Agenda item

At its meeting on 14 October 2019, the Joint Coventry and Warwickshire Health OSC (JHOSC) gave initial consideration to this review. This Committee is asked to comment on the stroke review proposals, in order that members’ views are submitted to the next JHOSC meeting on 22 January 2020.

The Coventry and Warwickshire Joint Health Overview and Scrutiny Committee (CWJHOSC) had given initial consideration to the stroke services review at its meeting on 14 October 2019. It had agreed that the proposals be reviewed by each council’s OSC, before their respective findings were considered at a further CWJHOSC meeting scheduled for 22 January 2020.

This item was introduced by Adrian Stokes, who took members through the key sections of the report. The aim was to improve stroke services. Comparisons of the performance and outcomes of current services against best practice showed that better health outcomes and more effective and efficient services could be achieved. There was unwarranted variation and inequity in the range of services available. Options for the future delivery of stroke care had been co-produced and appraised through a process involving extensive professional, patient and public engagement.

The resultant pre-consultation business case (PCBC) described the process and outputs in detail, proposing the implementation of a new service configuration, which was outlined in the report. The preferred pathway and delivery model would create services that met best practice for stroke care. The report stated the public and patient engagement to help inform and shape the proposed pathway over the last four years and the clinical engagement undertaken. It was acknowledged that it was unusual for only one option to be proposed, but the reasons for this were also reported.

Details were provided of the assurance process completed through NHS England in 2019 and the provisional assurance granted, subject to minor amendments. These amendments had been completed, and the resulting consultation document signed off by local CCGs in preparation for consultation.

The consultation document had been circulated and it went live on 9 October 2019. The announcement of the General Election meant that public events due to be held in November and December had to be postponed but they had been rescheduled. The financial aspects were reported and this proposal represented an investment of nearly £3.1 million into the Coventry and Warwickshire health system.

The Chair invited Councillor Joe Clifford, Chair of Coventry City Council’s Health Overview and Scrutiny Board to give a summary of the key issues raised when it had considered the stroke review proposals. Councillor Clifford confirmed the following areas had been discussed:

·         The benefits of the revised stroke pathway

·         The impact for WMAS in meeting the service requirements

·         Staff recruitment and retention

·         The financial benefits from reductions in social care costs

·         The requirements for public transport to ensure visitors were able to visit patients, especially when they were in rehabilitation centres

Overall, the Coventry Board viewed that the proposals were safe for the patients who were the main priority; visitor issues were not as important. The Chair thanked Councillor Clifford for this input.

Questions and comments were invited, with responses provided as indicated:

·         Clarification was provided on the time spent in the Hyper Acute Stroke Unit (HASU), the discharge to home arrangements and arranging packages of care at home. It was expected that stroke patients would move from the HASU after 72 hours, but be kept under observation in the collocated ASU typically for eleven days before the early supported discharge (ESD) process was instigated.

·         Patients would only be discharged when it was safe for them to do so, but some could be discharged within one or two days.

·         Some patients would require longer, possibly up to six weeks, dependent on the impact of the stroke. Approximately 23% of ESD stroke patients would require a package of care after discharge from hospital.

·         Reference was also made to the bedded rehabilitation proposals and after care at home. There would be a significant reduction in social care costs in the longer term resulting from this model. It was emphasised that the proposals had already been implemented where possible, but there was currently a gap in the community care aspects of the pathway meaning people were spending longer in bedded rehabilitation.

·         Recognition of the work undertaken over many years and the consultation undertaken in designing the pathway

·         It was questioned how the public could be involved and the potential for lay member participation. Adrian Stokes agreed that the proposal for lay members was a good idea and could be accepted.

·         More detail and assurances were sought on workforce aspects, risk analysis and mitigation, as well as the proposals for ‘front loading’. At the recent Rugby consultation event there had been concerns raised by some NHS staff. There was a need for effective communication in communities to explain how the pathway would work in practice. Adrian Stokes agreed that recruitment had been identified as a risk area and there would be a ‘stop/go’ decision before full implementation. There were vacancies in some community services, especially for therapy posts. An outline was given of the work to raise awareness of the new model, the career opportunities it presented and the end to end pathway being implemented, which should be attractive to staff. There would be opportunities for staff to rotate amongst the different specialisms from acute services to therapy, gaining a broad knowledge and skills. It was known that many staff did not want to specialise too early in their career. Budgets for workforce and leadership had been increased. Often people left to seek progression, so offering good training in house and the opportunity to progress were further drivers to retain staff. There were not many areas with this end to end pathway currently.

·         An assurance was sought on the anticipated position after 6,12 and 24 months in regard to the community services. The timeline was to start the recruitment process in April/May 2020. There were more vacancies to be filled for Warwickshire than Coventry. It was anticipated that the ‘go/no’ decision for changes to acute care could be taken from April 2021, subject to attracting sufficient staff, but this could take longer.

·         A member commented that the Heathcote rehabilitation hospital was in Warwick not Leamington. Whilst a fine point, this could bring into question other aspects of the proposals. He added that this model was based on one introduced in London, which may be appropriate for the City of Coventry, but not a mainly rural county like Warwickshire, especially in terms of travel times and the ‘golden hour’ for commencement of treatment. Assurances were sought that WMAS could achieve response times and had the equipment and staffing to diagnose stroke cases. The member had received feedback from NHS employees that the stroke proposals had largely been implemented at Warwick Hospital some time ago.

·         Pippa Wall spoke about the WMAS recruitment and training programmes, its dynamic deployment model, to ensure it had full rotas and achieved response time targets. The additional funding in the stroke service proposals would provide for three additional ambulances for the area. There were no concerns that WMAS would not be able to achieve the timescales required in the majority of cases.

·         The allocation and sufficiency of staff across treatment centres was raised, using the example of physiotherapy staff. There was an offer to provide this clarity immediately after the meeting, but in summary it was equitable across the area, taking account of travel times within Warwickshire.

·         Concern was raised about the current gaps in community support for rehabilitation services. These should be addressed now, not wait for the recruitment of staff as part of these proposals, which could take a year to implement. This was acknowledged and could be started from the next university intake.

·         In the very rural areas of Warwickshire, there was concern that target response and transfer times would be slower than the stated averages. Further detail was needed on this area and where patients would be transferred to, as other hospitals could be closer than University Hospitals Coventry and Warwickshire (UHCW). Pippa Wall acknowledged this was a challenge, but it was managed, on a daily basis, through dynamic deployment of WMAS resources. It could not be guaranteed that every patient would be reached within the target timescale, but further reference was made to the additional ambulance resource allocations. Rose Uwins added that patients would be taken to the nearest HASU and for the majority of cases this would be UHCW. In 67% of cases where stroke was detected, the patient was already transferred to UHCW for thrombolysis (an injection to break down the blood clot). This point was challenged as some patients were transferred to the nearest hospital.

·         More information was sought on how atrial fibrillation (AF) services would be implemented, to ensure earlier diagnosis and prevent some stroke cases, which the proposals were modelled on. The focus would extend beyond GP doctors. It would include all staff in the pathway through awareness raising to those who provided services to the sectors of the population most likely to be at risk of a stroke.

·         The travel times between rural and urban areas in the south of Warwickshire and UHCW were stated by several members. This would be exacerbated if there were travel delays through a road accident. Pippa Wall reiterated the modelling used for the stroke service, which followed that implemented successfully for major trauma cases. The WMAS clinicians had studied the proposals. There was access to the air ambulance when required and the additional ambulances would provide further assurance. Claire Quarterman added that the clinical team would be assembled ready to meet the stroke patient at UHCW. This would reduce significantly the time between arrival at hospital and commencement of treatment.

·         Clarity was sought about the ‘golden hour’ for treatment to commence. This term came about from a campaign to encourage a rapid response where a potential stroke case was identified, especially when thrombolysis injections became available. The time for its administration was within four hours of the stroke occurring and its benefits were explained. The timescales for physical removal of blood clots, which took place at University Hospitals Birmingham were also explained.

·         It was questioned if the two proposed rehabilitation centres for the south of Warwickshire would be of sufficient capacity. Assurance was provided that a number of snapshot audits had been undertaken over an 18-month period, by a range of clinicians. The modelled number of beds had been increased to provide additional capacity.

·         It was questioned if processes were in place to ensure that patients who had suffered a stroke were immediately transferred to UHCW.

·         Chris Bain advised that Healthwatch Warwickshire (HWW) had attended a number of the consultation events. There were a number of recurring themes concerning transport, travel times and staffing. He sought reassurance that patients would be heard and their ‘lived experiences’ captured. These would inform implementation and provide a sense check on an ongoing basis. Assurance was also sought that the service provided and outcomes would be equitable. He confirmed that HWW would be making this response to the consultation.

·         Where patients presented at A&E, it was confirmed that potential stroke cases were prioritised. More detail was sought about transfers from the emergency department to the HASU. Stroke patients were met at A&E by the stroke team. The care started immediately with transfer to the specialist unit as soon as was possible.

·         Ambulance handover delays at hospital were possible. However, these were minimised by affording priority on arrival to the ambulances carrying a stroke patient. The clinical team was assembled and given regular updates on the expected time of arrival.

·         Further detail was sought on the impact of bed reductions contained in the proposals. Six beds were currently available for bedded rehabilitation within a frail elderly persons’ unit at Rugby. The concerns raised at the Rugby consultation event had been noted. There had been a series of audits across the system, to assess the bed numbers required. The proposals had modelled for additional bed numbers and reference was made to the additional treatment at home and ESD plans too. 

·         Cross border arrangements were raised especially for services delivered by WMAS, close to the Gloucestershire and Worcestershire borders. A member asked which hospitals people were transferred to. An individual example was quoted, which would be pursued outside the meeting. It was confirmed that there were mutual aid arrangements with neighbouring ambulance trusts. The WMAS dynamic deployment model enabled ambulances to be relocated to ensure cover was maintained in all areas.

·         The adequacy of car parking at UHCW was raised. There were proposals to build a multi-storey car park for staff which would free up more visitor parking. This was subject to a planning application. 

·         It was important to inform the public that where a stroke case was suspected that this was brought to the attention of staff at hospitals, so they could immediately be transferred to the HASU. 

Resolved

1.         That the Overview and Scrutiny Committee has noted the pre-consultation business case and consultation documentation and the  changes to the dates of the consultation, due to pre-election guidance.

2.         That the key concerns raised during the meeting be summarised and shared with party spokespeople, before being submitted for consideration at the Coventry and Warwickshire Joint Health Overview and Scrutiny Committee meeting on 22 January 2020.

In closing the item, the Chair thanked members and NHS representatives for their contributions.