I think this is an acute issue for Clinical Neurophysiology affecting both physiologists, scientists and doctors.
Background
Intraoperative neurophysiological monitoring (IOM) is a valuable adjunct for neurosurgical operative techniques, and has been shown to improve clinical outcomes in cranial and spinal surgery. Demand has risen significantly in the UK over the past 5 years. It is not necessarily provided by NHS hospitals so may be outsourced to private companies, which are expensive and at cost to the NHS trusts. The training pathways in intraoperative monitoring are currently very undefined. It has been added to the 2021 Clinical Neurophysiology SpRs curriculum but with only 20 cases required, and many centres unable to provide this, the competence at the end of training is very uncertain. A post CCT fellowship curriculum was written in 2021 but there are significant barrers to implementating this. I will discuss the benefits and challenges of developing an in-house service and implications for the future training of the NHS workforce.
Methods
We surveyed NHS neurosurgical departments across England regarding their expenditure on IOM over the period January 2018 – December 2022 on cranial neurosurgery and spinal surgery. Out of 24 units, 22 responded to our Freedom of Information requests and 19 provided data. Information on the NHS tariffs and salary costs were complied for comparison. One unit which provides significant in house neuromonitoring provided detailed accounts of the costs per case for spinal, brainstem and cranial cases.
Results
The total spend on outsourced IOM, across the units who responded, was over £7 million in total for the four years. The annual total increased, between 2018 and 2022, from £1.1 to £2.6 million. The highest single unit yearly spend was £568,462. This is in addition to salaries for staff in neurophysiology departments. The costs of in house monitoring ranges from £1500 to £2000 for spinal and cranial cases respectively.
Conclusion
IOM is valuable in surgical decision-making, planning, and technique, having been shown to lead to fewer patient complications and shorter length of stay. Current demand for IOM outstrips the internal NHS provision in many trusts across England, leading to outsourcing to private companies. This is at significant cost to the NHS. Although there is a learning curve, there are many benefits to in-house provision, such as stable working relationships, consistent methods, training of the future IOM workforce, and reduced long-term costs, which planned expansion of NHS services may provide.