Why are stroke services being reviewed?
Currently, there are seven hospitals that provide stroke care in Kent and Medway with some areas of good practice, but patients across the county do not receive a consistent standard of care across 24/7.
Over the past year, a stroke review, commissioned by the local CCGs has been underway. It involves stroke survivors, people who have high risks of having a stroke, the public and hospital, ambulance and community clinical representatives from all NHS trusts in Kent and Medway. This review focuses on acute care, in particular the first 72 hours after a suspected stroke. There is clear evidence that specialist stroke care delivered over 24/7 improves outcomes for patients, reducing the number of people who die from a stroke and supports stroke survivors to regain maximum independence.
Are you putting patients first?
In line with national best practice for patients, the primary aim of the Stroke Review is to ensure that anybody who has a stroke, day or night, anywhere across the county has the best chances of survival and recovery.
Will there be continued investment?
The level of available funding in these services remains unchanged, but a number of different ways of working or ‘models’ are being evaluated to make sure people in Kent and Medway can access excellent stroke care that consistently meets national standards. The recommendations will ensure that the resources available are used well and effectively across Kent and Medway.
Has a decision been made about where stroke services will be?
No decisions have been made about future locations of services yet. However, an options modelling process, led by a group of clinical representatives from each hospital trust, has discussed key factors. These include workforce, travel time to hospital, patient care and how services might work across various hospital sites.
These key factors have also been discussed in detail with members of the public, voluntary organisations, stroke survivors and their families or carers to understand what is important to patients and their families.
The sites of hyper acute stroke units need to fit with other critical clinical areas such as a fully-functioning Emergency Department, a 24/7 medical team and 24/7 imaging services. Plans will therefore need to align to the wider Five Year Forward View discussions and the Sustainability and Transformation Plan involving acute hospitals which is currently being developed.
We are now in the public engagement stage of the process, and formal consultation will follow when that is completed. Decisions about any changes to stroke services in Kent and Medway will not be made until after the formal public consultation process has been completed.
Does clinical evidence support the case for change?
There is a comprehensive body of evidence that supports the establishment of a 24/7 specialist-led service. The best practice guidance is that death rates are reduced and long term outcomes are improved if stroke patients are treated in a high quality stroke unit where they get rapid access to diagnostics, specialist assessment and intervention. Briefing for engagement event attendees – October 2016
Such a unit needs to have a specialist workforce treating the right number of patients (enabling them to sustain and improve their skills), and to be available 24 hours a day, every day.
The national strategy, and guidance from Professor Tony Rudd, the National Clinical Director for Stroke, highlight that recovery from a stroke is significantly influenced by the percentage of patients:
- Seeing a stroke consultant within 24 hours
- Having a brain scan, ideally within an hour of admission and at least within 24 hours of admission
- Being seen by a stroke-trained nurse and one therapist within 72 hours of admission
- Being admitted to a dedicated stroke unit within four hours of arriving at A&E
- Having clot-busting drugs (if appropriate) ideally within one hour of arriving at A&E and at least within six hours
- Having a specialist swallow screening within four hours
And that the most significant interventions are:
- A nutritional assessment and swallowing assessment within 72 hours
- Receiving adequate food and fluids for the first 72 hours.
How are decisions made?
A Stroke Review Programme Board – made up of clinical experts and patient representatives including the Stroke Association as core members, alongside senior representatives from all eight clinical commissioning groups, NHS England, South East Coast Ambulance Service, Clinical Networks, engagement leads and the Stroke Clinical Lead for Kent, Surrey and Sussex – agrees what action needs to be taken for the review to be successful.
The process is overseen and supported by the NHS South East Strategic Clinical Network and the National Clinical Lead for Stroke, Professor Tony Rudd. A clinical reference group (CRG), consisting of clinical and operational representatives from all local acute hospital trusts and providers, links into the Board.
Because hyper-acute stroke units must be on sites which can offer the full range of emergency facilities required (such as 24/7 CT scans), the Kent and Medway Sustainability and Transformation Programme Board (made up of the chief executives of all NHS organisations in Kent and Medway, the Kent and Medway Health and Wellbeing Board chairs, directors of public health and directors of social care) will need to sign off the final site recommendations.
Publicly elected members of the Kent Health Overview and Scrutiny Committee and the Medway Health and Adult Social Care Overview and Scrutiny Committee have formed a Joint Health Overview and Scrutiny Committee (JHOSC) to oversee each stage of the review on behalf of local people. They have reviewed and approved the Case for Change and the decision making process.
Regular updates, information and assurance are given to them and they are involved in the process of agreeing options that the public, clinicians and others in Kent and Medway will be consulted about.
Final decisions are made by the governing bodies of the individual clinical commissioning groups.
Decisions about any changes to stroke services in Kent and Medway will not be made until after the formal consultation process has been completed.
Will families and carers’ views about travel times for visiting people in hospital be taken into account as part of the review?
The priority for this review is to ensure the best clinical outcomes for stroke patients in the first 72 hours after a suspected stroke which can happen at any time of day or night. Stroke is a medical emergency and initial ambulance journey times to hospitals with appropriate clinicians and facilities are critical. However, we have had lots of feedback so far about how any proposed changes might affect travel times for people visiting relatives in hospital. It is an important part of recovery in the weeks following a stroke for loved ones to be able to visit and so although this will be considered, it is not a deciding factor. Patient safety is our priority.
If existing hospitals lose their stroke units as a result of the review is there a risk of closure of hospitals?
The review will not threaten the viability of hospitals, as there is a high demand for services other than stroke care. One of the reasons for the review is that on their own, the existing seven units do not consistently see enough stroke patients per hospital and departments are sometimes under-used. It is hoped that the review will help to free up capacity in other areas of hospital care.
If you reduce the number of stroke units, will they be able to cope with the same number of patients currently treated?
There is national clinical evidence to show that seeing between 600-1500 patients per year provides stroke teams with the best chance of building on and developing their skills as they become more experienced, resulting in better chances of recovery for patients. New models of stroke care with fewer units will mean that specialist stroke teams are able to treat more patients at each unit with the right level of staffing for optimum levels of treatment any time of day or night.
Is this review a cost-saving exercise?
This review is not about saving money. It is about improving the consistency and quality of stroke care that is provided across the county. Reconfiguration of services will require an increased level of investment, but this is a worthwhile change that needs to be made to ensure that people in Kent and Medway receive the best care if they experience stroke.
When stroke units are reconfigured, what safeguards will there be to make sure that patients get to the right place and is there a danger of some units not being staffed straight away?
After public consultation, when decisions are made, there will be a robust transition plan which as always, will require all organisations to work together in the interests of patients. Whatever plan is decided, this will be safe and sustainable to ensure the best care for patients. For some units there will be a need to recruit new staff and for other, existing staff will continue to carry out the good work that they already do. With regards to ambulance transfers to the right units, this is something that already happens with other specialities that rely on rapid treatment, such as emergency treatment for heart attacks. There is already a county-wide agreement across the health sector that appropriate patients are transferred by ambulance to emergency heart care centres, and stroke care will be similar.
How does the local Kent and Medway Sustainability and Transformation Plan and the national NHS Five Year Forward impact on the review?
These plans are strategic and not focused on clinical specialties. The plans set out how the NHS as a whole needs to do things differently and work together more closely in the coming years to increase prevention of ill-health and improve out-of-hospital care so that people can be treated and supported closer to home. The specifics of the Kent and Medway plan are not yet decided, but the work of the stroke review and the feedback we receive will feed into this process. There will be opportunities for members of the public to engage and eventually a public consultation about local STP proposals.