Monday 20 June to Sunday 11 September 2011 haveasay.uk

Monday 20 June to Sunday 11 September 2011 www.haveasay.org.uk

A public consultation on proposed changes to hyperacute stroke services in County Durham and Darlington

Welcome and introduction

David GallagherDirectorNHS County Durham and Darlington

Introduction to consultation

• We are now in a formal 12-week consultation process

• Scope of consultation includes:- Hyperacute stroke services in County Durham and Darlington- Durham and Darlington hospitals - No other services

• The organisations involved are:- NHS County Durham and Darlington- County Durham and Darlington NHS Foundation Trust

Today’s public meeting

• One of eight public meetings in the formal consultation

• Will last 90 minutes including group discussions and a Q&A session

• Introduction to panel members

• All views will be fed into consultation process

• We are audio recording all comments made today

• A transcript of today’s public meeting will go on www.haveasay.org.uk

Housekeeping

• No fire drill is expected

• Please switch mobiles off or to silent mode

• Hearing loop system available

Why review hyperacute

stroke services?

Ben ClarkHead of Strategy and PlanningNHS County Durham and Darlington

Some key facts about stroke

• Major cause of death and disability across County Durham and Darlington

• 1,100 people in the region suffer a stroke each year

• More common locally than in other parts of the UK

Useful definitions

HYPERACUTE STROKE SERVICES

• Needed when a patient is at their most seriously ill

• Covers the period of time from the onset of stroke to the first 48/72 hours of care afterwards

THROMBOLYSIS

• Use of drugs to break up a blood clot

• Essential part of hyperacute stroke services

• Given no more than four and a half hours from start of symptoms

Useful definitions

TELEMEDICINE

• Enables patients to be assessed remotely by specialist clinicians based elsewhere

• Uses a video-link

• Relatively new but safe way of working

Useful definitions

TRANSIENT ISCHEMIC ATTACK (TIA)

• Known as a ‘mini-stroke’

• Temporary stroke symptoms, usually lasting minutes

• Risk of more severe stroke

Useful definitions

Drivers for change – key quality standards

• Accelerating stroke improvement programme

• Local strategies and policies

Patients should:• Have 24/7 access to hyperacute stroke services and be

directly admitted to specialist stroke unit• Be assessed by expert stroke clinicians within 24 hours• Have a brain scan within 24 hours• Have results interpreted by a stroke specialist• Have thrombolysis treatment if needed• Have the ability to swallow tested • Be monitored 24/7 in a high dependency bed• Receive 24/7 care from range of specialist clinicians• Receive seven-days a week TIA service

Drivers for change – key quality standards

The story so far…

• Review of full stroke pathway

• Role of Stroke Strategy Implementation Group (SSIG)

• Stakeholder event in December 2010

• Hyperacute services were where the most immediate difference could be made to patients

The current situation and why this needs to change

Dr Bernard EsisiSpecialist Stroke ConsultantCounty Durham and Darlington Foundation Trust

Current situation

University Hospital of North

Durham

• Hyperacute stroke services• Monday-Friday 08.00-18.00• Alternate weeks out-of-hours• Vascular surgery for carotid disease

Darlington Memorial Hospital

• Hyperacute stroke services• Monday-Friday 08.00-18.00• Alternate weeks out-of-hours• Vascular surgery for carotid disease

Bishop Auckland Hospital

• Centre of excellence for rehabilitation• 7-day stroke rehabilitation • Physiotherapy, occupational therapy, speech therapy

Five-day TIA serviceThree clinics at Bishop Auckland Hospital

Two clinics at University Hospital North Durham One clinic at Darlington Memorial Hospital

Why the current situation cannot continue

• Staffing and recruitment pressures

• Not enough direct admissions to stroke units

• Need to provide seven-days a week TIA service

Staffing and recruitment pressures

• National shortage of expert stroke physicians

• National shortage of therapists and specialist nurses

• Optimum number of full-time consultants for a two-site hyperacute stroke service is six

• Only two full time stroke consultants in County Durham and Darlington and two part-time consultants

• Delays in assessment and treatment of stroke patients

There are not enough direct admissions into stroke units

• Most stroke patients spend time in Accident & Emergency or Medical Admissions Units • Small number directly admitted to stroke units

• Delays in specialist assessment and treatment

• Unnecessary longer stays in hospital

Need for 7 days a week TIA service

• Currently provided five days a week

• Difficulties with staff being split between three sites (inc. Bishop Auckland Hospital)

• Enables TIA patients to be seen within a 24-hour time period

Benefits of hyperacute services on single site

• Consistent access to specialist stroke consultants, including out-of-hours

• Direct admissions to a stroke unit

• Immediate assessment by specialist stroke consultant

• Access to seven-day TIA service with assessment in 24 hours

• Thrombolysis given in a more timely manner following arrival at hospital

• More patients receiving thrombolysis

• Access to seven days a week therapy service

Doing nothing is not an option

• We cannot continue to provide hyperacute stroke services at two hospital sites

• Fast, safe access to specialist stroke services is essential to survival and recovery

• All patients in County Durham and Darlington deserve the best possible treatment

The options appraisal process

Rachel Emery Commissioning lead for strokeNHS County Durham and Darlington

The Stroke Strategy Implementation

Group (SSIG)• Set up to enable the implementation of recommendations highlighted within the Stroke Strategy (2007) and improve stroke services across County Durham and Darlington

• Membership includes a stroke consultant, stroke clinicians, a consultant in public health, carers of stroke patients, the Stroke Association (representing patients), social care, regional cardiovascular network managers, and commissioners

• The SSIG asked a sub-group to carry out a case for change options appraisal for hyperacute stroke service configuration

Options considered

• Long list of options reduced to shortlist of eleven

• Two site 24/7 hyperacute model - one option

• Single site 24/7 hyperacute model - three options

• Two site hyperacute model plus out-of-hours diversion to single site 24/7 hyperacute - two options

• Two site + transfer including telemedicine plus single site 24/7 hyperacute model - two options

• Single site 24/7 hyperacute model plus collaboration for transfer with neighbouring Trusts - two options

• CDDFT not to have a hyperacute service - regional model - one option

Benefits Criteria

• Clinical quality - the best for patients

• The service must be sustainable and flexible

• All patients must have fair access to services

• Must be an efficient service

• Must enable better workforce planning

• Functional suitability

• Acceptability to the Trust

• Cost effectiveness

Weighting of criteria

How scores were determined

Could hardly be better 10

Excellently 9

Very well 8

Well 7

Quite well 6

Adequately 5

Somewhat inadequately 4

Badly 3

Very badly 2

Extremely badly 1

Could hardly be worse 0

ResultsRegional modelsTwo site + transfer modelSingle site models


Criteria Score Weight Weighted score

Clinical quality 9 17 153

Sustainability/flexibility 10 16 160

Equity of access 7 15 105

Efficiency 8 14 112

Workforce 8 14 112

Functional suitability 7 11 77

Acceptability 6 8 48

Cost-effectiveness 8 6 48

Total weighted score 815

University Hospital of North Durham





Efficiency 8 14 112

Workforce 8 14 112





Current two site model





Efficiency 6 14 150

Workforce 4 14 56





Scores for single site model vs. current two site model

What were the differences in the top two scores?

• Equity of access

• Functional suitability

The preferred option for hyperacute stroke services in County Durham and Darlington

Dr Mike LavenderConsultant in Public Health MedicineNHS County Durham and Darlington

Bishop Auckland Hospital: 7-day stroke rehabilitation service

University Hospital of North Durham

• 24/7 hyperacute stroke services

• 20 stroke beds

• Full range of intensive and critical care facilities to support hyperacute stroke service

Our preferred option


• Assessment of self-presenting stroke patients by stroke specialists via telemedicine

• Use of intravenous drugs to stabilise patients before transfer to University Hospital of North Durham

Between the hours 9am – 5pm patients with a suspected stroke will be taken to the nearest A&E department. These patients will be assessed and then transferred onto the hyper-acute stroke unit.

Current in-hours pathway

Stroke ward

Stroke ward

Darlington

Darlington

Durham Durham

Bishop Auckland

Rehabilitation

Outside of 9am – 5pm, patients will be taken to the site with the open hyper-acute unit for that week. This alternates between UHND and DMH on a weekly basis.

Current out-of-hours pathway

Stroke ward

Stroke ward

Darlington

Darlington

Durham Durham

Bishop Auckland

Rehabilitation

1st week

Outside of 9am – 5pm, patients will be taken to the site with the open hyper-acute unit for that week. This alternates between UHND and DMH on a weekly basis.

Current out-of-hours pathway

Stroke ward

Stroke ward

DarlingtonMH

Darlington

Durham Durham

Bishop Auckland

Rehabilitation

2nd week

In the preferred future option, all patients suffering a suspected stroke would be taken to the single site and directly admitted onto the hyper-acute ward without waiting for assessment in A&E.

Slight increases in journey times would be offset by this reduction in delay with the direct admission.

Preferred future pathway

Stroke ward

Durham Bishop Auckland

Rehabilitation

In the preferred option, patients self-presenting with a suspected stroke at UHND would go straight up to the hyper-acute unit. Patients self-presenting at DMH would be seen by an Acute Physician who would use “tele-medicine” linked to UHND to assess and treat the patient. Once stable, the patient would transfer to UHND.

Stroke ward

Durham

Darlington

Bishop Auckland

Rehabilitation

Preferred future pathway - self presenting

• Shorter travel times

• More people suffering a stroke in County Durham

• Essential ultrasound, CT and MRI diagnostic facilities more readily available

Why Durham? Important information which supports our preferred option

Shorter travel times

• Information from the Development and Assessment of Services for Hyperacute stroke (DASH) research project, carried out by Newcastle University

• Analysis of average ambulance travel times for suspected stroke patients taken to Durham and Darlington hospitals between Jan-Dec, 2010

Durham 16 mins

Darlington 17 mins

• Analysis of suspected stroke incidences between Jan-Dec, 2010

• Number of patients from North Yorkshire treated in County Durham and Darlington: 9

• Patients in East of County Durham treated in Sunderland and Stockton

More stroke cases in County Durham

University Hospital of North Durham 925

Darlington Memorial Hospital 683

More stroke cases in County Durham

• More capacity at University Hospital of North Durham for ultrasound, CT and MRI scanning

• Patients can access essential tests sooner

• Enables quicker diagnosis

• Supports swift access to urgent surgery if needed

More access to diagnostic facilities

• Shuttle bus runs between three hospital sites

• £2.50 per journey

• Bus pass holders travel free after 9.30am

• Staff travel free

• Inconvenience minimised – 48-72 hour hyperacute period

• Clinical benefits of specialised care make excess

travel worthwhile

Transport implications and solutions

• Delivers a balance between specialised care and care closer to home for the majority of patients

• Not about saving money

• The preferred option will lead to improved recovery rates for patients

• Safeguards stroke hyperacute service for County Durham and Darlington patients

Preferred option summary

The consultation process

Rachel EmeryCommissioning lead for strokeNHS County Durham and Darlington

Your views are equally important

Four tests for proposed service change:

Support from GP commissioners

Strengthened patient and public

engagement

Clinical evidence base

Consistency with patient choice

• Take part in public meetings such as today

• Complete the online questionnaire at www.haveasay.org.uk

• Email us at [email protected]

• Write to us

• Complete the paper questionnaire in consultation documents

• Request more information or a dedicated consultation session for your group/organisation on 0191 374 4253

How you can get involved

• Do you agree the current split-site model for stroke hyperacute services cannot continue?

• Do you agree our single site hyperacute stroke service is the best model?

• Is specialist care more important to you than care closer to home?

• Do you agree our preferred option of the University Hospital of North Durham the best option?

• If you don’t agree with the preferred option, what alternatives, if any, would you like to see implemented and why?

What we want to know

Your chance to have your say: group discussions and Q&A session

David GallagherDirectorNHS County Durham and Darlington

Group discussions: 20 minutes

• Is a single site the best option?

• Is our preferred option of University Hospital of North Durham the best model?

Feedback from group discussions

One key point per group

Questions for the panel

The next steps

• NO DECISION HAS BEEN MADE

• Consultation closes 11 September 2011

• All views and comments independently collated, analysed and reported

• Final report considered by NHS County Durham and Darlington Joint Board

• Responses and outcomes reported to both council health scrutiny committees

• All feedback and final report made available on www.haveasay.org.uk

Thank you for your contribution

www.havesay.org.uk

[email protected]

Hyperacute Stroke ConsultationFREEPOSTRRXK-CZGR-TJJAUnit GLumley CloseThirskYO7 3TD

To request more information or arrange a dedicated consultation session for your group/organisation contact us on 0191 374 4253

Monday 20 June to Sunday 11 September 2011 haveasay.uk

Documents

stroke specialist

onset of stroke

hyperacute services

darlington durham

specialist stroke unit

darlington county durham

expert stroke clinicians

planningnhs county durham