How changing Stroke Pathways is known to save lives

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Yeovil’s Stroke Unit controversy – amid the public debate, Rachael Rowe looks at the pros and cons of NHS Somerset’s plans to centralise services

Yeovil Hospital

The NHS in Somerset is recommending centralising its stroke service. In January NHS Somerset’s Integrated Care Board (ICB) voted for a single emergency stroke unit for the county at Musgrove Park Hospital in Taunton, and the closure of the hyper-acute unit at Yeovil Hospital, which provides an acute stroke ward with specialist services for people who have had a new suspected stroke. Centralising services is recommending nationally – it saves lives.
But the threatened closure of the Yeovil unit has raised concerns from local people and politicians. Under the ICB plans, Yeovil District Hospital will keep 12 acute stroke beds – where people can be cared for, from 72 hours after a stroke. But it will lose its four hyper acute beds.

Strokes in Somerset
A stroke is a medical emergency, and for each minute treatment is delayed, four million neurons and 12 million brain cells die. Swiftly getting the very best treatment is critical, as is access to stroke rehabilitation. The way that stroke is treated today is radically different to that of even 20 years ago, when people were simply given some rehabilitation.
Today, people with a suspected stroke can expect a CT scan, access to clot-busting drugs, rehabilitation and, where appropriate, specialist procedures. In London, centralising the stroke pathway saves almost 100 lives each year.
Nationally, the chance of a stroke affects 1.8 per cent of the population, but Somerset has an older age profile, so it is higher at 2.3 per cent and Dorset is higher still at 2.55 per cent.
Those higher figures are a vital reason for prioritising stroke care in the South West.
The public can also play a critical role. Nine out of ten strokes are preventable, according to the Stroke Association. Smoking, obesity, atrial fibrillation and drinking excess alcohol all increase your risk of a stroke. Around 5.5 million people in the UK have no idea they have high blood pressure – getting it detected and treated can significantly reduce the risk of a stroke. Preventing strokes in up to 90 per cent of sufferers would result in massive savings in resources. A national review (GIRFT) of stroke services in 2019 found care in Somerset was good.
However, stroke medical teams were not always able to perform rapid assessments, CT scans could not always be provided within an hour, clot-busting drugs were not always given within the critical time frame, and it was challenging to get an MDT (Multi-Disciplinary Team) assessment for therapy. Clearly, something had to change.
Proposals to centralise stroke services in Somerset are not new. Since 2013, there have been at least three commissioned reports by the health organisations, visits by experts, and recommendations to centralise the hyper-acute stroke service so that stroke patients will go to Taunton or Dorchester. Locals know that the stroke unit at Yeovil Hospital is not solely for the people of South Somerset – a quarter of users come from North Dorset. If it is safe to close, as claimed, why has it taken so long?

Distance and Staff
When centralised services were recommended back in 2014, a major analysis of travel times was also commissioned. The review showed that from some parts of Somerset, patients would be unable to get to a hyper-acute stroke centre within an hour. A further review of times in Somerset for the latest report shows that there would be an increase in journey times in some areas. Is it better to travel for slightly longer to get the best and most appropriate treatment, given that all the research supports centralised services?
Concerns have also been raised by local politicians about transferring the sickest patients to Bristol or Southampton. West Dorset MP Chris Loder says: ‘It is a fantasy to believe that stroke patients from Yeovil will stay in Somerset. They will not go to Taunton for their treatment; they will go to Dorchester, and if necessary on to Southampton.’
Transfers to Southampton give certain people a fighting chance of receiving a thrombectomy – a revolutionary new treatment to remove a clot from the brain. Somerset and Dorset have never had neurosurgical centres, and residents have always had to travel to be treated by a brain surgeon. Given the choice of surviving a stroke and reducing the effects of long-term disability, or choosing to not travel to Southampton, few would refuse to travel. In the past year, 17 people from Somerset received this life-saving treatment.
There is a national shortage of stroke consultants and specialists in England, which means it is increasingly difficult to find new staff. Although Yeovil has recently recruited new stroke consultants, there remain challenges in covering on-call rotas at both Taunton and Yeovil, which means the target of a seven day service is more difficult to achieve.

Postcode lottery
Perhaps more concerning is that currently there is unequal care for people experiencing a stroke in Somerset. A spokesman for NHS Somerset said: ‘There is currently variation and inequitable provision of hyper-acute and acute stroke care across the county, especially over weekends and out of hours, where it takes significantly longer for patients to receive treatments such as thrombolysis. Patients admitted to Yeovil District Hospital at weekends are unlikely to see a consultant stroke specialist until after the weekend. There is no weekend outpatient service for patients suffering a TIA (transient ischaemic attack, or ‘mini stroke’) in the Yeovil area.
‘We are failing to meet several national performance targets in relation to hyper-acute and acute stroke care, which has a negative impact on clinical outcomes, including rates of thrombolysis and thrombectomy, time taken to receive thrombolysis, TIA assessments falling outside of 24 hours and access to MDT assessments.’
Underpinning the decision to centralise services is the need to provide a service that enables everyone to get the best possible care – not just pockets of the general population. It’s a difficult decision to make, but the research consistently shows that, when specialist services like hyper-acute stroke are centralised, more lives are saved.
Dorset County Hospital NHS Trust was approached for a response but was unable to comment due to the pre election period.
The Stroke Association was approached for comment and did not respond by the publication deadline.

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