Agenda item

In attendance for this item were:

Worcestershire NHS Clinical Commissioning Groups: Mari Gay, Chief Operating Officer and Lead Executive for Quality and Performance

Worcestershire Acute Hospitals NHS Trust: Paul Brennan, Chief Operating Officer and Deputy Chief Executive

Stroke Association – Sarah Adderley, Head of Support for Central England and Lorraine Wright, Support Manager for Worcestershire

The HOSC had requested an update on stroke services provided within acute hospital settings when a patient first requires diagnosis and hospital treatment.

The Worcestershire NHS Clinical Commissioning Groups (CCG) Chief Operating Officer (COO) referred to the report included in the agenda and advised that stroke services for Worcestershire were centralised at Worcestershire Royal Hospital (WRH), and rehabilitation was centralised at Evesham Community Hospital. This meant a much better patient flow however currently, acute stroke services across Herefordshire and Worcestershire Sustainability and Transformation Partnership (STP) were challenged by workforce shortages, and therefore unable to meet the clinical standards for 7-day services. This situation reflected the national picture.

As part of an STP programme, a number of potential models had been looked at with partners, with focus on alternative workforce models with less consultant focus whilst remaining safe. The preferred option was a centralised acute stroke service for Worcestershire and Herefordshire at WRH site, however this was no longer feasible due to capital constraints at a national level. Therefore, the STP Programme Board had been tasked with developing an alternative service model that would deliver outcomes of 7-day working. Two options were being worked through and commissioners would be happy to return to HOSC for further discussion.

Following recruitment campaigns, the workforce situation was at its strongest point yet for a number of years but it remained a struggle to ensure a 7-day service. A lot of stroke prevention work was also taking place however a significant increase in strokes was predicted in the 75 plus age group in the next ten years.

The Worcestershire Acute Hospitals NHS Trust (WAHT) Chief Operating Officer (COO) advised that within Worcestershire, performance against the Stroke Sentinel National Audit Programme (SSNAP) had improved from level D to C, A being the aspiration. Currently there were 5 consultants employed and 6 were needed to be able to aspire to the 7-day service model. In summary it was a picture of improvement but with issues around staffing and 7-day services.

The aim was to have a single service across Herefordshire and Worcestershire, with acute stroke services on one site and rehabilitation on another. Recruitment was being targeted at joint appointments across the two Trusts, which could reduce the travel to work distance for consultants and bring variety to their work through delivering a service at two sites. The current stroke ward was too big for need meant that it was used by other patients.  During the Autumn wards were due to be moved around so that the stroke ward would be adjacent to A&E and radiology, improving flow and service score.

Comment was invited from the representatives present from the Stroke Association and the Head of Support for Central England reported that she was pleased to be working as part of the STP, met regularly with the CCG COO and endorsed the picture given of stroke services. The situation was concerning, since timely access to experienced expertise was a key factor in this medical emergency situation.

The Chairman invited questions and the following main points were made:

·         In response to a query, the WAHT COO clarified that stroke services were provided 24 hours a day, 7 days a week; it was on site consultant cover which was currently not available 7 days a week, although consultants were always on call out of hours

·         When asked about the advantages of a centralised model as opposed to maintaining services in both Worcestershire and Herefordshire and how great were the issues of staffing and funding, the CCG COO pointed out that the aim was to build resilience for the future and a 7-day service on both sites would require significant capital. Recruitment drives had now brought some success and it must be remembered that a vast group of clinical practitioners were involved in the acute phase of stroke services, who fulfilled a lot of the care for patients. For the next 2 to 4 years the focus would be on delivering services across both sites with flexible staff  and telemedicine links. It was confirmed that agency staff costs were not an issue.  The capital costs of the centralisation option were confirmed as £46 million.

·         The CCG and Acute Trust COOs were asked to clarify where stroke patients were taken from across the county and it was explained that the ambulance would go directly to WRH. A very small percentage may be taken to the Alexandra Hospital if it was unclear the patient was having a stroke.   Patients needing further rehabilitation would be transferred to Evesham Community Hospital. Feedback from patients had been very positive.

·         A HOSC member asked what treatment was given at specialist acute stroke services, and it was explained that for suspected strokes, patients would have a scan. For some strokes it may be possible to dissolve the blood clot with amazing results; thrombolysis was possible in around 2-3 patients a day but it needed to be timely, hence the importance of the FAST campaign, and unfortunately many strokes occurred while people were asleep. The system was designed to treat patients as soon as possible and give improved outcomes.

·         It was confirmed that if commissioners and providers reached the point of being able to proceed with a centralised model, then consultation would take place.

·         It was explained that the chart (page 11 of Agenda) included the mechanisms to assess the different pathways for stroke.

·         A HOSC member said that she felt reassured by the information provided and was very pleased that staff were being trained to look after people with strokes. Whilst the current situation was not perfect, it appeared much better.

·         A HOSC member queried what care someone having a stroke on a Saturday would receive and was advised that they would be taken to WRH by ambulance and then scanned. Weekend care was the same except a consultant would not be on site, but would be on call to provide specialist advice.

·         When asked about the impact of hospital handovers on stroke patients, where timely treatment was so important, the WAHT COO explained that the ambulance would alert the Emergency Department (ED) before arrival and there was a specific ED response for these instances.

·         When asked how services would extend to 7 days given overall recruitment problems, the WAHT COO emphasised that stroke services were provided across 7 days (with the exception of a consultant being on site 24/7). In order to provide on-site consultant cover 24/7 Worcestershire required two more consultants but the situation for Herefordshire was more challenging and all aspects and functions of the workforce were being looked at.

·         In response to a question, it was confirmed that recruitment drives extended to overseas and 73 nursing staff would start over the next six months, whom it would be important to support and help settle. It was confirmed that all NHS partners had been required to consider their plans for Brexit.

·         A HOSC member asked about plans to improve scanning pinchpoints and whether staff could be trained to the radiology role, and the CCG COO acknowledged the challenges but advised that WAHT had a very strong diagnostic improvement plan and there was work to try and highlight the profession to schools and to attract staff to the area. The Stroke Association representative referred to meetings of the West Midlands Programme Board and advised that every Trust was in the same position.

·         Key points for the CCG and WAHT COOs were the preference in the long-term for a centralised model, the fact that workforce issues would remain therefore building resilience was important. Additionally, they emphasised the importance of prevention work to mitigate the stroke predictions for the future.

·         The Chairman asked about care for patients while options were being worked through and referred to stroke performance statistics from the recent WAHT Board papers for June which indicated that 35.7% of stroke patients were admitted to the stroke ward within 4 hours and that only 43.3% had their CT scan within 60 minutes. The CCG COO referred back to the problem of the stroke ward beds not being ring-fenced causing problems with bed availability when stroke patients were admitted (5 to 7 a day), and the plan from September for a smaller ward with ring-fenced beds. Additionally, work was needed to ensure the pathway from the ED front door to the scanner worked consistently, which the work to increase the workforce was designed to help. If the required capital became available for the long-term model, all the work done towards this model remained on the table and in the meantime from August there would be some sharing of workforce across the Herefordshire and Worcestershire sites. The big risk was if consultants were to leave.

The Chairman thanked those present for their attendance and praised the success of the rehabilitation side of stroke services, which was highly thought of.