now a duty of the doctor to ask why? And make sure refusal is knowledge driven and without duress or coercion from outside agency.
If you have any tests carried out you MUST make a follow up appointment to discuss. Doctors can be criticised for not doing so.
Using medications to help any problem has the same principle of consent. We work on the basis that any drug can cause any side-effect, in any person, at any time. If we never had to prescribe another drug in the rest of our lives it wouldn’t be too soon but then large numbers of people would be denied medicines that actually provide a great deal of help. We know that there can be occasional very serious reactions to drugs. Think of penicillin allergy as a good example. Fortunately most of the medicines in neurological practice if they have side-effects will settle very rapidly or go away if the medicine is stopped. The only reason to take a medicine is if the symptoms suffered are such that treatment is requested.
A very good example of this conundrum is the use of Aspirin is well known to stop people having strokes and heart attacks. The amount of good of this very simple medicine in low dose is quite extraordinary from the scientific studies. Every now and again somebody however will get gastric irritation and even get a gastric bleed. Is that a reason not to take the drug under any circumstance? Again the final decision is for each individual but perhaps we are giving insight as to the near impossible situation in which we find ourselves particularly with regard to consent. We do not know how much time is right in the consenting process. How much information is the right information and does everybody really want to know every single micro complication that can occur that each of us as doctors may never actually see in the whole of our career. The courts now perceive that there is no amount of information that is too much and that every single possible risk needs to be explained in detail. Everyone is supposed to think about whether or not they have a treatment. The only issue with that analysis is that if urgent surgery is delayed then the surgeon will be criticised for not operating earlier but how do you operate earlier when you are supposed to give people time to think and make informed decisions.
The basic message is to ask questions to any doctor you see. Do your own internet research using the websites of the main support groups and if there is anything you do not want to happen don’t do it but make sure you put in writing to the doctor that it is your decision that you don’t want to have investigation or the treatment recommended.
Most neurology assessments involve a new patient consultation, investigation and then a further consultation dealing with the results and hopefully setting up a treatment programme. Sometimes more investigation will be needed. The insurers do not these days allow monitoring or simple follow up. This in itself applies enormous pressures to the doctors. Always and never, never apply in medicine. Up to 40% of people for instance with neurological symptoms will not have a definite diagnosis which is challenging in itself.
If it is agreed that we do not need to meet routinely that does not mean that you are ever discharged from care. If the symptoms persist, change or you continue to have worry than just book a further appointment. You can always ask for a second opinion which will be willingly offered, name suggested or the advice given to see your own GP for discussion. It is my view that we all need to take ownership of our own health after all our bodies and minds are our number one asset.
Other treatments that may be given or recommended include physical treatments, injection treatments, talking therapies and pharmacotherapy. In effect discussing these requires a whole text book of neurology. Any treatment programme will be discussed as appropriate.
Neurologists do not function alone. They work carefully with neuroradiologists, neurophysiologists, neuropsychologists and in fact every other specialty. They also refer to physiotherapy, occupational therapy, speech therapy and dieticians.