Monday 20 June to Sunday 11 September 2011 haveasay.uk

1. A public consultation on proposed changes to hyperacute stroke services in County Durham and Darlington Monday 20 June to Sunday 11 September 2011 www.haveasay.org.uk

2. Welcome and introduction David GallagherDirector NHS County Durham and Darlington

3. 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

4. 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 onwww.haveasay.org.uk

5. Housekeeping • No fire drill is expected • Please switch mobiles off or to silent mode • Hearing loop system available

6. Why review hyperacute stroke services? Ben Clark Head of Strategy and Planning NHS County Durham and Darlington

7. 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

8. 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

9. Useful definitions • 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

10. 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

11. Useful definitions • TRANSIENT ISCHEMIC ATTACK (TIA) • Known as a ‘mini-stroke’ • Temporary stroke symptoms, usually lasting minutes • Risk of more severe stroke

12. Drivers for change – key quality standards • Accelerating stroke improvement programme • Local strategies and policies

13. Drivers for change – key quality standards • 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

14. 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

15. The current situation and why this needs to change Dr Bernard Esisi Specialist Stroke Consultant County Durham and Darlington Foundation Trust

16. Current situation University Hospital of North Durham Darlington Memorial Hospital Bishop Auckland Hospital • Hyperacute stroke services • Monday-Friday 08.00-18.00 • Alternate weeks out-of-hours • Vascular surgery for carotid disease • Centre of excellence for rehabilitation • 7-day stroke rehabilitation • Physiotherapy, occupational therapy, speech therapy • Hyperacute stroke services • Monday-Friday 08.00-18.00 • Alternate weeks out-of-hours • Vascular surgery for carotid disease Five-day TIA service Three clinics at Bishop Auckland Hospital Two clinics at University Hospital North Durham One clinic at Darlington Memorial Hospital

17. 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

18. 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 twofull time stroke consultants in County Durham and Darlington and twopart-time consultants • Delays in assessment and treatment of stroke patients

19. 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

20. 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

21. 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

22. 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 • Allpatients in County Durham and Darlington deserve the best possible treatment

23. The options appraisal process Rachel Emery Commissioning lead for stroke NHS County Durham and Darlington

24. 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

25. 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

26. 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

27. Weighting of criteria

28. How scores were determined

29. Results Single site models Two site + transfer model Regional models

30. Scores for single site model vs. current two site model

31. What were the differences in the top two scores? • Equity of access • Functional suitability

32. The preferred option for hyperacute stroke services in County Durham and Darlington Dr Mike Lavender Consultant in Public Health Medicine NHS County Durham and Darlington

33. Our preferred option University Hospital of North Durham Darlington Memorial Hospital • 24/7 hyperacute stroke services • 20 stroke beds • Full range of intensive and critical care facilities to support hyperacute stroke service • 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 Bishop Auckland Hospital: 7-day stroke rehabilitation service

34. Darlington Durham Current in-hours pathway Stroke ward Rehabilitation Darlington Stroke ward Bishop Auckland 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.

35. Darlington Durham Current out-of-hours pathway Stroke ward 1st week Rehabilitation Darlington Stroke ward Bishop Auckland Durham 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.

36. DarlingtonMH Durham Current out-of-hours pathway Stroke ward 2nd week Rehabilitation Darlington Stroke ward Bishop Auckland Durham 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.

37. Rehabilitation Stroke ward Bishop Auckland Durham Preferred future pathway 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.

38. Stroke ward Rehabilitation Durham Bishop Auckland Preferred future pathway - self presenting Darlington 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.

39. Why Durham? Important information which supports our preferred option • Shorter travel times • More people suffering a stroke in County Durham • Essential ultrasound, CT and MRI diagnostic facilities more readily available

40. 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

41. More stroke cases in County Durham • 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

42. More stroke cases in County Durham

43. More access to diagnostic facilities • 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

44. Transport implications and solutions • 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

45. Preferred option summary • 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

46. The consultation process Rachel Emery Commissioning lead for stroke NHS County Durham and Darlington

47. Your views are equally important Four tests for proposed service change:

48. How you can get involved • Take part in public meetings such as today • Complete the online questionnaire at www.haveasay.org.uk • Email us at stroke@haveasay.org.uk • 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

49. What we want to know • 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?

50. Your chance to have your say: group discussions and Q&A session David Gallagher Director NHS County Durham and Darlington