West Yorkshire & Harrogate Sustainability and Transformation Plan (aka Healthy Futures joint committee) is zooming ahead with a public “engagement” on hyper acute stroke unit cuts and centralisation – while claiming that the Sustainability and Transformation Plan document is “mistaken” in saying that the number of hyper acute stroke units in the area must be cut.
Jo Webster, Chief Officer of Wakefield Clinical Commissioning Group – the lead commissioner in the STP, told Councillors at the West Yorkshire and Harrogate Joint Health and Overview Scrutiny Committee meeting on 23 January 2017:
“The STP is mistaken, the decision hasn’t been made, I apologise. We wouldn’t go into consultation having made the decision.”
She misled the Joint Health Scrutiny Committee meeting by claiming that the Sustainability and Transformation Plan proposals for cutting the number of hyper acute services are based on 2012 data. They’re not. The data is from 2014/15.
The West Yorkshire and Harrogate Sustainability and Transformation Plan says (p 53) that the five hyper acute stroke units in West Yorkshire “are not sustainable for the future” and that the Strategic Clinical Service’s blueprint
“indicates we will need to reduce the number of hyper-acute stroke services across West Yorkshire and Harrogate”.
The blueprint shows that Harrogate and Huddersfield Hospitals don’t have enough stroke patients for a hyper acute stroke unit.
Jo Webster told the Scrutiny Committee that Pinderfields has a “gold standard” hyper acute stroke “pathway”: the patient goes straight to the stroke team, is scanned and then goes to the ward. This speeds up the time to receiving the thrombolysis drug.
This doesn’t happen in the rest of the region but the STP wants this at all acute trusts that are delivering a hyper acute service.
West Yorkshire and Harrogate Joint Health and Overview Scrutiny Committee Councillors are in the dark about how the staffing needs for the proposed hyper acute stroke services “reconfiguration” fit with the overall STP plans for the area. This is because Sustainability and Transformation Plan Leader, Rob Webster, is withholding key Sustainability and Transformation Plan appendices about finance, efficiency and workforce.
The Scrutiny Committee Chair Cllr Gruen told Jo Webster,
“I’m not content that we have the STP but that most of it that is relevant is hidden away and not made public.”
Wakefield Cllr Betty Rhodes was equally unimpressed with the public “engagement”, which has been contracted out to Healthwatch. She pointed out that Healthwatch is being paid by the NHS to undertake the engagement work , while saying it’s independent of them.
The Healthwatch rep claimed that this doesn’t compromise their independence.
The meeting heard nothing about the lack of evidence of the effectiveness and value of thrombolysis – the key drug used in treating hyper acute stroke patients.
Speeding up stroke patients’ access to this drug is the driver of the plan to centralise hyper acute stroke services. But thrombolysis carries serious risks and the balance of medical costs and benefits to patients is a close call.
After the meeting, retired consultant and campaigner with Doctors for the NHS Colin Hutchinson said,
“The risks attached to thrombolysis for treatment of acute stroke are never mentioned when we are told that service reconfiguration is so necessary: it is portrayed as an unalloyed good thing.”
Sustainability and Transformation Plan is “mistaken” and needs “refreshing”
Cllr Smaje drew attention to the contradiction to Jo Webster’s statement to the meeting that the STP joint committee have not yet concluded that they are going to reduce the number of hyper acute centres, and the STP’s clear statement that such a reduction will take place.
Put on the spot, Jo Webster denied that the decision had been made, apologised for the STP “mistake” and claimed,
“ We wouldn’t go into consultation having made the decision.”
Cllr Smaje quoted from the STP where it mentions the Hyper Acute Services blueprint and asked Jo Webster to clarify if she was saying that is the information she has.
Misinformation about data
Jo Webster said that the blueprint is based on 2012 data and they need to “refresh” it to 2016 data. She added,
“This means that reducing the number of units might not be the best outcome. There may be a better way of reconfiguring than to reduce the number of units.”
The blueprint shows that West Yorkshire and Harrogate would have 2-4 hyper acute stroke units following reconfiguration, depending on the “activity” – ie numbers of stroke patients – at each unit.
But the data used in the activity tables is from October 14 – September 15. So where is the 2012 data that Jo Webster said was the problem?
I checked with the Sustainability and Transformation Plan Communications Lead who replied,
‘As you identify, the Blueprint document does not include activity data from 2012. It is sourced from hospital episode statistics (HES) and the stroke sentinel national audit programme (SSNAP) for the financial year 2014/15, with updated SSNAP data for the period October 2014 – September 2015 used for modelling purposes.
We are currently producing the strategic case for change for stroke services across West Yorkshire and Harrogate to ensure they are sustainable and resilient. This document is being co-produced with leading specialists and clinicians. This will be made publically available once completed’.
Harrogate and Huddersfield Hospitals don’t have enough stroke patients for a hyper acute stroke unit
The blueprint shows that Harrogate Hospital expects only 331 stroke admissions per annum in 2020 and Calderdale & Huddersfield NHSFT expects only 488 stroke admissions per annum in 2020 – both below the 600 minimum established in the blueprint.
The two Calderdale Councillors didn’t say anything about this – or anything else.
A Councillor from North Yorkshire was concerned about the Harrogate situation. He said,
“Before, we were told this was about shortage of money and of stroke consultants – now they’re saying it’s to benefit patients. It’s to be done across the STP – a body is being set up for that. From April 1, STPs are only way transformational money is available – is this programme eligible for this?”
Jo Webster said that Harrogate deals with a small number of strokes and has a single consultant. There are “resilience issues” but the STP haven’t concluded this service will go. But it’s not just about stroke services, it’s the diagnostics – scans etc – and the aftercare – therapists, so they need to see if these are available.
Access to transformational funds is provided on footprint basis for the leadership to decide where best in the footprint to allocate it.
Hidden STP finance, workforce and efficiency appendices
Cllr Rhodes said that the stroke service report refers to the Sustainability and Transformation Plan. When making these reviews and decisions, finance, workforce and efficiency plans were submitted to the STP. She said,
“To enable us to seek further clarity we ought to have those background papers to see how this plan fits into the STP workforce, efficiency and finance plans.”
Jo Webster agreed that there were draft STP appendices. She said that they hadn’t concluded the financial arrangements or got the money, which needs to be agreed with NHS England and NHS Improvement; some contractual negotiation is going through the 3rd stage. Once concluded they will bring it and share it with JHSC.
She said that they not are hiding and withholding information – the financial arrangements have not been concluded.
Jo Webster added,
“I represent the STP – some information has been released, most has been redacted but I will work with the Scrutiny Officer on this. There is nothing about withholding information from scrutiny or the public when it’s ready to be released.
The main purpose of the STP is to solve the care and finance gaps, which has to be across a bigger footprint. How can we engage more proactively?”
Cllr Gruen said he would take this on trust but the proof of pudding is in the eating and if the Clinical Commissioning Groups put themselves on the side of NHS England they will be tarnished because the public will not accept the withdrawal of money from the NHS.
No scrutiny of questionable clinical effectiveness of centralised hyper acute services
Councillors did not question the assumption that centralised hyper acute services are better for patients than stroke services in district general hospitals.
However, this is questionable.
Thrombolysis is held to be essential in the management of stroke and this has been the driving force in centralisation of hyper acute stroke services – but it is not suitable for all stroke patients and it causes symptomatic brain bleeding in a number of them.
The National Institute of Neurological Disorders study found that the use of fibrinolysis (thrombolysis) in the 15% or so of patients for whom it was appropriate led to a 13% increase in the rate of full recovery, but it also led to symptomatic brain bleeding for 5.8% of patients in the treatment group within 36 hours.
There was no survival benefit at one year but there was an excess mortality of 2.6% from brain bleeding at 36 hours in the treatment group.
For every hundred patients who make a full recovery, 44 suffer symptomatic brain bleeding within 36 hours of treatment and 20 die acutely. There is a 20-38% chance (depending on the score used) that the patients who died would have otherwise have completely recovered if they hadn’t had the fibrinolysis/thrombolysis.
So it is a close call whether the medical benefits outweigh the medical costs. And then add in the opportunity cost of employing 24 hour on-call stroke doctors and moving patients and closing peripheral beds and it is not clear at all that centralisation of hyper acute stroke services should be happening.
According to the best possible modelling, the centralisation of stroke services in London has led to a 1.5% reduction in mortality at 90 days. This is a slender gain when we know that a number of patients have been injured or have died as a direct result of the intervention.
The centralisation of stroke services in Manchester showed no reduction in mortality beyond that which was seen throughout England as a whole. ( see BMJ 2014:349:g4757)
(This information is taken from an article by Peter Trewby in the NHS Consultants Association March 2014 Newsletter.)