What are we asking you to consider
We want you to tell us what you think about our preferred option 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 so it can support stroke patients with more complex needs
What are the services and how are they organised (pre COVID-19 temporary changes)?
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: which is a ‘clot busting drug’ used to treat stroke caused by a blood clot; and
- Mechanical thrombectomy: which is ‘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.
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 from Lincoln County Hospital and Pilgrim, Boston Hospital. Grantham & District Hospital does not provide these services. If patients with suspected stroke present at Grantham & District Hospital they are rapidly transferred to the most appropriate site. All three of these hospitals provide TIA clinics.
A summary of stroke service provision at ULHT’s hospital sites ‘pre COVID-19’ is set out below.
Lincoln County Hospital
Hyper-acute stroke service including Thrombolysis
Acute stroke service
Pilgrim, Boston Hospital
Hyper-acute stroke service including Thrombolysis
Acute stroke service
Grantham & District Hospital
TIA clinics confirm?
TIA clinics held elsewhere?
Please see earlier section for description of temporary changes in response to COVID-19
Neither of the hyper-acute services at Lincoln County Hospital or Pilgrim, Boston Hospital provides mechanical thrombectomy. Where clinically appropriate, our Lincolnshire stroke teams refer patients to Queens Medical Centre in Nottingham to receive this procedure.
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.
What are the challenges and opportunities for stroke services
This section sets out the challenges and opportunities for stroke services and what we hope to achieve by making changes.
- 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. Which 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, Boston Hospital 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, Boston Hospital is highly unlikely to admit more than 600 stroke patients a year, every year.
- We need more doctors and nurses 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, Boston Hospital 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.
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.
- Achieving a balance between access and ensuring the long term sustainability of services.
- Ensuring 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 through building a strong, high quality and successful service.
- Enabling stroke patients to 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.
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.
The feedback from engagement about stroke services and how we have used it
There has been ongoing engagement with the public throughout the Lincolnshire Acute Services Review programme, particularly through the ‘Healthy Conversations 2019’ engagement exercise.
Some consistent themes in relation to hospital stroke services, 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 need 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, Boston Hospital and overburdening the Lincoln County Hospital site.
We have consistently looked to take into account all public and stakeholder feedback throughout our work.
What is our preferred option
Our preferred option 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 are unaffected (double check).
This would mean hyper-acute and acute stroke services would be consolidated at Lincoln County Hospital and no longer be provided from Pilgrim, Boston Hospital.
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 short listing 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, Boston Hospital, 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 outcomes of the evaluation in terms of the attendees that showed a preference for a proposal are set out below.
Support for change proposals for hyper-acute and acute stroke services
Support for change proposal
Consolidated on Lincoln site
Provided from two sites – Lincoln and Boston
As we have developed our proposals we have considered the quality and equality impact of the preferred option for stroke services.
Through our equality impact assessment we identified two groups of people, defined by protected characteristics, 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 below. 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
- Consolidating hospital stroke services helps address the significant workforce shortages and challenges experienced by these services by:
- Concentrating specialist skills and expertise together to ensure clinical staff maintain and develop these to provide the best possible and safest care.
- Making hospital stroke services more attractive to doctors, nurses and therapists to work in.
- 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.
Potential adverse impacts
- For those patients who would previously have been admitted to Pilgrim, Boston Hospital 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.