By Steve Wilkins – briefing for people going to a Listening Event.
THE case that is being made to centralise stroke services into just 3 Hyper Acute Stroke Units (HASUs) in Kent & Medway is that this will benefit people who have strokes because they will receive greater intensive treatment, faster with a dedicated multi-disciplinary team of specialists for up to 72 hours followed by up to 15 days in a co-located Acute Stroke Unit (ASU). This, it is claimed, will reduce the number of deaths from stroke and long term permanent disability, and that this outweighs the impact of the additional time it will take some people to get to the HASU.
When someone has the symptoms of a stroke, time is of the essence to minimise the damage. The patient needs to be scanned as soon as possible to decide whether this is the result of blood clot or a brain bleed because the treatments are very different. Most strokes are the result of clots and in these cases an assessment needs to be made as to whether the patient would benefit from a clot busting drug. This only applies to 10 -20% of cases but for these people the administration of the clot busting drug, a process called Thrombolysis, needs to take place as early as possible to ensure the best outcome.
While we accept that stroke services are currently poor in some parts of Kent and that the HASUs deliver benefits for people with stroke symptoms we do not agree that the distances and time it will take some people to reach a HASU are acceptable so we are proposing a different model (see below) to achieve better outcomes for everybody.
We believe that the model being proposed is also linked to another agenda, the establishment of just 3 hospitals delivering full A&E and specialist services with the consequent downgrading of the remaining hospitals as part of the Sustainability & Transformation Plan (STP) hospital re-configuration.
We already know that William Harvey Hospital in Ashford is the planned A&E and specialist services for East Kent and it is the only East Kent hospital being offered as a HASU in all 5 options being put out to consultation. Despite the fact that consultation on the full STP is due to start in April there has been no indication so far of what is being planned for hospital re-configuration in the rest of Kent. It seems very likely that whichever other 2 hospitals get the HASUs will also be the remaining 2 A&E and specialist services hospitals. Losing stroke services in some hospitals on the promise of better treatment in HASUs provokes much less widespread hostility than announcement that they are facing more general downgrading. Once HASUs are established however they can be used to justify the wider agenda.
The London Model
The model for HASUs in Kent & Medway is based on the model that operates in London that reduced the number of deaths from stroke by 100 and also reduced the length of time people stayed in hospital. However there are some major differences between London and Kent. The number of HASUs is decided on population figures not geographical area so London with a larger and more dense population has 8 HASUs whereas Kent is proposing just 3.
The London HASUs were set up so that everyone would be within 30 minutes or less of a HASU, in Kent it is one hour or less. London Ambulance Service figures show that the average travel time to HASUs is just 16 minutes. This is a world away from the situation in Kent where people have to travel longer distances, and it is some of the most deprived parts of Kent where stroke incidence is at its highest people will potentially have to travel furthest.
The Kent proposal admits that for a small number of people it may take more that hour and many people in Thanet for instance say that it takes more than an hour to get to William Harvey Hospital in Ashford. In mitigation Stroke Consultant Dr Hargroves has suggested that Ambulances could be fitted with video links to the HASUs so that some of the preliminary assessments can be done while in transit to reduce the time between arrival at hospital and treatment. In the US and Germany there are trials taking place fitting Ambulances with CT scanners and small laboratories so that all the necessary tests can take place while patients are being transported to hospital, but this is not being proposed here in Kent & Medway now or any time in the foreseeable future.
The best outcomes for people with stroke occur when they receive intensive treatment within 3 hours of the onset of the symptoms. There first needs to be a recognition of the symptoms which are not always obvious, a call for an Ambulance, the Ambulance to arrive, assess the patient and get them in the Ambulance, then travel to hospital for treatment. The target is then (hospital) ‘door to needle time’ of 30 minutes or less. Clearly the longer time people have to travel the less chance they have of receiving treatment within 3 hours.
The much shorter journey times may well account for the reduced number of deaths in London. There are currently no figures available that show what improvement is possible in an area more comparable to Kent.
There are also other potential explanations for the improved figures in London as admitted in the Kent & Medway Pre-Consultation Business Case which states:
It is not clear that the London model can be transferred to a more rural environment or how effective the centralised model would be outside urban areas (Hunter 2013, Morris 2014) if the populations and stroke types differed. Nor was it clear that the period from 2010-12 in London was typical, though all models seem to have been well tested for the sensitivity of their assumptions. London had made relatively less progress than the rest of England in the period leading up to reconfiguration of its stroke services; so did the gains in London just represent a catching up? When asked to adopt the London model, hospital managers in the Netherlands reacted by claiming that the reconfiguration in London has only managed to lift low levels of care to match the care quality already present in the Netherlands (Monitor Evidence Report 2014). *i.
Another key difference from the London model is that instead of 3 ASUs co-located with the 3 HASUs as is being proposed for Kent, London’s ASUs are located in 24 hospitals so that stroke patients are returned to a hospital close to their home after the intensive 72 hours in one of the HASUs. This also means that 24 hospitals retain all the additional services required to support ASUs which again raises the suspicion that the proposal to centralise stroke services in Kent is being used as cover to downgrade hospitals not designated as an HASU.
Will HASUs Reduce Long Term Disabilty?
In the presentation of the Pre-Consultation Business Case at the end January Dr Hargroves made much more of reducing long term disability than reducing deaths but again there are no figures that show how much, if any, disability is reduced by the centralisation of stroke units into HASUs. It is assumed that the reduction in length of stay in hospital is an indicator of reduced disability but equally crucial is what happens after people are discharged into the community for rehabilitation and aftercare. We know from the Community Health Re-Provisioning meeting in December that whereas the Stroke Units are dedicated specialist teams providing intensive treatment, in the Community the opposite is going to be the case, where specialists are going to be ‘upskilled’ into generalists which also means fewer people covering more jobs. It was reported at the last Medway Trades Union Council meeting that this had already occurred in at least one part of Kent.
Reduction in Beds
Although the figures are confusing because there is an inclusion of people from Bexley and a part of Sussex who would have to travel to a HASU in Kent there is a clear reduction in the number of stroke beds as part of this proposal. If you exclude beds currently outside of Kent the number of stroke beds we have now is 144. This will be reduced to anything between 127 and 98 depending on which of the 5 options is chosen.*ii
While the overall aim of the STP is to save money, the HASUs are going to cost £40m.This is similar to the cost of setting up 8 HASUs in London of £43m. This money is not coming from the NHS itself but is going to be borrowed externally. As we know from the disastrous PFI deals this is potentially going to lock the Kent & Medway NHS into large re-payments lasting for 20 years. Stroke care has changed profoundly over the last 10 years and is likely to change again over the next 10 years so we could be left paying for a model years after it has been superseded by newer models and techniques.
It is also something of a mystery as to why the NHS is prepared to spend so much on stroke services where the improvement in mortality is only 1.1%. That doesn’t seem very cost effective. We of course welcome any improvement in mortality and reduction in disability. I take the view that whatever money is necessary to improve people’s health and wellbeing should be found. Nevertheless, there are many other serious potentially fatal and debilitating illnesses and conditions that are not getting such lavish treatment.
The overarching priority for people showing symptoms of a stroke is to get scanned and treated as early as possible and the best results occur when this happens within 3 hours of the symptoms first occurring. The most time critical elements are scanning and where appropriate, thrombolysis. We believe that the additional travelling time of up to 1 hour or more, particularly for people in areas of deprivation and higher stroke incidence can be overcome by a slightly different model.
1. Patients showing symptoms of stroke are transported as quickly as possible to their nearest hospital whether or not it is a HASU.
2. Patients are scanned on arrival at that hospital via a video link to a stroke consultant at a HASU where the hospital is not a HASU.
3. The Consultant decides on the most appropriate treatment for that patient and thrombolysis is administered by suitably trained staff if appropriate.
4. Patients are then transported to the HASU for 72 hours for intensive monitoring and treatment from the specialist stroke team before being returned to an ASU at their local hospital.
This model takes account of the lack of specialist stroke staff, particularly Stroke Consultants where there is currently a 40% national vacancy rate. Video links to static hospitals are simpler than video links to ambulances on the move and most importantly it means that stroke patients are seen and treated in the shortest possible time. Locating ASUs in local hospitals where patients will stay up to 15 days also makes it easier for patients and their families to see each other regularly at a time of great anxiety and stress.
*i. https://kentandmedway.nhs.uk/wp-content/uploads/2018/01/Appendix-G-Evidence-Review-of-Hyperacute-Stroke-Units.pdf p21
*ii. https://kentandmedway.nhs.uk/wp-content/uploads/2018/01/180124-Stroke-PCBC-vFINAL.pdf p36
https://kentandmedway.nhs.uk/wp-content/uploads/2018/01/Appendix-L-Bed-and-capacity-modelling.pdf p12 onwards