Enhancing Acute Stroke Services in Lancashire and South Cumbria Frequently Asked Questions
 

In previous years the treatment and long-term outcomes provided in acute stroke centres (hospitals) within the region have not consistently met the national targets for stroke care. There are a range of reasons for this but improving our stroke services is not simply a case of throwing more money at it, although more money is now being made available.

To get the best possible results for patients, stroke survivors and their families, some elements of acute stroke services need to change, and this has been demonstrated by successes in other parts of the country. To provide the best stroke service for the people of Lancashire and South Cumbria and make the improvements needed, some changes in how these services are delivered need to take place.

Strokes are complex, and no two strokes are the same, but stroke care has developed in recent years, is better understood and its underfunding recognised. In addition, national efforts to improve stroke services have intensified over the last five years, although a shortage in suitably qualified and trained staff remains an issue. Looking into this complex area of service and the challenges it represents has taken some time, but Lancashire and South Cumbria now feels it has the knowledge, understanding and commitment to propose the way forward in providing the best possible stroke service for its population.

There are a wide range of stroke service enhancements that stroke survivors, carers and stroke service professionals and support workers have agreed are needed. Some of the main developments are:

• 3 Enhanced acute stroke centres across the region (one of which is a comprehensive stroke centre)
• Enhanced stroke rehabilitation services at all stroke centres
• 24/7, stroke specialist services available all year round
•  Maximised use of thrombolysis and thrombectomy to reduce deaths and disability
• The development of ambulatory care for the prompt and focused treatment of mini-strokes (TIAs)
• Enhanced Integrated Community Stroke teams providing multi-disciplinary rehabilitation and support to stroke survivors when they leave hospital, in all areas
• Improved filtering of stroke mimic patients to ensure stroke services focus on patients with strokes or mini-strokes (TIAs)
• All stroke survivors referred to the Stoke Association and given the ability to reconnect with Integrated Community Stroke teams at any time
• Fully trained workforce capable of meeting the timescales required to reduce the impact of stroke on survivors
• Development of prevention techniques to identify, treat and monitor people at risk of having a stroke or mini-stroke (TIA).

There are other enhancements and developments within each of the elements mentioned above that help in delivering an improved stroke service, but these are the headline developments.

One of the critical issues that stroke services across the country have faced, and continue to face, is the lack of suitably qualified and trained staff. This remains the case. It would neither be practical nor affordable to resource 5 fully functioning, effective, high-quality acute stroke centres across the region.  This would result in one or all of the centres struggling to meet or retain the level of expertise required to provide the quality of stroke services we aspire to. 3 acute centres is more achievable and sustainable and builds upon the current strengths of those centres. In addition, the proposed model of stroke service ensures that all patients will receive the same level of service, whatever their location.

In respect of the options for providing the right number of acute stroke centres for our area:

The first part of the options process was to consider how many acute stroke centres were needed to ensure a feasible, clinically appropriate, high-quality service could be delivered.

We currently have 5, so we looked at:

5 centre model, 4 centre model, 3 centre model, 2 centre model, Single centre model.

Our stroke numbers ruled out single and 2 centres, as the numbers would overwhelm this number of centres, would need greater levels of workforce and would mean more people travelling for the first 72hrs of care.

3 acute stroke centres was classed as the optimum number for the whole of Lancashire and South Cumbria

Both 4 and 5 centres were ruled out as completely unaffordable in terms of finance and workforce.

Once this was determined, it was then necessary to consider which of the existing stroke centres were best placed to become the future acute stroke centres. 

Two of the centres, in East Lancs and Preston, were automatically chosen to be sites on the basis of the number of stroke going to these local hospitals (greater than 600) and Preston being co-located with the regional Thrombectomy centre. 

The third centre was decided by using evaluation criteria agreed with stroke patients and carers, health and care professionals and commissioners, to assess each of the stroke centres accordingly. Furness General Hospital (FGH) was ruled out as outside the travel times for a greater amount of people. Due to the distance to travel, all patients who would normally attend FGH would continue to do so, but would be assessed using the triage, treat, transfer model to determine which patients would need to travel onto to an acute stroke centre for the first 72hrs of care.

Through the evaluation process it was determined that Blackpool should be the third centre, scoring above Royal Lancaster Infirmary (RLI). Once this was determined the model originally advocated triage, treat and transfer at RLI but, due to a clinical challenge from National Clinical Stroke Director, this was changed to a direct divert for RLI patients to the nearest Acute Stroke Unit which is Preston.

No, none of the existing stroke centres will close. All will remain operational. The proposals mean that all stroke centres will provide improved services going forward but two of these will provide fewer functions, focusing on enhanced stroke rehabilitation services. The critical stroke services provided in the first 72 hours will be concentrated in the 3 fully resourced acute stroke centres.

For example: a person presenting themselves at Furness General Hospital with the symptoms of a stroke will be assessed as soon as possible at Furness (within 30 minutes of arrival). If they have had a stroke, they will be given their initial treatment/medication (within 1 hour of arrival) then have an urgent transfer to the comprehensive stroke centre at Royal Preston, where they will receive specialised care for the first 72 hours. After 72 hours they will then transfer back to Furness General Hospital for stroke rehabilitation services and ongoing stroke care or return home with care from the Integrated Community Stroke Team.

The example given above is an example of triage, treat and transfer.  If the person presenting with the symptoms did not have a stroke or had a mini-stroke, they would continue to receive care at Furness General Hospital via ambulatory care or via the correct service for their condition. Only acute strokes would be transferred to an acute stroke centre, and this would be after initial treatment, including thrombolysis where this is appropriate, has taken place at Furness General Hospital.

The proposed changes will improve the times taken to treat stroke patients than is experienced currently.

A case in point is the use of thrombolysis. Thrombolysis is a clot busting drug that is used to break down and disperse a clot that is preventing blood from reaching the brain (causing a stroke). To be effective and significantly reduce the damage done, thrombolysis needs to take place within four and half hours of the start of stroke symptoms. In some cases, it can be applied within 6 hours. This means, that by the time someone reaches hospital (arrives at the ‘door’), thrombolysis must take place as soon as possible if it is going to work (where thrombolysis increases survival and helps people live independently after stroke). Thrombolysis is injected and referred to as the ‘needle’.  The shorter the ‘door’ to ‘needle’ time the better.

The proposed changes will improve the ‘door to needle’ time currently experienced by patients who attend Royal Lancaster Infirmary, even with transfers. The North West Ambulance Service has undertaken an extensive travel impact assessment to ensure treatment will be within the timescales required.

It is possible, in a very small number of cases, when patients are on the margins of the timescales, where these may not be met.  However, such patients are on the margins now.  This will improve for many but for a very few, they may still be on the margins.

This will be a phased approach over the next 2/3 years, as we need to put some services in and build up the workforce before moving any patients, in the meantime we are continuing with service improvements in each Trust. For this year (2021/22), this primarily relates to:

• rolling out or enhancing Integrated Community Stroke Teams,
• embedding stroke triage nurses at hospital front doors (emergency departments) and rolling out ambulatory care services (which ensures we get patients seen quicker, get their tests done in the same day and either discharged on the same day or admitted to a stroke unit. Patients that are non-stroke can then be cared for by the appropriate service/ward).
• and expanding the number of hyper-acute beds for thrombectomies at Royal Preston Hospital (which is the only centre where this specialist surgery takes place).

For 2022/23 it is proposed that the designated hospitals will prepare the ground to become the acute and comprehensive strokes centres, developing the equipment and facilities to become fully operational and all stroke wards (in all 5 areas) will continue to enhance their rehabilitation services.

Finally, it is proposed that 2023/24 will see the full expansion to acute and comprehensive stroke centres being made, with full staffing and facilities available. In addition, a 7 day fully staffed rehabilitation service at all stroke wards should become available.

No, not at the moment. The answer above goes someway to answering this question. There is a shortage of stroke qualified and trained staff nationally and there is insufficient equipment and facilities to meet our needs. The recruitment and training of staff to reach the workforce levels we require will take a few years, which is why we are proposing becoming fully operational under the new system of stroke care by 2023/24.

No, no staff will be made redundant as a result of these proposals.  Indeed, all stroke units, whatever their location, will need greater numbers of staff to deliver the level of stroke services we want to provide.

No, no staff will be required to relocate or transfer to another stroke centre. There may be opportunities for staff to apply for a post in another centre/location, but that will be a matter of personal choice and depend upon the relevant skills and experience needed to secure any opportunities.

No, we will not abandon the plans. We have mapped out the gaps within the workforce from current staff and the gaps against national recommendations and considered what we could do differently. We have a planned workforce recruitment plan that goes along with our phased investment plan. We are working collaboratively with Health Education England and the local universities to look at the supply and demand of roles and training opportunities, shaped by existing staff groups within acute stroke care, working collaboratively across the Trusts.

In addition, some of the developments and enhancements to hyper acute and acute stroke care within our existing stroke centres are not dependent upon recruiting additional staff but are best served by ensuring the training of the existing workforce is maximised.

These are not additional centres as they are already functioning. We have developed a phased workforce plan, as part of the phased investment plan. We are developing a Lancashire and South Cumbria workforce strategy which has come from a detailed consideration of several important factors, including what is recommended, what is needed, safe staffing levels, new roles, and working collaboratively with Health Education England and local universities around supply and demand.

We have been working with the University of Central Lancashire throughout the process, which is a major education and training centre for health service staff, and with other centres nationally, to promote the recruitment of stroke related specialities.  Therefore, the recruitment process will be phased over a period of three years.  During this period, we will be developing the facilities and environment to attract staff to the new acute stroke centres.

An investment of £6.1million capital expenditure and £12.9million additional annual revenue expenditure is required to enhance acute stroke and community rehabilitation services to the level that is being proposed.  This is the largest increase in expenditure for stroke services for many years.

We have linked with North Cumbria and other localities to apply their lessons learnt to our enhanced programme of care.  North Cumbria’s new configuration of stroke services has resulted in them going from a C to an A rating.  This is not the same as taking residents views from outside our area into account, however, as these are not necessarily relevant to our arrangements, despite potential similarities. The views and input of Lancashire and South Cumbria patients and residents has been taken into account throughout and this will continue going forward.

All existing stroke services are as safe as we can make them, but these are currently operating as a 5-day limited service.  Our aim is to have 6- and 7-day services so that there are more staff available, with new technology and new imaging. This will allow us to recognise stroke patients earlier and give patients more opportunities to access thrombolysis and thrombectomy.  This in turn, will reduce the number of lives lost.

The number of lives that could be saved is an expectation and is not a guarantee. What is also important is the reduction in disability in patients, allowing an increased level of independence in what is estimated at over 300 patients each year. There is no doubt that lives can be and will be saved by making the enhancements and developments identified. This is an expectation that is impacted by many variables, but, based on data and experience elsewhere, this is an expectation that is reasonable and has every chance of being met or exceeded.

A. The main (F.A.S.T.) signs of a stroke are:

Facial weakness - if they cannot smile or thier face falls on one side;

Arm weakness - if they cannot raise both arms and keep them raised;

Speech problems – if their speech is slurred or difficult to understand;

Time – if you see any of these signs it is time to call 999 immediately.

Other signs of a stroke include:

• Sudden weakness or numbness on one side of the body, including legs, hands or feet.
• Difficulty finding words or speaking in clear sentences.
• Sudden blurred vision or loss of sight in one or both eyes.
• Sudden memory loss or confusion, and dizziness or a sudden fall.
• A sudden, severe headache.

If you notice any of these signs you should call 999 immediately. FAST action is critical for any signs of a stroke.

The assessment of stroke services and the development of a new stroke service specification has been taking place over a period of time and began in 2015. A broad range of people and groups have been involved and this includes:

• health service commissioners,
• hospital and community stroke professionals, including consultants and nurses,
• stroke survivors and their families/carers,
• the Stroke Association,
• other voluntary support groups,
• public health specialists,
• primary care practitioners (GPs),
• North West Ambulance Service,
• various other health and care professionals,
• members of the public and
• decision making bodies in NHS and local authority organisations.

Most of these groups have been involved throughout the process.

The onset of Covid-19 has delayed the process of improvement by over 12 months and has had an impact on the ability to involve a wider range of groups during this period.

The involvement of stroke survivors and their carers/families have been crucial to the stroke service development process from the beginning.

Patient representatives have been members of the Stroke Review Board from its inception in 2015 and on other groups throughout the process. The Stroke Association has also been involved from the outset and through them a broad range of stroke survivor and carer groups have been contacted and involved.

Group information and discussion sessions with stroke survivors and carers have ensured their input into the Stroke Service Specification; the improvement proposals for acute stroke services; the evaluation criteria and the evaluation process for the improvement of acute stroke services; campaign materials for stroke prevention and the development of the Stroke Information Guide, an interactive and informative guide to stroke that was made available across the region.

The experience of stroke survivors, their carers and families have both motivated and shaped the development of all these documents and the proposed actions to improve these services for them and those who follow.

. Our workforce is a concern as we do not currently have enough staff for the region. It is our ambition to have a phased workforce approach.

Current staff will not be expected to move; in the future we will be taking a network approach to recruitment. We are developing a strategy that ensures we have enough of the right workforce in the right area, and that we have a robust training and education programme for the future of all stroke staff.

Preston is to become a comprehensive stroke centre as part of these proposals. Maintaining a comprehensive stroke centre requires adequate levels of staff to maintain shift patterns, provide cover for sickness, leave and other absences and to provide a high level of qualified and trained staff 24/7, 365 days a year. Relocating staff to another centre reduces the capacity within Preston and places the same problems of maintaining staff levels at Royal Lancaster. It also presents potential staffing and union concerns regarding the relocation of staff who are based, and may live, in the Preston area.

In addition, our discussions with stroke survivors have indicated that travelling to a centre where they can receive the care they need is not an issue as long as that can be done within the timescales.

No, this is not being done in response to the report being submitted by the CQC. The Acute Stroke Business Case has been in development for over 2 years and the model was agreed in January 2019. The most recent changes are taking place in response to a clinical challenge from national stroke leads, which is based on the clinical and practical experience of delivering hyper acute and acute stroke services in other areas of the country and in other countries.

Any improvements requested by the CQC for Royal Lancaster Infirmary will continue to be put in place, as the proposed new arrangements for acute stroke centres in Lancashire and South Cumbria require staffing and facility enhancements that will not be in place until 2023.

No this is not feasible. The North West Ambulance service have undertaken a travel risk assessment and it takes longer to get to Carlisle, so more patients would lose the opportunity for thrombolysis and thrombectomy.

We utilise the North West air ambulance for transfers to the thrombectomy centres when required from Furness General Hospital.  The air ambulance is only available for daytime hours. The number of transfers for this are minimal at the present time, with around 7 last year and estimated to be around 22 per year over the next 2 years.

Any patient that normally attends FGH and RLI will be included.

There are transformations all over England, with differing levels of change and complexity. Many small stroke units joined up out of necessity during the pandemic due to staff shortages. There have been a lot of lessons learnt and we have reviewed and evaluated some of them to inform our decision-making processes.

As above, the stroke centres at Kent and Medway NHS had to join together during the pandemic as a necessity.  As part of the judicial review, the judge also ruled that the safety of the patients had not been taken into consideration, only the views of the sites who did not want to give up a service.  As a result, the judge found in favour of the changes.

The stroke unit at Blackpool had a lot of contingency plans put in place following the incident. It is a safe place for patients to go to and a safe place to work, but ongoing investigations keeps bringing this issue back into the limelight, which causes distrust all over again. Being the third acute stroke centre means that significant service development and improvement is being facilitated.

For patients and their carers/families, we know we are making a difference if they can receive a quick and thorough response at the right time, every time to some simple but vital questions:

• What has happened to me?
• What will my life be like now?
• If I need advice or help, where do I go?
• How do I access the help?
• What can I do to help myself/my family member?

Across the Stroke Centres we are monitoring several elements, and this includes:

• the SSNAP results (the national data used to check the performance of stroke units),
• the number of stroke patients,
• how quick they are seen,
• how quick scan is,
• how quick they are given treatment,
• the increase in thrombolysis and thrombectomy rates,
• the length of stay in hospital,
• the reduction in inpatient rehabilitation,
• the number of referrals to community teams,
• and patient experience outcomes (such as the 5 questions asked above).

These will be permanent changes to the arrangements for providing hyper acute and acute stroke services across Lancashire and South Cumbria.

Stroke patients and their carers and families, together with representatives of the Stroke Association, have been deeply involved in the process for change from the beginning and indeed before any changes were being considered. The Health Overview and Scrutiny Committees of Lancashire and Cumbria considered the consultation with patients and families to be appropriate and proportionate.

However, now that the options have been determined and agreed, a robust wider public engagement process is now being planned which will inform residents of Lancashire and South Cumbria of the enhancements and request feedback on concerns and issues around the implementation of the changes.