IRP recommendation to the Minister of State for Well being on Kent and Medway stroke companies (accessible model)

1. Letter to the Minister of State for Well being

30 September 2019

Expensive Minister,

Thanks for forwarding copies of the referral letter and supporting documentation from Councillor David Wildey, Chair, Medway Council Well being and Grownup Social Care Overview and Scrutiny Committee (HASC). NHS England and NHS Enchancment (Kent, Surrey & Sussex) accomplished the Impartial Reconfiguration Panel (IRP) info template. An inventory of all of the paperwork acquired is at Appendix One. The IRP supplies this recommendation in accordance with our agreed protocol for dealing with contested proposals for the reconfiguration of NHS companies.

In contemplating any proposal for a considerable growth or variation to well being companies, the Native Authority (Public Well being and Wellbeing Boards and Well being Scrutiny) Rules 2013 require NHS our bodies and native authorities to fulfil sure necessities earlier than a report back to the Secretary of State could also be made. The IRP supplies the recommendation under on the idea that the Division of Well being and Social Care is glad the referral meets the necessities of the laws.

2. Background

The mixed inhabitants of Kent and Medway is roughly 1.8 million folks dispersed throughout a large geographical space of 1,368 sq. miles. Throughout the protection of Kent County Council, the county contains Canterbury, Margate and Ashford within the east, Maidstone and Tunbridge Wells extra centrally, and Dartford to the west. The unitary authority of Medway, together with Rochester, Chatham and Gillingham, individually covers an space to the north of the centre of the realm. The general inhabitants is projected to develop to 2.2 million folks by 2031 as a consequence of a mix of an ageing inhabitants and deliberate housing growth. The lengthy shoreline offers rise to challenges in offering accessible companies.

Stroke companies in Kent and Medway are at the moment offered at six acute hospitals throughout 4 NHS Trusts – Darent Valley Hospital (Dartford), Maidstone Hospital, William Harvey Hospital (Ashford), Medway Maritime Hospital (Gillingham), Queen Elizabeth the Queen Mom Hospital (Margate) and Tunbridge Wells Hospital (Pembury).

A evaluation of acute stroke companies started in Kent and Medway in December 2014 in response to considerations about efficiency and sustainability of hospital stroke companies. This was demonstrated by poor Stroke Sentinel Nationwide Audit Programme (SSNAP) scores throughout all hospital websites reflecting a transparent want to enhance the standard of stroke care to stop avoidable demise and incapacity from stroke. The evaluation was initially led by a Joint Committee of the eight medical commissioning teams (CCG) in Kent and Medway. A Scientific Reference Group and Stroke Programme Board had been established to supervise growth of the case for change.

The primary of a sequence of medical senate experiences reviewed the case for change in June 2015. It confirmed that higher outcomes for sufferers presenting with stroke at hospitals in Kent and Medway may very well be achieved by their being handled in a specialist stroke unit that would present what’s required seven days per week – a hyper acute stroke models (HASU) for the primary 72 hours adopted by an acute stroke unit (ASU) for subsequent acute hospital care. It really helpful consideration of the entire stroke and transient ischaemic assault (TIA) affected person pathways, taking account of proof about minimal volumes of instances in models and time particular requirements for delivering hyper acute care, addressing workforce points in additional element and a deal with future demand, prevention and inequalities.

The case for change was printed in July 2015 and set out the subsequent steps for the evaluation to develop and assess the impression of service reconfiguration choices to fulfill greatest apply and ship sustainable hyper acute/acute stroke companies for Kent and Medway. NHS representatives offered a report on the evaluation to a gathering of the Medway HASC on 11 August 2015. The Committee agreed that the reconfiguration of hyper acute/acute stroke companies constituted a considerable variation and famous preparations in place for Kent County Council Well being Scrutiny Committee to be consulted that will necessitate the necessity for a joint well being scrutiny committee to be established.

On 8 January 2016, NHS representatives attended a gathering of the Kent and Medway Joint Well being Overview and Scrutiny Committee (Joint HOSC), comprising representatives from Kent County Council and Medway Council, to debate the stroke evaluation. Joint HOSC members attended a ‘Stroke Problem Occasion’ in March 2016. The Joint HOSC met once more in April, August and November 2016. Throughout September and October 2016, 4 engagement occasions had been held with stroke survivors, households and members of the general public.

Work continued throughout 2017 to provide a protracted record of choices, develop hurdle standards to create a medium record of choices, resulting in the event of full analysis standards that may very well be utilized to succeed in a shortlist of choices. In July and August 2017, eight focus teams involving stroke survivors, carers, employees and the general public had been held along with a public assembly and on-line survey to assemble views on analysis standards. Joint HOSC members attended analysis workshops in August and September 2017 together with NHS commissioners and suppliers.

On 12 December 2017, the Joint HOSC was formally notified that the Joint Committee of CCGs (JC CCG) had been expanded to incorporate Bexley CCG and Excessive Weald Lewes Havens CCG as exercise modelling had highlighted the extent of exterior flows of stroke sufferers to Kent and Medway from Bexley and East Sussex. As a consequence of the additional evaluation, the well being scrutiny committees in Bexley and East Sussex had been suggested of the evaluation and each decided that the rising proposals to reconfigure stroke companies in Kent and Medway constituted a considerable variation to companies for his or her areas. This generated a statutory requirement to ascertain a brand new Joint HOSC involving Kent County Council, Medway Council, Bexley Council and East Sussex County Council.

Previous to the institution of the brand new Joint HOSC, representatives from the respective scrutiny committees of Bexley Council and East Sussex County Council attended the 22 January 2018 assembly of the prevailing Joint HOSC as non-voting visitors. The assembly thought of proposed choices and the session plan for the evaluation. Membership and phrases of reference for the brand new Joint HOSC had been mentioned.

As a part of the NHS England assurance course of, a evaluation of the proposals was undertaken by the Oversight Group for Service Change and Reconfiguration and NHS England Nationwide Funding Committee. They agreed that the 4 checks had been met and the mattress closures take a look at handed, confirming their help for the proposals to proceed to session. A pre-consultation enterprise case (PCBC) was printed on 24 January 2018 and the JC CCG formally agreed to seek the advice of.

A public session, ‘enhancing pressing stroke companies in Kent and Medway’, started on 2 February 2018. 50,000 session paperwork and 98,000 leaflets had been distributed all through the realm and 28 listening occasions had been held throughout the ten CCG areas, together with avenue surveys, roadshows and employees engagement occasions and discussions. Views had been sought on 5 three-site choices for HASUs, every with an ASU and TIA service alongside:

• choice A: Darent Valley Hospital, Medway Maritime Hospital, William Harvey Hospital
• choice B: Darent Valley Hospital, Maidstone Hospital, William Harvey Hospital
• choice C: Maidstone Hospital, Medway Maritime Hospital, William Harvey Hospital
• choice D: Tunbridge Wells Hospital, Medway Maritime Hospital, William Harvey Hospital
• choice E: Darent Valley Hospital, Tunbridge Wells Hospital, William Harvey Hospital

Views had been additionally sought on whether or not three was the correct variety of HASUs and on the standards used for evaluating choices. The session closed on 13 April 2018.

Evaluate and consideration of the responses to session was undertaken from Could 2018 onwards. A session evaluation report was produced by DJS Analysis, an unbiased analysis consultancy. A session exercise report was additionally produced and each experiences had been offered to the Joint HOSC at its assembly on 5 July 2018. Some 5,000 responses to the session had been acquired by way of emails, questionnaires, social media and feedback from listening occasions, focus teams, phone surveys and outreach engagement with hard-to-reach teams. Nearly all of responses supported the institution of HASUs in Kent and Medway and three areas was usually thought of to be the proper quantity (albeit with some choice for 4 models amongst Thanet residents). High quality and entry to specialist companies had been thought of to be the important thing points with the primary concern round journey instances. Whereas choice A was essentially the most most popular choice adopted by choice B, the rankings for all choices had been shut. The Joint HOSC resolved that feedback be handed to the JC CCG in regards to the implementation of the rehabilitation pathway and that additional consideration be given to, and assurance about, journey instances – significantly within the Thanet space.

By the autumn of 2018, work continued to judge the shortlist following session, determine a most popular choice and develop a decision-making enterprise case (DMBC). NHS representatives attended a gathering of the Joint HOSC in September 2018 and the Medway HASC in October 2018. A casual briefing assembly with Medway HASC members was held in the identical month. NHS representatives held casual conferences with members of Swale Borough Council and with the Joint HOSC in November 2018.

A Joint HOSC assembly on 14 December 2018 acquired a submission from Medway HASC expressing the view that the HASU websites chosen weren’t within the pursuits of the well being service in Kent and Medway and that there had been flaws within the course of for choosing the websites. The Joint HOSC agreed to refer the HASC’s contentions to the JC CCG.

The Joint HOSC met on 1 February 2019 to contemplate the DMBC and agree its formal suggestions. In accordance with the Joint HOSC’s phrases of reference, Medway members of the Joint HOSC submitted a minority response to the JC CCG on 6 February 2019, upfront of that Committee’s assembly on 14 February 2019, requesting that the CCGs delay taking a call to implement choice B and develop a DMBC for choice D. On 14 February 2019, a decision-making assembly of the JC CCG determined to undertake choice B which might see the institution of HASUs at Darent Valley Hospital, Maidstone Hospital and William Harvey Hospital. At its closing assembly on 26 February 2019, the Joint HOSC resolved to not refer the proposals to the Secretary of State and to help the choice of the JC CCG topic to the NHS making an enterprise to evaluation the availability of acute and hyper acute companies ought to demographic adjustments require it.

The Medway HASC met on 12 March 2019 and resolved to refer the proposals to the Secretary of State.

In April 2019, purposes for judicial evaluation of the JC CCG’s resolution had been launched.

On 20 June 2019, Thanet District Council wrote to the Secretary of State to specific considerations in regards to the proposals and calling for a fourth HASU to be established on the Queen Elizabeth, the Queen Mom Hospital in Margate.

On 21 June 2019, Councillor Jarrett, Chief of Medway Council, wrote to Lord Ribeiro, IRP Chairman, enclosing documentation referring to the purposes for judicial evaluation. An additional letter to Lord Ribeiro was acquired from Medway Council on 17 September 2019 enclosing paperwork hooked up to the claimant’s grounds for judicial evaluation. The Panel understands that two purposes for judicial evaluation have been rolled into one listening to as a consequence of happen on 3-5 December 2019.

3. Foundation for referral

Councillor Wildey’s letter of 27 March 2019 states that:

I’m writing in my capability because the Chairman of Medway Council’s Well being and Grownup Social Care (HASC) Overview and Scrutiny Committee on behalf of Medway Council (“the Council”) pursuant to the Council’s powers beneath Regulation 23 of the Native Authority (Public Well being and Wellbeing Boards and Well being Scrutiny) Rules 2013 (“the Rules”) to report back to you that the Council considers that the choice taken on 14 February 2019 (“the Resolution”) by the Scientific Commissioning teams overlaying Kent and Medway (“the CCGs”) to make a considerable variation to the NHS stroke companies shouldn’t be within the pursuits of the well being service in Medway or the broader inhabitants of Kent and Medway.

4.
IRP view

With regard to the referral Medway Council HASC, the Panel notes that:

• the evaluation of pressing stroke companies in Kent and Medway has been the topic of detailed well being scrutiny by an appropriately fashioned joint well being scrutiny committee that determined to not refer
• the medical case for change is properly established and broadly accepted
• though the medical mannequin primarily based on three HASUs shouldn’t be disputed by Medway Council, it has raised some considerations about distance to be handled
• figuring out the popular choice integrated session suggestions and new info that had emerged
• pressing stroke companies are however one aspect of a complete strategy to lowering the dangerous impression of stroke on inhabitants well being

5. Recommendation

5.1 Scrutiny

The IRP finds itself once more commenting on the method for establishing and working joint well being scrutiny committees. On this case, a joint well being scrutiny committee was established by Kent, Medway, Bexley and East Sussex Councils because the well being physique to be consulted on issues referring to the planning, provision and operation of the well being companies within the space beneath the Native Authority (Public Well being, Well being and Wellbeing Boards and Well being Scrutiny) Rules 2013. The Joint HOSC is the suitable and solely scrutiny physique with which the JC CCG wanted to seek the advice of on its proposals for stroke companies. Additionally it is the one physique that the NHS is required to offer info to in these circumstances. The NHS on this occasion made further efforts to interact with the constituent scrutiny committees individually however finally – though the Joint HOSC determined to not refer the matter – nonetheless discovered that its choices had been the topic of referral to the Secretary of State by a type of constituent committees, specifically Medway HASC.

The Medway HASC has questioned whether or not the inclusion of Bexley and East Sussex inside the scope of the evaluation led to ‘disproportionate weight’ being given to the well being wants of these residents on the expense of residents in Kent and Medway. The Panel considers that the NHS appropriately thought of the well being wants of all these more likely to be affected and that native authority boundaries mustn’t current a barrier to the planning of applicable well being care. The structure of the brand new joint scrutiny committee and voting rights attributed to constituent members is a matter for that committee to find out and never for the IRP or the Secretary of State.

The Panel does, nonetheless, want to document its view that each the NHS session and the method by which native authority scrutiny was carried out had a lot to be recommended.

Subsequent to its referral, Medway Council dropped at the eye of the Panel ‘{the catalogue} of failures’ within the JC CCG’s decision-making uncovered by the papers for the approaching judicial evaluation. Referral to the Secretary of State and judicial evaluation are solely separate processes and the Panel has at all times been clear that it doesn’t advise on issues which can be for legal professionals and the courts however fairly considers every case on its deserves, according to our basic phrases of reference.

5.2 Proposals not within the pursuits of the well being service

Because the South East Scientific Senate famous in its evaluation of the popular choice, fashionable stroke care can solely ship the absolute best outcomes for stroke sufferers in specialist models which have the required experience and services accessible across the clock. Nationwide stroke requirements and audit knowledge reveal that the present sample of stroke companies in Kent and Medway falls brief of what’s required and what’s being achieved elsewhere. The Panel agree that this hole is cheap trigger for contemplating choices to create specialist models for pressing stroke care.

Though the proposal to organise pressing stroke care across the growth of three mixed HASUs/ASUs in Kent and Medway has not been disputed by Medway Council, focus of companies for all times threatening circumstances into fewer areas naturally raises considerations. Within the case of stroke, outcomes are positively related to well timed entry to evaluation and remedy thus recognising stroke signs, attending to a specialist unit and receiving immediate care on arrival are essential. On this context, the NHS adopted the South East Scientific Senate commonplace of 120 minutes from name (to ambulance) to needle (potential administration of thrombolysis) and within the absence of appropriate knowledge, used 60 minutes journey as a proxy measure in its evaluation of choices.

The Panel famous that beneath all of the choices for public session, this proxy measure was not achieved by a couple of minutes for a small a part of the inhabitants, notably within the north east of Thanet, who can be handled at William Harvey Hospital, Ashford for pressing stroke care. Nevertheless, according to the intent of the 120 minutes commonplace, the chance exists, with the correct operational procedures and educated employees in place, to mitigate journey time with sooner care on arrival, noting {that a} well-functioning HASU can obtain a median of half-hour for ‘door to needle’. Taking this into consideration with the evident advantages to sufferers of getting specialist centres that deal with a minimum of 500 instances a yr, the Panel agree that three HASUs with alongside ASUs is the correct manner ahead.

While the case for creating three specialist centres is frequent trigger, Medway Council have disputed the JC CCG’s resolution to proceed with the popular Possibility B (Darent Valley Hospital, Maidstone Normal Hospital and William Harvey Hospital), arguing that Possibility D (Tunbridge Wells Hospital, Medway Maritime Hospital, William Harvey Hospital) is preferable.

The method and technique used to determine the popular choice had been mentioned with the Joint HOSC on 5 September 2018 and are described absolutely within the DMBC. Within the Panel’s view, they’re in keeping with the strategy used to determine the 5 session choices and fairly tackle board related info that emerged after the publication of the PCBC and thru public session. An up to date evaluation of the 5 choices throughout all of the analysis standards and sub-criteria was accomplished to tell the ultimate alternative of most popular choice. Critically, it discovered that for choice D (and choice C) the Princess Royal College Hospital in Bromley can’t accommodate the additional move of stroke instances that consequence from not having Darent Valley Hospital as a HASU and while this may need been examined earlier it can’t be ignored in reaching a closing resolution a few most popular choice. Possibility D can be comparatively poor worth for cash (together with choice E) due to the elevated capital prices of constructing Tunbridge Wells Hospital a HASU. On the steadiness of the knowledge offered in regards to the closing analysis of choices, and the way it was used to tell the JC CCG’s decision-making a few most popular choice, the Panel finds no motive to contradict the ultimate judgement in favouring choice B over choice A as a result of it evaluates strongest on workforce and gives confidence in means to ship.

The Panel is anxious that Built-in Influence Assessments (IAA) for service adjustments shouldn’t be a ‘tick field train’ however fairly that they inform choices and result in applicable actions. By way of equality, the post-consultation IAA makes clear the constructive impression of improved well being outcomes. It additionally notes that some sufferers and guests will expertise elevated journey prices, that are more likely to impression disproportionately upon these on decrease incomes. The necessity to mitigate the latter has been recognised by the JC CCGs in reaching their resolution and motion is being taken by way of Journey Advisory Teams. On this case, the Panel agrees that the IAA is a vital consideration however not a trump card in alternative of location of HASUs which should mirror and steadiness all of the components included within the analysis of choices.

Pressing stroke companies are however one aspect of a complete strategy to lowering the dangerous impression of stroke on inhabitants well being, an impression felt all of the extra keenly in areas of upper deprivation. The South East Scientific Senate critiques have really helpful the event of wider plans to deal with stroke prevention, rehabilitation and long-term care. The JC CCGs have dedicated to this strategy and work is underway to provide enterprise instances. The Panel agrees that these have to be accomplished alongside the event of the HASUs. The event of preventive companies focused at populations with most to profit should contain working with stakeholders and companions in public well being and native authorities.

6. Conclusion

There may be ample proof to reveal that the institution of HASUs results in higher outcomes when it comes to mortality, severity of long-term incapacity and decreased size of hospital keep. Whereas their location inevitably includes some measure of compromise, when coupled with plans to enhance prevention by way of main care, post-stroke rehabilitation and long-term care, these proposals signify a chance to enhance well being companies considerably for the populations of Kent and Medway and the encircling space.

The NHS England assurance course of concluded that the Secretary of State’s checks and the fifth mattress take a look at had been glad. The Panel agrees.

Lastly, the Panel needs to emphasise that the aim of session is to hunt views and discover choices in creating proposals. Whereas it might, because of session, transpire that one choice enjoys a selected degree of public help, session shouldn’t be a reputation contest and shouldn’t be thought to be such.

Yours sincerely,
Lord Ribeiro, CBE
IRP Chairman

7. Appendix One – record of paperwork acquired

7.1 Medway Council HASC

1. Referral letter to Secretary of State from Councillor David Wildey, Chairman, Medway Council HASC, 27 March 2019, attachments:
2. Appendix A – Medway Council submission to Joint HOSC, 14 December 2018
3. Appendix B – Stroke evaluation Joint HOSC Minority report, 6 February 2019
4. Appendix C – Agenda of Medway HASC assembly, 12 March 2019
5. Appendix D – Draft minutes of Medway HASC assembly, 12 March 2019
6. Appendix E – letters between Medway Council Chief and Senior Accountable Officer, 4, 24, 28 January 2019
7. Letter to Lord Ribeiro, IRP Chairman, from Councillor Alan Jarrett, Chief of Medway Council, attaching authorized bundle referring to utility for judicial evaluation
8. Letter to Lord Ribeiro, IRP Chairman, from Laura Caiels, Principal Lawyer, Place Authorized Providers on behalf of Medway Council attaching claimant’s grounds for judicial evaluation, 17 September 2019

7.2 NHS

1. IRP template for offering evaluation info with embedded paperwork.
2. Kent and Medway stroke service reconfiguration briefing, NHS England, March 2019
3. MTW stroke report, 23 July 2019
4. Letter to stakeholders from Stroke Programme Board, 24 July 2019

7.3 Different

1. Letter to Secretary of State for Well being and Social Care from Councillor Robert Bayford, Chief of Thanet District Council, 20 June 2019
2. Electronic mail from Habib Tejan, former Mayor of Medway, 18 September 2019