Why are stroke services changing across north Cumbria?

The North Cumbria Health and Care System is aware of concerns within the community about the development of a Hyper Acute Stroke Unit (HASU).

We want to be clear that this significant investment in services will bring benefits for all patients across north Cumbria. We hope answering these questions may help reassure our community.

We are planning to modernise and improve the care provided to stroke patients by developing an enhanced service called a HASU, not previously available across north Cumbria which has been proven to improve mortality and reduce long term disability.

What are the changes we are planning?

The development of a hyper acute stroke unit (HASU) at the Cumberland Infirmary will mean all potential stroke patients are initially brought to the unit at Carlisle where they will have access to a specialist stroke team made up of consultants, nurses and therapists 24 hours a day 7 days a week.

Admission to this unit is likely to be for a maximum of 72 hours at which point the patient will be discharged home, or if they need more support and are from west Cumbria can be transferred to the West Cumberland Hospital. Patients from the north of the county requiring extra support will remain in Carlisle.

Considerable work has been done alongside the work to develop a HASU to ensure that robust early supported stroke discharge (ESSD) teams support patients home, or closer to home, more quickly.

This is in line with national best practice.

Stroke treatment is about regaining independence – reducing long term disability.

Access and treatment at a HASU in its own right improves mortality (death rate) and long term ability to a far greater extent than traditional models.

What do we have at the moment?

We have two 5 day a week services – at the West Cumberland Hospital in Whitehaven and the Cumberland Infirmary in Carlisle. We have stroke rehabilitation and post-stroke services at both sites.

We have a brilliant team doing their best in the face of a national shortage of stroke specialist staff – consultants and nurses – that are under immense pressure. It isn’t sustainable.

We should have 6 stroke consultants, but in fact we have 1 substantive consultant and two locums. We have struggled to recruit for several years.

Don’t we have that now at both sites?

No – there is a 5 day service at both sites, with the care of potential stroke patients admitted out of hours, looked after by general medical staff.

We should be offering the most modern service in line with national best practice.

What happens elsewhere?

National best practice is to treat patients at a HASU, where a team of specialists are able to provide timely and effective intervention and early decision making. Most other areas of the UK already offer HASU care from specialised units and we believe the people of north Cumbria deserve the same.

Patients treated in a HASU generally have better functional outcomes and fewer complications.

Why is it being planned for Carlisle?

Because Carlisle is closer to Newcastle, where a small number of patients may need transfer for more complex neurological interventions.

What if people from west Cumbria can’t get there in time?

A very small number of patients may benefit from a specific treatment called thrombolysis. This is a clot-busting treatment that in some patients restores blood flow to the brain. There is a four and a half hour window for patients who are eligible for this treatment.

However, patients must be carefully assessed, as administering thrombolysis to some patients could cause harm.

Only 10-15% of patients could be eligible for thrombolysis. Of those patients only 30% receive any benefit from the treatment.

So of 200 potential stroke patients seen at the West Cumberland Hospital every year around 20 are eligible, and of those only around 6 will receive any benefit, whereas all 200 will receive improved outcomes by attending a HASU.

By developing and investing in service to have a specialist centre accessible 24 hours a day, 7 days a week, we are increasing the speedy and specialist assessment and care for all stroke patients.

We are designing services for ALL stroke patients, not just the 10% that may be thrombolysed.

All patients will benefit from the care offered by a specialist team in the 72 hours after a stroke. Just by offering the enhanced service at weekends we increase the support for patients who are admitted with potential stroke on 120 more days a year than our current service.

What is changing at the West Cumberland Hospital?

There will still be inpatient stroke rehabilitation and stroke review clinics at West Cumberland hospital.  We are also planning new early supported stroke discharge teams to improve the rehabilitation patients receive after discharge from hospital.

Assessment and treatment at Carlisle is only for the initial acute phase.

When was all this decided?

It was part of the Healthcare For The Future public consultation September to December 2016 with the decision made by NHS Cumbria Clinical Commissioning Group’s (CCG) Governing Body in March 2017.

The information was discussed during the presentations at all public meetings, a stroke-focused public event was held and it was discussed and covered in the local media.

The consultation documents also clearly outlined the potential disadvantage to a handful of patients who may be eligible for thrombolysis and miss the window. It also pointed out the huge benefit from the rest of the population by expanding and specialising these services. It is important that our health and care system is open and honest with our community about the impact of changes.

This option was developed working with NHS England’s stroke lead Tony Rudd and other independent clinical experts with input from the Stroke Association.

Is it unsafe for critically ill patients to travel for urgent care?

All potential heart attack patients from across north Cumbria are already treated at the Heart Centre based at the Cumberland Infirmary. The outcomes for patients have improved greatly – this includes patients travelling from west Cumbria. We would expect similar benefits for stroke patients.

It is very unusual for stroke patients to die very rapidly after a stroke. Very poorly patients are likely to die in the days after becoming ill.

Why can’t you leave things as they are?

We can’t leave things as they are because it is right to modernise and improve our services for people living across north Cumbria.

We know there are national shortages of stroke specialists – we have several vacancies – and we must make the best use of our precious resources.

If we leave things as they are our services will become increasingly fragile. There is a real risk to the service if we lose any more staff, and we know the service as it stands is putting our staff under increasing pressure.

We believe we will have more success recruiting to a modern service.

When will the HASU be in place?

To create a HASU requires a significant investment for north Cumbria. We will need to make sure the unit is ready, a second CT scanner is in place, and our new workforce model is effective. We are working towards the Autumn.

What is happening now?

Last month NHS North Cumbria CCG’s Governing Body reviewed the progress being made in planning the new HASU to ensure transition to the new services would be safe and effective and agreed that the work was progressing well.

We are working towards opening the HASU later this year and we are holding workshops with our community, organised by the Stroke Association, to ensure the voice of patients, their family and carers and the wider community helps shape the implementation plans.

We have held workshops in Workington and Carlisle, we are planning more in Copeland and Eden.

How can you prevent a stroke?

You can give yourself the best chance of avoiding health problems by remaining active and having a healthy diet.

To minimise the risk of a stroke have your blood pressure checked regularly and keep it under control with medication if needed.

What should I do if I suspect a stroke?

Don’t wait to see if it passes. If you have any of the symptoms highlighted by the FAST campaign seek help.

Face – drooping of the face

Arm – weakness in the muscles

Speech – is unexpectedly slurred

Time to seek help – call 999.

Comments from clinical leaders:

Dr Paul Davies, consultant stroke physician and clinical lead for North Cumbria University Hospitals Trust said: “Stroke care has changed dramatically over the last ten years and the current model of two stroke units in North Cumbria is no longer providing the most up to date care for patients in North Cumbria.

“Most areas now have access to hyper acute stroke units where expert opinion can be accessed any day of the week.  To do this many stoke units have merged into bigger units, admitting patients from wider areas.  The results have been falling mortality and better outcomes from stroke.

“The distances and travel times in north Cumbria are significant, but this model of care should provide a more resilient service and improve outcomes for everyone.”

Dr David Rogers, medical director for NHS North Cumbria CCG, said: “This new model will see services offered 24 hours a day, 7 days a week and will be better for all of our community.

“Patients from west Cumbria will have to travel in the future for specialist treatment and then can return to the West Cumberland Hospital for rehabilitation after that short initial phase.

“But the benefits for staff and patients will be considerable and help people live a better life after stroke.”

TIMELINE

2012 – Concerns raised about the ability to staff a 2 site service across north Cumbria and awareness of the growing challenge of a developing national shortage of stroke specialists

2010 – Work to develop first HASU in UK in London and in Manchester

2014 – Specialist centres available 24-7 acknowledged as best clinical practice

Sept 2016 – The Healthcare For The Future public consultations outlines the reasons a HASU is the preferred model for north Cumbria.

March 2017 – NHS North Cumbria CCG agrees to the option developing a HASU

April 2017 – Work starts to develop the HASU model, identify additional CT scanner and estates changes and develop a sustainable workforce model

March 2018 – Local workshops to ensure the patient, carer and community voice is involved as implementation plans are drawn up

April 2018 – NHS North Cumbria CCG agreed plans were developing well and to continue the progress.

Autumn 2018 – provisional start date

What is the national situation?

75% hospitals have 7 day a week services. We don’t have that in north Cumbria.

Information provided the Sentinel Stroke National Audit Programme (SSNAP)

https://www.strokeaudit.org/Documents/National/AcuteOrg/2016/2016-AOAInfographic.aspx