At the moment we don’t have any hyper acute stroke units in Kent and Medway and most of our hospitals struggle to consistently meet national best practice standards of care for stroke patients, for example giving people a brain scan within an hour of getting to hospital. This is mainly because our resources are stretched too thinly across too many hospitals.

We want to make sure urgent stroke services in Kent and Medway can meet national best-practice standards so that patients get the best possible care and outcomes. To make this possible we believe we need to consolidate our resources into three specialist hyper acute stroke units, instead of having six general stroke units that can’t consistently deliver best-practice. We have planned carefully to make sure that the travel time to the proposed new hyper acute stroke units would be as short as possible.

Reorganising urgent stroke services in the way we are proposing would mean everyone treated for stroke in Kent and Medway would get consistently high-quality care regardless of where they live or what time of day or night a stroke occurs. We know from national and international evidence, and from examples in other parts of the country that hyper acute stroke units help reduce disability and death from stroke. In London, hyper acute stroke units have reduced deaths from stroke by nearly 100 a year.

We also believe we would find it easier to staff our services and have the other resources needed (such as scanners) available all the time.

At the moment we don’t have any hyper acute stroke units in Kent and Medway. This means that patients treated in our area do not consistently have access to care from a team of stroke specialists and therapists round the clock with consultants on the wards seven days a week. Also:

• We only have one third of the stroke consultants needed to deliver a best practice service in all hospitals
• Fewer than one in three stroke patients are getting brain scans in recommended time
• Half of appropriate patients not getting thrombolysis (clot busting drugs) in recommended time of two hours from calling an ambulance
• Only one unit in Kent and Medway is seeing enough stroke patients for staff to maintain and develop expertise (recommended minimum of 500 stroke patients per year)

All these factors mean we are not offering the best care to people experiencing stroke. We want to change this as soon as possible.

If the proposals are introduced it would mean changing from providing stroke services in six hospitals across Kent and Medway to concentrating our acute stroke resources on three hospitals.

Depending on where you live, the ambulance journey to reach one of the proposed hyper acute stroke units may be longer than being taken to your current nearest A&E. However, a shorter journey to a hospital without a hyper acute stroke unit can be worse for stroke patients than a longer journey to a hyper acute stroke unit. The evidence tells us that keeping to a minimum the time it takes from calling 999 to getting a brain scan and appropriate treatment gives stroke patients the best outcomes. Because hyper acute stroke units have dedicated teams on hand 24-7, they can often respond faster when a patient arrives at hospital than A&E departments without a hyper acute stroke unit. This cuts down the overall time between calling 999 and getting treatment, even if the patient has travelled further.

The evidence, from elsewhere in the country where similar changes have already been made, shows that patients who are treated in a hyper acute stroke unit have a much better chance of surviving and making a good recovery, even if they travel further to get there.

We have spent a significant amount of time modelling the travel times as part of the development of these proposals. All five of the proposed options mean that 99.9% per cent of people could reach a hyper acute stroke unit by ambulance within an hour. The journey for the remaining people would be just a few seconds longer.

For all the proposed options, over 90 per cent of people could reach a hyper acute stroke unit within 45 minutes by both ambulance and car.

Around 75 per cent of people could reach a hyper acute stroke unit within 30 minutes by both ambulance and car. In developing our shortlist of potential options, we rated the options with the shortest journey times for the most people more positively.

Having more than three hyper acute stroke units would spread our staff and patients too thinly to make the service safe, sustainable and to allow the delivery of high quality care. By consolidating specialist staff, our equipment and other resources into three hyper acute stroke units we would be able to provide care to the best-practice standard that all patients should expect, and staff want to provide.

Stroke specialists, and other stakeholders, including patients and the public, have broadly agreed that the option of one or two hyper acute stroke units should be excluded. This was because three units will make the system more resilient – for example to help manage peaks in demand, or if one unit was not usable due to damage from say a flood or fire – as well as offering fast access to patients.

This consultation is looking specifically at possible changes to the acute hospital services that treat a stroke when it happens through to when patients are able to return home. However, as part of our wider work on stroke we are looking at both prevention and rehabilitation.

Rehabilitation is an essential part of stroke care, and it begins as soon as patients arrive in hospital. A significant amount of the care people receive in hospital stroke units is rehabilitation and helping them to limit the long-term impact of the stroke.

Once people are ready to go home many will continue to need on-going rehabilitation support. These services do need to be close to where people live and, on the whole, would be provided outside of hospitals. Though some elements of rehabilitation such as physiotherapy sessions may be run from local hospitals.

As part of implementing hyper acute stroke units we would fully develop the links (pathways) to local rehabilitation and support services such as social care and access to mobility aids.

At different stages of the evaluation process we excluded some of the hospitals in Kent and Medway because they did not meet the required criteria. The Queen Elizabeth the Queen Mother and the Kent & Canterbury hospitals have been excluded from all the shortlisted options.

Both hospitals are run by the East Kent Hospitals University NHS Foundation Trust; who also run the William Harvey Hospital. We have worked closely with the Trust to look at each site’s potential to be a hyper acute stroke unit:

• Kent & Canterbury Hospital – does not currently provide a stroke service or the range of other emergency and urgent care services that are needed to support a hyper acute stroke unit. This meant it did not pass the 2nd stage of our evaluation process.
• Queen Elizabeth the Queen Mother Hospital – does have the emergency and urgent care services needed to support a hyper acute stroke unit, but does not have a range of other services that are desirable to have alongside a hyper acute stroke unit. This meant that while it was included in our medium list; it was evaluated less favourably than the William Harvey which has both the needed and desirable services.

We also asked the Trust whether it could develop 2 hyper acute stroke units. They concluded that it would be very difficult to attract enough specialist stroke staff to run 2 units; so options including both the Queen Elizabeth the Queen Mother and William Harvey sites were evaluated more poorly and did not make the shortlist that is part of this consultation.

 

There is a separate review of the possible options for the future location of emergency care and specialist services in east Kent. It would be wrong to wait for this work to be completed because this would slow down the essential decisions we need to make on stroke services. If, following the east Kent review, the William Harvey Hospital was no longer a long-term option for emergency and specialist services and these moved elsewhere – then we would anticipate any hyper acute stroke service would also move with them, subject to consultation.

In December 2017, we published the ‘medium list’ of options for how hospital services in east Kent might be organised in the future. One of these options included the creation of a new hospital site in Canterbury. This is being looked at along with other ways of providing emergency hospital care across east Kent. Any decision to build a new hospital would be subject to planning permission and part of a much longer process. We need to act now to create a new and better system for urgent stroke services across the whole of Kent and Medway based on the facilities that we currently have. If a new hospital is built and the William Harvey Hospital was no longer a long-term option for emergency and specialist services – then we would anticipate any hyper acute stroke service would also move with them, subject to a formal public consultation.

There is a shortage of stroke consultants – nationally around 40% of stoke consultant posts are vacant – and of specialist stroke nurses and therapists. This is partly why we want to organise services so that can use the staff we have more effectively. All the proposed options will mean we need to recruit additional consultants, but we have evaluated the options which require the fewest additional consultants more highly. It is also better for us to concentrate these scarce doctors in fewer hospitals to provide the highest quality care around the clock, rather than spread them too thinly across a more hospitals.

If these proposals go ahead, we will develop a detailed staff development and recruitment plan as part of establishing hyper acute stroke units. We know from other areas around the country that hospitals with hyper acute stroke units find it easier to recruit stroke consultants and other specialist stroke staff because they offer better opportunities for professional development, and allow staff to care for patients in line with national best practice.

We know from staff feedback that specialist stroke staff support the development of hyper acute stroke units to improve the quality of care for patients. At the moment we face staffing challenges with significant vacancies in the stroke services at all six current sites. We believe that setting up three hyper acute stroke units would improve recruitment and retention in the medium to long term, however, there may be short term disadvantages.

The changes would mean that some existing staff would be asked to change where and how they work. For some staff this would mean longer travel times to work, different shift patterns, working with different people and in a different environment. All organisations across Kent and Medway will use best endeavours to support staff in making the transition so we retain our existing staff within the stroke units, but for some the impact of these changes on work and home life may not be acceptable and we may be at risk of losing some of our talented and dedicated stroke staff. However, if changes were unsuitable for individuals, we expect that most would be offered alternative roles allowing them to stay on the same site.

During the development of the options, some staff and local people have expressed concern that if a hospital does not have a hyper acute stroke unit it may be at risk of losing other specialist services, or not being considered for the development of these services in the future. Although hyper acute stroke units are dependent on other services such as emergency medicine and A&E, we are not proposing any changes to these services at sites which do not develop a hyper acute stroke unit. These services do not depend on having a hyper acute stroke unit at the same hospital.

It should be noted that a wider review of hospitals in East Kent will be taking place separately to the stroke consultation. Information on this will be published at https://kentandmedway.nhs.uk/where-you-live/plans-east-kent/

More information about co-dependent services

Part of our evaluation process looked at what ‘co-dependent’ services are needed for a hyper acute stroke unit. Co-dependent services are other hospital departments that are essential to the safe and effective treatment of stroke patients. Some of the co-dependent services that need to be on the same hospital site as a hyper acute stroke unit include emergency care and acute medicine, critical care units, x-ray, CT and MRI scanning, occupational therapy and physiotherapy.

There are also some specialist services that it is beneficial to have on the same site as a hyper acute stroke unit, for example a trauma unit, vascular surgery (surgery carried out on blood vessels) and interventional radiology (to support developing mechanical thrombectomy). When we evaluated the potential options, we rated hospitals which have these beneficial services more highly than those without.

All stroke services across England provide regular performance information to the Sentinel Stroke National Audit Programme (SSNAP), run by the Royal College of Physicians.

They publish data quarterly and annually. Their website has interactive maps and easy read reports by region. The following links may be of interest:

• Regional reports https://www.strokeaudit.org/results/Clinical-audit/Regional-Results.aspx
• Interactive maps https://www.strokeaudit.org/results/Clinical-audit/Maps.aspx

To see Kent and Medway data select South East SCN from the regional filter options.

National clinical guidance supports the development of specialist stroke units which provide a full range of services 24/7 and see enough patients for clinical staff to maintain and develop their specialist skills.

Areas that have already done major stroke reconfiguration include: London, Greater Manchester, Northumbria, parts of East Midlands, Heartlands in Birmingham, Newcastle, and Surrey.

Other areas going through the same process as Kent include South Essex, Sussex, Devon, Sunderland, Cumbria, Cheshire and Lancashire.

More information on other parts of the country that have changed stroke services is available in a news item from Professor Athony Rudd, National Clinical Director for Stroke, NHS England.

Our proposals would mean there would be 127 dedicated (or ring-fenced) stroke beds. The majority of these would be in the three hospitals with hyper acute and acute stroke units in Kent and Medway. Almost all the options would require an increase in dedicated stroke beds at the Princess Royal University Hospital in Orpington, Eastbourne District General Hospital and/or the Royal Sussex County Hospital in Brighton.

At the moment the six hospitals in Kent and Medway providing acute stroke care do not have beds that are ring-fenced only for use by stroke patients. The beds in the stroke units are used for patients with other conditions if they are needed (and some stroke patients are cared for in beds not on stroke units). To calculate the number of beds used by stroke patients (including TIA and mimics) we have looked at the number of stroke cases and the average length of stay. This tells us how many “bed days” per year were actually used by stroke patients. The average over the three years from 2014/15 – 2016/17 has been 134 beds (including ten at the Princess Royal University Hospital).

The new model of care would need slightly fewer beds because implementing hyper acute stroke units will improve care and mean the time people spend in hospital would reduce. Taking into account the improvement that would be offered by new services, we would need 127 ring-fenced stroke beds to meet the needs of people whose nearest stroke service is currently at a Kent and Medway hospital. Each of the five shortlisted options would provide these 127 beds, however the number of beds at each site varies between options. Some options have more beds provided outside of Kent and Medway than others. Regardless of the location of the beds, they would all be ring-fenced for stroke patients and not used for patients with other conditions.

The table below shows the breakdown of beds for each option (will require a full size laptop/PC screen to view)

Option	Site 1	Site 2	WHH	PRUH	Eastbourne	Brighton
Option A	Dartford	Medway	53	8	3	1
	32	30
Option B	Dartford	M’stone	51	3	3	1
	33	36
Option C	Medway	M’stone	50	25	3	1
	21	27
Option D	Tun.Wells	Medway	50	22	0	1
	35	19
Option E	Dartford	Tun.Wells	54	0	0	0
	52	21

We have been conservative in our calculations to ensure we would have sufficient bed capacity. In calculating the beds needed we have also considered population growth and aging together with improvements in stroke prevention that has seen a reduction in the number of strokes. These factors taken together mean the number of strokes is not expected to rise significantly in the future.

You can read our full bed and capacity modelling document in the consultation supporting papers (Appendix L).

As part of the evaluating options we looked at the co-dependent and co-adjacent services which the South East Clinical Senate have identified as being relevant to hyper acute stroke services. Co-dependent services means ‘essential’ to have on site to support a hyper acute stroke unit (which QEQM does have). Co-adjacent services are ‘desirable’ to have on-site (which QEQM does not have a complete set of).

The table below lists which of the desirable services are available or not at the QEQM (5/7 indicates a weekday only service). The top 5 are considered the most important to be able to see patients on site in a HASU and be available 24/7.

Desirable services for co-location with HASU	Availability on site 24/7 at QEQM
Nephrology	N
Palliative care	Y
Neurology	N
Speech and language	5/7
Dietetics	5/7
Opthalmology	Y
General surgery	Y
Trauma	N
Orthopaedics	Y
Hub vascular surgery	N
Neurosurgery	N
Critical care (paediatric)	N
Acute stroke unit	Y
Inpatient dialysis	N
Acute paediatric	Y
Nuclear Medicine	5/7
Interventional radiology (IR)	N
Clinical and lab microbiology	N
Urgent diagnostic haematology	Y
Acute inpatient rehabilitation	Y

 

In addition to the South East Clinical Senate list of co-dependent and co-adjacent services, the Kent and Medway stroke review evaluated sites on their potential to offer mechanical thrombectomy in the future. This information is also published in appendix N, and the position at QEQM is summarised below:

Provision of optimal clinical co-adjacencies for mechanical thrombectomy	Availability on site at QEQM
Interventional neuro-radiology	N
Acute cardiac Primary Percutaneous Coronary Intervention (pPCI)	N
CT & CT angio-gram	Y
MRI angio-gram	Y
Neurology	N
Interventional radiology suite	N
Designated trauma unit	N