Stroke services

We want you to tell us what you think about our preferred change proposal to develop:

• A ‘centre of excellence’ in Lincolnshire for hyper-acute and acute stroke services at Lincoln County Hospital
• Which would be supported by enhancement of the community stroke rehabilitation service across the county, so it can support stroke patients with more complex needs​​​​​

Hyper-acute and acute stroke services are provided from hospitals that treat the sickest of patients:

• Hyper-acute stroke services care for people in hospital in the first 72 hours (it may be less) after their admission for a stroke, when more specialist ‘critical’ care is needed
• Acute stroke services care for people in hospital after the first 72 hours of having a stroke (including in- hospital rehabilitation) and until they are ready to be discharged to another service and/or go home

These hospital stroke services are provided by highly trained and skilled doctors, nurses and therapists who specialise in looking after people who have had a stroke. They work as a multi-disciplinary team to provide the most appropriate care tailored to the needs of individual people.

Two key hospital services for the treatment of strokes are:

• Thrombolysis: a ‘clot busting drug’. Only strokes caused by blood clots (about 85% of all strokes) could be considered for thrombolysis, which is appropriate to under 20% of these strokes only. It is time critical, as can only be given within 4.5 hours of stroke onset

and

• Mechanical thrombectomy: ‘clot retrieval’ through a procedure where a ‘guide wire’ is used to remove the clot causing the stroke, usually used in conjunction with thrombolysis. This is a relatively new procedure only available in a small number of hospitals, the nearest of which is Queen’s Medical Centre in Nottingham. It is not currently available in Lincolnshire

In addition, these hospital stroke service teams also run transient ischaemic attack (TIA) or ‘mini stroke’ clinics (in outpatient services), where patients whose symptoms have resolved but are still thought to be ‘high risk’ will be seen the next day by a stroke consultant and have appropriate investigation and results for the patient all in the same day.

Prior to the temporary changes made in response to COVID-19, United Lincolnshire Hospitals NHS Trust (ULHT) provided hyper-acute and acute stroke services, as well as TIA clinics from Lincoln County Hospital

and Pilgrim Hospital, Boston. Grantham and District Hospital does not provide these services. If patients with a suspected stroke present at Grantham and District Hospital they are rapidly transferred to the most appropriate site.

A summary of stroke service provision at ULHT’s hospital sites ‘pre COVID-19’ is set out below.

Working alongside the Lincolnshire hospital-based stroke services is the Lincolnshire community stroke rehabilitation service. This service aims to reduce the length of stay of patients within hospital stroke units, to improve the patient and carer experience following a stroke, and to offer a seamless transfer of care for patients from hospital to home.

This section sets out the challenges and opportunities for stroke services and what we hope to achieve by making changes.

Challenges

• The national best practice is that hyper-acute stroke units should admit a minimum of 600 patients a year – below this level doctors and nurses in hospital stroke services risk becoming deskilled. This in turn means patients may not get the best or safest care in the future:
  • Lincoln County Hospital admits around 670 stroke patients a year and Pilgrim Hospital, Boston around 500 stroke patients a year
  • Even when considering growth in the size and the ageing of the local population over the next five years, Pilgrim Hospital, Boston is highly unlikely to admit 600 stroke patients a year, every year
• We need more doctors, nurses and therapists to deliver the existing hospital stroke services, but there aren’t enough locally and nationally:
  • This means there are significant problems staffing our hospital stroke services – and we have already seen temporary closures of some of our services because there aren’t enough doctors or nurses available
  • Both the Lincoln County Hospital and Pilgrim Hospital, Boston stroke services have struggled to consistently perform well in the national audit of service quality and performance, despite the skills and dedication of our staff. This is reflective of the challenges set out above

Opportunities

By making changes, we can look to ensure:

• High quality hyper-acute and acute stroke services are delivered in Lincolnshire in a sustainable way for the long term, by:
  • Ensuring hospital stroke services are based on national clinical evidence
  • We achieve a balance between access and ensuring the long term sustainability of services
  • Our hospital stroke services receive over 600 stroke patients a year so that our doctors and nurses here in Lincolnshire maintain and develop their specialist skills and expertise
  • Improving the ability of hospital stroke services to attract and retain talented and substantive staff by building a strong, high quality and successful service, reducing our reliance on temporary, expensive staffing solutions
  • Stroke patients spend the minimum time necessary in a hospital bed, by ensuring community services have the right skills and capacity to support stroke patients at home, or as close to home as possible
• Patients are more likely to receive timely assessment, treatment and diagnosis when they arrive at hospital
• Patients are more likely to see the right specialist, first time, 24/7 and receive the best possible care
• Health outcomes and the overall patient experience are improved
• ​​​​​​Reduced burden of stroke on patients, families, carers and the wider health economy through better outcomes for patients
• More working age patients will be able to return to work, and lead more fulfilling lives

We know that this approach already works well in other services in the county. Through the establishment of the Lincolnshire Heart Centre at Lincoln County Hospital, Lincolnshire residents already have first-hand experience of the benefits to patient care that can be achieved by bringing together and consolidating highly specialist clinical expertise into a centre of excellence. ​​​​​​

There has been ongoing engagement with the public throughout the Lincolnshire Acute Services Review programme, particularly through the ‘Healthy Conversation 2019’ engagement exercise.

Some consistent themes in relation to hospital stroke services, including some specifically related to those living in the Boston area, have been shared by the public and stakeholders throughout our engagement to date:

• Consolidation of hospital stroke services in order to provide specialist, expert standards of care is reasonable, however this needs to be balanced against the possible negative impacts of increased travel times, which needs to be mitigated
• It is important that patients should be able to undergo rehabilitation and ongoing care nearer their homes
  • Specific to the Boston area:
  • Concerns about ambulance service response times to Lincoln County Hospital and treatment not being started within 60 minutes
  • Concerns about a loss of services at Pilgrim Hospital, Boston and overburdening the Lincoln County Hospital site

We have consistently looked to take into account all public and stakeholder feedback throughout our work.

Our preferred proposal for change is to establish a ‘centre of excellence’ for hyper-acute and acute stroke services at Lincoln County Hospital, which would be supported by increasing the capacity and capability of the community stroke rehabilitation service. TIA clinics would be unaffected at Pilgrim Hospital, Boston.

This would mean hyper-acute and acute stroke services would be consolidated at Lincoln County Hospital and no longer be provided from Pilgrim Hospital, Boston.

It is anticipated the change would affect, on average, 1 to 2 patients a day. These patients would receive hyper- acute and acute stroke services at an alternative hospital.

A key part of our process to evaluate options to tackle the challenges we face was to hold a clinically- led health system stakeholder workshop and four workshops with randomly selected members of the public.

For Stroke Services two solutions remained following the shortlisting of options:

• Consolidate hyper-acute and acute stroke services on the Lincoln County Hospital site, supported by an enhanced community stroke rehabilitation service
• Provide hyper-acute and acute stroke services from Lincoln County Hospital and Pilgrim Hospital, Boston, supported by a combined medical on-call rota

Attendees at the workshop were asked to think about the advantages and disadvantages of the two proposals against agreed criteria.

The table below summarises the level of stakeholder and public support for each change proposal.

As we have developed our proposals we have considered the quality and equality impact of the proposal for change for stroke services.

Through our equality impact assessment, we identified two groups of people, one of which is defined by a protected characteristic, which may be more likely to be impacted positively or adversely by this proposal.

These groups are age and those who are economically disadvantaged.

Our observations from these assessments are set out opposite. We will continue to review and develop these, including the impact on different groups of people within our population, with independent support, through our public consultation in light of the feedback we receive.

Potential positive impacts

• Evidence that consolidating hyper-acute and acute stroke services on a smaller number of sites where specialised staff and equipment can be concentrated means patients are:
  • More likely to survive and recover more quickly.
  • More likely to have a reduced length of stay in hospital
  • More likely to continue to lead more fulfilling lives in the future, such as being able to return to work
• Consolidating hospital stroke services helps address the significant workforce shortages and challenges experienced in these services by:
  • Concentrating specialist skills and expertise together to ensure clinical staff maintain and develop these to provide the safest and best possible care
  • Making hospital stroke services more attractive to doctors, nurses and therapists to work in
  • Reducing reliance on temporary, expensive staffing solutions
• Consolidation of hospital stroke services on the Lincoln County Hospital site allows more patients to benefit from these services being located on the same hospital site as the highly successful Lincolnshire Heart Centre, which include:
  • Increased access to important time critical interventions
  • Increased access to acute imaging services, further reducing time to treatment
• Consolidation of stroke services on the Lincoln County Hospital site ensures patients are closer to Nottingham’s Queen’s Medical Centre in the instance they require mechanical thrombectomy.

Potential adverse impacts

• For those patients who would previously have been admitted to Pilgrim Hospital, Boston with a stroke (1 to 2 a day on average), treatment would be received at an alternative site with the facilities and skills to look after the most seriously ill patients.
  • Lincoln County Hospital is expected to be the alternative site for the majority of patients, with a minority going to Peterborough City Hospital, and Queen Elizabeth Hospital at Kings Lynn on occasion
  • These patients would get the specialist input they require at the right time and receive the best possible care. However, it is acknowledged that needing to travel further for this care may be seen as an adverse impact by some people.
  • Of those patients seen at an alternative site, it is estimated that there would be no increase in the number of patients travelling more than 60 minutes by ambulance, the threshold set by the local health system for this type of activity.
  • The friends and family of those patients receiving treatment at an alternative hospital, which better meets the patients care needs, may have to travel further to see them.​​​​