Yeovil without...

Fit for my Future plans to move all stroke services to Musgrove in Taunton. This leaves Yeovil without a service. For stroke patients time is of the essence. Is this saving money - or costing lives?

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Yeovil Without

Sometimes when you write things down, you can feel you are working in splendid isolation, divorced from other people’s reality. So it comes as a pleasant surprise to discover that you are voicing a very real concern felt by others. But not everyone is empowered to make their voices heard. Which is I guess, where we come in.

Just such a case occurred recently when Fit For My Future put forward plans to close down the stroke service in Yeovil. Fit For My Future is these days, part of the Somerset Integrated Care Board (ICB) which in turn is a partnership involving Somerset NHS Foundation Trust, Somerset Council, and a number of other bodies with an interest in healthcare in our county.

It is only a matter of a couple of weeks since Yeovil District Hospital NHS Foundation Trust formally merged with Somerset NHS Foundation Trust to form one new trust. It now covers the whole of the Somerset County Council area (with apologies to the good citizens of Frome and its environs who actually look to Bath for their hospital services). It encompasses some primary care, mental health services and the two acute hospitals at Yeovil and Taunton.

The merger has been coming for a while. The management teams were merged into one from 1 January this year. On the 1 April the two trusts came together as one officially.

What do we mean when we say merger? Once upon a time your humble correspondent worked in one of the large accounting firms. They were always having mergers. But some looked less like a merger than others.

When Dearden Farrow merged with Binder Hamlyn, the new firm was called Binder Hamlyn. When Binder Hamlyn was merged with Arthur Andersen, the new firm was called Arthur Anderson. You get the picture. The senior management and the name belonged to one dominant firm. It might have been called a merger, it looked like a takeover.

When Binder Hamlyn was merged with Arthur Andersen, the new firm was called Arthur Anderson

And so it has been with this NHS merger. Nearly all of the management in the merged team running both trusts since the 1 January come from Somerset NHS Foundation Trust (the Trust). And the newly merged trust is called? Yes you guessed, Somerset NHS Foundation Trust.

It is inevitable, indeed in some areas quite logical, that the new service should look to save money by streamlining. Shorthand for closing down services that are duplicated in both hospitals and having one centre of excellence. You will rarely hear the words “it is to save money.” More likely there will be a clinical justification put forward. But the hard reality of the modern NHS is that it really is about saving money.

When it comes to stroke services there are a number of issues to consider. Firstly strokes are a major issue for the NHS. Dr Rob Whiting, Consultant Stroke Physician and Clinical Director for Neuroscience and Stroke explains: “Stroke is a medical emergency and the third most common cause of death for people under the age of 75 in the UK. There is clear evidence that patients benefit most from being treated at a hyper acute stroke unit in the first 72 hours after their stroke.”

We can take further advice published by the NHS on its website. The following words come straight from an NHS press release: “NHS is urging the public to act F.A.S.T. and dial 999 when stroke strikes. The F.A.S.T. (Face, Arms, Speech, Time) acronym is a simple test to help people identify the most common signs of a stroke, and emphasises the importance of acting quickly by calling 999.”

It could not be clearer. With strokes, speed is of the essence. The time taken from the stroke happening to getting treatment can have a fundamental bearing on the outcome for the patient.

For stroke patients in South Somerset, the closure of stroke services in Yeovil could have a significant and detrimental impact on their outcomes if a stroke strikes. Anyone living in or around the town will have a journey of a few minutes turned into a 50 minute trek across the county to access urgent treatment. If that sounds bad, think of poor patients in Wincanton. For them the journey in an emergency will take over an hour.

Similarly the journey time will increase significantly for those in Castle Cary, Bruton, Crewkerne, Ilminster and Chard.

“The sooner you’re treated, the better your chance of recovery.”

That is just simple geographical fact. The Somerset team at Fit For My Future know this. In their own documentation they say “The sooner you’re treated, the better your chance of recovery.”

In fact the trust’s Dr Rob Whiting, acknowledges as much: “With stroke, what matters is the total time taken from calling 999 to having a scan and starting the right treatment. Travelling an extra 20-30 minutes by ambulance to a specialist stroke unit might worry people but it does mean we can start scanning and treatment as soon as the patient arrives.”

Well yes, if that isn’t already too late. And by the way for people in south east Somerset it is more like an hour not 20-30 minutes.

So why are Fit For My Future pushing the closure of stroke services at Yeovil Hospital? This is their justification: “In Somerset, both Yeovil District Hospital and Musgrove Park Hospital have hyper acute stroke units, and acute stroke units. While the care delivered across local trusts currently is high-quality neither hospital has the right number of specialist staff needed to provide the units with 24/7 consultant cover.”

At present neither hospital is able to provide a 24/7 stroke service. In other words, the Trust has a recruitment problem. Of course the Trust could solve that problem by going out and recruiting more staff. But this is not the preferred course of action. Indeed it is a course of action the Trust are clearly not prepared to contemplate.

Under new management. And about to lose its stroke service?

Another argument put forward by the Fit For My Future for change is that they are not set up to maximise the skills and experience of staff. “Currently, Yeovil District Hospital doesn’t see the minimum recommended number of stroke patients (500–600 per year) for staff to maintain their skills and build expertise.” Yes - ish. But its pretty flimsy as arguments go. Yeovil has always had over 400 admissions a year. And Taunton has never had more than 708. The difference between the two is marginal to the 500-600 minimum level.

Be that as it may - the fact is that the Trust want to deliver all stroke services from Taunton. There are two types of stroke service:

• There is the hyper acute stroke unit (HASU). This is the specialist critical care received in the first 72 hours (or sooner if medically stable) after having a stroke. This includes rapid access to a specialised for specialist assessment, scanning, diagnosis and treatment.

• There is also acute care. This provides acute hospital rehabilitation for those who need it, providing daily specialist input from medical, nursing and therapy staff.

What the ICB have to do, before implementing their plans, is undergo a public consultation. You can read their documentation here. That will run until 24 April. So if you read this and want to give your view, you need to get your skates on. You can answer their questionnaire here

Everyone at the ICB is at great pains to point out that: “no decision has been made yet. Public consultation gives people the opportunity to provide their views before any decisions are taken.” This is actually untrue.

One decision has effectively already been made. A single hyper acute stroke unit will be run from Musgrove Park Hospital, Taunton. No equivalent facility will be provided from Yeovil. If you look at the consultation document, the two options (A and B) that are being consulted on both include just one HASU facility in Taunton.

The possibility of one HASU in Yeovil has been rejected. Why? Because of “Increased travel times for patients and their families.” That statement makes sense because Yeovil is obviously not as central to the area of Somerset the Trust serves as Taunton is. However it has seemingly not crossed the minds of the Trust’s gurus that, and this is not rocket science, closing Yeovil’s HASU will also result in “Increased travel times for patients and their families.”

This is important. The significant impact of moving stroke services to Taunton, is the time taken to get stroke victims to the hyper acute stroke unit. This is where the increase in journey time is likely to make a big difference. This is where the biggest impact on medical outcomes is likely to occur.

With strokes, time is of the essence

Many patients arrive by ambulance and it is well documented that ambulance times to attend an emergency, such as a stroke, are not what they could be. Then on top of that the journey the ambulance must take will be even longer, up to 30 minutes longer than is the case today. And those 30 minutes could be vital. Of course the paramedics may be able to help the situation and ring ahead to ensure the HASU is as ready as it can be when the patient eventually arrives.

That said the ICB acknowledge that around 17% of all patients bring themselves in to the HASU. So no blue lights, no paramedics on hand and still a journey time of an extra 30 minutes or so.

Yet this, the most important decision being made, in terms of medical outcomes, appears in the literature to be a decision that has been all but made. You are merely asked in the consultation if you agree with it or not. Which is telling.

The two options you are being asked to give an opinion on, are simply whether to have one acute service in Taunton (option B) - or one each in Taunton and Yeovil (option A). Which arguably are the less medically significant aspect of the proposed changes.

Even with the acute services though, there are issues. When Peter Lewis, Chief Executive of Somerset NHS Foundation Trust says: “experience from elsewhere has shown that consolidating stroke care can provide more sustainable services and better outcomes for more patients.” He probably means well. It is just that a man who is a Chief Executive on a salary of £255,000 isn’t likely to know much about travelling on buses.

If he did, he would know that getting to and from an acute unit in Taunton, whether for patients or their families, is not easy from the more rural backwaters of South Somerset. In many areas it actually won’t be possible.

Are there any other options that could be considered? Well yes but again it will involve spending money. Though the Trust’s accountants might like this because it is capital spend rather than revenue spend.

NeuroLogica and MEYTEC both based in Germany have developed a specialized stroke ambulance, called VIMED STEMO. It carries a portable CT scanner and a point-of-care laboratory for nearly-instant diagnosis and initiation of treatment in stroke patients. It sounds ideal for a rural area like Somerset.

Mobile stroke unit developed in Germany

If Fit For My Future are not willing to pay to recruit the staff they need to operate the stoke service 24/7 in both Yeovil and Taunton, this at least offers a viable alternative. Yes the units are expensive. But other countries have invested in them successfully. Norway is a country with vast tracts of open space, if anything the population outside Oslo is even more isolated than that in Somerset. Last year a study carried out in Norway on mobile stroke units suggested that taking just 260 patients on board the unit made it cost effective*.

Yet this solution was not even considered and ruled out. It was an option simply overlooked by the Fit For My Future team.

As to the public, what do they make of it? For those living around Taunton there’s little to be concerned about. For the triangle of Glastonbury, Langport and Somerton, it will make little difference. Yeovil and Taunton are equi-distant.

Inevitably, those living around Yeovil will be very concerned. As we noted above as we started work on this piece, we realised we were in good company. Somerset Councillor Steve Ashton has raised serious concerns. A number of other members of the public have been in touch to register their shock at the proposals. The Chairs of Patient participation Groups in North Dorset and South Somerset have written an open letter to the Trust. As they say they “represent the views and opinions of the many thousands of patients registered at our respective General Practice Surgeries. Having carefully considered the two options presented in your public consultation, we have grave concerns about the potential harm to patients if either option is adopted unamended.”

we have grave concerns about the potential harm to patients if either option is adopted unamended

It is of course only a consultation. However as we note above the decision on the HASU looks to be all but a done deal. And Fit For My Future have a track record when it comes to manipulating consultations. When they proposed the closure of mental health beds at St Andrew ward in Wells and moving them to Yeovil, the consultation did not give them the answer they wanted. The public didn’t like it. The majority did not want to see St Andrews ward closed.

Needless to say the public from the Wells area gave the most negative responses. To anyone not from an NHS background, it is pretty obvious that those most effected by a decision, will be most likely to give a view on it.

So what did Fit For My Future do? They examined the data and decided that respondents from the Wells area were biased. Therefore there views could not be given the same weight. Effectively negating the actual result of the consultation. Then went ahead and implemented the decision they had wanted to implement all along.

It is not hard to anticipate that the same manipulation trick is likely to be applied when this public consultation is completed. The views of those from South Somerset can simply be discounted as being biased and hey presto, Fit For My future will do as they wish. We would of course, be delighted to be proved wrong……

* Cost-Effectiveness of Mobile Stroke Unit Care in Norway by Ulrikke Højslev Lund, Anna Stoinska-Schneider, Karianne Larsen, Kristi G. Bache and Bjarne Robberstad

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