Critical care for people who have had a stroke

When a person has a stroke we know that the first few hours after the stroke are critical. If the right treatment can be given to the person during these first few hours they will have a much better chance of surviving the stroke and recovering from it. There are two critical time periods after having a stroke:

• The first four hours after a stroke are important - during this time some patients may benefit from being given a powerful clot-busting medication that can dissolve the clot that caused the stroke - this is called thrombolysis treatment.

• The first 72 hours after a stroke are important - evidence shows that if patients receive the right medication, are monitored very closely and start having therapy treatments they are much more likely to make a better recovery and be less disabled by the stroke in the long term.

The treatment that should be given during this first 72 hours is called hyper acute stroke services. This is the recommendation of national organisations like the Royal College of Physicians (RCP) and the National Institute for Health and Care Excellence (NICE), as well as the Government. We want anyone living in our area that has a stroke to be able to get the right treatment as quickly as possible, any time of the day or night.

This means hyper acute stroke care needs to be provided 24 hours a day, 7 days a week (24/7). To do this we need to have teams of specialist staff working around the clock. We also need to provide the right equipment to help staff make decisions about how best to treat each patient.

Two years ago, the Clinical Commissioning Groups (CCGs) across Yorkshire and the Humber asked for reviews of hyper acute stroke services to be done across the entire region.

This was because some hospitals were facing challenges in delivering hyper acute stroke services, with some having difficulty maintaining a seven day, round the clock service.

In South Yorkshire and Bassetlaw this review was carried out by Commissioners Working Together.

Between 2014 and 2015 we met with doctors, nurses and healthcare staff in hospitals, NHS staff who commission hospital and GP services, and data and clinical experts about what the future for critical care for stroke patients might look like in our region.

In particular:

• · We asked hospitals to look at the national core standards for providing critical stroke care for patients and assess how they were doing.
• · We gathered data on the numbers of people needing the service and the numbers and type of staff working in them.
• · We met with hospitals to assess and agree all the information and their current challenges.
• · We held a series of workshops with staff and stakeholders to look at and agree the issues.

You can read more about the background and national context for change in the case for change and pre-consultation business case.

We carried out a review of the hyper acute stroke services in the hospitals in our region. This is what we learned:

• Doctors, nurses and healthcare staff all agree that the way critical care for stroke patients is provided across the region won’t meet their high standards in the future – this needs to change.
• Three out of the five hyper acute stroke services in the region admit less than 600 patients a year (below the national best practice of 900).
• We need more stroke doctors and nurses to run the services – but there aren’t enough locally or nationally.
• Not all stroke patients are seen by a stroke doctor or admitted onto a stroke unit as quickly as they should be.
• There is a shortage of speech and language and occupational therapists who help rehabilitate people who have had a stroke.
• How fast tests are done – which helps to diagnose patients – varies from hospital to hospital.

You can read more detail about the review, the information we gathered and how we analysed it in the pre-consultation business case (pages 40 to 58).

To help us with our review, between January and April 2016, we asked you, patients and the public, what would matter to you if you or a loved one had a stroke.

You said it was important to:

- Be seen quickly when you arrive at a hospital

- Be seen and treated by knowledgeable staff

- Have a safe and quality service

- Have fast ambulance response and travel times

- Have good access to rehabilitation services locally

All feedback has been used to help develop our proposal for the future of hyper acute stroke services.

You can read the pre-consultation engagement report here.

They are:

Where you are cared for up to the first 72 hours (or sooner if medically stable) after having a stroke when
you need more specialist 'critical'care.

They are not:

- “Acute stroke” units/wards - which is where you are cared for after the first 72 hours of having a stroke
until you are ready to go home from hospital.

- Rehabilitation services, such as speech and language and physiotherapies, which help you get better once you've gone home from the hospital.

We are not proposing to close any stroke units.

1. Three out of five of hyper acute stroke units (HASUs) admit less than 600 patients a year.

This is below the national best practice minimum - meaning stroke doctors and nurses in some of our units risk becoming deskilled - which in turn would mean you may not get the best possible or safest care in the future.

2. We need more stroke doctors and nurses to run the existing services - but there aren't enough locally and nationally.

This means there are problems with medical cover in our local hospitals - and we have already seen temporary closures of some of our services because there aren't enough doctors or nurses available.

3. How quickly scans and tests are done and reported varies from hospital to hospital.

Due to a delay in the necessary tests being done, which help to diagnose patients, there is a delay in some treatments that should be given after having a stroke.

We want every stroke patient in our region to have the safest and best possible care so they get better quicker and have less chance of living with a disability when they go home.

The proposal to change how hyper acute stroke services are provided in South and Mid Yorkshire, Bassetlaw and North Derbyshire is based on how people receive care and treatment.

The South Yorkshire and Bassetlaw hospitals are all in an NHS region that works together around ‘patient flow’ – that is, where patients naturally go for their care and treatment. There are some people who live just outside this area who will also ‘flow’ into it – and this is why we are also working with North Derbyshire and Wakefield clinical commissioning groups (CCGs).

For the hyper acute stroke service proposal, Wakefield wasn’t included in the review because their stroke services are connected to another ‘patient flow’ area (West Yorkshire). However, Chesterfield was and although our review showed the numbers of patients admitted each year was below the national minimum standard of 900, the service is part of a different ‘patient flow’ region (East Midlands) and therefore outside of our control. Chesterfield may be considered as part of an East Midlands review in the future.

There is one proposal we would like your views on.

If you live in South Yorkshire and Bassetlaw and North Derbyshire and have a stroke, you would receive hyper acute stroke care in:

- Chesterfield Royal Hospital

- Doncaster Royal Infirmary

- The Royal Hallamshire Hospital, Sheffield

This would mean that Barnsley and Rotherham hospitals would no longer provide hyper acute care for people who have had a stroke. Although Chesterfield Royal Hospital receives less than 600 patients a year, it is in a different NHS region (East Midlands) and therefore remains as a centre in our proposal. These services may be considered as part of an East Midlands review in the future.

After the first 72 hours of receiving critical care, if you live in Barnsley or Rotherham and are well enough, you would be transferred to your local hospital for the remainder of your care.

We are not looking to make changes to 'acute' stroke care which is care received after the first 72 hours until you go home from hospital and this will still be provided in all our local hospitals.

Rehabilitation services, such as speech and language and physiotherapies, which help you to get better once you leave hospital, will still also be provided closer to where you live.

We are recommending that we change services by working together better to improve survival rates while also improving the quality of life for patients by reducing their chances of living with disabilities once they leave hospital.

Based on feedback from our doctors, nurses and regional and national clinical experts, we think our proposal would allow us to do this.

In our survey, we ask if you think there is another option we could consider. If you wish to describe this and say why you would prefer this option, please either fill in the survey or send your option to:

helloworkingtogether@nhs.net or by post to FREEPOST COMMISSIONERS WORKING TOGETHER (you don't need a stamp and by putting just these words on the envelope it will get to us).

In the future, if you have a stroke, you would be taken to a hyper acute stroke unit in Doncaster or Sheffield for the first 72 hours of your care. If you live in the north of Barnsley, you may also be taken to Wakefield for these few days. At the moment though, nothing will change and you will be taken to and treated in Barnsley and Rotherham.

We developed the options with clinical and managerial NHS staff who provide hyper acute stroke services in our region's hospitals and also with the NHS staff who 'buy' and monitor the standards of the services (in clinical commissioning groups). This 'stroke group' was set up to support and oversee the review and has been meeting regularly to consider how we can make the improvements needed.

We looked at:

- Getting to a hospital - can patients easily access these services, either independently or by ambulance within 45 minutes? (Which is the national standard)

- Number of patients - if services changed, would the remaining HASUs be able to treat the potential higher number of patients being seen?

- Impact on other areas - would changing services in our region affect services and patients in neighbouring areas?

- Patient experience - based on what our pre-consultation told us was important to people (access to expert, quality care, travel times etc), would the proposed options deliver this and improve current patient and carer experience?

- Seven day services - would we have enough capacity to be able to provide these services seven days a week?

- Number of staff - how could our current workforce best meet the needs of our patients?

Decisions to consider or rule out options were based on which would provide the highest quality and safe services for patients as well as making sure they are sustainable for the future. This was done in three stages.

In the first stage of the review, we looked at:

Our review was shared with the Yorkshire and the Humber Senate - who give independent strategic clinical advice - who supported our findings. They also recommended that our review was considered in context of the full regional picture and any potential impact.

In the second stage of the review, we considered the options for transforming how we provide care. We also listened to advice from experts in the Yorkshire and Humber Clinical Network about how hyper acute stroke services should look across our region.

Their review looked at travel times and the size of units and recommended that we consider reducing to two hyper acute stroke units in South Yorkshire and Bassetlaw.

Although Chesterfield has been a part of our review, their hyper acute stroke services are part of the East Midlands region - and are therefore out of our control. As further proposals to change hyper acute stroke services in Chesterfield may be considered by an East Midlands review in the future, we felt it was important to raise awareness of both our and potential future changes with the people of Chesterfield and include them in our consultation.

Dr Peter Anderton, stroke consultant at Doncaster and Bassetlaw Hospitals NHS Foundation Trust, and regional stroke lead for Commissioners Working Together, said:

“By changing the way you receive care after having a stroke, we can make our services safer and of a higher quality whilst also reducing your chances of living with a disability afterwards.

“At the moment, some of our stroke teams don’t treat as many patients as teams in other hospitals, meaning they have fewer opportunities to develop their skills and introduce new treatments – which could mean that in the future, some of our patients may not get the best care they deserve should they have a stroke. This, combined with a national shortage of specialist staff, means we need to act now and use our staff and facilities in a different way to make sure that everyone in our region has access to the best services and fast treatments after having a stroke.

“For some patients in Barnsley and Rotherham, this may mean being treated in a hospital that isn’t their local one for the first 72 hours – but it also means they will receive high quality specialist care. We have been working with our ambulance service colleagues to ensure all patients will be taken to the most appropriate hyper acute stroke service unit within the critical time needed.

“After the first 72 hours of care, or sooner if medically possible, patients will be transferred to their local stroke ward for the remainder of their care. Rehabilitation services, such as ongoing speech and language therapy, physio and occupational therapies which assist the journey of stroke recovery, will also remain closer to where people live.”

During our pre-consultation phase, we asked Dr Graham Venables and Dr John Bamford - both Clinical Directors for Stroke at the Strategic Clinical Network - why we needed to change the way we provide hyper acute stroke services.

You can view what they said here.

How many people will this affect?

Barnsley Hospital’s hyper acute stroke service treats around 550 stroke patients every year which is 16% of all stroke patients across South Yorkshire, Bassetlaw and North Derbyshire.

Rotherham’s hyper acute stroke service treats around 480 stroke patients every year which is 14% of all stroke patients across South Yorkshire, Bassetlaw and North Derbyshire.

Will this mean extra patients going to the other hospitals – and if so, how will they cope?

Discussions are taking place with the hospitals now around possible future changes and this includes managing any increases in numbers of patients in a careful and planned way. Although the increase in numbers is relatively small overall, changes would only be made if all the right measures were in place, including numbers of staff, speed of tests and standards being met. – making the services safe and sustainable in the future.

What is the spend per head?

The NHS spend for stroke is calculated on the costs of inpatient care and in 2015/16 we know that this was approximately £10.2 million across the five CCGs in South Yorkshire and Bassetlaw. This breaks down as £1.6 million in Barnsley, £0.7 million in Bassetlaw, £1.5 million in Doncaster, £1.9 million in Rotherham and £4.5 million in Sheffield.

The average spend per head in 2015/16 across South Yorkshire and Bassetlaw was £3409 for inpatient care and treatment.

There are other costs associated with stroke care, such as those within emergency departments, but these are difficult to assign directly to stroke care and treatment. There are also variations in how people are admitted. In Sheffield, patients go straight to the hyper acute stroke unit but in other hospitals, they go via A&E. In addition, some patients present with ‘mimics’ (the term used by doctors when a patient’s symptoms could be a stroke but after tests show they are not).

Is 45 minutes to the hospital fast enough?

Yes. The 45 minute travel time has been set as a reasonable period to ensure that there is no excessive delay in getting people to hospital.

When a person has a stroke we know that the first few hours after the stroke are critical. If the right treatment can be given to the person during these first few hours they will have a much better chance of surviving the stroke and recovering from it. There are two critical time periods after having a stroke:

• The first four hours after a stroke are important - during this time some patients may benefit from being given a powerful clot-busting medication that can dissolve the clot that caused the stroke - this is called thrombolysis treatment.
• The first 72 hours after a stroke are important - evidence shows that if patients receive the right medication, are monitored very closely and start having therapy treatments they are much more likely to make a better recovery and be less disabled by the stroke in the long term.

The treatment that should be given during this first 72 hours is called hyper acute stroke services. This is the recommendation of national organisations like the Royal College of Physicians (RCP) and the National Institute for Health and Care Excellence (NICE), as well as the Government. We want anyone living in our area that has a stroke to be able to get the right treatment as quickly as possible, any time of the day or night.

Are people in primary care trained to spot strokes?

Yes. GPs are trained to identify the symptoms of stroke.

They also work with patients who are at risk of a stroke to help them manage their health and reduce the chances of having one. This includes looking at lifestyle factors – such as a healthy diet, exercise, maintaining a healthy weight, stopping smoking and reducing or stopping alcohol. They are also increasingly starting to identify and support people with atrial fibrillation (AF) – a common heart condition that causes an irregular heartbeat and increases the risk of stroke.

Are there enough staff to support rehabilitation services?

Rehabilitation services for people who have had a stroke aren’t part of the proposals. The proposals are only for the first 72 hours of care after someone has had a stroke. All local rehabilitation services will stay the same.

Is it dangerous to travel further?

No. Changes like the ones being proposed in our region have already been made in London and Manchester.

Evidence from these changes has shown that a centralised model of hyper acute stroke care, in which hyper acute care is provided to all patients with stroke across an entire geographical area, can reduce death rates and length of stay.

I live in Barnsley/Rotherham where will I go if I have a stroke?

In the future, if you have a stroke, you would be taken to a hyper acute stroke unit in Doncaster or Sheffield for the first 72 hours of your care. If you live in the north of Barnsley, you may also be taken to Wakefield for these few days. At the moment though, nothing will change and you will be taken to and treated in Barnsley and Rotherham.

For Barnsley patients needing thrombolysis changes to care has already started due to a sudden unexpected change to medical staffing availability. This treatment is just one aspect of hyper acute stroke services, so if this wasn’t needed for the patient, they would continue to be cared for in Barnsley.

Is this about cutting costs?

No, the proposals are not about cutting services or saving money. The review of hyper acute stroke services took place because the quality of care and outcomes and experience for people was not the same in all hospitals. We want to improve quality, outcomes and experiences – which save lives and means every stroke patient in our region has the best possible care, helping them to get better quicker and have less chance of living with a disability when they go home.

How much money will you save?

We are still working on the financial business case but our projections suggest the proposals would be either cost neutral or cost slightly more. We would also need to invest some money to make the changes.

Why can’t you just improve services locally?

The review into hyper acute stroke services showed us that there is a shortage of clinical staff and that care and treatment was variable, with some people having better experiences, better outcomes and better access than others. The commissioners agreed that everyone in our region should experience the highest quality and safest service possible and have been looking at options to make improvements.

We therefore need to look beyond our current boundaries for solutions.

Who will pay for me to travel?

Stroke patients would be transferred by ambulance to the best place to meet their needs. For relatives, some people qualify for help with travel costs under the healthcare travel scheme. This would be assessed by staff at the hospital and if eligible, costs would be paid.

If people were taken to specialist stroke centres, they would be treated there for up to the first 72 hours. After this time, or as soon as they are well enough, they would be transferred back to their local hospital.

How will my relatives get to see me? Where can they stay?

Relatives would need to make their own way to the hospital, at the time of the stroke and also when visiting you. Unfortunately there are no overnight facilities for visitors in any of the hospitals in our proposals.

You’re closing stroke services, what’s next?

We are not closing local stroke services, it is just the first 72 hours of care that we are proposing to change. The acute stroke units in Barnsley and Rotherham would continue to operate as they do now.

We are also proposing to change the way children’s surgery is provided across the same geography.

This means we would no longer carry out operations on children for some conditions on a night, at weekends or where there is an overnight stay. Each hospital would still have children’s services and provide day case surgery. You can read more about these proposals here.

There are no plans to close other services.

Is this the first step to closing local hospitals?

There are no plans to close any hospitals.

The changes proposed are entirely about ensuring everyone in our region has the best experience and outcomes, faster treatment and better access to services.

During the public consultation period, we are responding to your questions. Please email us helloworkingtogether@nhs.net with your questions.

After the consultation all the feedback will be collated and given very careful consideration by the Joint Committee of Clinical Commissioning Groups (JCCCGS), which is made up of representatives from the CCGs in Commissioners Working Together.

This will involve discussions about what changes could or should be made in response to the comments received. All the Councils in South and Mid Yorkshire, Bassetlaw and North Derbyshire have set up a Joint Scrutiny Committee to consider the proposed changes. The Joint Committee will take a view on the consultation process.

Legislation also allows the Joint Committee to make recommendations on the proposed changes to the CCGs, which it may choose to do after it has examined these in detail. The CCGs will also need to satisfy a very detailed assurance process carried out by NHS England. This process is used for all service reconfiguration and organisations proposing changes need to show that such proposed changes are based on strong patient and public engagement, patient choice and clinical evidence and have support from local doctors and other clinicians, sound workforce plans, are financially viable, that consideration has been given to accessibility and have been subject to an equality impact assessment. Proposed changes also need to be underpinned by a communications and engagement plan.

The final decision will be made, in public, by the CCGs as the bodies responsible for planning and buying health services for local people. Reports including feedback and the consideration given by the CCGs will be made public. There would also need to be discussions with the ambulance service to take into account the impact of increased journeys. If we gained all of the necessary approvals, phased implementation would begin in 2017.

We will widely communicate the findings from the consultation - which are being analysed independently - with all our stakeholders, the public and staff.