Published: 2 February 2018
The NHS in Kent and Medway, Bexley in south east London and the High Weald area of East Sussex, is today launching a public consultation on the future of urgent stroke services in Kent and Medway. The NHS is asking for people’s views on proposals to establish new 24/7 hyper acute stroke units in Kent and Medway. The consultation runs from today, Friday 2 February 2018 for 10 weeks until midnight on Friday 13 April 2018.
To take partpeople can read the consultation document, participate in public meetings and events, and complete an online or postal questionnaire. There will also be specific engagement through focus groups and other work with people whose views are less likely to be heard, and people whose age, ethnicity or other factors puts them at higher risk of a stroke.
Dr Mike Gill, Independent Chair of the Joint Committee of Clinical Commissioning Groups for Kent and Medway Hyper Acute and Acute Stroke Services said, “This consultation is an opportunity to make your voice heard and help us design the best stroke services in Kent and Medway. We encourage everyone to respond, whether you have been involved in the earlier work or not; whether you work in the local NHS or are a resident; whether you have first-hand experience of stroke or not. All views are important to us.”
At the moment there are no hyper acute stroke units in Kent and Medway, and urgent stroke care is provided at six hospitals. The changes to stroke services are being proposed because currently hospitals are not able to consistently deliver the standard and quality of stroke care that people should be able to expect.
The proposals have been developed by stroke doctors and other stroke specialists. They are in line with evidence-based best practice on how urgent stroke services can be run to give patients the best possible outcomes and reduce death and disability from stroke.
The proposals recommend creating three hyper acute stroke units in Kent and Medway and give five different options for where these three new units could be located. If the proposals go ahead, urgent stroke services would not be provided in other hospitals in Kent and Medway.
Each of the proposed hyper acute sites would also have an acute stroke unit to give patients expert care after the first 72 hours until they are ready to leave hospital, and a clinic for assessing and treating transient ischaemic attacks (TIAs or mini strokes).
The shortlist of possible locations is:
1.Darent Valley Hospital, Medway Maritime Hospital, William Harvey Hospital
2.Darent Valley Hospital, Maidstone Hospital, William Harvey Hospital
3.Maidstone Hospital, Medway Maritime Hospital, William Harvey Hospital
4.Tunbridge Wells Hospital, Medway Maritime Hospital, William Harvey Hospital
5.Darent Valley Hospital, Tunbridge Wells Hospital and William Harvey Hospital
The order of the shortlist is not a ranking and no preferred option will be identified until doctors and others taking the decision about the future organisation of stroke services have fully and carefully considered all the evidence and data available, including feedback from the public consultation.
“I am delighted that we’re launching this consultation today. There is clear evidence that patients benefit most from being treated at a hyper acute stroke unit in the first 72 hours after their stroke, even if that means ambulances driving past the nearest A&E department to get to one,” said Dr David Hargroves, clinical lead for the stroke review and senior stroke consultant at East Kent Hospitals University NHS Foundation Trust.
“We know that patients might currently be able to get to an A&E fairly quickly and the thought of travelling further seems to go against the ‘Act F.A.S.T.’ advice. With stroke, what counts is the total time it takes from calling 999 to having a scan and starting the right treatment. Spending 15 minutes in an ambulance but waiting three hours in A&E is worse than an hour in an ambulance going to a specialist unit that can scan you and start treatment within 30 minutes of arrival. It is also vital for patients’ recovery that over those first three days they are seen by a stroke consultant every day, and regularly assessed by specialist therapists – something we can’t always offer at the moment.”
“Stroke is a medical emergency and the third most common cause of death for people under the age of 75 in the UK,” said Dr Diana Hamilton-Fairley, Medical Director of Medway NHS Foundation Trust. “Almost two-thirds of stroke survivors leave hospital with a disability, such as sight problems, limb weakness or communication problems. We are convinced these proposals for hyper acute stroke units in Kent and Medway will improve the quality of services and help us achieve better outcomes for the 3,000 stroke patients treated in our area each year.”
“Across Kent and Medway, stroke services are not consistently organised in a way that delivers the most efficient or effective care. Experience elsewhere has shown that consolidating stroke teams should provide better care in the future: that must be the aim of us all,” said Dr Steve Fenlon, Medical Director of Dartford and Gravesham NHS Trust. “The involvement of the public will help us shape the model of care and provide support to our committed healthcare professionals delivering this vitally important service.”
Dr Peter Maskell, Medical Director at Maidstone and Tunbridge Wells NHS Trust, said: “We welcome the opportunity to take part in this important consultation to improve stroke care for patients across Kent and Medway, and encourage as many people as possible to take part so their views are heard.”
A meeting on 31 January 2018 of the Joint Committee of Clinical Commissioning Groups for Kent and Medway Hyper Acute and Acute Stroke Services, which has delegated authority from each of the eight Kent and Medway clinical commissioning groups (CCGs), NHS Bexley CCG and NHS High Weald Lewes Havens CCG, gave the go-ahead to the public consultation which is launching today, 2 February 2018. It will run for ten weeks, until midnight 13 April 2018.
To find out more about how to respond to the consultation, please visit www.kentandmedway.nhs.uk/stroke
Urgent stroke care best practice
Stroke doctors emphasise that to get the best possible outcomes, patients need to be seen by stroke specialists in a hyper acute stroke unit, even if that means a longer journey to reach the right hospital. These services should be available 24 hours a day, seven days a week. We don’t currently have any units consistently working in this way in Kent and Medway. The graphic below gives further details of the care that ideally should be given during the critical 72 hours following stroke
In London, deaths from stroke fell by almost 100 in the first year after hyper acute stroke units were introduced.
What is different about the hyper acute stroke units?
The evidence shows that patients get the best outcomes when they are admitted quickly to a specialist stroke unit and cared for there for the first 72 hours following a stroke. These units are called hyper acute stroke units or HASUs. National standards and best practice guidance describe a hyper acute stroke unit as:
- run by a multi-disciplinary team of specialist stroke staff (that is, a team with a mix of professionals such as consultant doctors, radiologists, occupational therapists and physiotherapists, specialist stroke nurses, speech therapists, dietitians and so on)
- treating at least 500 confirmed stroke patients each year. This is to ensure the staff see enough patients to maintain their competency levels and build their expertise
- open 24 hours a day, seven days a week with access at all times to brain scanning equipment and clot-busting drugs (thrombolysis) and the consultant cover to review scans and provide thrombolysis
- admitting people quickly onto the unit avoiding waits in A&E
- offering patients and carers high quality information and support.
After the first 72 hours, or once they are stable, patients should then be cared for on an acute stroke unit until they can be discharged with a comprehensive plan for ongoing rehabilitation.
Stroke patients should receive at least 90 per cent of their inpatient care in a specialist stroke service (hyper acute stroke unit and acute stroke) rather than on general hospital wards.
Hospitals not included in the shortlist of options
At different stages of the evaluation process some of the hospitals in Kent and Medway were excluded because they did not meet the required criteria. Following evaluation, two sites are not in any of the shortlisted options:
Queen Elizabeth, the Queen Mother Hospital: Some hospital trusts in Kent and Medway currently provide stroke services on more than one hospital site. We asked these trusts to assess whether they could set up and run more than one hyper acute stroke unit. East Kent Hospitals University NHS Foundation Trust (EKHUFT) concluded that it would be very difficult to attract enough specialist stroke staff to safely run two units. Therefore, options with a hyper acute stroke unit at both the William Harvey Hospital and the Queen Elizabeth the Queen Mother hospital (the two sites managed by EKHUFT) were evaluated more poorly than the other options.
Kent and Canterbury Hospital: The reasons outlined for why the Queen Elizabeth, the Queen Mother Hospital are not included in proposals also applies to the Kent and Canterbury Hospital. Namely, East Kent Hospitals University NHS Foundation Trust (EKHUFT) concluded that it would be very difficult to attract enough specialist stroke staff to safely run two units.
In addition, the Kent and Canterbury Hospital does not currently offer acute stroke services or the range of other emergency and urgent care services that are needed to support a hyper acute stroke unit.
Of the sites run by the trust, (notwithstanding the note below about potential future changes in east Kent) the William Harvey Hospital was identified as the best option for a hyper acute stroke unit. This was in part because of the existence of other services that are desirable to have located alongside a hyper acute stroke unit.
Review of hospital services in east Kent
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 conclude and slow down the essential decisions we need on stroke. If, through the east Kent emergency and specialist service review, William Harvey Hospital were no longer to be a long-term option for emergency and specialist services and these moved elsewhere – then we would anticipate any hyper acute stroke service would move with the co-dependent services, subject to public consultation.
Each option allows at least 98 per cent of people whose nearest service would be in Kent and Medway to get to a hyper acute stroke unit by ambulance within an hour. This is particularly important for people – 10 to 20 per cent of stroke patients – whose stroke is caused by a blood clot. Best practice standards say all patients should have a brain scan and those with a blood clot should start treatment with clot-busting drugs within two hours of calling 999. The Clinical Reference Group that has been supporting the stroke review believes a journey time of an hour allows hospital staff sufficient time to achieve this standard. This approach was supported by the independent review conducted by the South East Coast Clinical Senate.
Developing the proposals
In developing the proposals, there has been a rigorous process to review how urgent stroke services could be organised. The process involved stroke doctors, nurses, therapists and other stroke specialists, along with stroke survivors, carers and the public. They considered how many hyper acute stroke units would be needed in Kent and Medway and what combinations of existing hospitals could deliver the best access to patients, quality of care, and ability to recruit and retain staff, as well as many other factors. The shortlist of possible options for the location of hyper acute stroke units in Kent and Medway is based on this work.
Making these changes would require up to £40million investment in building work and equipment at hospitals and for recruiting more staff across the county, but experience from elsewhere shows it costs less overall when patients are treated in hyper acute stroke units. This is because more patients can leave hospital sooner, and with less disability, they need less support in the long-term.
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, causing damage to the brain tissue.
The effects of a stroke depend on which part of the brain is injured and how severely it is affected. We know that the care given in the first 72 hours after a stroke has the greatest impact on reducing long-term damage and disability.
The type of treatment needed depends on the type of stroke, and whether it is caused by a bleed or a blockage, which can only be determined by expert diagnosis.
What is the impact of stroke?
Stroke is a major health problem in the UK. There are around 32,000 stroke deaths in England each year. More first time strokes are now occurring at an earlier age compared to a decade ago. Public Health England data show that while 59 per cent of strokes occur in people aged 70 plus, more than a third – 38 per cent – are in people between the ages of 40 and 69.
Some groups of people are more at risk of a stroke, including older people and people with Indian, Bangladeshi and Pakistani heritage. Smoking and obesity are also major factors in increased stroke risk.
However, stroke is a preventable and treatable disease. Fewer people have been dying of stroke since the late 1960s. This is in part due to a better understanding of the causes of stroke, and how to prevent them. It is also because of the development of specialist stroke units and the use of clot-busting drugs, called thrombolysis.
Public Health England’s Act F.A.S.T. stroke campaign urges the public to call 999 if they notice even one of the signs of a stroke in themselves, or in others:
- Face – has their face fallen on one side? Can they smile?
- Arms – can they raise both their arms and keep them there?
- Speech – is their speech slurred?
- Time – time to call 999
For further information, please visit www.nhs.uk/actfast