Stroke service at Yeovil to go
Following a meeting of NHS Somerset, the decision to close the Hyper Acute Service in Yeovil has been confirmed. But serious questions remain unanswered
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Stroke service at Yeovil to go, unanswered questions remain
Today the board of NHS Somerset unanimously passed plans to close the Hyper Acute Stroke Service (HASU) in Yeovil. The board stressed that this was a clinical decision only, but more of that later.
The proposal would see the HASU in Yeovil closed down over a two year period. A new HASU in Dorchester would provide a service to south east Somerset. Taunton would maintain its HASU which would have more staff and offer a better service than either HASU can currently offer. All three hospitals would retain beds and clinicians to support an Acute Stroke Unit (ASU).
The degree of public outrage at the possibility of the Yeovil unit being closed was there for all to see. A large demonstration took place outside NHS Somerset’s Yeovil HQ and public questions took a full hour to get through, as speaker after speaker pointed out the public opposition to the move.
The meeting was considerately chaired by Paul von der Heyde. Everyone who wated to, got to ask their questions and everyone got an answer. It may not have been the answer they wated, but they were heard.
The fact that the (overwhelmingly hostile) feedback from the public consultation had been in the hands of NHS Somerset since September was brushed over. Whilst we were told that board members had all seen it well before today’s meetings, no-one could supply any explanation as to why it had not been made public until 19 January.
The presentation of the case for going forward with the plan revealed some new information which was of interest. The big concern of residents of south east Somerset is that the extra time taken to getting to the proposed new centralised HASU in Taunton will mean worse outcomes for patients from the Wincanton area. In other words, there will not be an equal service for all residents across Somerset.
NHS Somerset’s Bernie Marden summed up the case as follows: In modern stroke care if you concentrate expertise and equipment and decision making, you improve outcomes. 24 hour, 7 days a week, 365 days a year is the service we need and that could best be delivered from Taunton.
If suffering a stroke you do need to get to the right place ASAP. But once there you need the best and most rapid clinical intervention.
Evidence is that better outcomes are achieved with a centralised service. That does have to be weighed against time taken to get there and NHS Somerset accept this.
However the plans proposed for Somerset will depend on Wincanton patients, rather than being sent to Taunton, going to Dorchester. That increases journey time by 17 minutes. Marden then explained that evidence from Northumbria - a rural area like Somerset - suggested increased time spent travelling to a hospital was offset by the speed of treatment on arrival. This is referred to as door to needle time.
Unfortunately his argument was then destroyed by one of the slides of the presentation to the board meeting by the Stroke team at Taunton. The slide clearly showed that for 35% of Somerset patients the door to needle time could be anything from 10 minutes earlier than it is today, to 10 minutes later. It was clear that it was inconclusive at best, that outcomes would improve and the lack of precision was worrying, given the importance of improved outcomes to the business case.
For the other 65% of patients (presumably those living close to Taunton) outcomes would be better or the same as today.
So the whole purpose of closing the Yeovil HASU, to reduce door to needle times, it turns out, is not actually supported definitively by the data.
The debate on what to do threw out some interesting omissions and one unanswered interjection. The latter provided by Adam Dance, Somerset Councillor and Lead Member for Public Health, Equalities and Diversity. He pointed what he saw as a flaw in the argument.
If money was available to be spent (Somerset money) on building up a HASU in Dorchester, why would the money not be better spent doing the same for Yeovil?
why would the money not be better spent doing the same for Yeovil?
This interjection visibly annoyed the stroke service representative from Taunton, but there was no answer to the question. The board let the issue go and it was left hanging. The fact is that Dorchester Hospital has no HASU. It aims to build one from scratch. It will not be on stream until 2025.
Cllr Dance merely pointed out that exactly the same could have been done at Yeovil. And his question deserves to be answered.
Duncan Sharkey, chief executive of Somerset Council followed a similar line of questioning. He asked what would happen if Dorchester were unable to recruit and could not deliver their part of the plan? After all recruitment was one of the problems that has held the Yeovil HASU back in recent years.
David Mcclay responded that the Yeovil HASU would be kept open as a backstop and the HASU service would not be stood down until Dorchester was in a position to take over. But that response too sort of harked back to the issue raised by Cllr Dance.
The GP representative on NHS Somerset is Dr Balian. He wanted to know if there was going to be just one HASU in Taunton, could the board at least be reassured that both the Taunton and Yeovil ASU would be of a similar standard. That there was equality of healthcare for stroke sufferers across the NHS Somerset area.
The board were duly given that reassurance.
Another interesting intervention came from Peter Lewis, Chief Executive of Somerset NHS Trust (owner of both Taunton and Yeovil hospitals). Mr Lewis raised serious concerns about finance. This is, he understood, not to be a cost saving exercise, but requires serious monetary investment. NHS Somerset would be investing £1.8m of Somerset money into an NHS Dorset hospital, ie Dorchester. That left him feeling uncomfortable.
He also pointed out that while the clinical case had been well made, as things currently stood, it was not clear that NHS Somerset actually had the funds to invest in the project. So how could the board be sure that even if the project was started, it would ever be finished for a lack of finance?
Again there was a lot of hesitation. But no-one appeared to have an answer to present. In the end the board was forced to agree to take the clinical decision today, but with the proviso that final sign off would only be given when the financial case was presented. That case needed to demonstrate that NHS Somerset had the funds to deliver the new service. The board agreed that the finance issue would be presented at their next board meeting (scheduled for March).
If that left a hole in the argument for the new service, albeit one that could be patched up later. However Public Health Director Trudi Grant blew a still bigger hole in the argument. She suggested that while investing in improving stroke care was all well and good, it was only part of the clinical pathway.
Trudi Grant blew a still bigger hole in the argument
She suggested that if the same time, effort and resource had been put into stroke prevention as had been put into stroke treatment, the overall investment might deliver a better result. It was an intervention that might have been better made earlier in the process.
But the inability to answer the question left it hanging like a sword of Damocles over the whole issue. The question could not be answered because the work had not been done. Perhaps it should have been?
She then weighed in with a fact to back up her case. She suggested that 40,000 people in Somerset are walking round with high blood pressure but who don’t know it. She pleaded that we need to do work on this. High blood pressure is implicated in 70% of strokes. She asked the board to dedicate itself to looking at doubling down on high blood pressure.
She did get a few murmurs of assent, but no firm minuteable commitment was forthcoming.
A vote on the clinical decision to move to the model of one HASU in Taunton, another in Dorset and two ASUs in Yeovil and Taunton was taken. The vote was unanimously in favour. But the fact that serious questions remained unanswered undermined any reassurance that what is happening may after all be in the best interests of Somerset residents
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Will the financial case include stroke prevention I wonder? The Director of Public Health makes good points, but as ever the NHS is more than willing to spend on the latest high tech interventions at huge cost (which in itself may well be justified), but not to invest in much cheaper prevention which would actually prevent lots of strokes. They sign up to prevention in theory, but not with the ££s.
Thanks for the update.
It was always a foregone conclusion to close Yeovil, perhaps the question should be asked was, how much did the public consultation cost?