West Surrey Stroke Services: Report for Committees in Common September 2017 Surrey Stroke Services Review: The Story So Far 1
1. Introduction West Surrey Stroke services have been subject to review as part of the wider Surrey Stroke review process initiated in 2014. Following a significant programme of work involving experts, patients, public, voluntary sector, commissioners and service providers, a stroke pathway and service specification were developed and approved by the Stroke Committees in Common. The specification and outcome of the review were subjected to NHS England assurance processes and passed stages 1 and 2. This enabled the 2 constituent Clinical Commissioning Groups, Guildford and Waverley CCG and North West Surrey CCG, to undertake a full 90 day public consultation from 6 th of February to 30 th of April 2017. The purpose of this report is to present to the Committees in Common (CiC) the response to the public consultation outcome, in order for the CiC to make a decision regarding the future configuration of stroke services for their populations. The full public consultation feedback report is presented separately. 2. Background Surrey Stroke Review About 2,500 people in Surrey suffer a stroke every year. To have the best chance of recovery, people need to get help from specialist hospital services fast and then receive ongoing support in their communities. The National Stroke Strategy (2007) highlighted that providing better care for people with stroke could save lives, reduce levels of disability and use services more appropriately. Surrey s doctors, nurses, therapists and others are committed to helping people who have had a stroke and their families. Over the past 3 years, health and social care organisations and the voluntary sector have been working with people affected by stroke, clinicians and national experts to make care even better in Surrey. The Surrey Stroke Services Review began in late 2014 to consider how to provide the safest and most effective services for local people, now and to ensure their sustainability in the future. Model of care The Review considered stroke services throughout the pathway of care, from ways to prevent strokes through education and preventive medicines, through to gaining rapid access to specialist care in hospital after a stroke, through to ongoing rehabilitation and support in the community after discharge from hospital. 2
In the first 72 hours after a stroke, people receive care in hyper acute stroke units (HASUs). This is highly specialised care requiring experienced staff and specialist equipment. After this, people step down to acute stroke units (ASUs), where follow-on hospital care is provided. When people are ready to leave acute stroke units, they usually attend community rehabilitation services or receive support in their homes. Findings of the Review The Review identified key principles for services in the community and in hospital, based on feedback from people affected by stroke, clinicians and other stakeholders and evidence from research and local services. Services in the community Principles for developing services further in the community include: 1. ensuring an ongoing focus on prevention, such as educating clinicians and members of the public about preventive medication 2. making sure services are accessible, including for people not currently part of early supported discharge (ESD) schemes 3. providing seven-day flexible services framed around people s individual needs 4. using simple standardised acceptance criteria for services 5. ensuring better links and more integration between services such as health and social care and hospital and community services, and making sure there are no delays in handovers to other services. This may include having staff rotating between hospital and community services and having Band 4 assistants working across disciplines 6. making sure there are early supported discharge services with appropriately sized teams and skill mixes 7. greater involvement of GPs in people s ongoing care 8. training across all staff groups 9. greater focus on helping families and carers feel well informed and supported 10. self-management support, support groups, signposting, vocational rehabilitation and other services to help people get back on their feet after a stroke 11. working with charities and voluntary services so the resources they have available are better used and promoted. This may include linking to voluntary transport services 3
12. ensuring that everyone has six month and annual reviews after discharge from hospital 13. making sure there is fast and easy access to equipment and resources 14. improving the recording of data and use of outcome measures across services in the community Services in hospital Research evidence and guidelines told us that at least 600 people per year should be seen at a HASU in order for clinicians to keep their skills up to date. A review by a national panel of experts alongside local clinicians found that having three hospital sites in Surrey offering a HASU would allow Surrey to achieve the volumes needed, make sure specialist staff are available and future-proof for a growth in activity as the population ages. Having considered all of the evidence and feedback, the stroke review panel agreed that the most clinically effective, clinically and financially sustainable option was a 3+3 model i.e. 3 co-located HASU/ASU. This co-located model involves three HASUs spread across Surrey, taking people from initial presentation until 72 hours. Most people would arrive by ambulance, but this would also include walk in emergency department attendances that would need to be transferred to the HASU sites. After 72 hours, people would be transferred to an ASU located in the same hospital as the HASU. People would not be repatriated to their local hospital. Once the stay at ASU ended, they would be part of the community pathway. The national experts supporting the Surrey Stroke Review recommended that two of the three HASU sites should be Frimley Hospital and East Surrey Hospital with a third at either Royal Surrey County Hospital or Ashford and St Peters Hospital Foundation Trust. Their recommendation was based on activity, location and co-dependencies with other services. It is not based on current performance against the national stroke audit data (because this can always be improved). Subsequent to this recommendation both RSCH and ASPH undertook an impact analysis and made the decision that the third co-located HASU/ASU would be at ASPH. The recommendation took account of the age profile of both health economies and the benefit of ensuring that services are co-located with vascular service provision. The subsequent model proposed by both RSCH and ASPH was subject to public consultation. In the intervening period an interim model for stroke services has been implemented for patients in Guildford and Waverley, this was as a result of reduced consultant workforce in RSCH impacting on service safety. The interim 4
model followed the proposed stroke flows from that population going to ASPH (40%) and Frimley Park Hospital (60%) with repatriation to ASU at RSCH when clinically stable. Whilst not following the full proposed new stroke pathway, the interim arrangement did allow the proposed model and patient flow assumptions to be tested. There has been significant work undertaken between SECAMB, Commissioners and providers to ensure that patients were taken to the nearest hospital. 3. Stroke Service Public Consultation Guildford and Waverley CCG and North West Surrey CCG undertook the public consultation and provided the rationale for the proposed changes as outlined below. In addition the CCGs presented information to the public regarding the potential impact on them for the different local populations across the 2 CCG areas. 5
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The CCGs commissioned an independent analysis and review of the consultation feedback from the NHS Transformation Unit. The results and analysis will be presented separately to the Committees in Common, however the outcome has been given consideration by the CCGs and the commissioner response is provided below. 4. Commissioner Response to Public Consultation NWS CCG and G&W CCG have reviewed the detailed response from the public consultation and have listened to the feedback and concerns raised by the population served. Critically there are 5 areas that we need to respond to the CiC, they are: 1. Respond to the key themes of the public consultation, as presented in an independent report 2. Agree for the West system the HASU/ASU provision and the TIA provision. 3. Agree for the West system (for Guildford and Waverley resident population and for NW Surrey resident population respectively), the hospital/bedded rehabilitation facilities associated with the HASU/ASU provision. 4. Affirm commitment to the additional resource across the integrated stroke care pathway from onset of stroke to six month follow up. 7
5. Recognise the commitment of SECAMB to support delivery of the model of care. Take any other decisions required in relation to the West Surrey Stroke System and any of the key themes of the consultation that may emerge, that would otherwise be taken by the CCG Governing Bodies. 1.0 Key themes from Public Consultation Concerns about the removal of services from the Royal Surrey County Hospital, preference to position some of the stroke services at the Royal Surrey County Hospital and concerns about the future of that hospital. These comments about the change are particularly notable amongst the respondents from Guildford, Waverley and East Hampshire The importance of timely stroke treatment Recognition that creation of specialist units with specialist workforce and equipment has benefits, with differences of opinion on where these units should be located The importance of equitable access and concerns that the plans create inequity of access across the county References to travel distance and time, linked to implications for timely treatment, visitor access and patient wellbeing The importance of ambulance availability and concerns about SECAMB ambulance times in relation to the current service and the success of the proposed plans Other aspects of travel, such as public transport issues Consideration of care once stroke patients are discharged from hospital Provision of measures to help those with learning disabilities adapt to changes Expected population growth in south Surrey with related concerns about the service for this population under the plans Importance of access to finance and practical implementation in achieving plans Response: Both CCGs have reviewed the responses and consider the benefits of the proposed improvements in the pathway such as increased psychological support, consolidated workforce to improve outcomes have been recognised by the public. The investment committed by the CCGs to introduce 6 month follow up post discharge remains a key feature of the new pathway. 8
In terms of travel times and equity of access, there has been significant work with SECAMB, FPH and ASPH to ensure door to needle times are modelled and the proposed pathway enables some new ways of working to enable a swift handover to the stroke team on arrival. The CCGs consider that the isochrome modelling and subsequent work has resulted in ensuring that patients will be taken to the nearest HASU when identified as FAST positive. The chart below highlights the geographical alignment to each HASU. Postcode district Town Coverage Time to FPH Time to ASPH Variance GU1 GUILDFORD GuildfordTown Centre 23 mins 21 mins 2 mins Slyfield 26 mins 19 mins 7 mins Merrow 30 mins 21 mins 9 mins GU2 GUILDFORD Stoke Park 25 mins 19 mins 6 mins Onslow Village 16 mins 23 mins 7 mins Park Barn 22 mins 21 mins 1 min University of Surrey 21 mins 21 mins 0 GU3 GUILDFORD Normandy 16 mins 30 mins 14 mins Puttenham 21 mins 23 mins 2 mins Worplesdon 19 mins 23 mins 4 mins Christmas Pie 17 mins 25 mins 8 mins Flexford 17 mins 24 mins 7 mins GU4 GUILDFORD Burpham 27 mins 16 mins 11 mins Chilworth 29 mins 27 mins 2 mins Jacobs Well 25 mins 17 mins 8 mins Shalford 26 mins 28 mins 2 mins GU5 GUILDFORD Albury 33 mins 32 mins 1 min Bramley 27 mins 32 mins 5 mins Shere 38 mins 32 mins 6 mins From the modeling above it is proposed that, where there is no difference, SECAMB crews will make a local decision on destination taking into account road conditions and any adverse events such as road works or accidents. All other areas will be conveyed to the nearest HASU which will be enacted through an operational instruction to the SECAMB crews. Formal agreement has been received from SECAMB that this instruction will be implemented in line with the Stroke Services Review outcome timelines. 2.0 West System HASU/ASU and TIA provision Both CCGs consider that the benefits of the co-located HASU/ASU model in terms of improving patient outcomes, workforce and both clinical and financial sustainability, as identified through the Surrey Stroke Review process and expert panel, remain valid for the populations of Guildford and Waverley and North West Surrey. 9
Detailed analysis of the 2017/18 projected activity for ASPH and FPH has been undertaken to assure that it is in line with the proposed critical mass from the evidence used to inform the Surrey Stroke Review i.e. 500 strokes per annum to meet the minimum number for a HASU, 600 strokes per annum to reach the critical mass to secure clinical and financial sustainability. Projected activity for 2017/18 is outlined below: ASPH projected stroke activity is 768 strokes from all catchment areas. TIA and mimic projections will see c1108 admission to the ASPH HASU FPH projected stroke activity 840 assuming 65% of G&W patients flow to the HASU. TIA and mimic activity projections will see c 1630 admission to the FPH HASU From the above data the test for a requirement to have 2 co-located HASU/ASU for West Surrey (and 3 across Surrey) has been met ie both units above 600 strokes per annum. Response: In response to the public consultation commissioners requested providers review the proposed models of care to seek to address the concerns raised. Frimley Health and RSCH have subsequently submitted a case for a networked HASU and ASU with the ASU being sited in RSCH. This proposal builds on the original submission from Frimley Health for the Borders system in September 2016, which was previously assured. Following a full assessment panel review, the proposal offered by Frimley Health and Royal Surrey was assessed by the CCGs to both meet the requirements of the specification and provide a response to the issues identified as part of the public consultation. The amended proposals for stroke provision in West Surrey, including the proposal for networked HASU/ASU between Frimley Health and RSCH, has been subject to the NHS England assurance process which has resulted in consent to proceed to Committees in Common for CCGs decision. 3.0 West system hospital/bedded rehabilitation facilities The proposed pathways identified a number of options for bedded rehabilitation for both CCG populations. For North West Surrey the options considered were Woking Community Hospital and/ or Ashford Hospital For the Guildford and Waverley population the options considered were Farnham Community Hospital and Milford Community hospital. 10
Specialist stroke and neuro rehabilitation at the Bradley Unit, Woking Community Hospital is intended to remain on that site serving a wider population as is currently in place. Response : North West Surrey CCG considers that there are significant benefits to consolidating stroke rehabilitation services on a single site, the case for critical mass and workforce is well made in terms of the HASU/ASU and is applicable for rehabilitation beds also. NWS CCG considers that there should be a process of movement to single site provision over the next 2 years and in line with the full deployment of the stroke pathway and delivered flows in line with modeling. G&W CCG considers that bedded specialist rehabilitation in RSCH linked with the provision of the ASU, with access to non specialist rehabilitation within the community is the best fit for the local population, taking into account transport links, public opinion and to meet the specification as determined by best available evidence. 4.0 Affirm commitment to the additional resource across the integrated stroke care pathway from onset of stroke to six month follow up. The proposal was to invest additional monies c 403k in the proposed pathway and to fund Best Practice tariff through a capitated envelope approach. Response: Through the process of the review and consultation and through applying the learning from the interim arrangements in RSCH, the commissioners confirm the additional funding for 6 month follow up, psychological support and Best Practice tariff where it has been achieved. The position of the CCGs is that the capitated envelope approach will not be pursued and that all episodes of stroke will be funded through paying tariff, and funding Early Supported Discharge and community services in line with existing funding arrangements. 5.0 Recognise the commitment of SECAMB to support delivery of the model of care. Considerable feedback has been received through the public consultation regarding travel times to the HASUs and ambulance response times in general but from Waverley in particular. NWS CCG, as lead SECAMB commissioner for Surrey, is working closely with SECAMB to deliver improved response times across Surrey. Additionally there are new developments, recently announced which will be modeled in to improve ambulance services across England; this is the Ambulance response programme as launched by the Secretary of State in July. SECAMB have been working with ASPH and CCGs regarding the modeled flows, and as outlined above are continuing to support delivery of the flows to ASPH and FPH in line with the fastest route modeling. Response: 11
Both CCGs and SECAMB are committed to joint working to improve overall response times. CCGs and SECAMB have agreed actions to achieve a flow of 30-35% of Guildford patients to ASPH where it is the nearest HASU and 65-70% to FPH where it is the nearest HASU. The original modeling identified flows of 60% to FPH and 40% to ASPH and the CCGs will continue to work with SECAMB to achieve the optimal flow of patients to their nearest HASU whilst acknowledging that there may be some variance at times. 5. Conclusion NWS CCG and G&W CCG are committed to improving the outcomes for patients who suffer a stroke in our populations. The benefits of concentrating expertise and services on fewer sites makes a compelling argument. The Surrey Stroke Review recommended 3 co-located HASU/ASU across Surrey and the proposal for West Surrey is HASU/ASU at both FPH and ASPH. In responding to the consultation the commissioners recommend that : NWS population is best served by a co-located HASU/ASU at St Peters Hospital, Chertsey in line with the original proposal. Further that bedded rehabilitation continues to be provided from Ashford Hospital while the stroke pathway is mobilised with increased early supported discharge (ESD) provision, that over a period of 2 years that ASPH consolidate stroke rehabilitation beds to a single site. Guildford and Waverley population will be best served by co-located HASU/ASU at ASPH, and HASU at FPH with a networked ASU in RSCH. Further, that specialist bedded rehabilitation is provided from RSCH. NWS CCG and G&W CCG are committed to ensuring that the stroke pathway delivers the improved outcomes for patients and that the hospitals providing the stroke services are sustainable for the future. In order to ensure that the pathways set out in this document are delivered, as modeled, the CCGs will establish a Surrey wide stroke oversight group which will include the commissioners and providers across Surrey to ensure that Surrey wide services are sustainable going forward and any interdependencies are identified and managed. The stroke oversight group will have a specific focus on ensuring the West Surrey pathway is delivered in line with the proposals set out in this document and will have a responsibility to address issues where they arise, taking remedial actions should they be necessary. The Committees in Common is recommended the above as the outcome and CCGs response to the Surrey Stroke Review and feedback from the public consultation. Date: August 31 st 2017 Authors: Karen Thorburn, Director of System Redesign North West Surrey CCG Niki Baier, Director of Contracts, Guildford and Waverley CCG 12