Report from Broadstairs Listening Event

Broadstairs Listening Event (public consultation meeting), Stroke Review report:

24.03.2018 (week 7 of the 10 week consultation)

The venue was full, with all 110 seats full, and some people being turned away as they hadn’t booked. Ten members of SONIK were present in the audience (we had requested a place on the panel to provide some balance, but had been refused). Also present in the
audience were councillors Iris Johnson, Paul Messenger, Lesley Game, and Karen Constantine, and prospective parliamentary candidates for Labour Raushan Ara, Rebecca Gordon Nesbitt and Helen Whitehead, as well as ex Councillor and CCG member Clive Hart. Neither of our local MPs were present.

The panel: Dr Tony Martin, Dr David Hargroves, Patricia Davies, Caroline Selkirk and Susan Acott.

At the beginning of the meeting, Candy Gregory handed over a formal letter from SONIK stating that the consultation process has been inadequate and requesting that the committee withdraw their plan or reconsult. Copies of this letter were also given out to the audience. Patricia Davies responded that the letter will be ‘logged’, and Carly Jeffrey of SONIK stated that is must be read and responded to before it is logged.

What was different about this meeting to preceding ones? Our questions were answered directly without intervention from the chairperson, who at previous meetings had rephrased people’s questions and in some cases bundled numerous questions together. This time, there was no attempt to do so. Also,the chair stated that any unasked questions could be written on cards, handed in, and said they would be answered on the Kent & Medway STP website. At previous meetings, they said they’d ‘feed the questions back’, meaning that nothing would be done with them until after the consultation had ended.

The audience, yet again, were pretty well informed, and asked very pertinent questions around ambulance journey times and ambulance response times, they asked why there is no national approach to stroke recruitment and staffing, and it was commented that this needs to be established before regional areas move to the HASU model.

Also raised were: funding for specialist training, travel difficulties to Ashford, family accommodations, the fact that Thanet healthcare is struggling already, and they asked why QEQM hospital isn’t on the table forthis consultation. One audience member asked for a show of hands, and the response was almost universal for keeping services at QEQM hospital.

An ex- Speech and Language therapist talked of her experience of trying to get back into the role, specifically with the high costs of training. SONIK members asked about the effect on hospitals left behind, the inadequate evidence on death and disability outcomes, inequality of care, and acute bed numbers.

Dr Tim Winch made some very good evidence based points; the audience were very interested in what he had to say, and he got a big cheer from the crowd. He ended by telling the panel that they should ‘hang their heads in shame’.

The two voices from the audience that were in agreement with the panel are both known to the panel – GP Sarah Philips, who quoted the now discredited death and disability evidence from London, and Patricia Funnell, ward manager of QEQM’s stroke unit. Patricia has been at every Thanet meeting so far; this time stood up and said that all who work in the QEQM stroke unit are behind the plan.

SONIK do not believe this to be true, but it is not something that can be proved one way or the other when staff are scared to speak out for fear of the workplace bullying that is known to happen to whistleblowers in the NHS. Dr David Hargroves is Ms Funnell’s direct line manager.

There are 5 new videos from Saturday up on the FB page – please take a look to see what happened at the meeting:


What has happened to CAMHS?

If you attempted to telephone your local Child and Adolescent Mental Health Service (CAMHS) in the first weeks of September, in Broadstairs or Canterbury, or anywhere else in Kent or Medway, you will have been greeted by a monotonous tone signalling that the telephone line had been disconnected.

No-one was warned about this; not the patients, families, GPs or other professionals, or even the staff who work in these clinics. The reason the phones were disconnected was because the management of Kent CAMHS services migrated from its former provider, Sussex Partnership Foundation Trust (SPFT) to the new provider, North East London Foundation Trust (NELFT) on 1st September 2017.

As well as the telephone lines being disconnected, the electronic patient record system shut down, pending referrals were closed, and staff email accounts were disbanded. CAMHS, as you know it, was effectively cut off.

SPFT had been responsible for Kent CAMHS services for the past four years since they successfully won the tender from East Kent Hospitals Trust (EKHT). One can only assume that the tender, like any other, was won on a ‘provide more for less’ basis. SPFT’s head offices are in Swandean and Arundel; hours away from the Kent services they were commissioned to provide. The tender brought uncertainty for clinical and admin staff including restructuring, redundancies and reapplications for jobs with obvious implications for patients and families – all at financial cost to the NHS.

It also meant a massive rebranding of everything from letter heads to the signage outside every single clinic. There were new mobile and desktop telephones, laptops and ipads for all staff as well as new paper and electronic patient record systems.  As well as new contracts for buildings maintenance, IT support, heating, lighting, telephones, even alarms – all at a financial cost to the NHS. The initial tender was for three years and so from about 18 months in, senior and middle managers became embroiled in writing a new tender bid, travelling by car, with expenses paid in addition to their salaries, to meetings in Sussex; a tender they ultimately lost –  all at financial cost to the NHS.

There was also a cost to staff and to patients and families who moved further and further down on managers’ lists of priorities as the deadline for tender grew closer.

On 1st September, NHS Clinical Commissioning Groups (CCGs) and Kent Local Authorities awarded the new tender to NELFT. Staff were issued with brand new mobile and desktop telephones as well as desktop and laptop computers – a further financial cost to the NHS.

There was another new electronic patient record system to be trained in; two days’ worth of training for every clinical and admin staff member, as well as additional training in health and safety and the obligatory Meet and Greet with lunch provided – a further financial cost to the NHS.  NELFT’s mission is to deliver an ‘easily accessible, emotional wellbeing and mental health service to children and young people’*. CAMHS tier 2 and tier 3 services in Kent and Medway no longer exist. Let’s be clear here; they no longer exist.

In Kent the new service is Children and Young People Mental Health Service (CYPMHS) while in Medway it is the Young People’s Wellbeing Service (YPWS). NELFT were also chosen to develop and deliver an all-age eating disorders service (AAEDS) across Kent and Medway. Again, a tender won, one assumes, on a promise to provide more for less.

These new services are currently in a period of consultation. Uncertainty around what they will look like in reality is set to continue until this period ends on 1st April 2018. The consultation period has been billed as ‘business as usual’ by managers but anyone trying to access the services or work within them will know that this is not the case at all. Chaos and confusion reign. Staff and union representatives have been provided with the consultation document which reiterates that NELFT ‘are not consulting on what will be delivered as this is pre-determined’*.

In January 2018 staff began the process of re-applying for jobs; either their own or a de-banding because, in reality, there aren’t enough clinical or admin roles to go round. There are no receptionist roles at all. Staff will face a choice between agreeing to relocate anywhere across the county, accept a demotion or resign. Many are opting for the latter in a bid to avoid going down with the sinking ship.

One of the criticisms of CAMHS, as it was, was high referral criteria and long waiting lists. NELFT’s response to this is Single Point of Access (SPA). There is a Kent SPA based in Maidstone and a Medway SPA in Chatham that take referrals from anyone, including self-referrals from patients aged 0 – 19 years and their families.

SPA is commissioned to receive, screen and direct referrals as well as provide advice, information, consultation and support to referrers and other services; that’s a big ask. The idea behind the model is to ‘allow more children and young people to obtain better help and support sooner’*. The previous CAMHS service, which was under-staffed and under-funded, failed to meet the mental health needs of young people in Kent.

The new service promises to do much more for much less. It’s not working; SPA currently has a backlog of almost 500 referrals waiting to be triaged in East Kent. Once triaged, these patients will enter the system and be signposted out or sit on internal waiting lists for treatment.

The new service will consist of five care pathways*. These are:

  • Early help pathway
  • Behavioural and conduct pathway
  • Neurodevelopmental and learning disability pathway
  • Mood and anxiety pathway
  • Complex pathway

The specialist learning disabilities and challenging behaviour (LDCB) and children in care (CiC) teams that sat within CAMHS will be disbanded. To reiterate, tier 2 and tier 3 CAMHS no longer exist. The five care pathways will be led by band 7 clinicians, who will act like (but not be remunerated as) managers. The care pathway services will be provided by multi-disciplinary pathway workers employed at band 6 and mental health workers employed at band 5. To bastardise an old adage; you pay peanuts; you get CYPMHS.

Name and address withheld

*Quotes and CYPMHS structure taken from the Consultation document

*Proposed posts

Position Band Canterbury full time equivalent Thanet full time equivalent 
Consultant Psychiatrist Consultant 1.20 2.00
Trainee Doctor CT2 0 1.00
Senior Clinical Psychologist or Psychotherapist 8b 1.00 1.00
Integrated Team Manager 8a 1.00 1.00
Clinical Psychologist/ Family Therapist/ Psychotherapist 8a 1.20 1.80
Pathways leads 7 5.00 5.00
Youth Offending Worker 6 1.00 1.00
Multi-disciplinary Pathway Worker 6 5.50 6.50
Mental Health Worker 5 1.00 1.50
Medical Secretary 4 0.50 1.50
Assistant Psychologist 4 2.50 3.00
Administrator 3 2.50 3.00
Total full time equivalent staff 22.4 28.3



SONiK launches challenge to the STP document

Drafted with advice from our legal team: Harrison Grant Solicitors, click the link:

Signed Letter to Stroke Review Committee requesting the withdrawal of stroke review plan or reconsultation X




Response to Cllr Paul Messenger from Save Our NHS in Kent (re Stroke review plans in Kent)

Paul Messenger (PM): I am genuine in my worries that mis info is being put out there possibly scaring badly some elderly Thanet residents that they will ‘die in ambulances’

SONiK: If you had attended any of the listening events in Thanet, you’d know that many elderly people are quite capable of making up their own minds on this, and they will attend these meeting and make very intelligent points. They are angry about this, and possibly they are scared of ‘dying in an ambulance’, but they are certainly not scared of standing up in a hall full of people and putting pertinent questions to the panel.

PM: I’m quite prepared to work with anyone who approaches an issue in a calm evidence based way.

SONiK: Our website site is full of evidence-based responses to the case put by Kent and Medway STP. Have you read any of our briefings or articles?

PM: It is fact that Hyper Stroke units are superior to existing ‘normal ‘ provisions. It is also fact that SECAmb can deliver patients to WH well under the hour. It is fact that the prescribed clinical advice for ‘call to needle’ is 120 mins.

SONiK: None of the things you quote above are unequivocal facts.

PM: I have had meetings with QEQM staff and James Pavey, Head of operations SECAmb so I’ve done the leg work – and none I repeat none of those shouting and screaming outside the QEQM have even bothered to seek the evidence.

SONiK: That is incorrect. A number of us in SONIK (Save Our NHS in Kent) attended the full presentation (a 3 hour meeting) at County Hall in Maidstone on January 31st where the entire plan was laid out in detail. We have seen all the evidence that the Kent & Medway STP provide, including reading the 151 page document in all its detail. Then we gathered a team of volunteer researchers who have scrutinised the evidence, and found some of it wanting. In addition to that, we have sought out studies that contradict the points made by the STP. We also have a number of doctors in our group who have been working on this with us, and they agree that there are many problems with the arguments made in the stroke review plan. Have you scrutinised the consultation materials at all? Or have you just allowed people on the STP to give you a quick briefing, and then taken all they say as ‘fact’? As an elected representative I really hope you put a little bit more effort in than that.

PM: My only interest is the welfare of Thanet residents not to scare them to bits just to further what is a national ‘underfunding’ agenda you lot are forever campaigning for.

SONiK: I think you are grossly misunderstanding the mood of people here in Thanet. I have spoken to so many people about this issue in Ramsgate, and none of them need any prompting in their reaction to this plan – it is very rare that you meet someone who thinks that being taken to Ashford in an emergency situation with a time sensitive and very serious condition like stroke is a good idea. When this was proposed in London, it was stipulated in the plans that all patients must be able to reach a HASU (Hyper Acute Stroke Unit) within 30 minutes. In South Yorkshire, it was stipulated that all patients must be able to reach a HASU within the ‘critical time’ of 45 minutes. And now in Thanet, we are told an hour will be alright.

PM: We are very lucky to have a fantastic hospital for Thanet and the staff work incredibly hard there for us. And to look out their windows on a weekly basis and see demonstration after demonstration inferring the service is not up to scratch must be so demoralising for them.

SONiK: The staff at QEQM hospital are demoralised by the consultation materials and videos that imply people are left waiting for 3 hours in A&E when they have a stroke. We know from people on the ground that patients go straight through to the stroke unit. Also, QEQM rates higher than the national average for rapid diagnosis of strokes, and higher than most hospitals in Kent. It is indeed a good hospital.

PM: So yes I’ll work with you if you drop the banners, cut out the megaphones, and realise that all health matters are apolitical.

SONiK: Are you calling on those 400 or so people who gathered on Feb 24th to stop protesting? Protests are a legitimate way to draw attention to an issue within a democracy: I don’t see why you have a problem with that. If we hadn’t protested we wouldn’t have the amount of members that we now do; we wouldn’t be able to draw people together around this very serious issue. As a councillor who represents us at county level, I don’t think it is very inappropriate of you to place conditions such as ‘drop the banners’ on whether or not you will ‘work with’ members of the public. You are obliged to work with all members of the public. You say ‘all health matters are apolitical’ – where did you get that idea? The NHS will always be political as long as it’s paid for with taxpayers’ money. When people pay their NI contributions and then find they’re getting a raw deal, they will make their concerns felt, and you should not seek to quash that response.

Carly Jeffrey

Save Our NHS in Kent


REPORT: Listening Event 26 Feb

A summary of the Listening Event at Margate Football Club, Kent and Medway stroke Review, 26th Feb 2018.

People arrived and seated themselves at round tables facing the panel at the front of the room. Each table had one facilitator from the Kent and Medway STP (Sustainability and Transformation Partnership, the group of NHS executives who created the stroke review plan) seated amongst the audience members. There was a brief presentation, followed by an open Q&A session, which went as follows:

It was argued by various audience members at length that three HASUs (Hyper Acute Stroke Units) are not enough, that it must be possible to find enough consultants to staff at least one extra unit, and that the distance to Ashford is not safe for emergency treatment. The panel’s responses to this relied heavily on the argument that workforce shortages are the reason why there can only be three stroke units for all of Kent in their plan, despite the geographical size of the area.

Members of the public referred to the FAST initiative, the golden hour, the need to be seen as quickly as possible, and the journey time being over an hour from Thanet to Ashford.

People commented that this was not a true consultation for the people of Thanet and East Kent, as there is in fact no choice; this area has been presented with one option only, the questionnaire does not allow people here to reflect their need for the best quality stroke care at QEQM, as that option was taken off the table before the consultation began.

Another person asserted that the option for East Kent (Ashford) is not really even in East Kent, it is in mid Kent.

These were the questions that were not properly answered, causing the audience to become agitated and call for clear answers:
– This plan means a reduction in the number of acute beds, how is this an ‘improvement’?
– Is it possible to train nurses to administer thrombolysis and then we could have more HASUs (Hyper Acute Stroke Units) rather than just 3 for the whole of Kent?
– Will you confirm that the STP (the NHS executive body who designed the stroke review) is committed to saving £457m from Kent’s NHS budget by 2020?

One questioner talked about difficulties getting to Ashford without a car on a weekend, and described her two options when she had to take her sick daughter from Cliftonville to William Harvey Hospital in Ashford; her choices were either a £70 taxi both ways, or a journey over 2 hours each way with two train journeys, lots of walking and a bus journey. She didn’t feel her daughter could cope with the public transport option, so she had to pay a large sum for 2 cabs; as a low income earner, she felt this was not acceptable.

Also raised was this question regarding potential privatisation: “Will the new stroke units be put out to tender?” This was one area where panel were willing to give clear answers, and the answer was ‘no’ to this. They were also asked “Will you be following the London model which includes ambulance transfers in the payments made to the stroke providers?”, and the panel answered that SECamb will continue to provide the service, and that SECamb will continue to use private providers to cover some of their service, as they do currently.

There was much frustration from the public due to what appeared to be evasion from the panel. The chair was also attempting to avoid certain questioners because they had already asked a question; this and the chair’s decision to call and end to open Q&A while there were still many questions to be asked spilled over into disruption of the meeting, in the form of people standing up to show that they wanted the Q&A to continue. This action was led by a member of SONIK. A good portion of the room were standing, maybe two thirds of the audience, if you exclude the facilitators sitting at each table. After that, the meeting broke down as many people left to get home in the snowy weather, and a few stayed to take part in the facilitated round table groups. The chairperson was quoted after the meeting as saying he’d been given a set structure and timings to follow, and that everyone should be limited to one question unless the timings allowed a second “go” round.

It’s safe to say that the panel from Kent and Medway STP did not manage to reassure or persuade the audience on this occasion; Save Our NHS in Kent will be attending or getting reports from future meetings where possible.

Dr Tony Martin (Head of Thanet Clinical Commissioning Group and Manager of Bethesda GP Surgery)
Dr David Hargroves (Clinical Lead for Stroke in East Kent)
Caroline Selkirk (Accountable Officer for Medway CCG)
James Pavey (Regional Operations Delivery, South East Coast Ambulances East)
Susan Acott (Chief Executive,  Dartford and Gravesham NHS Trust, interim CEO, EKHUFT)



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.

Our Model

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. p21

*ii. p36 p12 onwards