Glady Nadar Arulmani

Ever since 2011 neuro-physiotherapist Glady Nadar Arulmani had argued that community neuro-physios, who are extended scope practitioners, could take on a significant amount of work usually referred by GPs to hospital neurology outpatients. This, he asserted, would speed up patient access to neurology assessment, diagnosis and appropriate treatment, cut waiting times, and free up neurologists to deal with more complex cases.

Sitting in his consultation room at ourZone, a community treatment, learning and social hub in Rochester, Kent, softly spoken but with a note of steely determination, Glady explained that managers liked his idea ‘but didn’t feel it was a priority at that stage, also we couldn’t work out the practicalities of how we’d do it in terms of funding issues’.

He said neurologist colleagues were also sceptical – some considering physiotherapists were not of the right level of skill to take on their work, or did not realise that physiotherapy was a profession full of sub-specialities.

But persistence has paid off. Desperate for new solutions to rising referrals and increased waits, with approval of Medway and Swale Clinical Commissioning Group (CCG) and other stakeholders, his managers allowed him to carry out a pilot scheme which revealed that just over 70 per cent of GP neurology referrals in the CCG area could be seen by an extended scope neuro-physiotherapist. Of the 70.65 per cent of patients in the pilot only 1.75 per cent needed to be referred to neurology and the remainder were managed in community. The patients’ feedback were also very positive. Now the service has been given the official stamp of approval and extra resources to pay for another neuro-physiotherapist and a nurse. A neurologist has even agreed to supervise extended scope neuro physiotherapist in Botox training for migraine patients. 

Neurological Assessment Service

Glady gained a BSc in physical therapy in Mumbai in 1994 and completed his MSc neurological physiotherapy in 1996. He was always fascinated by neurology and neurophysiology and worked in a range of clinical, teaching and leadership roles in India. He came to the UK to take up a post in stroke services at Medway Teaching Primary Care Trust in 2005. In 2011 a role came up for an outpatient neuro-physio within the same organisation (now called Medway Community Healthcare), which meant he could see patients with a broader range of neurological problems.

It was then he realised there was a place for a physiotherapist-based Neurological Assessment Service (NAS) along the lines of systems that already exist in orthopaedics where specialist physios carry out assessments and send people for investigations and do a differential diagnosis of the problems.

By 2016, armed with an independent prescriber qualification, he again put forward the idea of taking some of the burden off neurology by seeing and assessing patients, most of whom could be managed by his team in the community. Again managers liked the idea but were too stretched to spare him for such a specific role.

In 2019 faced with rising numbers of referrals and 18-month plus waits, exacerbated by a shortage of neurologists, the CCG realised radical change was needed.

Before the pilot started Glady, along with his manager, GP and CCG representatives, audited 100 neurology referrals to Medway Hospital and found that around half could easily have been managed in community. ‘This was a very important finding. We found patients with carpal tunnel syndrome who should have gone to musculoskeletal team or patients with memory concerns who should have gone to memory clinic, but were inappropriately sent to neurology,’ he said.

An encouraging GP engagement workshop further supported development of the NAS plan.

‘The pilot scheme, which started in November 2019, found that in a typical week the NAS received an average 15 to 20 referrals each day, of which 70 per cent could be managed in the community by NAS and around 30 per cent should go either to neurology or other specialities.

‘Because the audit was successful, and we got fantastic feedback from patients, the CCG agreed to find the money for a permanent contract and for one more permanent member of staff and for a band 7 nurse. This absolutely was the seal of approval,’ Glady said.  

Pathways

Glady explained that the pathway starts with electronic GP referral to neurology, which are screened by a NAS clinician, who carries out assessment, investigation, diagnosis and management. Patients are either discharged with positive outcome back to their GP or referred to other appropriate services. ‘That streamlines things – you are creating more space for the neurologist to see appropriate patients, patients can be seen much quicker so they can be diagnosed and start treatment much earlier than they would otherwise,’ he said.

Most of the NAS patients have headaches, migraines, dizziness, balance problems, essential tremors or paraesthesia. There is a plan to start a community diagnostic centre by the integrated care board which will enable direct access to diagnostics such as MRI and X-ray for NAS clinicians. 

Glady feels that his work is good example of the CSP’s Four Pillars (of Physiotherapy) that define a physiotherapist working to consultant or advanced practice level – excellence in clinical skills, research, education and leadership. To back this up he reels off an impressive body of work, teaching, research experience and qualifications including supplementary and independent prescribing. 

Looking to the future

Glady feels that the NAS could be introduced elsewhere so long as it is led by an extended scope neuro-physiotherapist who has experience of working with a range of neurological conditions, a robust theoretical background, and great assessment skills and knowledge. Prescribing qualifications are also an asset. ‘It’s not something that is for all physios as there is huge accountability with the post due to the complex nature of neurological conditions – patient safety is key. And we need to work in partnership with GPs, CCGs and neurologists.’

‘But there is still a lot of work to be done to earn the respect and trust of the neurologists. Three years down the line we are still fighting to prove that neuro-physiotherapy can support neurologists.

I want to inspire physios across the UK to consider doing similar things because it’s not acceptable for a patient to wait 18 months to two years to see someone with neuro expertise for their headaches, migraines, dizziness or balance when they can be successfully managed in the community sooner. It gives me a lot of joy that it has taken shape here. We need to fine tune things but it’s only going to get better from here on.