Agenda item

Attending for this Item from Herefordshire and Worcestershire Integrated Care Board (HWICB) were:

Mari Gay, Managing Director and Lead Executive for Quality and Performance

Anita Roberts, Stroke Programme Manager

Tom Grove, Director of Communications and Engagement

HOSC Members had been provided with the Agenda Report, which had also been considered by the Health Scrutiny Committees in Herefordshire and Powys. 

Stroke was a serious, life-threatening condition which required immediate urgent action.  The Herefordshire and Worcestershire Integrated Care System (HWICS) wanted to ensure that high quality stroke and TIA (transient ischaemic attack or mini stroke) services were delivered across the 2 Counties and had prepared an Issues Paper highlighting the challenges currently faced and outlining potential solutions.

At present, across Herefordshire and Worcestershire, services were provided by Worcestershire Acute Hospitals NHS Trust (WAHT), Wye Valley NHS Trust (WVT) and Herefordshire and Worcestershire Health and Care NHS Trust (HWHCT).  In addition, the Stroke Association was commissioned to offer stroke rehabilitation and support.

The population of the 2 Counties was growing, getting older and living with more long-term health conditions, meaning more people were at risk of having a stroke, most significantly after the age of 60.

Several service challenges were highlighted, including the ability to recruit staff with specialist stroke skills to provide 24 hours a day, 7 days a week services across the 2 Counties.  At present, the service at WVT was reliant on 2 locum consultants and there had been times when the unit at WAHT was at risk.

The Herefordshire and Worcestershire Stroke Programme Board had outlined 4 potential solutions for Acute Stroke Unit (ASU) and Hyper-Acute Stroke Unit (HASU) services:

Option 1 – No change to the current service across Herefordshire and Worcestershire

Option 2 – 7 day HASU at 1 site and 7 day ASU at 2 sites

Option 3 – No HASU nor ASU in either County (HASU and ASU out of area) 

Option 4 – 24 hour/7 day HASU and ASU on 1 site with stroke specialist consultant cover (potentially Worcestershire Royal Hospital)

The preferred clinical model was Option 4 as residents would access services locally, however a business case was required.  An engagement exercise was in progress to gather early views of patients and stakeholders.  Transport and population modelling were still required before further discussions at the Stroke Programme Board.  Any potential solution would require various stages of governance, including a full public consultation on any proposed changes ahead of a final decision being made.

Members were invited to ask questions and in the ensuing discussion, key points included:

·         When asked the extent of the impact of ambulance handover delays on stroke patients, it was clarified that patients conveyed with a potential stroke would be taken from the ambulance quickly for diagnostic testing, however a delay may occur if no HASU bed was available.  Time waiting for an ambulance was unknown, therefore it was vital that patients with any symptoms immediately called 999

·         Service centralisation was not unusual.  It was an attractive model for the recruitment of specialist staff, which under the current system was of concern

·         WAHT had clinical nurse cover 24 hours a day and potential strokes would be confirmed by a CT scan.  Around 70% of strokes were ischaemic strokes

·         It was suggested that 3 patients each day were brought into Worcestershire from Herefordshire and Powys.  Residents of Worcestershire were mainly conveyed to WHAT hospitals, however, residents in the North could be taken to Birmingham or Dudley for example and in the South, to Gloucester

·         Clarification was given that stroke services covered the whole pathway including community care and potential requirements for Care Homes or NHS Continuing Healthcare (CHC) funding

·         In relation to rehabilitation, there was concern whether patients had capacity to make decisions and whether family members fully understood the decisions being made

·         When asked why the Alexandra Hospital in Redditch was not being considered as a location, it was explained that Worcestershire Royal Hospital was geographically more central to the whole of Herefordshire and Worcestershire and the Alexandra Hospital lacked the space required

·         A Member asked for clarification of a ‘golden hour’ which was given as the goal for onset of stroke symptoms to treatment time of 60 minutes or less to improve outcomes from an ischaemic stroke.  The thrombectomy rate within this timeframe was about 10% however should be around 20%

·         Currently 12 Consultants were required to cover Herefordshire and Worcestershire and if the service was centralised, 6 Consultants would be required.  New posts could be created to enhance the offer and attract additional staff

·         A business case would have to be developed and a funding bid, for both capital and revenue, would have to be submitted.  Regionally, the current situation was high on a risk register

·         When asked about the level of current early engagement, the Director of Communications and Engagement was invited to provide the update.  Members were told that HWICB had given this a lot of thought.  Information had been shared through existing networks, stroke survivor groups and social media and focus groups were planned.  Literature was available in various languages, including Welsh, and was included on the vaccination buses.  In addition, all relevant health scrutiny committees had discussed the issues.

The Managing Director of Healthwatch Worcestershire was invited to comment on the discussion and advised that he was a Member of the Stoke Programme Board.  Some incidents which Healthwatch had been alerted to had helped to influence the work being undertaken.  It was known that some suggestions did not sit comfortably with clinicians, such as increased telemedicine, however, it was generally agreed that the preferred solution would improve the situation for patients across Herefordshire and Worcestershire and Healthwatch was in full support of Option 4, despite the financial challenges faced.