Thursday, 27 April 2017

Here is my contribution to the Stroke consultation.

Dear Sir/Madam

Public Consultation on ‘Improving Stroke Care in West Surrey’

Siting of HASUs

I would ask the CCG to step back from its proposal for the siting of HASUs in West Surrey and objectively ask whether it has got the balance of risks to patients correct. I recognise that to change this aspect will be extremely difficult for those who have worked on this matter for so long but nevertheless, for the sake of patients, I would ask them to have the courage to change if, on reflection, it is not in the best interests of the public who are at risk.

I support the reasoning to concentrate services in just two well-staffed and supported HASUs in West Surrey. However siting them in Frimley Park and St Peters is not the right solution geographically. Speed in getting stroke victims to a HASU is paramount. The consultation repeatedly presents a travel time of 2 hours from onset to treatment in a HASU as if anything less is not of significance. This is not so. 2 hours is regarded as a maximum: less is highly preferable.

The proposed configuration is for two hospitals which are both in the north of West Surrey (and only about 20 minutes apart by road), and closing the one hospital i.e. Royal Surrey which is in the middle of West Surrey. This is unbalanced. It puts at significant risk stroke victims in Guildford and particularly those south of Guildford e.g. Cranleigh and Haslemere. The contention that the ambulance service can still get patients to these hospitals to meet the 2 hour maximum from stroke onset is not tenable given the unsatisfactory performance of that service (which has been clear to the public for a long time and continues despite many undertakings to improve). In any case 2 hours is a maximum not an optimum. Very clearly these patients could get to the Royal Surrey far faster and in that respect alone are being put at significant increased risk.

The choice between the Royal Surrey and St Peters, it is said, was left to the two hospitals to decide between themselves. That decision should be reviewed independent of any of those who have so far been involved.

It the two HASUs were located at the Royal Surrey and Frimley hospitals stroke victims who would otherwise go to St Peters would split between Royal Surrey and Frimley. The admissions to Royal Surrey would rise to over 700 (CAP Geminini Report on stroke modelling commissioned by the CCG) well above the 500 regarded as the minimum optimum size stated in the consultation booklet. With Frimley being close to St Peters to the North and Royal Surrey being close to patients to the south of St Peters this would be a preferable risk balance given the excessive travel times to Frimley and St Peters from places such as Cranleigh and Haslemere.

I recognise that St Peters has the advantage of undertaking vascular surgery which some stroke victims will require. However such surgery is not time-sensitive in the same way as initial stroke treatment. Such patients can be safely transferred to St Peters. Although this is not desirable for the few patients concerned, it is not unsafe.

It is fundamental to any proposal for change that the current performance of hospitals be taken in to account.  The latest case mix Standardised Mortality Ratios for stroke published by SSNAP (the CCG’s preferred source of data) shows
  • ·         Royal Surrey’s SMR as 1.0 i.e. mortality as “expected” for its case mix
  • ·         Frimley’s SMR as 1.08 i.e. 8% higher than expected
  • ·         St Peters as 1.15 i.e. !5% higher than expected – very worrying

St Peter’s mortality should be subject of serious investigation quite apart from the matter of this consultation. That patients currently taken to the Royal Surrey from Guildford should now be being taken to a hospital with such a substantial mortality rate is extremely disturbing.

Siting of ASUs

Even if HASUs are sited as proposed in Frimley and St Peters hospitals, I believe that the CCG should carefully consider views on where post-HASU acute care should take place.

The Royal Surrey has indicated an interest in being part of the acute stroke pathway post-HASU and I strongly support that proposal.

I am very aware of the very strong public and patient concerns about the risks associated with increased travel times to the two HASUs from Guildford and places south such as Cranleigh and Haslemere, compared with travel to the Royal Surrey. These concerns are greatly reinforced by the poor performance of the ambulance service - an aspect which we hope the CCG will determinedly address.

If the two HASUs are sited as proposed, the CCG should reconsider the siting of the ASUs in the light of accessibility of Frimley and St Peters Hospitals to relatives and friends of patients post-HASU. Both are extremely difficult to get to for very many in the Royal Surrey catchment area particularly south of Guildford but also for Guildford itself. I understand that clinical outcomes are no worse for non-co-located HASU/ASU configurations than they are for co-located ones as currently proposed. I believe that In London and Manchester, for example, HASUs and ASUs are not necessarily co-located. Thus I ask that the CCG reconsider this aspect and seriously examine the possibility of an ASU at the Royal Surrey to which appropriate patients could be relocated post-HASU. Even if siting an ASU (as formally defined) at the Royal Surrey is rejected, I nevertheless believe that positioning some part of the acute stroke service at the Royal Surrey as part of the stroke pathway from HASU to home or rehabilitation in a Community Hospital, would be warranted and would meet the very strong concerns being expressed by the public regarding visiting.

Ray Rogers

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