What is the stroke services review and consultation about?
We are proposing to establish hyper acute stroke units in Kent and Medway, and the proposals recommend establishing three units. The proposals also set out a five options for where these three units could be located across Kent and Medway.
Under the proposals, hyper acute stroke units would also have:
- an acute stroke unit where people may go after the initial 72 hours for further care until they are ready to be discharged
- a transient ischaemic attack clinic (TIAs are also known as “mini strokes” and can be an indication that a stroke may follow).
These five proposed options are:
- Darent Valley Hospital, Medway Maritime Hospital, William Harvey Hospital
- Darent Valley Hospital, Maidstone Hospital, William Harvey Hospital
- Maidstone Hospital, Medway Maritime Hospital, William Harvey Hospital
- Tunbridge Wells Hospital, Medway Maritime Hospital, William Harvey Hospital
- Darent Valley Hospital, Tunbridge Wells Hospital and William Harvey Hospital
The order is not a ranking and we are not identifying a preferred option until we have fully and carefully considered the views and feedback gathered via public consultation alongside any additional information gathered.
The consultation runs from Friday 2 February until Friday 13 April 2018.
Why do things need to change?
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.
What will the benefits be of these proposed changes?
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.
How is this proposal different from what we do now?
- 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.
Will it take longer for some patients to get to hospital with these proposed new plans? Is that safe?
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.
Could you explain more about how you considered travel times for patients when deciding on the proposed shortlist?
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.
Why are you proposing three HASUs specifically?
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.
How does the rehabilitation and long-term care of stroke patients fit in to these plans?
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.
Why are some hospitals in Kent and Medway not included in any of the 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.
How does the work looking at the configuration of hospitals in east Kent link in with these proposals?
Are there enough staff to support these proposed changes?
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.
Under the proposals, what would happen to staff at existing stroke units not chosen to be a HASU?
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.
Will hospitals that don’t have a hyper acute stroke unit end up losing other services?
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.
What information is available about the quality of current stroke services?
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.
Where else in the country have stroke services been reorganised?
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.
Will there be fewer stroke beds across Kent and Medway compared to now?
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|
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).
What co-adjacent services does Queen Elizabeth the Queen Mother Hospital not have?
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|
|Speech and language||5/7|
|Hub vascular surgery||N|
|Critical care (paediatric)||N|
|Acute stroke unit||Y|
|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|
|Acute cardiac Primary Percutaneous Coronary Intervention (pPCI)||N|
|CT & CT angio-gram||Y|
|Interventional radiology suite||N|
|Designated trauma unit||N|