Introduction

This report is provided in response to the motion agreed at the Kent HOSC to consider stroke which took place on 22nd March 2019[1]. The response has been developed based on all the detailed clinical evidence and other data gathered throughout the five years of the acute stroke services review. This evidence has been published in our pre-consultation business case (PCBC) and decision-making business case (DMBC), shared with HOSC members, and regularly discussed with the Kent and Medway Joint Health Overview and Scrutiny Committee who support our decision. This response includes advice from the Director of Public Health for Kent County Council.

Other documents that have been shared with HOSC members and support this response include, the full set of appendices to the DMBC, the presentation made to the Joint Committee of CCG’s (JCCCG) in the decision-making meeting on 14th February 2019 and the confirmed resolutions agreed by the JCCCG.

Response to the motion

NHS Long Term Plan

The implementation of Hyper Acute Stroke Units (HASU’s) is recognised in the national NHS Long Term Plan as a key component to improving stroke care and addressing inequalities in the current configuration of services. The plan states:

“Areas that have centralised hyper acute stroke care into a smaller number of well-equipped and staffed hospitals have seen the greatest improvements. This means a reduction in the number of stroke receiving units and an increase in the number of patients receiving high quality specialist care.”[2]

The plans to reconfigure stroke across Kent and Medway from six sites providing some level of acute stroke care into three fully designated HASU’s is therefore in line with the national plan.

Benefits of HASUs for Kent and Medway

The Kent and Medway review of urgent stroke services is led by stroke consultants, nurses and therapists from across Kent and Medway. The plans for changes to stroke services in Kent and Medway were developed by these medical specialists, with the support of leading national stroke doctors, and are based on the Royal College of Physicians’ 2016 clinical guideline on stroke[3], which is the nationally recognised source of best practice for stroke care.

The guideline explicitly recommends that people suspected to be having a stroke should be admitted directly to a hyper acute stroke unit. This is because the evidence is clear that what saves lives and reduces disability is people getting expert care, treatment and monitoring in a specialist centre providing 24/7 care in the vital few days after their stroke, even if they travel further to get there.

The plans are also in line with the National Institute for Clinical Excellence (NICE) recommendation which is to:

 “Admit everyone with suspected stroke directly to a specialist acute stroke unit after initial assessment, from either the community, the emergency department, or outpatient clinics”[4]

Evidence from other areas in England that have already reconfigured stroke services clearly demonstrate improved survival from stroke, and reduced lengths of stay in hospital – due to patients recovering more quickly.[5]

Call to needle times

We strongly refute the assertion in the motion that ‘the proposal presents an unacceptable and increased risk of mortality or permanent impairment of health to those at or beyond the extreme limit of internationally recommended “emergency call to needle time” at a HASU: in this case nearly 145,000 residents in Thanet’.

It is important to note the following about thrombolysis (clot busting) treatment:

  • current evidence shows that it does not reduce mortality – i.e. it is not lifesaving, however the evidence does show it reduces disability
  • it is only suitable for around 20% of stroke patients

The current evidenced best practice standards for treating stroke indicate that, should a clot busting drug be the possible treatment, it should be administered within 4.5 hours from the onset of a patient’s symptoms. The South East Coast Clinical Senate has a regional ambition of providing thrombolysis within 120 minutes of the 999 call being made (‘call to needle’ time). The new HASUs for Kent and Medway will work to this timescale for all patients including those from Thanet. This is not ‘at or beyond the extreme limit’.   

The travel time data is taken from a nationally recognised data source called Basemap which records actual journey times across Kent and Medway, using satellite navigation system data from many thousands of journeys. This means that all the congestion, tourist traffic, accidents and bad weather, and any other factors that affect journey times across Kent and Medway are included in the data we have used to calculate journey times to the new HASUs.

To validate the accuracy of the data, South East Coast Ambulance NHS Foundation Trust compared their actual blue light journey times with Basemap data and found that their transfer times between Thanet and Ashford were a few minutes faster. Therefore we have a very high level of confidence that the travel times are accurate and not under stated.

Regardless of this, it is important to remember that the benefits patients get from hyper acute stroke units do not depend on how near or far the units are from where they live, rather they come from being cared for 24 hours a day, including at weekends, by stroke specialists during the critical first few days following a stroke. It is this expert care that improves survival and reduces disability. Some of the most important benefit’s HASUs give include:

  • monitoring and managing blood pressure and reducing the risk of blood clots to help prevent further strokes
  • providing intensive care and support to prevent life threatening complications following a stroke such as heart attacks, clots in the legs and lungs, and infections 
  • giving specialist swallow assessments within a few hours of admission to ensure patients can eat safely without inhaling food into their lungs, which can cause fatal infection
  • providing intensive stroke-specific physiotherapy, including at weekends, to improve mobility and reduce long-term disability
  • giving occupational therapy to ensure patients are safe in their homes when they are discharged
  • working closely with community-based rehabilitation and social care teams to ensure the right support is in place for people when they go home.

In other areas of the country, where HASU’s are already in place, such as Northumbria, travel times for some of the population are up to one hour and 10 minutes (which is in excess of our maximum travel times) and there has not been any increase in mortality. The Northumbria unit has demonstrated an improvement in time to give the clot busting drug and a reduction in the length of stay for patients in the unit i.e. patients recover more quickly and are able to go home sooner.

Lifestyle factors

Lifestyle factors are attributed to many disease processes including stroke and we recognise that Thanet residents, along with other deprived areas of the county, have a higher level of lifestyle risk factors such as smoking and obesity. We also recognise that in Thanet the diagnosed prevalence[6] of atrial fibrillation (a significant risk factor for stroke) is 2.5% and the estimated prevalence is 3.0% – indicating that there could be an undetected stroke risk within the community. The most effective way of managing this risk is through primary prevention (preventative methods aimed at the whole population) such as GPs monitoring and managing patients’ high blood pressure and AF symptoms in the community, as well as making sure there is good support for lifestyle changes such as reducing smoking and healthy eating. In recognition of the importance of prevention, the JCCCG agreed an additional motion for prevention at the decision-making meeting on 14th February.

Public health colleagues have confirmed that they recognise the evidence base supporting the provision of hyperacute stroke services in ensuring the best outcomes for patients experiencing a stroke as specified by the NICE guidelines[4].

Stroke staffing numbers

None of our six hospitals currently providing stroke care, including QEQM, have enough specialist stroke staff to provide the service seven days a week that our patients should be able to access. As an example, the absolute minimum number of consultants required to staff a 24/7 rota is 6 per unit and we currently have a total of 10 across Kent and Medway.  This is 26 consultants below the current minimum requirement for six units.

How the staffing of individual units compares to other ‘non city’ district general hospitals is not relevant to the provision of stroke services which require a specialist workforce. We are not looking at the staffing of individual units, but instead are focused on making sure we have the right specialist staffing across the combination of three new units we have decided to establish as part of a Kent and Medway stroke services network.

Conclusion

In summary, our current stroke units are under performing and have been for a long time, despite the best efforts of our hardworking and dedicated staff. The latest SSNAP data shows all D and E rated units in the South East are in Kent and Medway, and we have the only E rated unit in the country.

More patients are dying and being left with life-long disability and ongoing care needs than need to be. We predict we will save an additional life every fortnight across the whole of Kent and Medway and this prediction is supported by the actual lives saved in other areas of the country that have already implemented HASUs. Our most senior stroke doctors and other stroke specialists have led this review and have made these recommendations for change. We have spent a number of years and been through an intensively scrutinised process to arrive at the recommended preferred option which will deliver the very best care for all of the patients who will use the specialist stroke units.


[1] https://democracy.kent.gov.uk/mgAi.aspx?ID=50657

[2] https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-quality-and-outcomes/better-care-for-major-health-conditions/stroke-care/

[3] https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines

[4] https://www.nice.org.uk/guidance/ng128/chapter/Recommendations#specialist-care-for-people-with-acute-stroke

[5] BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1

[6] Prevalence is a statistical concept referring to the number of cases of a disease that are present in a particular population at a given time, whereas incidence refers to the number of new cases that develop in a given period of time.’