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.