The report attached at Appendix A provides an update on NHS Herefordshire and Worcestershire ICS on stroke services across Herefordshire and Worcestershire.  This includes a paper on Improving Stroke (including TIA) Services across Herefordshire and Worcestershire, September 2022. The committee is asked to consider and comment on the information provided and seek assurance that the wider public engagement undertaken on this will be focused on delivering the required improvement further inform possible solutions.

The Managing Director and Chair of the Stroke Programme Board for the Herefordshire and Worcestershire Integrated Care System (ICS) gave a presentation on ‘Stroke Services: Pre-consultation Engagement Autumn 2022’, as published in a supplement to the agenda (link to the presentation).  This included slides showing:

·             Welcome and introduction, identifying that around three people each day had a stroke in Herefordshire, Worcestershire and Powys, the number was set to rise as the population aged, and the ICS was looking at the way in which stroke and TIA (transient ischaemic attack or ‘mini-stroke’) services were organised and run;

·             The National Stroke Pathway and current acute hospital treatment, rehabilitation and after care settings;

·             The case for change which included the difficulty to recruit stroke specialist consultants, resulting in reliance on support from outside the ICS area to ensure 7-day access, and keeping services as locally accessible as possible but balanced with providing the best care for patients;

·             The identification of four potential solutions [1. No change to current service / 2. One hyper-acute stroke unit (HASU) and two acute stroke units (ASU) / 3. HASU and ASU out of counties / 4. HASU and ASU on one site], with ‘potential solution 4’ being the preferred solution by the clinicians and following the options appraisal but this would not be taken forward until there had been full engagement with the public and with stakeholders;

·             Diagrams of the potential solution (with movement to HASU / ASU at Worcestershire Royal Hospital) for Herefordshire and Powys patients where Herefordshire County Hospital was the nearest imaging centre, and for Worcestershire and Herefordshire patients where Worcestershire Royal Hospital was the nearest imaging centre; and

·             People were being invited to have their say during September – November 2022, it was acknowledged that previous engagement had highlighted that some families in Herefordshire had expressed concerns about being able to visit Worcestershire Royal Hospital, especially if they did not have access to their own transport.

The principal points of the discussion included:

1.           In response to a question from the Chairperson, the Stroke Consultant said that the infrastructure and workforce issues meant that it was unlikely that two HASU sites could be operated in the near future and the ‘hub and spoke’ model was considered the best way to move forward.

2.           A committee member commented on the difficulties for the ambulance service to meet demand currently.  In response, the Managing Director outlined the dedicated pathways for suspected stroke, intended to reach assessment imaging within the ‘golden hour’, and said that the ICS would work with the ambulance service on the agreed model to support the movement of patients.  The committee member considered that this would be a concern for the public and suggested that this should be referenced in the consultation.

Another committee member questioned whether there was confidence that the ambulance service had the capacity for the extra journeys.  The Managing Director said that more capacity would be commissioned and this might only involve a small number of patient transfers each day. 

3.           In response to a question from the Vice-Chairperson, the Programme Lead for Cancer and Stroke said that the public health modelling included previous incidents of strokes and forecasting forward to 2035.  It was noted that up to half of suspected strokes were ‘stroke mimics’ resulting from other medical conditions and did not need to continue on the stroke pathway.  The Managing Director added that the age profile over the next 15 to 20 years was of particular concern.

4.           The Vice-Chairperson considered that, although there might be an aspiration to improve pathways, this was really about making a service work in a system that was struggling.  Noting the effect of delay on stroke severity and recovery, it was also considered that early treatment in remote populations seemed vital. 

The Managing Director emphasised that assessment imaging and thrombolysis treatment would continue to be undertaken at the closest hospital and the intention was to improve hyper-acute care.  The Chief Transformation and Delivery Officer added that there could be clinical benefits from potential solution 4, with stroke specialist consultants able to support decision-making around thrombolysis.

5.           The Chairperson commented on the need to consider the scenarios for patients in England living near the England-Wales border.  The Managing Director advised that a time study had been undertaken previously but this did need to be refreshed.

6.           In response to a question from a committee member, the Managing Director commented that investment would be dependent on financial frameworks from the government, adding that potential solution 4 could involve some capital requirements and a lot of revenue costs.  Prevention was one of the top four priorities in the ICS but there were competing priorities, and the ICS would need to consider the cost / benefit analysis.  The challenges of keeping services maintained and resilient were noted, particularly given the ageing population.

7.           A committee member said that additional certainty about the ongoing role of community hospitals was welcomed.

8.           In response to a question from a committee member, the Managing Director commented on the need to ring-fence assessment imaging slots for stroke patients.

9.           In response to a further question about capacity to meet future needs, the Managing Director commented on: how the modelling would inform the commissioning; the national workforce challenges; and the consideration being given to tasks being undertaken in different ways.

The Vice-Chairperson highlighted that the reference to ‘around three people each day’ having a stroke in Herefordshire, Worcestershire and Powys was a mean and not a modal figure, and there was a need to accommodate actual frequency distribution in the modelling, such as the variations on certain days and during different times of the year.

10.        In response to a question from a committee member, the Managing Director and the Stroke Consultant outlined the system for discharging patients and for communications between acute, primary care and community care providers.

11.        A committee member suggested that, given the potential for some stroke survivors to have a recurrent stroke, consideration could be given to a stroke alert bracelet.  It was noted that there was no existing national or local scheme currently.

12.        In response to a question from the Chairperson, the Stroke Consultant advised that most TIA follow-ups, particularly primary care referrals, were face-to-face with tests undertaken on the same day.

13.        The Leader of the Council drew attention to the wording in the glossary to the report (agenda page 80) that ‘For most people, thrombolysis needs to be given within four and a half hours of stroke symptoms starting’ and to the wording on the Stroke Association website that ‘After thrombolysis, 10% more patients survive and live independently’ (link to the website), and considered that the importance of this window for treatment should be communicated to communities more widely.

The Leader said that public services should not balk from saying that this was the best that could be done with the resources available.

The Chairperson thanked all the attendees for their participation in the substantive agenda items.

The Chairperson drew attention to recommendation detailed in the report (agenda page 67) and the committee considered further observations and suggestions.

RESOLVED:

That the committee notes the wider public engagement being undertaken on improving stroke services across Herefordshire and Worcestershire will be focused on delivering the required improvement to further inform possible solutions, and the committee makes the following observations and suggestions:

a.           The consultation on the model should consider how services can get early diagnosis and treatment to people in remote populations; specifically for patients to be able to get treatment within a four hour period.

b.           There was a need to understand the budget implications and how the proposals would affect costs in reality, and how the Integrated Care Board would make decisions on the consideration of the cost / benefit analysis.

c.           There was a need to be confident of the capacity of ambulance services and other local services to support the preferred model, as part of the future-proofing of the proposals.

d.           That people that have suffered a stroke be offered bracelets to identify their increased risk of stroke.

e.           That consideration be given to those patients on the Monmouthshire border and whether there were any prejudices to outcomes arising from travel times.

f.            That 24/7 assessment imaging at Hereford County Hospital should be retained in the model.

g.           The model should show confidence that it can accommodate fluctuation in demand over the average.

h.           That the perceived tension between patients being seen at Worcester and the public health need to be seen quickly should be considered.

i.             That it is recognised that increased travel times for relatives may arise and, where practical, provision should be made for visitors.