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Background to the stroke care review in Kent and Medway

 

We started reviewing our stroke services in Kent and Medway in late 2014. It has been a long and detailed process involving a wide range of clinicians, patients and the wider public. There is a strong view that stroke care could and should be improved. In many cases people have urged us to make changes as quickly as we can. The review is in response to national evidence, requirements, and recommendations specifically for ‘hyper-acute’ and ‘acute’ stroke care – in particular, the need for a specialist stroke unit to be available seven days a week. Find out more about the history of the review below.

What patients and the public told us during the review

Stroke survivors, their families and carers, and members of the public have played a key part in shaping potential future models of care. Varied, robust and in-depth engagement has taken place with stroke specialists, clinical staff, voluntary organisations, stroke survivors, families and the public in Kent and Medway to gather people’s views and insight.

A number of public listening events, focus groups with the Stroke Association, roadshows, people’s panel engagement events and other events have been held since July 2015.

From the start, some people suggested there should be fewer sites that admit stroke patients for the first 72 hours, and that travelling further may be acceptable, depending on how far.

In November and December 2015, three deliberative events, called ‘People’s Panels’, looked in detail at the case for change, and questioned the proposals for improving future stroke care. They also voted on different aspects of services – establishing what they, as patients and carers, value most.

Having been through the very detailed process of voting on their priorities, the People’s Panels overwhelmingly recognised the need for a reduction in stroke units from the current seven sites, voting 49 to two in favour of this.

They rejected the one, two or three-site models, and agreed that six sites would not deliver the required improvements. Their preference was for a four or five-site model.

The People’s Panels said the most important aspects of stroke services were:

  1. Round-the-clock services: access to all stroke-related services 24/7
  2. Quality of care: safe, high quality care for all patients
  3. Workforce: dedicated 24/7 specialist teams.

To find out more about these early discussions, read our report: https://democracy.kent.gov.uk/mgConvert2PDF.aspx?ID=61536 .

The following autumn, in September and October 2016, there were four further meetings with stroke survivors, family carers and members of the public who had been involved in previous engagement.

These events updated participants on the detailed work that had taken place over the previous nine months and explored people’s concerns and outstanding issues.

They took the form of two conversations, in which the then Programme Director Oena Windibank, the Chair of the Clinical Reference Group (stroke consultant Dr David Hargroves) and members of the Review Programme Board were asked questions and challenged by the Chief Executive of Healthwatch Kent and the Stroke Association Area Manager. The conversations included the emerging evidence that three hyper acute stroke units looked like the right number for Kent and Medway.

Oena Windibank gave a presentation to a Stroke Survivors Group in Swale which was attended by 30 stroke survivors and family carers.

People’s concerns were mainly about:

  • the cost of the proposed changes and how this would be funded
  • the need for more information and greater openness about the sites under consideration
  • the need for more information on the options for different numbers of sites, and how they were tested
  • staffing levels – throughout the different stages of stroke care – and recruitment
  • travel times – the reality of busy areas, different levels of traffic at different times.

A full report of these events is available at: https://democracy.kent.gov.uk/documents/s73808/Stroke%20Engagement%20Report.pdf

Testing the criteria for taking decisions

In July and August 2017, we asked stroke survivors, carers, staff and the public about their views on what those taking the decision on stroke services should consider when looking at possible options.

They were shown a set of draft evaluation criteria and asked to comment on them.

Eight focus groups (one in each Kent and Medway clinical commissioning group area) were held with the Stroke Association, and there was an online survey, and a public meeting in Ashford.

What stroke experts told us during the review

The Clinical Reference Group, which is made up of doctors, nurses and other specialist stroke staff, provides clinical guidance and assurance to the stroke review.

The group said that ideally there would be hyper acute and acute stroke services at each acute hospital. However, they recognised that this is not possible because there are not enough specialist doctors, nurses or therapists to offer a seven-day service at every site.

They discounted “no change” because services need to be consistently improving for patients.

After reviewing detailed modelling work, the group recommended that there should be three hyper acute and acute stroke units alongside seven-day transient ischaemic attack (TIA) clinics for high risk patients in Kent and Medway. This was because:

  • Hyper acute stroke units must treat a large enough volume of patients for staff to retain their skills and for services to be cost effective. National guidance is that there need to be a minimum of 500 and a maximum of 1,500 stroke patients per year in each unit. Around 3,000 cases of stroke are treated every year in Kent and Medway: too many for a single unit.
  • National guidance is that at least six consultants are required to provide seven day a week cover for hyper acute and acute stroke units with more than 20 and up to 40 beds. The 3,000 stroke patients per year treated in Kent and Medway are expected to need 127 beds by 2020/21. This means that options with more than three units would have consultants who were under-used (because some or all of the units would have fewer than 40 beds). In addition, there are currently only 10 whole time equivalent (WTE) stroke consultants in Kent and Medway. We already need to recruit eight more consultants for three hyper acute and acute stroke units. There is a national shortage of stroke consultants (for example, in 2016, 40 per cent of hospital sites had at least one unfilled post for a stroke consultant) and it would not be possible to recruit the additional consultants required to staff more than three units (it would require at least an additional 14 consultants to staff four or more units).

Therefore, the clinical reference group recommended that options with four, five, six or seven sites should be excluded.

The consensus from stakeholders, including clinicians and the public, has been that if there were only two hyper acute and acute stroke units, they would be too big, would lack resilience (if something happened to disrupt services at one of them) and it would be too difficult to move to two units in the short term. Therefore, clinicians recommended options with two sites should be excluded.

The clinical reference group recommended that there should be three hyper acute and acute stroke units alongside seven-day transient ischaemic attack (TIA) clinics for high risk patients in Kent and Medway. This recommendation was put to the Stroke Review Programme Board.

What is a stroke?

 

Stroke is a serious, life-threatening medical condition that happens when the blood supply to the brain is cut off by either a blockage or a bleed in one of the blood vessels. The first 72 hours after a stroke are the most important in terms of getting the right, specialist treatment for the patient as quickly as possible, so that there is less chance of harmful long-term effects on that person.Diagram explaining care timeline during the first 72 hours after a stroke

Dr Hargroves, Stroke Consultant and Chair of the Clinical Reference Group for the Stroke Review says:

“Excellent and swift care across Kent and Medway at the point of a stroke or suspected stroke, is only possible by arranging services so that enough specially skilled doctors and nurses are available in  stroke units designed for the particular needs of stroke patients.

“A stroke can be life-threatening, so doctors need access to rapid diagnostic tests to confirm what type of stroke has occurred and what specific treatment the person may need as quickly as possible, day or night and every day of the week.

Evidence shows that to best maintain their skills, specialist stroke staff should treat somewhere between 600 and 1400 strokes, or suspected strokes every year”.

Approximately 3,000 people a year are treated for stroke in the current stroke units across Kent and Medway.

 

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