Oena Windibank (Programme Director, Kent & Medway Vascular and Stroke Services Reviews), Patricia Davies (Accountable Officer, NHS Dartford Gravesham and Swanley CCG and NHS Swale CCG and Senior Responsible Officer, Kent & Medway Stroke Review) and Lorraine Denoris (Public Affairs and Strategic Communications Adviser, NHS Dartford, Gravesham and Swanley CCG) were in attendance for this item.
(1) The Chairman welcomed the guests to the Committee. Ms Davies began by outlining the review. She stated that the review began 18 months ago with the formation of the Stroke Review Programme Board to develop a new model of care which would meet the national standards; the Board was made up of representatives from the eight Kent & Medway CCGs, the Stroke Association, clinical experts and patient representatives. She noted that the process was overseen by Professor Tony Rudd, the National Clinical Lead for Stroke. She explained that since the last JHOSC, the clinical data had been reviewed again and a series of engagement events were held which JHOSC members were invited too; the feedback from patients at these events was that patients felt cared for but recognised that the current model was not meeting national standards. She noted at the last Stroke Review Programme Board on 24 November, a three site option was agreed to be the optimum model for stroke services as detailed in the supplementary paper. She stressed that the locations of the three sites had not been determined and would depend on the output from the Kent & Medway Sustainability and Transformation Plan (STP) as a number of other services needed to be collocated on the site including a major A&E and trauma units. She stated that the original 27 configurations had been reduced to nine and each of those configurations met the 45 minute travel time and 120 minute call to needle standard.
(2) Ms Windibank stated that the feedback from the recent engagement events, about workforce, travel time and rehabilitation, was similar to previous events and would be used to inform and influence detailed modelling. She noted that an initial gap analysis on the out of hospital pathway had been undertaken and services were variable across the county; a more detailed analysis would be carried out. She explained that a wider clinical and stakeholder engagement event was planned for early 2017 which would be used to test and validate a three site option. Ms Denoris highlighted that the recent engagement events brought together patients, carers, stroke survivors alongside clinicians to look at the emerging options, challenges and solutions.
(3) Members of the Committee then proceeded to ask a series of questions and make a number of comments. A number of comments were made about rehabilitation services. Ms Davies acknowledged that community rehabilitation services were variable in Kent & Medway and there was no definitive specialist rehabilitation service for stroke which was recognised by clinicians at the recent Review Programme Board. She highlighted that a specialist stroke rehabilitation pathway was being developed as part of the modelling for a three site option and would include consideration about how those stroke services would link to general rehabilitation as part of a patient’s recovery. She noted that there were good general rehabilitation services across Kent & Medway and it was for the STP and CCGs to develop rehabilitation services as part of their plans for local care. Ms Windibank noted that robust early supported discharge enabled patients to recover more quickly at home but also improved the quality of care provided to stroke patients who required a longer length of stay; there elements of early supported discharge in the county but it depended on workforce availability. Ms Davies reported that rehabilitation would become an integral part of the next phase of the review by the Stroke Review Programme Board. She noted that there was not a blueprint for stroke rehabilitation services and as part of the next phase there would be consideration of the workforce requirements to provide community and home based rehabilitation services. She also noted that there had been resounding feedback from stroke survivors and their carers about the provision of psychological services throughout a patient’s recovery, to enable stroke survivors to become independent and adapt to a change of lifestyle. She stated that psychological services would be included in the next phase of the review. She highlighted the experiences of a student who survived a stroke at the age of 19 and had initially struggled to move forward with her life post stroke. Ms Windibank reported that Dr Hargroves was leading on a piece of work with the cardiovascular network to look at best practice for rehabilitation which included the establishment of multidisciplinary teams. She noted that national recommendations on good stroke rehabilitation services were expected and would feed into the second phase of the review.
(4) In response to a specific question about financial optimisation, Ms Windibank highlighted that in addition to the tariff received by the Trust for the provision of stroke services to a patient, additional remuneration was available through a best practice tariff if patients were assessed quickly by a specialist team in a specialist unit. She noted that across Kent and Medway Trusts were struggling to achieve the best practice tariff and the remodelling of stroke services would put the Trusts in a better position to achieve the tariff.
(5) A Member enquired about collaboration with social services and the capital funding required for modernising the service. Ms Davies noted that social services were an important part of the discharge process and recognised that they were under enormous pressure. She stated there were also constraints on the health budget but there were opportunities through the STP for stroke service providers to utilise resources more efficiently by working collaboratively and reducing waste as recommended by the Carter Review and achieving the best practice tariff. She reported that there was phenomenal demographic growth in Kent and Medway and that the funding allocations did not take this into account. She explained that CCGs’ allocations were based on patients registering with GP practices which took two – three years to flow into the system. She stated that although this would not prevent the redesign of services to meet the needs of the local populations, this created a huge challenge for the health service coupled with the extreme pressures on social care. She stated that central funding for Kent and Medway needed to be reconsidered.
(6) A Member asked about the provision of local care and the workforce gap with a three site option. Ms Davies stated that there was a balance between specialist treatment and care close to home. She highlighted that travel times for patients and careers had been raised as an issue as part of the engagement events and the aim was to keep travel to a minimum. However she recognised the importance of a patient being seen quickly in a centre of excellence which provided high quality treatment would reduce the incidences of death and the impact of disability. She also stated that centre of excellences would provide better training, mentoring and development opportunities which would attract workforce; the current demand on workforce was unprecedented. She noted Kent and Medway lacked well recognised health and social care training facilities and it was the only county which did not have its own medical school, which had been proposed as part of the STP. She stated that there were opportunities to create links with the London Teaching Hospitals. She explained that reduction from seven to three sites would be phased to ensure the workforce was in place.
(7) A number of Members gave positive feedback about the engagement events which they had attended as observers. A comment was made about the number of attendees at the events and a question was asked about engagement with vulnerable groups, Ms Denoris explained that 200 invitations were sent out the recent engagement events and 69 people attended. There had been a deliberate decision to only invite people who had been engaged in the process so far so as not to repeat the previous engagement work. As part of the formal public consultation, an expanded invitation would be used alongside a range of tools and techniques to engage with the public. Ms Windibank stated that she had gone and met with vulnerable groups as part of the engagement process and at risk groups were considered as part of the equality impact assessment. Clinical evidence had found that the proposed consolidation would lead to improved outcomes for everyone including at risk groups but economics and travel times must be a key factor when considering the location of sites.
(8) Members enquired about the impact of PFI in determining site location and learning from best practice. Ms Davies noted that there was no pressure to locate a stroke unit at a PFI hospital site; the locations would be determined on the availability of co-dependent services at the site, travel times and the areas which had the highest prevalence of stroke now and in the future. She stressed that no decisions had been made about the location of the three sites. Ms Windibank explained that learning from best practice in the acute setting and rehabilitation was being undertaken by clinicians including visits to a range of site. It was recognised from these visits that there were areas of good practice being undertaken in Kent and Medway but it was not consistent.
(9) A Member asked about the maximisation of staff time and engagement with staff. Ms Windibank reported that the volume of patients would increase with a reduction in to three sites therefore maximising specialist staffing time. She noted that rotas would reflect quieter periods. She stated that as part of the engagement with staff, there had been conversations with staff about who did and did not want to move; it was hoped that the clinical event, planned for early 2017, would help to better understand staff’s concerns and how they can be supported to move. She noted that the feedback from the majority of staff is that they did not feel like they were doing a good job or delivering a good service; there is recognition amongst staff that reducing the number of sites would improve that position.
(10) A Member commented about a stroke group they had attended in Medway and found the stroke survivors were more concerned about the provision of the services to meet their needs, particularly group rehabilitation, than the number of sites.
(11) The Chairman invited Public Health representatives from Kent County Council and Medway Council to comment. Dr Duggal stated that as part of the STP discussions, prevention needed to be at the start of the pathway for stroke and cardiovascular diseases; initiatives such as smoke free hospitals would assist with the prevention agenda. Dr Burnett added that prevention did make a difference and gave the example of Sweden which had the lowest smoking rates in Europe. In achieving low smoking rates, it had significantly reduced the number of abdominal aortic aneurysm and the country’s screening programme now only screened smokers. He stated the industrialisation of prevention was an important component in reducing the demand for services and helping patients from deteriorating further.
(12) RESOLVED that the Kent and Medway Stroke Review Programme Board be requested:
(a) to note the comments about rehabilitation services, workforce and finance;
(b) to present the final recommendations for consultation to the Committee, as agreed by the Kent and Medway CCGs, prior to the start of public consultation.