Stroke care review

Update March 2019

Since 2014, commissioners have been talking to the public, stroke survivors, carers and clinicians across Kent and Medway about acute stroke services, with a view to improving clinical outcomes for patients. National and international evidence is clear that when stroke care is managed within specialist stroke centres, then survival rates significantly improve and disability from a stroke is significantly reduced.

The stroke review is led by the Sustainability and Transformation Partnership.. Currently stroke services do not consistently meet best-practice standards across the whole of Kent and Medway. The identification of a preferred option brings the NHS a step closer to improving stroke outcomes and reducing deaths and disability because of stroke.

Health commissioners from the eight clinical commissioning groups (CCGs) in Kent and Medway held a formal public consultation on stroke services in spring 2018, following detailed engagement and consideration of a wide number of options. The options of three possible locations included:

  1. Darent Valley Hospital, Dartford; Medway Maritime Hospital, Gillingham; William Harvey Hospital, Ashford;
  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

People were able to respond to the consultation online and printed copy, at listening events across Kent and Medway, by freepost, email and phone and via social media. The CCG also held roadshows at Sittingbourne Memorial Hospital, Sheppey Hospital, Sheppey Healthy Living Centre, Sheppey Gateway and Sittingbourne Community Centre.

Our roving roadshow provides the opportunity to hear what local people think about services, and about our plans to improve them. They complement other events and opportunities to engage.

A consultation activity report and consultation response report were produced following the public consultation and they are available here. The consultation activity report shows that the public consultation activity was comprehensive, reaching in excess of 2 million people, and generating over 5,000 responses. The responses to the consultation have been independently analysed to identify a number of key themes.

In September 2018, the Stroke Programme Board reviewed stroke services in response to national evidence, requirements and recommendations, particularly the need for patients to have access to a specialist stroke unit seven days a week.

The preferred option was identified following careful consideration of the responses to the public consultation, all the evidence and data gathered during the review, and further detailed evaluation of five shortlisted options including trust proposals for implementation.

Detailed and rigorous evaluations of all possible options were considered in reducing a large number of potential three site options to a shortlist. A shortlist was presented to a joint committee of clinical commissioners, independently chaired, who made the final decision on the shortlist for consultation.

The preferred option is to have hyper acute stroke units, alongside acute stroke units, at: Darent Valley Hospital in Dartford, Maidstone Hospital and William Harvey Hospital in Ashford.

In February 2019, the Joint Health Overview and Scrutiny Committee voted to support this decision.

What next?

The work now moves into the implementation phase. It is anticipated that the new stroke service will begin at Maidstone and Darent Valley hospitals in spring 2020 and at William Harvey Hospital in spring of 2021.

New approach to rehabilitation

The NHS is also announcing details of a proposed new approach to rehabilitation for stroke patients. A key theme from the public consultation was that good quality, well-resourced rehabilitation services, in or close to home, were of vital importance to local people. There are plans to gather views and feedback on the proposed new approach to rehabilitation from stroke survivors, their families and carers, front-line staff, local councillors and the public to help inform detailed implementation plans.

Look out for further information on the Kent and Medway STP website.

 

Background

Working towards excellent stroke care in Kent and Medway

The NHS in Kent and Medway, Bexley in south east London and the High Weald area of East Sussex, held a public consultation on the future of urgent stroke services in Kent and Medway. The NHS asked for people’s views on proposals to establish three new 24/7 hyper acute stroke units (HASUs) in Kent and Medway. The consultation ran from Friday 2 February 2018 for 10 weeks until midnight on Friday 13 April 2018.

A consultation document was available to read; people could participate in public meetings and events, and complete an online or postal questionnaire. There was also 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.

Creation of hyper acute stroke units

There are currently no HASUs in Kent and Medway, although urgent stroke care is provided at six hospitals. The changes to stroke services were proposed because currently hospitals were not able to consistently deliver the standard and quality of stroke care that people should be able to expect.

The proposals were developed by stroke doctors and other stroke specialists. They were in line with evidence-based best practice on how urgent stroke services could be run to give patients the best possible outcomes and reduce death and disability from stroke.

The proposals recommended creating three HASUs in Kent and Medway, and gave five different options for where these could be located. When the new HASUs are created, urgent stroke services will not be provided in other hospitals in Kent and Medway.

Each of the proposed HASU sites would also have an acute stroke unit to give patients expert care in 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).

Full shortlist

The full shortlist of possible locations was:

  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 was not a ranking and the preferred option was not identified until doctors and others taking the decision about the future organisation of stroke services had fully and carefully considered all the evidence and data available, including feedback from the public consultation.

Getting specialist care fast

“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 offer at the moment.”

The consultation was overseen by the Joint Committee of Clinical Commissioning Groups for Kent and Medway Hyper Acute and Acute Stroke Services, which has delegated authority from 10 clinical commissioning groups (CCGs): the eight CCGs in Kent and Medway, NHS Bexley CCG, and NHS High Weald Lewes Havens CCG.

The public consultation came after work in partnership by all eight clinical commissioning groups (CCGs) in Kent and Medway to review acute stroke services. The review started in 2015 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.

The review focused throughout on best clinical practice to improve outcomes for patients, particularly in the first 72 hours after a stroke.

Developing the proposals

In developing the proposals, there was 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 HASUs 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 was based on this work.

Stroke survivors, their families and carers, and members of the public played a key part in shaping potential future models of care. Varied, robust and in-depth engagement took place to gather people’s views and insight.  This included surveys, focus groups, listening events and clinical engagement events.

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

In September and October 2016, there was a further series of events involving people who had had a stroke, their carers, and members of the public.  Healthwatch Kent and Stroke Association quizzed Dr Hargroves and the Programme Director Oena Windibank, commissioners and representatives from other organisations including the ambulance service and public health, about the work to date.

Travel times

Each option allowed at least 98 per cent of people treated in Kent and Medway to access a HASU 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 review team of stroke specialists believed a journey time of an hour allows hospital staff to achieve this standard.

Cost

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 HASUs. This is because, when more patients can leave hospital sooner, and with less disability, they need less support in the long-term.

Symptoms of stroke

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