Improving Stroke Services for the People of County Durham And

Improving stroke services for the

people of County Durham and

Darlington:

A consultation proposal

document

March 2011 1

CONTENTS:

1. Introduction 2. Who’s who 3. Useful definitions 4. Scope of consultation proposal 5. Background 6. The case for change 7. Summary of proposed changes: what they mean for patients 8. Alternative options – and why these have been discounted in favour of the preferred model 9. The story so far: how the proposals were developed 10. Proposed consultation and communications plan 11. Appendices

Appendix 1: Options appraisal methodology and outcomes Appendix 2: DASH data analysis Appendix 3: Pre-engagement event 1: full stroke pathway review, December 2010, Appendix 4: Pre-engagement event 2: evaluation of options appraisal, February, 2011 Appendix 5: Draft consultation and communications plan Appendix 6: List of groups involved to date

12. Glossary of terms

March 2011 2

1.0 INTRODUCTION

Stroke remains a major cause of death and disability across County Durham and Darlington with around 1,100 people suffering a stroke each year. These patients need access to high quality, specialist hospital care to give them every opportunity to make a full and speedy recovery. While recent changes to local hospital services have helped to make improvements to stroke services, we recognise that much more needs to be done to ensure all patients have the best possible treatment.

Both clinical and stakeholder opinion suggest that centralising stroke hyper-acute services on a single hospital site is the best way to ensure that more patients have access to first rate care without having to travel outside of County Durham and Darlington.

NHS County Durham and Darlington in collaboration with County Durham and Darlington NHS Foundation Trust and other stakeholders, has carried out a review of stroke services. One of the main conclusions of the review is a recommendation to amalgamate hyper-acute stroke services on a single hospital site; the University Hospital of North Durham.

Here, patients will have access to 24-hour, specialist stroke care, seven days a week. Highly-trained paramedics will take people suffering a stroke to the hospital where they will be directly admitted to a specialist stroke unit, rather than having to wait in Accident and Emergency. Patients will be assessed, diagnosed and treated sooner thanks to access to specialist clinicians, high quality imaging equipment and closer working with related specialties such as vascular services.

This document will set out the clinical case for change, together with the development process underpinning the proposals. As the proposals constitute a substantial variation to existing service provision, NHS County Durham is proposing to hold a formal 12-week consultation to seek local views. This document is intended to inform local Health Overview and Scrutiny Committees’ decisions as to whether this is the appropriate course of action.

2.0 WHO’S WHO

2.1 NHS County Durham and Darlington NHS County Durham and Darlington is the name for the partnership arrangement between two primary care trusts, known separately as NHS County Durham and NHS Darlington. Working together, the organisation is responsible for commissioning – planning and paying for – £1.2billion worth of services on behalf of the 600,000 local people it serves. In order to improve the health and well-being of the local population, it buys services from local service providers such as hospitals, GPs, opticians, dentists and other independent, voluntary or community providers.

2.2 County Durham and Darlington NHS Foundation Trust (CDDFT)

March 2011 3 County Durham and Darlington NHS Foundation Trust is the main provider of hospital services to the people of County Durham and Darlington. It provides general acute and emergency hospital services from Darlington Memorial Hospital and the University Hospital of North Durham and provides planned care, rehabilitation and urgent care from Bishop Auckland Hospital. It also provides community hospital services from Shotley Bridge Hospital and Chester-le-Street Community Hospital as well as a range of outpatient and outreach services from other community sites.

County Durham and Darlington NHS Foundation Trust is the provider of hyper- acute stroke services for patients in County Durham and Darlington.

2.3 Stroke Strategy Implementation Group (SIG) The Stroke Implementation Group is a multi-agency group run by NHS County Durham and Darlington. It includes consultants, nurses, commissioning managers and stroke service user and carers among its members. The group’s work is closely connected to the National Stroke Strategy, published by the Department of Health in December 2007. The strategy provided a quality framework to improve stroke services throughout the care pathway and, locally, the SIG has focused on improving the quality of services and patient pathways for those suffering from stroke or TIA.

2.4 NHS North East NHS North East is the strategic health authority for the North East. It is responsible for ensuring that all health services are fit for purpose, well- planned, of high quality and meet Department of Health targets.

2.5 North East Cardiovascular Network The North East Cardiovascular Network is a virtual organisation, comprising clinicians and managers from a range of North East NHS organisations such as hospital trusts, ambulance trusts and both commissioning and provider primary care trusts. It strives to improve cardiac, stroke and vascular care for North East patients.

3.0 USEFUL DEFINITIONS

3.1 Hyper-acute stroke services

The term hyper-acute refers to the point at which a patient is at their most seriously ill and in need of access to rapid, specialist assessment and treatment. Following a stroke, a patient is therefore taken to a hyper-acute stroke service where they should have 24-hour access to:

 rapid assessment – a patient must arrive in a specialist stroke ward no more than two hours after having a stroke and be assessed by a specialist;  access to a CT scan within 30 minutes of arrival;  early treatment using clot-busting drugs (thrombolysis) if a scan shows they are needed within three hours of having a stroke (and 30 minutes of arrival);

March 2011 4  24/7 monitoring in a high dependency bed; and  a multi-disciplinary specialist team on call 24/7; including consultants, specialist nurses and therapists.

Once the patient is stabilised (usually within around 72 hours) they will be moved to an acute unit or a dedicated stroke unit where they receive further care and rehabilitation support.

Patients who have suffered a suspected transient ischemic attack (TIA), also known as a ‘mini stroke’, can use a 24-hour assessment service based in a hospital setting and within seven days for patients at lower risk.

3.2 Thrombolysis Thrombolysis is a type of treatment which uses drugs to break up a blood clot. An ischemic stroke is where the blood supply to part of the brain is interrupted by a clot or another blockage. Thrombolysis is therefore used to treat some patients who have an ischemic stroke and is vital to reducing the long-term impact of a stroke.

A scan will identify if a patient is suitable for thrombolysis – for some types of strokes, thrombolysis can worsen the condition so it is vital to identify the type of stroke with which a patient presents.

The window of opportunity for thrombolysis to be most effective for appropriate patients is no more than three hours from the onset of a stroke. However, to ensure the best clinical outcomes, patients must receive specialist treatment as soon as possible. It is safe to be administered only after examination by an experienced stroke specialist.

The effect of thrombolysis treatment for stroke patients is that:  10% have significantly improved outcomes,  40% see some improvement,  45% experience no change and,  5% endure possibly worse outcomes.

3.3 Transient Ischemic Attack (TIA) A TIA occurs when there is a temporary interruption in the blood supply to part of the brain, leading to a lack of oxygen to the brain. This can cause symptoms that are similar to a stroke, although they last only a few minutes and rarely longer than 24 hours.

3.4 Telemedicine This is a relatively new but safe way of working in the NHS which involves the use of technology to enable a patient to be assessed ‘remotely’ by specialists based elsewhere. A patient with suspected stroke symptoms may therefore present at a local hospital accident and emergency department to undergo a remote stroke and through the use of computer and video technology, will have a full

March 2011 5 assessment by a vascular neurologist at a hyper-acute stroke unit at a different location.

3.5 Drip & ship This is a term often used to refer to the management of patients as they are transferred to the most appropriate hospital site for treatment. For example, if a patient who has suffered a stroke goes to an accident and emergency department where there is no hyper-acute stroke service, that patient can be treated as quickly as possibly with intravenous drugs which will enable the patient to be safely transferred to a hyper-acute stroke unit for intensive monitoring and management.

3.6 Carotid endarterectomy This is an operation to remove the inner lining of the carotid artery, which is one of two major blood vessels in the neck that supply blood to the brain. Thickening of the artery walls may limit the blood supply to the brain and cause a stroke.

4.0 SCOPE OF CONSULTATION PROPOSAL This consultation proposal document focuses exclusively on proposed changes to hyper-acute stroke services as both clinicians and stakeholders have identified this as the priority part of the patient pathway.

It will focus ONLY on hyper-acute services for patients who would traditionally receive stroke acute care in the University Hospital of Durham and Darlington Memorial Hospital. 75% of all strokes experienced by people living in County Durham and Darlington are treated at Durham and Darlington hospitals. The proposed changes DO NOT impact on the stroke care pathway for patients living in East Durham who will continue to receive stroke hyper-acute care at City Hospitals Sunderland and the University Hospital of North Tees.

5.0 BACKGROUND

5.1 The National and Regional Strategic Context

5.1.1 Operating Framework for the NHS for 2011/12 Stroke continues to be as a key feature within national policy with an emphasis on the need for continual improvement, particularly for 24-hour, 7 day-a week access to hyper-acute services within targeted hospitals. A specific national quality and performance targets which relate to acute stroke services is: - the number of patients who spend at least 90% of their time on a stroke unit’.

The NHS is monitored on progress against this and held to account on delivery.

5.1.2 National Stroke Strategy The National Stroke Strategy was published by the Department of Health in 2007, outlining recommendations for health and social care in relation to the full stroke care pathway. It recommended that people who are suspected of

March 2011 6 having a stroke should be immediately transferred to a hospital providing hyper- acute services throughout the day and night. On admission to a specialist stroke unit the following should be made available:  Early expert multidisciplinary assessment  Rapid imaging and specialist interpretation of results  Determination of the most appropriate form of treatment  The ability to provide rapid intravenous thrombolysis if required The recommendations within this report relate to three specific quality markers within the report:

Quality marker 7 identifies the need for targeted hospitals to provide hyper-acute stroke services 24 hours a day and 7 days a week. With access to specialist triage, assessment, timely imaging and the ability to deliver intravenous thrombolysis within a 3 hour period from admission by a specialist physician. The strategy highlights the need for local commissioners and providers to regularly review pathways to ensure people suffering strokes are being appropriately transferred. A quick brain scan can determine what sort of treatment is the most appropriate. Quality marker 8 highlights that patients who are suspected as having an acute stroke receive immediate structured clinical assessment form the most appropriately qualified people. This standard emphasises the need for scanning equipment and clinical interpretation to be available 24 hours a day. This should also include swallow screening within a 24 hour period and identification of cognitive and perceptive problems. Quality marker 9 relates to the treatment aspect of the hyper-acute episode within the pathway. It states that all services relating to stroke are available in the same place by a multidisciplinary team with the most effective treatment options. It identifies the need for prompt access to a stroke unit and the need for continued specialist care for as long as necessary. There should be 24 hour access to imaging and if necessary thrombolysis. It is also necessary to provide rapid neurological care and specialist care for respiratory, swallowing, dietary and communication issues.

5.1.3 National Audit Office Report The 2010 National Audit Office report reported on national progress in stroke services since. It highlighted the following:  The proportion of stroke patients who spend more than 90% of their hospital stay on a stroke unit has increased from 51% in 2006 to 59% in 2008.  In 2006 fewer than one in five trusts offered access to thrombolysis for at least part of the week, in 2009 two thirds did. Access at weekends and evenings is still significantly limited

March 2011 7  In some health authority areas where there are high levels of rurality, hospitals are using telemedicine to enable doctors to make diagnoses and internet scans whilst off-site 5.1.4 Accelerated Stroke Improvement Programme The Accelerated Stroke Improvement Programme is a Department of Health initiative to improve stroke services in an efficient manner. This programme is being actively supported by NHS North East. One of the service areas highlighted for development is timely access to acute stroke and imaging. Locally, standards have been developed to measure progress against the initiative and to set a target for people to work towards. One of these specifically relates to hyper-acute services with 90% of stroke patients to be directly admitted to a stroke unit within 4 hours of arriving at hospital by April 2011.

5.1.5 National Institute for Clinical Excellence (NICE) Guideline NICE guidance introduced in 2009 underpins the policy context on stroke which relates to specialist care for people with acute stroke. It states that all people with suspected stroke should be directly admitted to a specialist stroke unit following an initial assessment. Brain imaging should be given rapidly if there is an opportunity for thrombolysis or early anticoagulation treatment.

At a regional level the North East Cardio-Vascular Network (NECVD), supported by NHS North East, has co-ordinated a programme of work to improve health outcomes of patients suffering a stroke across the region. This work focused on the hyper-acute element of stroke services and established regionally-set timescales with key milestones and gateways. As such, a regional timeline was set for 24/7 hyper-acute stroke services to be in place by December 2010. The NECVD is also pressing for the introduction of a 7-day service for patients experiencing a Transient Ischemic Attack (TIA).

5.2 The Local Strategic Context

5.2.1 Stroke Service Review In response to the national and regional drive to improve standards of care for stroke patients, NHS County Durham and Darlington embarked upon a Stroke Service Review. The organisation’s Stroke Implementation Group, multi-agency group including consultants, nurses, commissioning managers and stroke service users and carers among its members, led this piece of work. This review looked at the whole stroke pathway from stroke prevention right through to rehabilitation care offered after discharge from hospital. It highlighted a number of areas of progress together with areas for improvement. In relation to acute stroke hospital services, the need for greater direct admission to stroke services was highlighted together as well as concerns about the sustainability of the current hospital model of acute service provision across two hospital sites.

5.2.2 Seizing the Future

March 2011 8 County Durham and Darlington NHS Foundation Trust’s Seizing the Future programme proposed significant changes to the way local hospital services in County Durham and Darlington were configured. Following the approval of the proposals by NHS County Durham in March 2009, the service changes were implemented with effect from 1st October 2009.

The changes consolidated acute care at Darlington Memorial Hospital (DMH) and the University Hospital of North Durham (UHND). Planned care and rehabilitation is provided from Bishop Auckland General Hospital (BAGH) where patients have access to specialist rehabilitation to improve recovery.

As a result of these changes, since 1st October 2009, all patients experiencing a stroke have been treated at the University Hospital of Durham or Darlington Memorial Hospital when they are at their most seriously ill. They are then transferred to Bishop Auckland General Hospital for rehabilitation care when they are fit to do so.

5.2.3 Implementation of the two site model for 24/7 hyper-acute stroke services

In order to meet the North East Cardio-Vascular Network and NHS North East’s regional timeline for 24/7 hyper-acute stroke services in December 2010, County Durham and Darlington NHS Foundation Trust (CDDFT) submitted a plan which put forward the two site model (as outlined in Seizing the Future). This was supported by an action plan outlining the steps the trust would take in order to meet the regionally agreed criteria for provision of high quality hyper- acute services.

County Durham and Darlington NHS Foundation Trust, supported by NHS County Durham and Darlington, implemented the service changes within the current two site hyper-acute stroke service model that is now in operation.

Thrombolysis treatment became available in the County Durham and Darlington area out of hours and at weekends for the first time from 6th December 2010. Thrombolysis had previously only been available in County Durham and Darlington between 9am and 10pm, Monday to Friday.

5.3 Current stroke service provision Hyper-acute stroke services are currently delivered from both Darlington Memorial Hospital and the University Hospital of North Durham, Monday to Friday during normal daytime working hours. Out of hours hyper-acute stroke services, including the provision of thrombolysis, run from each hospital on alternating weeks, i.e. one week at Darlington and the next at Durham.

A TIA service, for patients experiencing a Transient Ischemic Attack (TIA), runs five days-a-week from both hospitals, including out of hours. The University Hospital of North Durham provides local vascular surgery for patients needing a carotid

March 2011 9 endarterectomy, an operation to remove the inner lining of the carotid artery which is one of two major blood vessels to supply blood to the brain.

Planned care and rehabilitation for stroke sufferers is provided from Bishop Auckland Hospital (BGH) where patients have access to 7-day-a-week specialist rehabilitation to improve recovery. Patients are transferred there once their condition is stable enough to allow this to safely happen.

6.0 THE CASE FOR CHANGE

6.1 Prevalence of stroke Stroke remains one of the three biggest causes of death in the United Kingdom, with approximately 110,000 new strokes diagnosed each year. In County Durham and Darlington, over 1,100 people suffer a stroke each year, with over 900 of these admitted to hospital as a result. Of those who survive, around half will end up with some kind of long term disability as a direct result of the stroke.

6.2 Risks of the status quo – why the two-site model cannot continue

6.2.1 Staffing and recruitment pressures Limited staffing levels for hyper-acute stroke services pose short term risks to clinical care and threaten the long-term sustainability of the current two site model. County Durham and Darlington NHS Foundation Trust currently has only two full time consultants for stroke hyper-acute services, supported by two part time consultants who are approaching retirement. This can result in the delayed assessment and treatment of stroke patients and presents significant challenges in the delivery of consistent, high quality clinical care.

Clinicians believe the optimum number of full time consultants for a two-site hyper-acute stroke service to be six. Any hope of future consultant recruitment is slim, however, due to the limited investment in stroke consultant training nationally. A greater number of local stroke centres also means greater competition for existing stroke specialists and centres of excellence often remain the most attractive employment option.

The service is also suffering from low numbers of specialist nurses and therapists and the Trust faces ongoing challenges to find enough staff for disciplines such as radiology that are necessary to support hyper-acute services 24/7.

6.2.2 Few direct admissions to stroke units The number of direct admissions to the two existing stroke units is low. The majority of patients who go straight to a stroke ward are admissions via a GP. Most ambulance-delivered stroke patients are admitted to the stroke unit via Accident and Emergency and Medical Admissions Units. This often results in

March 2011 10 delays in assessing and treating patients and leads to unnecessary longer stays in hospital.

6.2.3 Variable access to vascular services Many patients who have a stroke need some type of urgent vascular surgery, such as an operation to clear a blockage in the carotid artery, to improve blood flow to the brain. This surgery is available only at the University Hospital of North Durham and not Darlington Memorial Hospital. Stroke patients being treated in Darlington therefore must be transferred to Durham in order to have such an operation.

6.2.4 Limited Transient Ischemic Attack (TIA) Services A TIA service is currently only available at the University Hospital of North Durham and Darlington Memorial Hospital five days a week as oppose to the required seven-day-a-week standard. This means that the service is unable to assess all patients who are deemed to be a high risk TIA within the recommended time limit of 24 hours.

6.2.5 Inability to fulfill quality standards Clinicians believe that the ideal pathway of care for a stroke patient care, as highlighted below, is currently achieved for less than 10 out of approximately 900 stroke patients. Stroke service commissioners, providers and the patient and public stakeholders involved to date, collectively agree that this is unacceptable for the people of County Durham and Darlington. The local clinical consensus is that the Accelerated Stroke Metrics and NICE Quality standards for hyper acute stroke, as detailed in section 5.0, cannot be achieved with a two site model

6.2.6 Risk to multi-agency collaboration There is a real risk arising from lack of collaboration with other organisations. As the commissioners of the service, NHS County Durham and Darlington need to include 'collaboration' or cross boundary flow in a future model as 20% of strokes from County Durham are treated in trusts other than County Durham and Darlington NHS Foundation Trust.

6.2.7 Not best value for money While clinical quality and service sustainability are the primary drivers for this proposed service reconfiguration, the costs incurred by the current two-site model cannot be ignored. The cost of staff travel between two sites, compounded by the high premiums attached to locum consultants who are needed to ensure sufficient medical cover is available, make the current model of service provision significantly less cost effective than that of a single site.

7.0 SUMMARY OF PROPOSED CHANGES: WHAT THEY MEAN FOR PATIENTS

7.1 Future service provision – what the preferred option would look like

March 2011 11 The preferred service configuration model being recommended by NHS County Durham and Darlington is to consolidate stroke hyper-acute services onto a single site; the University Hospital of North Durham. This will mean patients being taken by ambulance directly to the University Hospital of North Durham. 90% of stroke patients will continue to arrive at hospital within 30 minutes. Paramedics will alert the Durham stroke unit to the patient’s anticipated arrival to enable appropriate preparations to be made.

The patient will be directly admitted to the stroke ward, without any unnecessary delays in Accident and Emergency or Medical Admissions Unit. He or she will be immediately assessed by a specialist stroke consultant before undergoing the required tests, such as having a CT scan, to confirm diagnosis. Any further diagnostic tests will be performed by a team of key clinicians who will be specialists in using and interpreting all necessary scanning and imaging equipment.

Should a patient present at Darlington Memorial Hospital by car or taxi, the patient will be assessed by stroke specialists at the University Hospital of North Durham via the use of telemedicine technologies. The patient will be given intravenous medication to stabilize their condition before being safely transferred to the University Hospital of North Durham for further, immediate care.

Patients who require vascular surgery to minimise the risk of further strokes will be referred for this immediately and will expect to have their operation at the University Hospital of North Durham, without the need for delays or transfers to other hospitals.

A full range of intensive and critical care facilities will be on site at the University Hospital of North Durham to support the hyper-acute stroke service, for those seriously ill patients who may need it.

When patients are fit to leave the hyper-acute stroke service, they will be transferred to the Centre of Excellence for Rehabilitation at Bishop Auckland Hospital where they can expect to receive a 7-day specialist stroke rehabilitation service. This will include input from a range of physiotherapists, speech and language therapists and occupational therapists as well as stroke support workers.

7.2 Benefits of a single site location By consolidating stroke hyper-acute services onto a single hospital site, stroke patients in County Durham and Darlington stand to gain the following:  Consistent access to specialist stroke consultants, including out of hours  Direct access to a stroke ward  Immediate assessment by specialist stroke consultants and the necessary multi-disciplinary team  Access to a 7-day-a week TIA service

7.3 Benefits of direct access to a stroke ward A single site service configuration will allow all patients to be directly admitted to a stroke ward. This will deliver the following benefits:

March 2011 12  Faster assessment and diagnosis by a specialist stroke consultant without waiting in Accident and Emergency or Medical Admissions Units  Reduce the time it takes for a patient to receive vital thrombolytic drugs once they reach hospital to no more than 20-30 minutes  More high risk TIA patients assessed within 24-hours

7.4 Benefits of preferred location By recommending that a single stroke hyper-acute service be based at the University Hospital of North Durham, patients will benefit from the following:  90% of patients reaching hospital in 30 minutes with an average travel time of 17 minutes; this would drop to 60% should the service be based at Darlington with an increased average travel time of 24-minutes  Access to more specialist diagnostic services resulting from a high throughput of patients  Faster access to vascular surgery due to closer alignment of related specialist services

7.5 Transport implications NHS County Durham and Darlington recognises that the preferred model has travel and transport implications for patients, carers, relatives and staff. These will be particularly prevalent for communities in the south of the patch who may have traditionally accessed hyper-acute stroke care in Darlington. While a stroke patient’s stay in hospital for hyper-acute treatment is expected to be short term, this does not lessen the transport concerns local people will inevitably have. A full transport appraisal will be undertaken to understand local transport needs and to ensure sufficient access to any preferred model that is eventually implemented.

7.6 Equality impact assessment A full equality impact assessment will be undertaken prior to the start of any formal consultation. This will evaluate the impact of the preferred model on local communities and enable early identification and prioritisation of issues.

8.0 ALTERNATIVE OPTIONS – AND WHY THESE HAVE BEEN DISCOUNTED IN FAVOUR OF THE PREFERRED MODEL (NB: Options are listed in order of the highest ranking, after the preferred model)

Single site hyper acute service based at Darlington Memorial Hospital with rehabilitation care provided at Bishop Auckland Hospital (2nd highest ranking option) This model would deliver equal clinical quality to the preferred model with direct access to a dedicated stroke unit and a 7-day TIA service all available. Economies of scale and greater efficiency in comparison to the current two-site model would also be achieved, creating greater flexibility in staffing availability and delivering sustainability. However, this model would fall short on equity of access, as has been evidenced through the analysis of stroke patient numbers and ambulance travel times.

Data shows that 30% less people suffering a stroke would reach hospital in the recommended 30-minute time target if the single site location was Darlington

March 2011 13 Memorial Hospital, than if the single site location was the University Hospital of North Durham. The average distance for patients being taken to Darlington Memorial Hospital is also five miles longer than if patients were taken to Durham. Given that speedy assessment, diagnosis and treatment is critical for stroke patients, it is therefore deemed safer to recommend a service which supports fast access for the greatest number of patients.

Furthermore, limited access to vascular ultrasound imaging technologies makes this model less suitable as a location. Vascular surgery is located at the University Hospital of North Durham and the alignment of hyper-acute stroke services to such services will mean that patients needing surgical interventions such as widening of the carotid artery, can be operated on sooner and with minimal disruption to their care.

Single site at University Hospital of Durham with drip and ship facilities to neighbouring hospitals in Newcastle and Teesside and rehabilitation care at Bishop Auckland Hospital (3rd highest ranking option) This model would mean stroke patients being taken by ambulance to the University Hospital of North Durham where they would be assessed and prescribed initial treatment by stroke specialists at the nearest hyper-acute stroke service using telemedicine facilities. These are likely to be in Newcastle for patients in the north and Middlesbrough or North Tees for patients living in the south. Patients would then be safely transported by ambulance to the specialist hyper-acute sites in Newcastle or Teesside, before potentially being transferred back to Darlington or Durham hospitals for the acute part of their care and ultimately to Bishop Auckland Hospital for rehabilitation.

This model has the potential to deliver higher standards of clinical quality than the preferred option due to the fact patients would receive hyper-acute care at regional centres of excellence with maximum staffing and equipment levels. It would be less accessible for patients and their relatives, however, due to the need to use hospitals outside of County Durham and Darlington. The added transport and transfer needs would also make this service model more costly than the preferred option.

Single site at Darlington Memorial Hospital with drip and ship facilities to neighbouring hospitals in Newcastle and Teesside and rehabilitation care at Bishop Auckland Hospital (4rd highest ranking option) As per the previous model, this would involve stroke patients being taken by ambulance to Darlington Memorial Hospital where they would be assessed and prescribed initial treatment by stroke specialists at the nearest hyper-acute stroke service using telemedicine facilities. These are likely to be in Newcastle for patients in the north and Middlesbrough or North Tees for patients living in the south. Patients would then be safely transported by ambulance to the specialist hyper-acute sites in Newcastle or Teesside, before potentially being transferred back to Darlington or Durham hospitals for the acute part of their care and ultimately to Bishop Auckland Hospital for rehabilitation.

This model would have the potential to deliver high standards of clinical quality than the preferred option due to the fact patients would receive hyper-acute care at

March 2011 14 regional centres of excellence with maximum staffing and equipment levels. It would be less accessible for patients and their relatives, however, due to the need to use hospitals outside of County Durham and Darlington. The added transport and transfer needs would also make this service model more costly than the preferred option.

Regional model (5th highest ranking option)

This model would mean all stroke patients in County Durham and Darlington being taken directly to stroke hyper-acute services in tertiary hospitals in either Newcastle of Middlesbrough. Once their condition was stabilized, patients would potentially be transferred back to Darlington or Durham hospitals for the acute part of their care and ultimately to Bishop Auckland Hospital for rehabilitation.

This model would offer the same high standards of clinical care to the preferred model and would be equally as sustainable for the future. Economies of scale would be achieved with sufficient staff and integration of services. Access problems would be incurred, however, due to the hyper-acute components of care not being delivered locally. Greater transport costs would also make this model less more expensive than the preferred model.

Single site at Bishop Auckland Hospital (6th highest ranking option)

This option scores low for clinical quality because Bishop Auckland does not have the necessary critical and acute care services to support hyper-acute stroke, and these are not sustainable at Bishop Auckland.

9.0 THE STORY SO FAR: HOW THE PROPOSALS WERE DEVELOPED

The development of NHS County Durham and Darlington’s preferred model of future stroke hyper-acute services has been informed by multiple sources; an initial full pathway review, two pre-engagement events with key local patient and professional stakeholders, a thorough options appraisal process and analysis of ambulance travel times to hospital for stroke patients (DASH data). This process is depicted in figure 1 and summarized in the sections below.

March 2011 15

Figure 1: Process of identifying a preferred option

9.1 Options appraisal process During January, 2011, the Stroke Strategy Implementation Group (SIG) oversaw an options appraisal process to evaluate eleven proposed models of hyper-acute services for County Durham and Darlington. This options appraisal was undertaken by a small sub-group of the SIG, comprising of County Durham and Darlington Foundation Trust’s lead stroke consultant and their clinical stroke service manager together with NHS County Durham and Darlington’s clinical public health lead and stroke service commissioning manager.

The 11 options evaluated were:

1. Two site 24/7 Hyper Acute model - UHND & DMH + Rehab BAGH 2. Single site 24/7 Hyper Acute model - UHND + Rehab BAGH 3. Single site 24/7 Hyper Acute model - DMH + Rehab BAGH 4. Single site 24/7 combined model – BAGH 5. Two site 24/7 Hyper Acute model - UHND & DMH + Rehab

March 2011 16 BAGH + OOH diversion to single site – UHND 6. Two site 24/7 Hyper Acute model - UHND & DMH + Rehab BAGH + OOH diversion to single site – DMH 7. Drip & ship including telemedicine + single site 24/7 Hyper Acute model - UHND + Rehab BAGH 8. Drip & ship including telemedicine + single site 24/7 Hyper Acute model - DMH + Rehab BAGH 9. Single site 24/7 Hyper Acute model - UHND + Rehab BAGH + collaboration for drip & ship with neighbouring Trusts 10. Single site 24/7 Hyper Acute model - DMH + Rehab BAGH + collaboration for drip & ship with neighbouring Trusts 11. CDDFT not to have Hyper Acute - regional model

The criteria used to evaluate each of the potential models was agreed and weighted in the following priority order:

 Clinical quality  Sustainability/flexibility  Equitable access to services  Efficiency of services  Workforce planning and implications  Functional stability  Acceptability  Cost effectiveness

A scoring process was then used to grade each criteria for each service model. A full breakdown of the criteria, weighting, scoring and options scores is detailed at appendix 1.

The 11 models were ranked in the following preferred order, according to the outcome of the scoring process:

Ranking Option Service model description Score number 1 2 Single site 24/7 Hyper Acute model - 841 UHND + Rehab BAGH 2 3 Single site 24/7 Hyper Acute model - DMH 815 + Rehab BAGH 3 9 Single site 24/7 Hyper Acute model - 771 UHND + Rehab BAGH + collaboration for drip & ship with neighbouring Trusts 4 6 Single site 24/7 Hyper Acute model - DMH 756 + Rehab BAGH + collaboration for drip & ship with neighbouring Trusts 5 11 CDDFT not to have Hyper Acute - regional 742 model 6 4 Single site 24/7 combined model – BAGH 667

March 2011 17

7 1 Two site 24/7 Hyper Acute model - UHND 590 & DMH + Rehab BAGH 8 6 Two site 24/7 Hyper Acute model - UHND 538 & DMH + Rehab BAGH + OOH diversion to single site – DMH 9 7 Drip & ship including telemedicine + single 532 site 24/7 Hyper Acute model - UHND + Rehab BAGH 10 5 Two site 24/7 Hyper Acute model - UHND 525 & DMH + Rehab BAGH + OOH diversion to single site – UHND 11 8 Drip & ship including telemedicine + single 506 site 24/7 Hyper Acute model - DMH + Rehab BAGH

9.1.1 Use of DASH data The DASH programme is a Newcastle University Research project which was utilised as part of the options appraisal process. The project used ambulance travel time data from the North East Ambulance Service to establish how long it would take stroke patients to reach hospital under the current split site model and the single site options of Durham and Darlington.

This exercise looked at all patients suspected of having a stroke who were taken to both the University Hospital of North Durham and Darlington Memorial Hospital by ambulance between September, 2009 and May, 2010. Travel times and distances were calculated from the postcode where the patient was picked up by the ambulance to their arrival at Accident and Emergency. During this period, 442 patients were taken to Darlington Memorial Hospital and 660 patients were taken to the University Hospital of North Durham. A full breakdown of the DASH data is at appendix 2 and the results are summarised below:

Current split site model, provided at UHND and DMH: The average travel time for stroke patients was 14 minutes with an average distance of 8 miles. This equated to 100% of patients arriving at hospital with 30 minutes.

Preferred single site option based at UHND: The average travel time for stroke patients was 17 minutes with an average distance of 12 miles. This equated to 90% of patients arriving at hospital with 30 minutes.

Single site option based at DMH: The average travel time for stroke patients was 24 minutes with an average distance of 8 miles. This equated to 60% of patients arriving at hospital with 30 minutes.

March 2011 18

9.2 Pre-engagement activity and feedback In November, 2010, NHS County Durham and Darlington hosted an engagement event to seek professional, patient and public feedback on the full stroke pathway. This highlighted a number of areas for improvement but added support to the clinical and regional drivers for change around stroke hyper-acute services. A summary of what attendees told us is at appendix 3.

It became clear that the hyper-acute part of the stroke pathway was the part where action could have the most immediate and fasted impact for the benefit of local patients. The event helped NHS County Durham to prioritise hyper-acute services for review and eventual improvement and the options appraisal outlined above ensued.

In February, 2011, the outcome of the options appraisal was presented to a second stakeholder audience at an engagement event in February, 2011. A variety of service users, carers, representatives from stroke interest groups and clinical and managerial professionals from local NHS services worked together at this event. The purpose of the event was to seek feedback on the priorities for improvement, the clinical case for change, the options appraisal methodology, the rationale behind a single site proposal, the use of ambulance travel time data (DASH data) and the preferred option. The feedback from this event is at appendix 4.

10.0 PROPOSED CONSULTATION AND COMMUNICATIONS PLAN Given the substantial nature of the proposed service changes, NHS County Durham and Darlington recognises the requirement for a formal consultation process. The views of both County Durham and Darlington’s Health Scrutiny Committees will help to determine this. NHS County Durham and Darlington understands and appreciates the legislative and policy framework around patient and public engagement and formal consultation and is fully committed to proactively seeking the views of local people in order to influence and improve the commissioning of local health services.

In preparation of a potential formal consultation on the proposed changes to stroke hyper-acute services, a draft consultation and communications plan has been developed. A full copy of the draft document is at appendix 5. This document suggests a framework for formal consultation including:  the scope of the consultation  key topics and questions for consultation  quality standards for the consultation process  methods of consultation

A full stakeholder analysis exercise will be conducted as part of this plan’s development. Learning points from previous formal consultations including Seizing the Future have been considered as part of the document’s development. Both County Durham and Darlington Health Scrutiny Committees are invited to contribute to the finalisation of this document. The views of members County Durham and Darlington’s Joint Local Involvement Network (LINk) Stroke Working Group are also being sought to ensure any formal consultation is as thorough and inclusive as possible.

March 2011 19

11.0 Appendices:  Appendix 1: Options appraisal methodology and outcomes  Appendix 2: DASH data analysis  Appendix 3: Pre-engagement event 1: full stroke pathway review, November, 2010  Appendix 4: Pre-engagement event 2: evaluation of options appraisal, February, 2011  Appendix 5: Draft communications and consultation plan  Appendix 6: List of groups involved to date

12.0 Glossary of terms  UNHD – University Hospital of North Durham  DMH – Darlington Memorial Hospital  BAGH – Bishop Auckland General Hospital  OOH – Out of hours  Rehab – Rehabilitation services

March 2011 20 Appendix 1: Options appraisal process: criteria, scores, weighting and outcomes

Criteria, scoring system and weighting

Rank Benefit Definition of Benefits 1 Clinical Quality Maintains or improves clinical outcomes; timely and appropriate services; minimises clinical risk 2 Sustainability/flexibility Ability to meet currrent and future demands in activity; ability to respond to local, regional, national service changes 3 Equity of access Reasonable access for urban and rural populations 4 Efficiency Delivers patient pathways that are evidence based; supports the delivery through access to resources 5 Workforce Provides environments which support the recruitment/retention of staff; supports clinical staffing arrangements 6 Functional suitability Provides environments suitable for delivery of care; clinical adjacencies with other relevant services/depts. E.g. imaging 7 Acceptability Acceptable to service users, carers, relatives, other significant partners 8 Cost effectiveness Provides value for money

Score description Score Could Hardly be Better 10 Excellently 9 Very Well 8 Well 7 Quite Well 6 Adequately 5 Somewhat Inadequately 4 Badly 3 Very Badly 2 Extremely Badly 1 Could Hardly be Worse 0

RAW Benefit Criteria Rank Comparison % WEIGHT 1-2 2-3 3-4 4-5 5-6 6-7 7-8

Clinical quality 1 100 100 17

Sustainability/flexibility 2 95 95 16

Equity of access 3 95 90.25 15

Efficiency 4 95 85.7 14

Workforce 5 95 81.5 14

Functional suitability 6 80 65.2 11

Acceptability 7 75 48.9 8

Cost effectiveness 8 75 36.7 6

603.1 100

March 2011 21 Results:

March 2011 22

1. Two site 24/7 Hyper Acute model - UHND & DMH + Rehab BAGH

Weight Criteria Notes to score Score Weight Score

Due to finite resource, coverage of stroke physician rota will be a Clinical quality challenge; this would have a direct impact on clinical quality 5 17 85 particularly out of hours, as patients may have to wait to seen.

Sustainability Lack of sustainability due to staffing levels. 16 64 /flexibility 4

Equity of Two site model thought to offer best fit in terms of equity of access 15 150 access following analysis of stroke admission data by geographical location. 10

Efficiency Reduced efficiency due to covering large area with finite resources. 6 14 84

Workforce Ability to maintain stroke consultant rota will be a challenge. 4 14 56

Functional Status quo maintained. 11 55 suitability 5

Assumption made that two site model would be more acceptable; as Acceptability 8 72 would not result in significant change 9

Cost Costs of travel between sites; locum premiums incurred to cover rota. 6 24 effectiveness 4

Total Weighted Score 590

March 2011 23

2. Single site 24/7 Hyper Acute model - UHND + Rehab BAGH

Weight Score Weight Criteria Notes to score Score

All patients DIRECTLY admitted to stroke unit; thrombolysis treatment Clinical quality initiated and administered within specialist unit; 7 day TIA service on 9 17 153 ward.

Sustainability Economies of scale on one site, which will allow for 16 160 /flexibility sustainability/flexibility for unexpected leave of absence. 10

Improved transport to hospital by ambulance service given single point Equity of of access; slightly higher proportion of patients presently admitted to 15 120 access 8 UHND.

Efficiency Supports delivery of hyper acute stroke pathway and TIA pathway. 8 14 112

Able to be managed by existing stroke consultants on rota; 24/7 consultant led stroke service; improved training for junior doctors and Workforce nursing staff; nursing and therapy staffing requirements complaint with 8 14 112 National Stroke Strategy; improve staff working conditions with cover for annual leave and other non-clinical commitments.

Functional UHND scored slightly more than DMH, due to establishment of a 11 88 suitability regular neurovascular MDT with vascular surgery. 8

Acceptability Assumed less favourable to populations in south. 6 8 48

Cost Less travel incurred; economies of scale make for more cost effective 6 48 effectiveness service. 8

Total Weighted Score 841

March 2011 24

3. Single site 24/7 Hyper Acute model - DMH + Rehab BAGH

Weight Criteria Notes to score Score Weight Score

All patients DIRECTLY admitted to stroke unit; thrombolysis treatment Clinical quality initiated and administered within specialist unit; 7 day TIA service 9 17 153 operation on ward.

Sustainability Economies of scale on one site, which will allow for 16 160 /flexibility sustainability/flexibility for unexpected leave of absence. 10

Equity of Improved transport to hospital by ambulance service given single point 15 105 access of access 7

Efficiency Supports delivery of hyper acute stroke pathway and TIA pathway. 8 14 112

Functional Poor access to vascular ultrasound imaging; vascular surgery located 11 77 suitability at UHND 7

Acceptability Assumed less favourable to populations in north. 6 8 48

Cost Less travel incurred; economies of scale make for more cost effective 6 48 effectiveness service. 8

Total Weighted Score 815

March 2011 25

4. Single site 24/7 combined model - BAGH

Weight Criteria Notes to score Score Weight Score

Lack of adequate MR and ultra sound imaging; lack of other speciality presence at BAGH; risks associated with lack of acute services on site Clinical quality - e.g. patients requiring ITU care; extra medical cover would be 7 17 119 required; deemed better that two site model as still one site, benefits from established therapy teams.

Sustainability Economies of scale on one site, which will allow for 16 160 /flexibility sustainability/flexibility for unexpected leave of absence. 10

Equity of Improved transport to hospital by ambulance service given single point 15 105 access of access. 7

Supports delivery of hyper acute care but no critical care/ITU which Efficiency 14 98 would result in repatriation of patients to acute site. 7

Pros - Dedicated facility for stroke patients; located within Centre of Rehabilitation Excellence; facilities for NG/PEG insertion / feeding / Functional videofluoroscopy equipment on site. Cons - lack of adequate MR and 11 33 suitability ultra sound imaging; lack of other speciality presence at BAGH; risks 3 associated with lack of acute services on site - e.g. patients requiring ITU care; extra medical cover would be required.

Acceptability Assumed less favourable choice due to geographical location. 5 8 40

Cost Would need to re-open ward at BAGH; additional costs for medical 6 42 effectiveness cover; imaging. 7

Total Weighted Score 709

March 2011 26

5. Two site 24/7 Hyper Acute model - UHND & DMH + Rehab BAGH + OOH diversion to single site – UHND

Weight Criteria Notes to score Score Weight Score

Maintaining in-hours cover still poses a quality issue; out of hours is Clinical quality 17 85 better. 5

Sustainability In hours problem still occurs. 16 64 /flexibility 4

Two site model thought to offer best fit in terms of equity of access Equity of following analysis of stroke admission data by geographical location; 15 135 access 9 OOH diversion reduces equity of access.

Efficiency Not efficient in terms of travel; for staff and patients. 5 14 70

Workforce Benefits OOH; loose in hours in terms of skills. 5 14 70

Functional UHND scored higher due to vascular surgery being available on same 11 77 suitability site; in hours would lose co-location with vascular surgery at DMH. 7

Acceptability Scored low due to travel; loss of continuity from local hospital. 3 8 24

Cost Re-diversion likely to be complex for NEAS; potential cost impact. 6 24 effectiveness 4

Total Weighted Score 549

March 2011 27 6. Two site 24/7 Hyper Acute model - UHND & DMH + Rehab BAGH + OOH diversion to single site – DMH

Weight Criteria Notes to score Score Weight Score

Maintaining in-hours cover still poses a quality issue; out of hours is Clinical quality 17 85 better. 5

Sustainability In hours problem still occurs. 16 64 /flexibility 4

Efficiency Not efficient in terms of travel; for staff and patients. 5 14 70

Workforce Benefits OOH; loose in hours in terms of skills. 5 14 70

Functional Lower score due to lack of co-location with vascular surgery in and out 11 66 suitability of hours at DMH. 6

Acceptability Scored low due to travel; loss of continuity from local hospital. 3 8 24

Cost Re-diversion likely to be complex for NEAS; potential cost impact. 6 24 effectiveness 4

Total Weighted Score 538

March 2011 28 7. Drip & ship including telemedicine + single site 24/7 Hyper Acute model - UHND + Rehab BAGH

Weight Criteria Notes to score Score Weight Score

Clinical quality Still loses out in cover in-hours. 5 17 85

Sustainability In hours problem still occurs. 16 80 /flexibility 5

Equity of Hyper acute care commenced at local hospital; hover acute phase will 15 105 access be delivered on single site. Population slightly higher in north Durham. 7

Efficiency Not efficient in terms of travel; for staff and patients. 5 14 70

Workforce Thought to be slightly better that two site model with OOH diversion. 6 14 84

Functional Benefits from co-location with vascular surgery at UHND 11 66 suitability 6

Acceptability Scored low due to travel; loss of continuity from local hospital. 3 8 24

Cost Potential double costs for transport. 6 18 effectiveness 3

Total Weighted Score 532

March 2011 29

8. Drip & ship including telemedicine + single site 24/7 Hyper Acute model - DMH + Rehab BAGH

Weight Score Weight Criteria Notes to score Score

Clinical quality Still loses out in cover in-hours. 5 17 85

Sustainability In hours problem still occurs. 16 80 /flexibility 5

Hyper acute care commenced at local hospital; however acute phase Equity of will be delivered on single site; scored less that UNHD due to 15 90 access 6 population.

Efficiency Not efficient in terms of travel; for staff and patients. 5 14 70

Workforce Thought to be slightly better that two site model with OOH diversion. 6 14 84

Functional Scored slightly less due to lack of vascular surgery at DMH 11 55 suitability 5

Acceptability Scored low due to travel; loss of continuity from local hospital. 3 8 24

Cost Potential double costs for transport. 6 18 effectiveness 3

Total Weighted Score 506

March 2011 30

9. Single site 24/7 Hyper Acute model - UHND + Rehab BAGH + collaboration for drip & ship with neighbouring Trusts

Weight Criteria Notes to score Score Weight Score

Clinical quality Regional centre open all time; clinical gold standard. 10 17 170

Sustainability Excellent sustainability. 16 160 /flexibility 10

Equity of Equity of access reduced when relying on neigbouring acute trusts. 15 105 access 7

Efficiency Relatively efficient; but repatriation does give inefficiency. 7 14 98

Workforce Not ranked as high as regional model. 8 14 112

Functional Not ranked as high as regional model. 11 88 suitability 8

Acceptability Deemed slightly better local drip and ship model. 4 8 32

Cost Cost for transport; impact on tariff. 6 6 effectiveness 1

Total Weighted Score 771

March 2011 31

10. Single site 24/7 Hyper Acute model - DMH + Rehab BAGH + collaboration for drip & ship with neighbouring Trusts

Weight Score Weight Criteria Notes to score Score

Clinical quality Regional centre open all time; clinical gold standard. 10 17 170

Sustainability Excellent sustainability. 16 160 /flexibility 10

Equity of Equity of access when relying on neigbouring acute trusts; population 15 90 access split taken into consideration. 6

Efficiency Relatively efficient; but repatriation does give inefficiency. 7 14 98

Workforce Not ranked as high as regional model. 8 14 112

Functional Not ranked as high as regional model. 11 88 suitability 8

Acceptability Deemed slightly better than local drip and ship model. 4 8 32

Cost Cost for transport; impact on tariff. 6 6 effectiveness 1

Total Weighted Score 756

March 2011 32

11. CDDFT not to have Hyper Acute - regional model

Weight Criteria Notes to score Score Weight Score

Clinically sound model; travel aspect needs to be taken into Clinical quality 17 153 consideration. 9

Sustainability Excellent sustainability. 16 160 /flexibility 10

Equity of Care not delivered at local hospital; reduced quality of access. 15 60 access 4

Efficiency Relatively efficient; but repatriation does give inefficiency. 7 14 98

Workforce Deemed best fit, 'Centre of excellence'. 9 14 126

Functional Deemed best fit, 'Centre of excellence'. 11 99 suitability 9

Acceptability Assumption that would score poorly as not providing local service. 2 8 16

Cost Cost of additional transport. 6 30 effectiveness 5

Total Weighted Score 742

March 2011 33

Appendix 2: DASH data analysis

Blue dots: stroke patients taken by ambulance to UHND

Red dots: stroke patients taken by ambulance to DMH

March 2011 34 Appendix 3: Pre-engagement event 1: full stroke pathway review, December 2010

Summary of event and what participants told us:

A range of feedback and views was received from local stakeholders at an event held on Wednesday 15th December 2010. The aim of the event was to provide an overview of the full stroke pathway and the improvements and developments that had taken place since previous involvement events, and to seek feedback from patients, carers and representative groups on how further improvements could be made in a number of areas.

Over 50 local stakeholders attended the event including members of the public, carers, partners, clinicians and support groups. Following a series of presentations on a range of services across the stroke pathway were delivered, participants worked in facilitated discussion groups to consider what they felt the best models and ways of delivering services across the whole pathway.

Feedback indicated general support for a single site hyper-acute model which would provide a local and sustainable centre of excellence. Consistency of provision across the area and at all times was a priority.

The main area of discussion was around the extent to which hyper-acute services should be close to home. Some views were that acute services should be as close to home as possible; others acknowledged the specialised nature of hyper-acute stroke services and felt that the model should support one centre of excellence to provide a fast and high quality treatment – even if this was regional – but with highly localised rehabilitation services which are not time dependent.

However, the current two site model was highlighted as causing potential confusion. Regardless of the service model, issues relating to access and response issues and to awareness raising and information sharing were also discussed.

In discussing models for other stroke services, there was a general view that no matter how effective hyper-acute services were, services post discharge were at risk of fragmentation and lack of consistency. The lack of connection between the acute and community settings was raised frequently. A single, consistent pathway with clear protocols across other organisations was felt to be a way forward in improving these services.

Those present asked how options for a hyper-acute service model would be developed, and how these would be evaluated. It was explained that clinicians, and service commissioners and managers had developed a number of possible options which had advantages and disadvantages depending on where patients live.

March 2011 35 Appendix 4: Pre-engagement event 2: evaluation of options appraisal, February, 2011

Around 40 people attended a pre-engagement event on 16 February, 2011, to share their views on the priorities for stroke service improvement and the process and proposals for changes to hyper-acute stroke services. A range of hospital clinicians and managers, GPs, stroke service users, carers and representatives from interested voluntary, community and representative groups heard a series of presentations, took part in facilitated table discussions and voted on a series of questions.

Summary of feedback to questions posed and accompanying notes:

Question 1 – Do you agree with the need to review the stroke services pathway?

Notes

Cases of not working for individual patients. Hyper acute pre-December. Vitally important to have 24/7 access to services. Better follow-up care required. Should be reviewed regularly – ongoing. Lots of previous discussion – no action taken relating to stroke services. Safety concerns, lack of investment in stroke services. Some complaints of aftercare. Personal experiences as catalyst for change – rationale that change can be achieved on the whole pathway scale.

March 2011 36 Question 2 – Do you agree with the need to address hyper acute stroke services?

Notes

Definition of hyper acute? Positive changes to date, more to be done. NOT currently delivering - review services 7 days week not robust. Share good practice from North Tees and Hartlepool Trust. Make one unit successful otherwise at risk of losing service. Hyper acute is only one small part – but life changing! This part of the pathway has to be right as patient outcomes are dependent on this element. Clinically, the first 3 to 4 hours is the most important. We need to address hyper acute, need to implement the National Stroke Strategy. If we are looking for the best it needs to be on one unit. It needs to be communicate properly, sometimes the general public gets the wrong message. We need to get 24/7 on one site. Confusing for the general public having two sites. Needs to be looked at – might not be a popular decision. Contention re: location needs to be sorted. Lots of talk about a single site. Personal experience of OOH care- some scope for improvement (out of region care). We want the best for our residents – it could happen to us!

March 2011 37 Question 3 – Do you agree that the status quo is not an option?

Notes

Staffing pressures. Staff resource is limited – number of consultants is a pressure between 2 sites. Fragile rota. No one can afford status quo as practices and populations change. If you cannot fully staff them and relying on retired people it is not sustainable. To recruit consultants it needs to be one unit with high standards – more attractive. If you consolidate, put the money on one site rather than two. If on one site, will that site only be used for strokes? Will other hospitals be affected by the loss of the stroke services? Need to have 24/7 thrombolysis – difficulties in alternating OOH services. Safety concerns with current model. Communications challenge – public safety v closer to home. Any lessons from StF in how we sell it? Risks around multiple site Perception of ‘losing’ it – it should be about what we ‘gain’. What are the chances of getting more consultants? Reluctance of young doctors.

March 2011 38

Question 4 – Do you agree that the split site model is not the answer?

Notes

Sure for the hyper acute side of things. Hard to judge without the information. Need to understand it in the context of the current pattern of community setting. Practicalities around staff travel. Impact on patient safety. North Tees and Hartlepool Trust – moved from two sires to single site successfully. Workforce is more skilled on one site. Workforce can be burnt out over two sites. Need to engage and educate patients that a single site would be a centre of excellence. Also other sites need to be seen in a good light so after hyper acute transfer patients are not reluctant to go. Need to ensure stakeholders (particularly GPs) can share information with patients. Consensus of table is to support single site. Workforce issues – need to provide best quality. Care needs to be taken to assure the public that they have access to the best service available regardless of where it is based. Access to specialisms on one site. Must support family/carers to access transport to single site. Social care support required. Would a single site be able to accommodate all stroke services? Will adequate parking be available for the increase in visitors? It needs to be sustainable, when the two consultants require it will not be sustainable. Communication is critical. Get the message across why a single site is the best model to the patients. Some concern for patient and carers’ transport. Concern of single site vulnerability to closure. How do consultants feel about the split site working? Views of staff and potential; travel implications for them. Implications for visitors? Just get on with it!

March 2011 39 Question 5 – Do you agree with the methodology used so far?

Notes

Agree but not just by 4 people - needs better representation (patients from each area?). DASH was not explained in the methodology document. No consultation outside of the provider and commissioner. No input from outside on the criteria and its importance. Principle is a good idea. On the scores, what makes it really good or really bad? Acceptability score near the bottom – is this to the Trust or the patients? Good that quality (patient safety) was top. The document does not explain the decision making progress. Missed an option – BAGH was the only given. Yes, the method works well. Expertise on one site - to be reviewed. Using number values helped clarify the methodology – notes relating to the scores are vital. Important that local clinicians are involved in engagements with the public. All feedback should be publicised – essential. Would like a breakdown of how these figures came about. Need more detail behind the figures. Durham easier to get to than Darlington, how did they arrive at that conclusion? How did they work out transport? Workforce and sustainability come hand in hand. Was visiting transport brought into it? Was it judged on the size of the hospital and car parking? Concerned at the methodology used for BAGH. Downgraded A+E in BAGH – it will be by-passed - where is the evidence for this? Who determined the criteria/weighting/scoring? How much time was spent on this? Needs to be in the public’s best interest. Needs to involve local groups/LINks possibly? Evidence that a lot of thought has gone into it - which is good. Question the objectivity of the methodology. How do we get some independence in this? Subjectivity of decisions in determining the methodology - need to trust individuals. Concern about personal predispositions involved. I want stroke consultants involved but not at the expense of their day job.

March 2011 40 Question 6 – Do you agree with the single site conclusion?

Notes

Agree with single site with one move – two step process. Rehab should be considered elsewhere other than BAGH. Is it a patient risk to have rehab at BAGH? Need to consider communities’ concerns. Yes, but needs consultation and the result of this must support single site. More information required on stroke prevention. Atrial fibrillation support is required. Yes for patient, carer, family transport. How is it going to sold? Engagement, marketing, communications. GPs talking to patients. Agree with single site but not dependent on the methodology used. Will there be sufficient capacity in a single site? What happens if beds are full? What does regional mean? Where, how practical? Regional model scores close to preferred option. Depends on sufficient capacity and the availability of sufficient 24/7 back up services.

March 2011 41 Question 7 – Do you agree with the use of the DASH data?

Notes

Could the data be used to identify the benefits of direct access to the stroke unit v access to A+E. Quite powerful to see (the presentation) Travel time is important – however, the travel time to Darlington to Durham is relatively short compared to elsewhere nationally. Pre alert - ensure advance warning is given to receiving hospital for prep. Final analysis (Durham site) showed 90% of patients arrived within 30 minutes. Data has academic background. Yes, but it did not use the BAGH data. It is useful but it could have had more figures for other options. Figures showed average travel time, what was the longest time? Affect of snow? People in North Durham will go to Gateshead – what about patient choice? Do these figures include those patients treated OOH Durham and Darlington? Durham – twice the number of Stroke incidents – augments argument for single site in Durham. Dales patients in helicopter to South Tees. We trust NEAS statistics – ‘concrete evidence’. Some need for assurance about the time period of the data – need to be up to date since Dec 2010 model introduced. Nationally funded programme to provide data.

March 2011 42

Question 8 – Do you agree with the preferred option?

Notes

Sensible option. Reliability of service. Workforce continuity.24/7 for thrombolysis and TIAs. Need to now start developing community rehab services and support this model. Yes, but population will need to be convinced. All evidence presented today points to a single site based at Durham. Will staff from the site no longer used be transferred to preferred site? Campaign needs to be implemented to ensure patients know how to access service. Is there any patient experience if they had attended a weekend service i.e weekend at Durham, weekday at Darlington? Communication, good explanation to patients is crucial. Drip & Ship, how quickly will they transfer over? Will A+E staff at Durham be trained to do that? Will we attract consultants to Durham? Does Durham have enough space, parking? Would we have the equivalent number of beds in one site? Communicate to key stakeholders in Darlington before the press? Put transport solutions in place before you start to communicate with the public. Need for 24/7 back up services – implications for other sites? Will other services need to leave Darlington to support hyper acute stroke services in Durham? What will we (Darlington) get instead? How do you assure us of long term stability of back up services? Will we still have staff in Darlington to support them? Will Darlington be a centre of excellence for anything? ‘Sustainable for the time being’ – what does that mean? Will we have to move again in the future? The public would prefer a radical solution now and let things settle down. Selling the message – Darlington people will see it as a loss. Learn from StF. Has the financial impact on the Trust been assessed?

March 2011 43

THEMES OF DISCUSSION

March 2011 44 Appendix 6: List of participants to date

 Stroke Strategy Improvement Group  County Durham and Darlington NHS Foundation Trust  North East Ambulance Service NHS Trust  North of England Cardiovascular Network  Durham County Council  Darlington Borough Council  Durham County Council Adults, Health and Wellbeing Overview and Scrutiny Committee  Darlington Borough Council Health and Wellbeing Overview and Scrutiny Committee  Age UK Darlington  The Stroke Association  County Durham Local Involvement Network  Darlington Local Involvement Network  Durham & Chester-le-Street Carer Support  Integrated Care Organisation Project and Practice Based Commissioning, Durham Dales  GP representatives  Derwentside Carers Centre  Sedgefield Locality Carers Centre  Stroke service users  North East Stroke Research Network  Stroke Research Nurse, Ward 4 Stroke and Rehabilitation Unit, Bishop Auckland Hospital  Darlington Society for the Blind  Four Seasons Healthcare  Peterlee Town Council  Shotley Bridge Support Group  Bridgehill Residents Association  Durham & District Women’s Cancer Support Group  Occupational therapists  National Council of Women Darlington and District Branch  Growing Older in Darlington  North Tees and Hartlepool NHS Foundation Trust  County Durham and Darlington Community Health Services

March 2011 45