In July the West Yorkshire and Harrogate Joint Clinical Commissioning Committee discussed Sustainability and Transformation Partnership proposals for centralising Hyper Acute Stroke Services, and the Healthwatch engagement exercises about this. This is part of the Sustainability and Transformation Partnership mission to make over £1bn cuts to NHS and social care by 2020/1 (compared with what would be spent if services were not radically cut between now and then).
The presentation on the Case for Change claimed that the status quo is not an option and that the reconfiguration and centralisation of stroke services in London and Greater Manchester has provided:
“Strong evidence that stroke treatment is better concentrated in specialist centres.”
NHS protector points out there is no such evidence
It was left to Calderdale & Kirklees 999 Call for the NHS to point out to the meeting that there is no such strong evidence, and that the costs/benefits of centralised specialist hyper acute stroke services are very finely balanced because of the risks of extra bleeds from the use of thrombolysis.
Referring to evidence given in an article by Peter Trewby in the NHS Consultants Association March 2014 Newsletter, Calderdale and Kirklees 999 Call for the NHS pointed out:
- 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)
- 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.
Clinical Network Clinical Director fully agrees about lack of evidence
Prof Graham Venables, the Clinical Director at Yorkshire and Humberside NHS England Clinical Network – who also works as a neurology consultant for BMI Thornbury Hospital in South Yorkshire – said he fully agreed with what Calderdale and Kirklees 999 Call for the NHS had said.
Following that jaw-dropping admission, he added that the overall gain from centralising hyper acute stroke services is because care is much better organised in hyper acute stroke units – eg assessment of swallowing, better positioning, better hydration. He said it was important to organise stroke care properly and carefully select people who can benefit from thrombolysis.
Physio and speech therapists work can be done properly anywhere
A nurse present at the meeting commented afterwards that the Professor’s admission of the accuracy of the thrombolysis research had pretty much destroyed the case for change and left him struggling to build a plausible case by talking about the importance of things like gag reflex assessment and positioning – but this should & could be done properly anywhere and doesn’t need centralised hyper acute services. The nurse added,
“Positioning is physio/nursing and gag assessments speech therapist/xray – why do patients need to travel miles from home for that?
What happens to generalists too, when we have all these distant specialist things? A&E is basically one big “jack of all trades” place with a wealth of varied experience. Currently patients who are FAST (face arms speech time) test-positive go to Halifax, but patients who fall through that initial screen net – the non obvious strokes or the ones that self present – also go to Huddersfield. Perhaps they are too high a risk or unsuitable for treatment, but they need all those things like positioning and gag assessment.”
The de-skilling of generalists in District General Hospitals is one opportunity cost to all these Sustainability and Transformation Partnership “work plans” for centralised hospital services. 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.
Joint Clinical Commissioning Committee and Healthwatch unfazed at being shown up for misleading themselves and the public
The Joint Clinical Commissioning Committee didn’t bat an eyelid when NHS England Clinical Network’s Clinical Director admitted the falsity of the evidence base for their Hyper acute stroke services case for change. And there has been no effective scrutiny of these proposals either, by the Councillors who should be doing this job.
Don’t be a silent witness! Report this crime! In your local paper, to your MP and Councillors, to your friends, neighbours and workmates.
Update – November 2018 decision to downgrade Harrogate stroke services to stroke rehabilitation only
At its November 2018 meeting, the West Yorkshire Joint Clinical Commissioning Committee decided that future specialist hyper-acute stroke services would be provided at:
- Mid Yorks Hospital Trust
- Leeds Teaching Hospital Trust
- Bradford Royal Infirmary
- Calderdale Royal Hospital
Stroke services at Harrogate District Hospital would be downgraded to provide only stroke rehabilitation services. Approximately 100 Harrogate stroke patients would be sent to Leeds Teaching Hospital for acute care and around 200 to York Teaching Hospital.
Update 22.6.22 – urgent action is needed to adequately staff acute stroke units in England
The annual report of the Sentinel Stroke National Audit Programme (SSNAP) acute organisational audit for 2021, published in June 2022, says that fewer than half of acute stroke units in England have the recommended number of trained nurses — a drop of 10 percentage points in two years.
Just 49 per cent of units met the minimum requirement for band six and seven nurses in 2021, compared to 59 per cent in 2019.
Between 2019 and 2021, the report also showed that the number of units in England which had the minimum recommended number of nurses on duty at 10am at weekends declined from 29 per cent to 24 per cent.
In addition, consultants are in short supply – 52 per cent of sites had at least one unfilled post, which generally takes 18 months to fill. From their webpage, it looks as it Calderdale Royal Hospital acute stroke services is among these sites:
“We are a team of 4 (aiming to be 5) full time stroke consultants and specialists…”
Gillian Mead, president of the British and Irish Association of Stroke Physicians, wrote in the introduction to the report:
“ Reconfiguration of existing resources can only do part of the way to improve quality of care: it is crucial that services are properly staffed.”
The report calls for an increase in the number of specialist nursing staff in stroke units – with three for every 10 beds, all of whom should be trained in swallowing assessments. At the moment the key performance indicator used in the audit is 2.375 band 6 and 7 nurses per 10 beds.
We told them so.
The shortage of trained nurses in the acute stroke services units is particularly shocking, given that Prof Graham Venables, the Clinical Director at Yorkshire and Humberside NHS England Clinical Network, informed us all at the West Yorkshire Joint Clinical Committee meeting that the overall gain from centralising hyper acute stroke services is because care is much better organised in hyper acute stroke units – eg assessment of swallowing, better positioning, better hydration.
Over last seven years, time from stroke symptom onset to hospital arrival has increased by 41 minutes
This is the finding of a so-far unpublished “Getting It Right First Time” (GRIFT) report, according to the Health Service Journal.
Janette Turner, an academic who led research on the last official review of ambulance response times, told the Health Service Journal that the real issue was insufficient resources, despite the GRIFT report’s attention to the change in categorisation of strokes and the target ambulance response time.
Strokes are currently treated as “category two” incidents, meaning they should get an ambulance response within 18 minutes. This categorisation was set up in 2017-18 and since then, the 18 minute target for category two calls has only been hit for a few months at the height of the covid pandemic, when call-outs were abnormally low.
Under the previous system strokes were classed “red two emergencies”, with a target response time of eight minutes plus a minute to gather information.
The GIRFT report also highlights the need for more interventional radiologists to be trained, and for capital investment to create new thrombectomy centres.