Agenda item

(To receive a report from Simon Evans, Health Scrutiny Officer, which invites the Committee to consider the details provided on the Lincolnshire Acute Services Review of Stroke Services; and to highlight any areas which the Committee’s working group might wish to explore in further detail. Senior representatives from United Lincolnshire Hospitals NHS Trust will be in attendance for this item)  

Councillor S R Parkin joined the meeting at 10.08am.

The Chairman invited Dr Abdul Elmarimi, Consultant in Stroke Medicine, United Lincolnshire Hospitals NHS Trust and Charley Blyth, Director of Communications and Engagement, Lincolnshire Clinical Commissioning Group, to remotely, present the item to the Committee.

In his introduction, Dr Abdul Elmarimi provided an introduction for Committee regarding the impact of a stroke on a patient; the services required to treat the three main levels of stroke within certain timescales, and the rehabilitation period required for a patient to recover from a stroke.

It was reported that Hyper-Acute and Acute stroke services were provided by highly trained and skilled doctors, nurses and therapists who specialised in looking after people who had had a stroke.

It was highlighted that there were two key hospital services for the treatment of strokes which were, firstly thrombolysis, a ‘clot busting drug’ which was used to treat strokes caused by blood clots.  The use of this treatment was time critical and had to be administered within 4.5 hours of the stroke’s onset; and the second treatment was mechanical thrombectomy or ‘clot retrieval’.  It was noted that this was a relatively new procedure and was only available in a small number of hospitals; the nearest for Lincolnshire was the Queen’s Medical Centre, Nottingham.

Appendix A to the report provide the Committee with further details relating to how services were currently organised at ULHTs hospitals (pre-Covid).

The summary of services pre-Covid was:

Lincoln County: Hyper-acute stroke services including Thrombolysis; Acute stroke Services and Transient Ischaemic Attack (TIA) mini stroke clinics; and

Pilgrim Hospital:  Hyper-acute stroke services including Thrombolysis; Acute stroke Services and Transient Ischaemic Attack (TIA) mini stroke clinics.

The Committee was advised of the challenges and opportunities for stroke services and what was hoped to be achieved by making the changes. It was highlighted that national best practice was that hyper-acute stroke units should admit a minimum of 600 patients a year, below this level doctors and nurses in hospital stroke services risked becoming deskilled.  The Committee was advised that Lincoln County Hospital admitted 670 stroke patients a year and Pilgrim Hospital, Boston around 500 stroke patients a year.  It was noted that even when considering growth in the size of the ageing population over the next five years, Pilgrim Hospital Boston, was unlikely to admit 600 stroke patients each year.

It was reported that more doctors, nurses, and therapists were needed to deliver the existing hospital stroke services and that there was a shortage of such staff locally and nationally. Locally, this was causing problems as there had already been a temporary closure of some of the stroke services as there was not enough doctors and nurses available.  As a result of this, both Lincoln County and Pilgrim Hospital Boston had struggled to consistently perform well in the national audit of service quality and performance, despite the skills and dedication of staff.

It was highlighted that feedback from engagement, particularly through the Healthy Conversation 2019 had supported the consolidation of hospital stroke services, and that this needed to be balanced against increased travel time for patients; ambulance response times; loss of services from Pilgrim Hospital, Boston, the overburdening of Lincoln County Hospital; and that a patient should be able to undergo rehabilitation closer to home.  It was highlighted further that all public and stakeholder feedback had been taken into consideration throughout the process.

The Committee was advised that the preferred proposal for change was to establish a ‘centre for 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. It was highlighted that the TIA clinics would be unaffected at Pilgrim Hospital, Boston.  It was highlighted further that the change would affect on average 1 to 2 patients a day receiving hyper-acute and acute stroke services at an alternative site.  However, the change would ensure  that stoke services were sustainable for the long term, the stroke service would receive over 600 patients a year, which would ensure that doctors and nurses maintained their specialist skills; it would improve the ability of hospital stroke services to attract and retain substantive and talented staff, reducing the reliance on temporary and expensive staffing solutions; stroke patients would spend the minimum time necessary in a hospital bed; patients were more likely to receive timely assessment, treatment and diagnosis when they arrived at the hospital; and overall health outcomes and patient experience would be improved.

It was reported that the option of basing the services at Pilgrim Hospital, Boston, instead on Lincoln County Hospital had been explored, but as a result, displacement would be higher, as more people would seek treatment outside of Lincolnshire.  It was noted that it was also difficult to attract staff to work at Pilgrim Hospital Boston.

During consideration of this item, the Committee raised some of the following comments: -

·       Recruitment issues: the Committee was advised that there had been a major shift over the last few years, with some professionals not considering medicine as a career, or a dedication, but as a skill they could sell to the highest bidder.  Some professionals were leaving their jobs to become professional locums as they had more flexibility.  Reassurance was given that the Trust sought the best locums they could, and that patient safety was a priority;

·       The critical period for stroke patients.  Some concern was expressed to the waiting times seen at hospitals; and whether stroke patients received treatment prior to arriving at the hospital.  The Committee noted that specialist nurses were available 24/7 and that paramedics would make contact from the site, and that sometimes patients were treated in the ambulance on route to the hospital.  The Committee was advised that someone admitted as a stroke patient at Lincoln would bypass A & E, as it was important for the patient to receive a scan as soon as possible,  so that if thrombolysis was the appropriate treatment, it could be administered within four and a half hours from the onset of the symptoms.  It was noted that 60% of scans were done within 1 hour; and that those timeframes were continuously improving as practices were being modified;

·       Whether consideration had been taken to the plans for stroke services for hospitals outside of Lincolnshire in the south of the County.  The Chairman advised the Committee that he had been told that a health system was prevented by law from destabilising the services provided in a neighbouring health system;

·       Further explanation was sought regarding the number of patients in line with best practice required for doctors and nurses to become deskilled (minimum 600 stroke patients), reference was made to the 500 stroke patients seen at Pilgrim Hospital, Boston.  The Committee was advised that the figure of 600 stroke patients made a stroke unit more sustainable.  It was highlighted that the audit had been very detailed and looked at 93 parameters per patient.  It was also highlighted that strokes cases seen at Pilgrim Hospital, Boston were less severe than those seen at Lincoln County Hospital, who needed to be seen by a specialist team.  As a result of the increasing preventive work being carried out in primary care the number of stroke patients was not increasing year on year.  The benefits of a single unit would be better for patients, and for staffing, as the current arrangements were not sustainable;

·       TIA service at Pilgrim Hospital, Boston.  The Committee was advised that there was national guidance on quick assessment, with patients having to be seen within 24 hours.   Confirmation was given that the TIA clinics would continue to be run at Pilgrim Hospital, Boston, three days a week.  The only change would be that patients with a high-risk score would be offered an appointment at either Boston or Lincoln. The higher risk ones if there was not a clinic in Boston would be offered an appointment in Lincoln. It was highlighted that most people would be seen within a one to two days, depending on the severity of the stroke.  The Committee was advised that for outpatient activity, patients would be offered appointments at peripheral hospitals closer to home, reference was made to Spalding and Skegness for follow up appointments;

·       Some concern was expressed on the data presented, particularly the high number of ageing patients on the east coast; and the travelling time for a patient from the east side of the County to be able to get to Lincoln or Peterborough. One member felt that without direct admission to Pilgrim Hospital, Boston, the proposal would create greater problems on the east coast.  The Committee was referred to page 41 of the report pack which provided details relating to hospital catchment areas; and information relating to the displacement of patients from Boston and surrounding areas if the preferred option was adopted.  It was highlighted that the analysis and modelling had been completed by Operational Research in Health Ltd (ORH) in 2018. It was noted that the ORH had used a combination of East Midlands Ambulance Service NHS Trust data and data on FAST-positive stroke patients from Lincolnshire.  It was noted further that travel time analysis had been undertaken to quantify the base position for Pilgrim Hospital, Boston patients and how travel times would be expected to change, as changes to the services occurred.  There was recognition of the issues raised and that the proposed model would ensure that patients received the best care; reference was also made to the potential for a mobile stroke unit (same size as an ambulance), which would be equipped with a scanner and connections to the central unit, which was part of the overall plan, once staffing levels were consistent;

·       Concern was also expressed to the difficulties patients were still encountering getting appointments with GPs in the Boston area; the long waiting times for ambulances on the east coast; and the poor state of the roads in Lincolnshire;

·       What could be done further to promote the County better to encourage medical staff to come to Lincolnshire.  It was agreed that the attractiveness of working in Lincolnshire needed to be promoted better and that having better quality services would be part of that package; and

·       The proposal presented appeared to work on the basis that staff working at Pilgrim Hospital, Boston would move to Lincoln to help mitigate the current shortages currently experienced within the stroke service.  A question was asked whether a plan was in place should the preferred option not happen.  The Committee was advised that staff had been moving to help provide cover, for services, however, staff had a choice.  It was noted that the service had staff currently travelling from Nottingham and Chesterfield.

The Chairman on behalf of the Committee extended his thanks to the presenters.

RESOLVED

1.      That the details presented on the Lincolnshire Services Review of Stroke Services be noted.

2.      That the Committee’s initial findings on the proposal be recorded for consideration by the Committee’s working group.