Guideline scope

1.1. Who is the focus?

1.2. Settings

• Primary and secondary care.

1.3. Activitiesr, services or aspects of care

1.4. Economic aspects

We will take economic aspects into account when making recommendations. We will develop an economic plan that states for each review question [or key area in the scope) whether economic considerations are relevant, and if so whether this is an area that should be prioritised for economic modelling and analysis. We will review the economic evidence and carry out economic analyses, using an NHS and personal social services (PSS) perspective, as appropriate.

1.5. Key issues and questions

While writing this scope, we have identified the following key issues, and key questions related to them:

1. Indications for referral to specialist care.

   1.1.

   Which criteria (symptoms, signs, risk factors and red flags) indicate the need for referral for further neurological assessment?

   1.2.

   Which criteria (symptoms, signs and risk factors) indicate there is no need for referral for further neurological assessment?

2. Examinations, assessment tools and investigative tests that non-specialists could use to help them decide whether a person with suggestive of a neurological condition should have further investigation or be referred to a specialist.

   2.1.

   What examinations should non-specialists carry out when a person presents with symptoms suggestive of a neurological condition?

   2.2.

   What assessment tools, such as algorithms, could non-specialists use when a person presents with symptoms suggestive of a neurological condition?

   2.3.

   What investigative tests should non-specialists use when a person presents with symptoms suggestive of a neurological condition?

3. Information, support and initial management advice for people with a suspected neurological condition and their family members and carers.

   3.1.

   What are the information, support and initial management advice needs of people who have a suspected neurological condition and their family members and carers?

The key questions may he used to develop more detailed review questions, which guide the systematic review of the literature.

1.6. Main outcomes

The main outcomes that will be considered when searching for and assessing the evidence are:

1. Time to referral.
2. Time to diagnosis.
3. Number of referrals.
4. Positive predictive value of symptoms.
5. Diagnostic accuracy of tests.
6. Patient satisfaction.
7. Carer satisfaction.
8. Quality of life.

2.1. NICE guidance

2.2. NICE Pathways

NICE Pathways brirtg together all related NICE guidance and associated products on a topic in an interactive topic-based flow chart.

When this guideline is published, the recommendations will be incorporated into the existing pathway on neurological conditions.

An outline of the new pathway, based on flie scope, is included below. It will be adapted and more detail added as the recommendations are written during guideline development.

3.1. Key facts and figures

Neurological conditions account for about 1 in 10 GP consultations, around 10% of emergency medical admissions (excluding stroke), and result in disability for 1 in 50 of the UK population (Local adult neurology services for the next decade: report of a wording party. Royal College of Physicians). It is estimated that 2-3% of children will have special needs or some level of disability, with most disabilities being neurological in origin.

Onset, progression, prevalence and severity vary across different neurological conditions. Some neurological conditions are present at birth, while others begin during childhood or as adults. Some conditions can be recovered from completely, but others can cause rapid deterioration or have a slower, more sustained disease course. Some conditions are fairly common, such as migraine (which affects 1 in 5 women or 1 in 15 men) and others are rare, such as Guillain-Barre syndrome (which affects about 1200 people in the UK per year). Most neurological disorders have an impact on quality of life, and some cause serious disability and have a substantial impact on the person and their family members and carers.

People often present with symptoms that are difficult to diagnose (functional symptoms) and can make diagnosing neurological conditions hard. Up to one-fifth of new neurology outpatients have functional symptoms.

3.2. Current practice

People with suspected neurological conditions often need referral to a specialist to be diagnosed. However, some referrals are unnecessary. On the other hand, some people with neurological conditions are initially misdiagnosed or have a delayed referral to a specialist. These issues with referral come from a lack of support and knowledge among non-specialists about neurological conditions. A report from the Neurological Alliance (The invisible patients: revealing the state of neurology services) found that nearly one-third of people with a neurological condition had to see their GP 5 or more times before being referred to a specialist.

People suspected of having neurological conditions may have additional information needs because of the type of investigations that need to be done; as well needing information on the possibility of living with a neurological condition.

3.3. Policy, legislation, regulation and commissioning