Journal ofNeurology, Neurosurgery, and Psychiatry 1992;55(Suppl):2-7

Neurology in the United Kingdom.I: historical development

R Langton Hewer, V A Wood

AbstractInternational comparisons suggest thatBritish neurological services are under-developed. Historical factors which havecontributed to the current state ofneurological services in the United King-dom are described. Key issues include thedominance of London and the concept ofspecialised hospitals in the early historyof neurology; the subsequent recognitionof the needs of other parts of the UnitedKingdom, of district general hospitals,and of patients with chronic neurologicaldisabilities not necessarily includedwithin the traditional bounds ofneurology; and the relationship betweenneurology and general medicine. Thepaper concludes with some suggestions as

to how neurology services might developin the future.

"The United Kingdom must have one ofthe worst neurology services in the WesternWorld." The speaker was a colleague fromNorth America and he was commenting on thesmall number of clinical neurologists in theUnited Kingdom (UK) compared with the restof the Western World. How could such a

comment have been made, 150 years afterneurology was officially recognised as a specialbranch of medicine, more than 125 years sincethe opening of the National Hospital in Lon-don,' and over 100 years since the formation ofthe Neurological Society of London and theinception of the journal Brain-A Journal ofNeurology?

Department ofNeurology, FrenchayHospital, Bristol, UK.R Langton HewerV A Wood

THE HISTORY OF NEUROLOGYNeurology as we know it today is founded uponthe brilliance, skill and persistence of our

eminent predecessors. Biographical sketches ofone hundred and forty six "Founders ofneurology" are presented in the book of thistitle by Haymaker and Schiller.2 Experimentalapproaches to the study of the nervous systemwere introduced by Thomas Willis (1621-75),the Oxford neuroanatomist. Willis' work led tothe first advances in knowledge of the nervous

system and, in his book "De Cerebri anatome"published in 1664, he was the first to use theterm "neurology", meaning the knowledge ofthe cranial, spinal and autonomic nerves.2

In the early nineteenth century there were

many significant contributions to neurologyfrom the UK. In 1817 James Parkinson (1755-1828) first recognised the disease since namedafter him, in his "Essay on the Shaking Palsy".3

Sir Charles Bell (1774-1842), Professor ofSurgery in Edinburgh, made a significant con-tribution to the knowledge of the nervoussystem. His famous book, "The Nervous Sys-tem of the Human Body", was published in1830 and was translated two years later intoGerman by Romberg who was, shortly after-wards, appointed to lecture on neurology inBerlin.'

In the later part of the nineteenth century,distinguished workers abroad and in the UK(such as Hitzig, Fritsch, Ferrier) defined theexistence of areas in the cortex of the forebrainfrom which movements could be elicited byadequate stimulation. Later it was found thatmessages from peripheral sense organs reachspecific cortex areas. "Clinical observationsalso demonstrated that in man the cortex isessential for purposive movement, conscioussensation, vision and hearing as well as for hismental and intellectual activity."'I

It was Jean Martin Charcot (1825-93), underwhom the French school of neurology attainedeminence, who first established clinicalneurology as an autonomous discipline andwho, in 1882, was appointed the first professorof diseases of the nervous system. Among hismany achievements he advanced the disciplineof nosology and established disseminatedsclerosis as an entity. His name is linked withperoneal muscular atrophy2 and many otherclinical syndromes.

NEUROLOGY IN LONDONThe National Hospital for the Relief and Cureof the Paralysed and Epileptic, as it was origin-ally called, opened in June 1860 in an old andill-adapted house in Queen Square, London,with accomodation for eight patients. Its foun-dation was due to the untiring efforts of MissJohanna Chandler, who for 15 years devotedher life to its welfare and to the comfort of itspatients.'

In the early years of the National Hospitallittle was known about the central nervoussystem and few of the more common diseaseswere clearly recognised.4 Its foundation,however, attracted the foremost neurologists ofthe day, and it soon became a focus for studyand a centre which rivalled the Salpetriere.5For some years London remained the only

place in the UK where people suffering fromdiseases and disorders of the nervous systemcould obtain specialist help. When PurdonMartin joined the National in 1920 littleneurology in this country was being practisedoutside London.6

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3Neurology in the United Kingdom. I: historical development

EXPANSION OF THE SPECIALTY

Neurology gradually expanded to the provin-ces, initially by former Queen Square housephysicians establishing chiefly neurologicalpractices.6 In 1954 the Royal College ofPhysicians (RCP) Committee on Neurologyreported that 50-60 neurologists were practis-ing in England and Wales, with 50% of theseworking in London.7 An enquiry among con-

sultant psychiatrists showed that "while theneed for neurological consultants was

adequately covered in London, it was not

adequately covered in the provinces".7By the late 1950s the view was commonly

held that there was no substitute for the specialhospital, in the context of a place of referencefor the difficult problem and as a training andresearch centre."'0 Some were of the opinionthat many of its functions could not be efficien-tly discharged by general physicians or

neurologists working in a general teachinghospital.'0 Others, however, recognised thatsome neurological disorders were not seen at a

special hospital and that the general hospitaloffered opportunities which were complemen-tary to those of the specialist institutions.89The 1954 RCP Neurology Committee's

report suggested a considerable increase in thetotal number of neurologists and a more even

distribution throughout the country, in accor-

dance with the distribution of the population.7Around the same period, during the 1940s and1950s, one of the fundamental basic concepts ofthe National Health Service-the DistrictGeneral Hospital-emerged. The idea of pro-

viding, under one roof, inpatient and out-patient facilities for the population of a Districtwas accepted in the hospital plan of 1962,which suggested hospitals of 600-800 bedsserving a population of 100 000-150 000-."

General hospitals have been viewed as havingdoctors allied to all the main specialties withinmedicine.12

In 1959 the ratio ofpopulation per neurolog-ist was reported to be 400 000 persons across

the metropolitan area and 1-2 million per

neurologist in the provincial regions.'0 Thevariation in regional ratios was wide, for exam-ple, although three neurosurgeons were pract-ising in Liverpool (Mersey Region, population2-1 m) there were no neurologists; in Newcastle(Northern Region, population 2-9 m) therewere four consultant neurosurgeons and twoconsultant neurologists.'0 During the 1960sand 1970s there was an increase in the numberof provincial neurological centres.'1'6The 1970 RCP Report on Neurological

Manpower suggested 2 2 consultant sessionsper 100 000 population.'7 These figures were

derived from the Platt Committee Report on

Medical Staffing Structure (1966).18 Thisfigure was accepted by the London HealthPlanning Consortium in their Report of a

Study Group on Neurology and Neurosurgery(1980).19By the mid 1980s, neurology as a specialty

had grown, but remained small. One hundredand ninety consultant neurologists were in postin the UK in June 1987 and the overall ratio ofpopulation to whole-time-equivalent (WTE)

neurologist was 373 000 persons to one.20 Onehundred and five consultant neurologists(55%) worked in the Thames Regions and/orthe special hospitals in London, and the ratioof population to WTE neurologists there was

20250 000 persons to one.In 1987 there was a wide variation in the

distribution of consultant neurologists indifferent parts of the country.20 Only 22% ofthe 200 Health Districts in England and Waleshad the equivalent of one full time neurologist(11 weekly sessions) or more-43% had lessthan three consultant neurological sessions perweek. The current organisation of neurologicalservices is discussed in more detail in oursecond article.2'

In 1988 the Association of British Neurolog-ists adopted the policy that each Health Districtshould have available to it the services of oneconsultant neurologist on the basis of at leastone full time specialist for each 200 000 per-sons.22 In his analysis of his own workload,Stevens considered that this must be regardedas an achievable interim objective because thereal need was probably for an even smallerpopulation per consultant.23

It is interesting that in 1987 in the UnitedStates there were about 32 400 people perneurologist and in Canada the ratio was about63 100 people per practising neurologist.Ratios are similar in most Western Europeancountries.The scope of neurological practice and care

in England, Canada and the United States wasanalysed by Menken et al.24 They asserted thatin the UK almost no emergencies were admit-ted to a neurologist's care and the British healthsystem assumes that general physicians havesufficient education, training and experience tomanage most of the common disorders thataffect the nervous system.The problem of the small number of

neurologists in Britain is compounded by thefact that the specialty of rehabilitationmedicine is under-developed. Most, if not allWestern countries, have a substantial specialtyof rehabilitation whose members are involvedin the management of disability due toneurological disease. This applies particularlyto North America, New Zealand and Australia.In theUK there is only a handful of consultantspractising full time in rehabilitation medicine,which was first recognised as a separatespecialty by the Department of Health asrecently as 1991. A report of the Royal Collegeof Physicians22 suggested that in each HealthDistrict there should be a total of 10 consultantsessions in rehabilitation medicine-possiblydivided between three consultants. The reportexpressed the view that neurologists, amongothers, could "take up" some of these sessions.

In the late 1950s Lord Brain highlightedchanges in the neurological scene which hadbeen brought about by new diseases and theincreased incidence of old diseases, togetherwith changes in the age distribution of thepopulation.8 He argued that the scope ofneurology was too wide for general physiciansto undertake all neurological work whichpresented in a general hospital.

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The RCP Neurology Committee's report of1954 argued that the need for more neurolog-ists could be demonstrated by the steadyincrease in the number of cases attending thenew neurology centres which had been set upover the past five years, as well as the turnoverof inpatients.7 Brinton also argued that "theestablishing of a neurological service quicklydemonstrates the need of the localpopulation".'0As Stevens recognised, the starting point in

establishing need is to estimate how muchneurological disease is present in the commun-ity.23 A major survey of the epidemiology ofneurological disease was undertaken by Brewiset al.25 They surveyed the population ofCarlisle and found that the total prevalence,adjusted for the British population, was 1 100/100 000, or one per cent (these figures did notinclude congenital or paediatric diseases). AHealth District (with a population of a quarterof a million persons) would contain at least2500 persons with significant neurological dis-ease. More recently, acute neurological diseasehas accounted for about 20% of admissions tomedical wards.26The scope of neurology was recognised by

the World Health Organisation to be so largethat it warranted a special volume of theInternational Classification of diseases-a copyof which was published for trial purposes in1987.27A recent review of the epidemiology of

neurological diseases28 suggests that the annualincidence of seven important causes of neuro-logical disability exceeds 500 per 100 000. Theoverall prevalance for this group is about 2500per 100 000, with 1400 being disabled (includ-ing about 500 epileptics on treatment).

NEUROLOGICAL DISABILITYIn 1959 Brinton highlighted two "new" bur-dens which he felt should be shouldered byneurologists: the medical care of epileptics andthe supervision of the neurological chronicsick.'0 He reported that no serious attempt toimplement the recommendations of the Cohenreport29 (on medical care of epileptics) had beenmade, and the problem of the chronic sick hadnot been officially tackled by the Ministry.'0Finding a hospital bed for an incurable patientwas difficult and, even when one was acquired,the patient was unlikely to receive any specialisttreatment and rarely any physiotherapy oroccupational therapy.'0 The RCP NeurologyCommittee's report in 1965 also reported that"the chronic neurological case seem(s) to beneglected through lack of facilities".30

Miller, in the late 1960s expressed the viewthat historical circumstance had deprived theclinical neurologist of responsibility for eitherthe long-term sick or care of the patient withchronic neurological disease.3' However, hestrongly contended that "there can be no doubtthat this responsibility belongs to him, and thatevery unit should undertake the supervision ofpatients in both groups".3'

In the 1980s physical disability was thesubject of considerable debate. Two reportsfrom the Royal College of Physicians of

London, "Physical Disability in 1986 andBeyond",32 and "The Young DisabledAdult",33 drew attention to the problems posedby physical disability. The former suggestedthat the management of disability is the respon-sibility of all clinicians, and that the provisionof appropriate generic services should helpthem to deal with their disabled patients. Bothreports identified three particular areas ofmajor concern to neurologists: 1) disabledpeople between the ages of 16-64; 2) patientsrecovering from a head injury; 3) the disabledschool leaver, most of whom suffer fromneurological disease.

RELATIONSHIP OF NEUROLOGY TO GENERALMEDICINEThe subject of neurology was recognised bymany in the 1940s to be so large that "to keepabreast with its theory and practice in all theiraspects is in itself sufficient to occupy the wholeprofessional time and energy of anyone whowishes to be a master of the subject".34 TheRCPs Committee on Neurology, however,stated that neurology must not allow itself to beseparated from general medicine.34 Theyrecommended that all neurologists should be ofconsultant status and should hold a higherqualification in general medicine (MRCP orequivalent) before starting 48 months whole-time study of clinical neurology.

In anticipation of the NHS, the 1945 reportsuggested that "the services of a trainedneurologist shall be available for any memberof the public who needs them irrespective ofhiseconomic position or place of residence".34 Thetotal number of neurologists in the UK at thattime was reported to be approximately 60. Itwas evident that many acute neurological caseswould not have access to a neurologist. Thecommittee suggested that "the care of suchcases will properly fall to the general physicianof the appropriate area or hospital who com-bines an interest and training in neurology withhis general medicine. Such clinicians, it ishoped, would establish a close liaison with theneurological centre in their region".4

In 1954 the RCP Neurology Committeereported its regret that the position ofneurology was worse (under the NHS) than ithad been in 1945.35 It suggested that some ininfluential positions held the view that thepractice of teaching and general medicinemight be impoverished by the appointment ofmore neurologists and that neurology in theprovinces should be carried out by generalphysicians. The Neurology Committee arguedthat this view was short-sighted and contrary tothe best interests of the Health Service and thata fully trained neurologist could make a con-tribution both in diagnosis and treatment inmost neurological cases. They did not suggestthat all cases of neurological illness besegregated under the direct care of a neuro-logist, but recommended that an expert neuro-logical opinion should be available whenever itwas needed.

In 1959 Brinton suggested that, to cover theserious shortage ofneurologists in England andWales, general physicians with an interest and

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some special training in neurology wereunquestionably useful in a few parts of theperiphery of the country, although they shouldmaintain a close contact with the nearestneurological centre.'0

In 1965 the RCP Committee on Neurologysuggested that neurology is best practised in ageneral hospital.0 They reported that theneurological sick were being nursed in generalmedical beds, without the benefit of the facilityof an efficient local neurological unit but thatsome sub-acute disorders might be referred to aneurological unit elsewhere, although chronicneurological cases seemed to be neglectedthrough lack of facilities. However, the reportstated that neurology cannot be practisedefficiently by a general physician, and that theconcept of a physician with an interest inneurology was "outmoded".

Later in the 1 960s Miller continued theargument, contending that there was a place forthe general physician with a special neuro-logical interest, and suggesting that advances inneurology should be achieved without dis-sociating the specialty from general medicine.3'He pointed out that remarkable cardiologicaladvances had been achieved without dissociat-ing the specialty from general medicine.3'Indeed, it is clear that many specialties, includ-ing endocrinology, chest disease and gastro-enterology, can be successfully combined withgeneral medicine.However, the Royal College of Physicians'

Report of 1986' suggested that it would be aretrograde step to appoint general physicianswith a special interest in neurology in DistrictHospitals. It was felt that general physicianswith an interest would not acquire the neces-sary expertise to deal competently with rareconditions and resources may be wasted by theuse of unnecessary investigations. The 1986report also suggested that physicians practisingspecialist neurology would need to have accessto beds on a neurological unit and this wouldnot be practicable for general physicians withan interest. The Committee felt that the onlysolution was expansion of the neurologicalconsultant establishment.

In the late 1 970s the Royal College ofPhysicians were reported to be aware of the"mounting anxiety that . . . general medicinewas being eroded by the development ofrelative specialties based on technology, theincreasing clinical commitment ofhaematolog-ists, the broadening interests of radiotherapistsand anaesthetists, and the growth of specialtiessuch as general practice, accident and emer-gency, and medical care of the elderly".37As in the 1950s, there seems to be an

indication that in the 1 970s and 1980sneurology and general medicine were becom-ing increasingly isolated from one another. Onthe one hand neurologists insisted that it wasnecessary to train "pure" neurologists andexpand the small consultant complement. Onthe other hand, physicians felt that generalmedicine should not be eroded by the creationand expansion of different specialties. Thedebate has now raged for more than 45 yearsand, at present, seems no nearer being resolvedin the 1990s than it was in the 1940s.

Neurological EducationThe scope of neurological disease is large, butthe complement of consultant neurologists issmall. The majority of patients with acuteneurological problems are currently beingmanaged in district general hospitals by generalphysicians. How well trained are they for thistask? Davidson and King37 examined thespecialist interest of 1031 general physicians inEngland and Wales and Northern Ireland.They found that few (9) had an expressedinterest in neurology, and only four hadneurology in their contracts.The cornerstone of teaching neurology

to undergraduates is seen to be clinicalattachment to a neurological department.'8Wilkinson's survey, in 1990,38 indicated thatthis was available to every student in 20 of the28 medical schools in the UK and was full timein just 11. The most common arrangementswere either full time for four weeks or part timefor six weeks.39 Only six schools had specificarrangements to give students any training in

38neurological/neurosurgical emergencies.Wilkinson's original survey38 also indicated

that "the assessment of students in neurology/neurosurgery is crucial in only one school". "In11 . .. schools, no specific assessment what-soever is made of students' knowledge, clinicalskills and attitudes in neurology and neuro-surgery."From Wilkinson's surveys it seems clear that

many students are qualifying in medicine with-out having received any form of systematictraining or assessment in neurology.

All trainee physicians will be involved withthe management ofsome neurological patients,but not all will have been attached to a specialistneurology firm. It is possible for a physician tobe appointed to a consultant post without everhaving had any specific neurology training.Precisely how often this happens is not known,but experience indicates that the situation isnot uncommon.

FUTURE ORGANISATION OF NEUROLOGY SERVICESThe considerable size and scope of theproblems posed by neurological disease hasbeen discussed elsewhere in this paper. Two ofthe most important elements are the smallnumber ofconsultant neurologists, and the lackof training of general physicians in neurology.This results in poor availability within HealthDistricts of expert neurological advice foremergencies, inpatients and outpatients. Otherresults include long outpatient waiting lists fora neurological opinion and poorly organisedservices for the neurologically disabled.

Clearly, the general requirement is toproduce the best possible service at reasonablecost. It will be necessary to develop minimumstandards of care for the common neurologicaldiseases and much discussion of these iscurrently occurring.' Agreed standards forpurchasers in the reorganised Health Serviceare required.The Association of British Neurologists

(ABN) has recently issued a Policy document,22which it suggests should be used as a basis for

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future planning. The essential elements are asfollows:1 " Each Health District should have available

to it the services of a consultant neurologiston the basis of at least one full time specialist... for each 200 000 of the population."

2 "Neurological services should be availablelocally so that the patient and his family donot need to travel further than is essential."

3 "Difficult problems will need to be dealtwith in the Neurological Centre."The more detailed recommendations of the

ABN for District services include the follow-ing:1 "The majority of neurological emergencies

in most Health Districts will continue, forthe foreseeable future, to be admitted underthe care of general physicians...(However) itshould be possible, easily and promptly, toobtain a specialist neurological opinion,ideally on site, for a neurological emergencyin the main District General Hospital."

2 "A neurological opinion should easily beobtainable in the main District GeneralHospital of each Health District for bothinpatients and outpatients."

3 "There should be a service for the manypatients with neurological disability in eachHealth District. Sufficient neurology ses-sions should be provided so that this objec-tive can be met."It is clear that general physicians will con-

tinue to be involved indefinitely with the man-agement of patients with neurological dis-orders. For this reason, it is suggested that allregistrars and senior registrars should havesome specific training in neurology. It is alsosuggested that some general physicians shouldbe encouraged to develop a particular interestand expertise in neurology.

Other ways of linking neurology and generalmedicine should be considered, for instance,the appointment of a general physician with aparticular training and interest in cerebrovas-cular disease.41 42 The option of dual accredita-tion of neurologists in neurology and generalmedicine should be considered-so thatneurologists could take their share of generalmedical "take". Other developments areobviously possible.

Medical services in London are in need ofreview4" and the King's Fund has set up aWorking Group to undertake this task. Clinicalneurology will obviously feature in such areview. As elsewhere in the country, anyrecommendations will need to balance therequirements for locally based services as dis-cussed above, with the need to maintain theresearch and educational activities which occurin the various undergraduate and postgraduateteaching hospitals-most of which are situatedin the middle of London.The role of the National Hospitals for

Nervous Diseases (in Maida Vale and QueenSquare) has changed over the last 40 years as aresult of the establishment of Regional centresand District services. However, the hospitalshave continued to provide a valuable secondaryand tertiary referral service for much of theUnited Kingdom. The National Hospitals also

provide a unique teaching service for neurolog-ists who will in the future work elsewhere in theUnited Kingdom and abroad. In addition, theNational Hospitals, together with the Instituteof Neurology, are a major focus forneurological research.

ConclusionsHow should we answer our North Americancolleague who expressed such concern aboutneurological services in the United Kingdom?Regretfully, we have to concede that there is anelement of truth in what he says, although hisassertion is clearly overstated. At the sametime, it will need to be pointed out that therehas been virtually no comparative evaluation ofthe quality of neurological services in variousparts of the world, including Europe. Nointernationally agreed yardsticks exist.To achieve the objective of providing an

effective neurological service for all UKresidents, it will be necessary to develop andagree standards of provision as a basis forassessing the adequacy of services. These stan-dards, once developed, can be used by pur-chasers of health care. The current reorganisa-tion within the National Health Servicepresents a window of opportunity. There is aneed for more neurologists and for improvedtraining for physicians. It is important toensure that we collaborate in what is a cause forconcern now, and is also a challenging task forthe future.

We are grateful for the considerable help we received from MrBen Toth, Librarian, in collecting together the references forthis article.

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6 Purdon Martin J. British neurology in the last fifty years:some personal experiences. Proc Roy Soc Med 1971;64:1055-9.

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