Agenda item

Oena Windibank (Programme Director, Kent and Medway Hyper Acute and Acute Stroke Services Review), Jackie Huddleston (Joint Associate Director South East Clinical Networks & Clinical Senate, NHS England - South (South East)), Patricia Davies (Accountable Officer, NHS Dartford, Gravesham and Swanley CCG and NHS Swale CCG) and Lorraine Denoris (Public Affairs and Strategic Communications Adviser, NHS Dartford, Gravesham and Swanley CCG and NHS Swale CCG) were in attendance.

(1)       The Chairman welcomed the guests to the Committee. Ms Davies began by outlining the background to the review. She explained that the seven sites currently providing stroke services in Kent and Medway were not consistently meeting national standards including the provision of a seven day service. She noted that a designated centralised 24/7 stroke unit with a multi-disciplinary specialist team was the most important element for stroke recovery. She reported that for the size of Kent and Medway’s population, 1.8 million, stroke care could be centralised into one or two units; however due its geography, demography and variations in deprivation one or two units would not be able to meet the recommended 120 minute call to needle standard for thrombolysis. She highlighted that only the three and four site model options had been taken forward by Review Programme Board due to workforce and travel considerations.

(2)       Ms Windibank explained that since the last JHOSC meeting on 29 April, the five site option had been removed by the Review Programme Board as it was highly unlikely to be staffed to a level where a 24/7 consultant led service was deliverable. The Board was now carrying out further detailed work for three and four site models including critical co-dependencies, workforce and travel times.

(3)       Ms Huddleston noted that patient outcome was the main focus of the review in Kent and Medway; she reported that the centralisation of stroke services in London had a significant impact on patient outcome. She stated that the South East Coast Clinical Senate had started to look at critical co-dependencies for stroke services in an acute setting which included access to CT and MRI scanning, acute medical rota and ‘hot’ emergency department to accept patients. She noted that the critical co-dependencies for other services such as critical care and vascular varied; a report by the South East Coast Clinical Senate into clinical co-dependencies of acute hospital services was used by other stroke reviews.

(4)       Ms Davies stated that the Review Programme Board was working with clinicians including Professor Tony Rudd, the national clinical director for stroke; there was agreement that a 24/7 stroke service could not be provided across seven sites. She noted the length of time to train specialised stroke nurses and consultants and the requirement for seven Whole Time Equivalent (WTE) consultants per site to be compliant. She highlighted that there would be further engagement with the public around three and four site models. She explained that stroke units would need to sit with co-dependent services in ‘hot’ sites; the location of the sites would be determined as part of the consultation for the Kent and Medway Sustainability and Transformation Plan (STP).

(5)       The Chairman invited representatives from Public Health in Kent and Medway to comment. Mr Scott-Clark noted the importance of prevention and rehabilitation; ambulance conveyances; and the delivery of the new model of care without variation. Dr Duke-Macrae stated the importance of prevention, including the risk factors which caused strokes, and the provision of services in the community for patients once discharged form an acute setting. 

(6)       Members of the Committee then proceeded to ask a series of questions and make a number of comments. A Member enquired about the travel times for three site combinations in Appendix One. Ms Windibank explained that the appendix used SECAmb data to show the travel times for all potential three site combinations in Kent and Medway. The included the maximum travel time, the number of people who would not reach a site within the target of 95% of patients achieving a 45 minute travel time, the number of people aged over 75 and the number of strokes which would take place outside of the 45 minute target. She noted that the maximum travel time took into account peak travel times and roads; ambulance conveyances could reduce the maximum travel time by 10%; and not all the options in Appendix One were being considered.  She reported that the Review Programme Board was now looking at potential sites and aligning them with activity at acute hospitals using qualitative data from SECAmb; the delivery of the new model was likely to be a phased approach with four sites in the interim.

(7)       In response to a specific question about access to services, Ms Windibank explained that the 45 minute target was from the time the ambulance left the patient’s home to arrival at hospital; and the 120 minute target was from the initial call to the ambulance service or where the patient first accessed the service to the point of treatment. Ms Huddleston noted that only 20% of stroke patients are eligible for thrombolysis which needed to be delivered within the 120 minute call to needle standard; it was currently only administered to 10-15% of patients across the South East region.  She stated that there was a tight eligibility criteria for thrombolysis and could only be administered after an MRI scan; there was very limited impact if it was not identified within the timeframe. She reported that she and Dr Hargroves were meeting with SECAmb to discuss rapid assessment by ambulance crew in detecting stroke symptoms.

(8)       A Member enquired about workforce planning. Ms Windibank reported that work had been undertaken with the Trusts to look at travel times from patient, family and staff perspectives. She stated that clinicians wanted to deliver a good service and were not able to provide this at present. She noted that when services were not perceived as good, it impacted on staff morale. She highlighted that staff wanted to work in centres of excellence which improved recruitment and retention. Ms Huddleston explained that a comprehensive workforce plan which included education and training had been developed with Health Education England.

(9)       A number of comments were made about the number of strokes in Kent and Medway, GP involvement and the financial modelling. Ms Windibank explained that there were 2500 strokes a year with approximately one to two strokes a day and 300 – 400 strokes annually at each Trust. Activity modelling had confirmed that 35% of patients brought to hospital by ambulance with stroke symptoms would not have had a stroke: 25% would have had a stroke mimic and 10% would have had a TIA. She noted that GP were involved in prevention, early supported discharge and rehabilitation services as part of a multidisciplinary team. Ms Davies explained that the review was looking to deliver a new model of care for stroke which was designed to achieve the national standards, meet best practice and provide consistent care. She recognised that there would be a cost to implement the new model but stated there would be a significant benefit for patients and health & social care services. She noted that the review needed to align to the STP which was looking to  review  the location of acute services and enhance out of hospital and primary care services.

(10)     A number of questions were asked about growth areas, diagnostic scans and public engagement & consultation. Ms Davies explained that cross border patient activity and growth had been taken into consideration as part of the modelling.  Ms Huddleston stated that there was a target for all stroke patients to be scanned using a CT scanner within an hour of arrival which was being met by the majority of the stroke units; it was dependent on CT scanners and radiographer availability. She noted that there was a national shortage of stroke consultants; consolidation provided opportunities to combine neurology and stroke consultants and provide British Association of Stroke Physicians training to general physicians. She explained that a consultant recruitment campaign would be part of the workforce plan. Ms Denoris reported that there would be further public engagement about three and four site model options. She stated that if the stroke review was to align to the STP process, there would be a formal public consultation which would include a number of formats including leaflets, surveys and face-to-face events. She confirmed that there would be a public engagement event held in Medway.

(11)     The Chairman invited Steve Inett to speak. Mr Inett explained that Healthwatch Kent was part of Review Programme Board and had attended the public engagement events. He noted that the public had been brought on a journey and their understanding had been developed through the events and were able to assist with the decision making. He stated the importance of Healthwatch becoming involved in the STP particularly if the stroke review was going to integrate into that process. Ms Davies confirmed that the stroke review was aligned to the STP but needed to move forward as soon as possible; it was important for stroke units to be linked with co-dependent sites. She explained that patients and independent members of the public who attended engagement events wanted to the planned improvements stroke services to be implemented quickly.

(12)     RESOLVED that:

(a)       the Kent and Medway Stroke Review Programme Board be requested to take note of  the Committee’s comments and take them into account including:

(i)            the provision of care for patients once discharged from an acute setting;

(ii)          workforce planning to include contingency if staff are not prepared to move to consolidated units;

(iii)         to clearly set out the case for consolidation as part of the public consultation;

(b)       the Kent and Medway Stroke Review Programme Board be requested to submit a draft copy of the public consultation  document to enable the Committee to provide comments prior to public consultation;

(c)        the Kent and Medway Stroke Review Programme Board  to present the final options to the Committee prior to public consultation.