A detailed analysis of the results of consultation on stroke services in West Surrey has been published albeit a decision has yet to be made known.402 questionnaires were returned, 178 people attended 13 events and there were 93 individual responses one of which was mine (see earlier blog). Geographically the responses from Woking, Weybridge and Chertsey, Staines and East Hampshire were small. Guildford and Waverly dominated.

Considering the following 3 statements:

• Access to seven day specialist stroke services should be provided at Frimley Park Hospital and St Peter’s Hospital to enable more people to survive a stroke and minimise risk of disability 
• Seven day clinics for transient ischaemic attacks (TIA) should be provided at Frimley Park Hospital and St Peter’s Hospital as part of the specialist stroke service
• The reason for concentrating in-hospital stroke specialist rehabilitation services in fewer hospitals in West Surrey is justified and supported

Overall the results were:

• ·         First statement 77% disagreed/strongly disagreed, 21% agreed/strongly agreed
• ·         Second statement 74% disagreed/strongly disagreed, 21% agreed/strongly agreed
• ·         Third statement 83% disagreed/strongly disagreed, 15% agreed/strongly agreed

 Geographically:

• In Guildford, Waverley and East Hampshire the majority of respondents disagreed with the statements but a significant proportion of respondents supported them.
• In Woking, the majority of respondents agreed with statements but a significant proportion disagreed.
• Responses from Weybridge & Chertsey and Staines were very low but agreement was almost 100%

 Most common themes were:

• Concerns about removal of services from Royal Surrey, preference to position some stroke services there and concerns about the hospital’s future
• Importance of timely treatment
• Recognition that specialist workforce and equipment has benefits, with differences of opinion on location
• Importance of equitable access but concerns that plans create inequity
• References to travel distance and time with implications for timely treatment, visitor access, patient wellbeing and public transport
• Ambulance availability and concerns about SECAMB.

 All very predictable. 

National Elderly-Friendly Quality Marks have just been awarded to Hindhead and Ewhurst wards in the Royal Surrey. This means that the Royal Surrey is home to three of the 26 wards which have been awarded nationally. The awards are are given by the Royal College of Psychiatrists. The award is based on assessors collecting information from patients, carers, visitors, ward staff and hospital managers and thus not lightly given. Myself and two fellow governors were involved in checking the wards for cleanliness, maintenance, general environment, presence of dementia friendly features and food quality. I can therefore testify directly to the justification for this national recognition - well deserved.

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

National statistics for stroke death rates show Royal Surrey has the lowest

Readers will know that it has been decided that there will be only two Hyperacute Units (HASUs) in West surrey i.e. St Peters and Frimley Park and that the HASU in the Royal Surrey will close. Those people in Guildford who have a stroke will now go to ST Peters and those south of Guildford e.g. Cranleigh will go to Frimley Park.

The rationale presented is that Surrey’s death rate is poor compared with places such as Inner London which has reorganised stroke services in to large centres and closed smaller ones. Thus Surrey should reorganise similarly.

This could be taken as implying that death rates in W Surrey hospitals are all worse than Inner London and, in so far as it is the HASU in Royal Surrey which will close, some may assume that it is the Royal Surrey’s death rate which is the worse. This is not so – read on.

NHS Digital is responsible for all national health statistics in the UK. Every year it publishes data on death rates within 30 days of emergency admission to hospital from stroke. The data is given for all providers (hospitals), Counties and Boroughs. Data is for every year since 2005/06 the latest being 2014/15 (the basis of figures below).

This data shows the death rate in inner London as 14,986 per 100,000. Surrey is 2.4% worse i.e. 15,347 (the consultation states 4.8% worse).

However

• RSCH had 327 emergency admissions and 49 deaths. Death rate was 14,211. The deaths were 27% lower than would be expected looking at the country as a whole.
• ASPH had 446 admissions and 70 deaths. Death rate was 14,843. Deaths were 20% lower than expected
• FP had 827 emergency admissions and 132 deaths. Death rate was 16,412. Deaths were 9% lower than expected.

Thus, re death rates, RSCH was the best and both RSCH and ASPH death rates were lower than Inner London.

FP (which treats more than sufficient numbers to be counted as of optimum size, has most of the characteristics which are being sought e.g. 7 day 24 hour consultant presence and is a hospital rated excellent) had a very significantly worse death rate than Inner London.

RSCH is 5% better than Inner London, ASPH is 1% better and FP is 9.5% worse.

These figures do not in themselves alter the rationale for change based on London’s experience but it does show that the Royal Surrey was good at handling strokes despite whatever impression might otherwise be gained.

I am in active correspondence with the CCG about these figures but to date no explanation as the FP data has been received but note I am not knocking FP but really knocking on the head any impression that RSCH's performance has been inferior.

Charge rises by 80%

The Care Quality Commission (CQC) is the national body which among other things inspects hospital performance. It levies a charge on all health authorities to cover its costs. I have just heard that its charge to the Royal Surrey is to rise from £160,000 to £288,912. This is a rise of 80% !!!!!!! For a body which is quick to criticise lack of efficiency and any overspends, this is disgrace. The problem is that these central bodies seem unaccountable to the public. Shame on the CQC to act like this at a time when all hospitals are struggling so hard to control costs and the salary increases for health workers are being held at 1%.

Stroke Consultation
The official consultation on Stroke Services in West Surrey has commenced and will close midnight on 30 April. If you want to have a say and/or learn more there is a calendar of events on www.guildfordandwaverleyccg.nhs.uk  where you can also find information about the proposed changes.There is a survey you can fill in on www.surveymonkey.co.uk/r/StrokeConsultationWestSurrey

Hyper Acute Stroke Services (HASUs) to stop at Royal Surrey in January

I have mentioned in previous blogs that a review of stroke services by CCGs had proposed that there be only three HASUs in Surrey i.e. at Frimley Park, St Peters and  East Surrey. That would mean that the HASU at the Royal Surrey would close and anyone with a suspected stroke would be taken by ambulance to St Peters (those to the south of Guildford would go to Frimley Park).

There is to be a public consultation early next year but, as I have pointed out before, I believed that the consultation would be meaningless and now that is clear. The Royal Surrey has just announced that as from January it will cease to provide HASU services and so patients in Guildford with suspected stroke will go to St Peters. Although the decision might be right for quality of care for the people of Surrey as a whole, this is a serious change in services provided by the Royal Surrey and of great concern to the public it serves. Despite this there has been no meaningful engagement by the Royal Surrey with its public or with its Members or with its governors. I chair the Patient Experience Committee. At its last meeting just 5 weeks ago stroke services was on its agenda but no hint of this forthcoming decision was given.

The Royal Surrey is a membership body which governors represent and in this case it is the people of Guildford who will be most affected. Time from suspicion of stroke to treatment is critical and, for those in Guildford, travel times by ambulance will be longer. Although this is but one factor to consider it is an important one. As one of the elected governors for Guildford I have repeatedly raised the matter of the CCGs stroke review but with little meaningful response. In this instance Royal Surrey’s engagement with those it serves scores very poorly.