Immediate hospital care after a stroke
Won’t more people die or be severely disabled if they have to travel longer to get to Southmead Hospital?
No. When you have a stroke, you’re more likely to survive and live with less disability if you go straight to a place that offers the most specialist treatment. This already happens for people who have a heart attack or major trauma.
That’s why we want everyone to go to a Hyper-Acute Stroke Unit, serving everyone in Bristol, North Somerset and South Gloucestershire. There is a balance between getting to hospital quickly and getting to the right place to receive high quality specialist acute care.
Southmead Hospital already has the specialist doctors and nurses and all the equipment needed. It provides special scans, surgery to remove blood clots, brain surgery and care from specialist stroke nurses. We want everyone in the area to have this care, not just people living closest to Southmead Hospital. 15 fewer people would die each year if they received their immediate treatment this way.
Analysis shows ambulances would get those who need emergency treatment to a specialist unit within 45 minutes. People from Sedgemoor in the very south of the area would be closer to Musgrove Park Hospital in Taunton, so ambulances would take them there. This would affect less than 1 person per week (about 30 per year).
National guidance and research says that people need to get to specialist hospital care within 4.5 hours after a stroke to have the best chance of surviving and avoiding severe disability. 100% of people in our area would be able to get to Southmead Hospital by ambulance in this time.
About 1,000 extra families each year would travel to visit someone having stroke care at Southmead Hospital under these proposals. Has visitor travel been considered?
We have set the impact on some visitor travel against the significant clinical benefits the proposals would bring, including fewer people dying from stroke each year. If we have a Hyper-Acute Stroke Unit and Acute Stroke Unit at Southmead Hospital, about 1,000 more people will go there for their immediate and ongoing hospital stroke care. For family and friends who live in Bristol who want to visit, this would be about an extra 3 miles of travel each way.
For people around Weston who want to visit, this would be around 27 miles more each way than going to Weston Hospital. This would take about 37 minutes in a private vehicle. On average, someone might stay at Southmead Hospital for around 9 days for immediate and ongoing hospital care. If someone from Weston visited every few days, this would be around 3 hours more travel time in total. This would affect about 230 families per year.
Three more hours travelling spread over the course of a week or so would be inconvenient for those 230 families. However, it would mean:
- everyone will have the best chance of surviving and thriving after a stroke
- 15 more people each year would survive their stroke
- 57 more people each year wouldn’t need to move into a care home permanently due to stroke
- people who have a stroke will be able to be assessed, diagnosed and treated quicker
- everyone in the whole area, including people from Weston, would be getting the highest quality care, latest equipment and most specialist staff, 24 hours a day, 7 days a week
Getting the highest quality care ‘up-front’ will mean people can leave hospital earlier. This should mean less travel time for people’s families overall.
Our proposals also mean that more care and rehabilitation will happen outside of an acute hospital and in the community or at home.
Why does the NHS want all immediate care at Southmead Hospital when transport is difficult in parts of North Somerset?
People will be more likely to survive and live with less disability if they go straight to a place that offers the most specialist treatment after having a stroke.
We know that this means people who want to visit family or friends in hospital from North Somerset will need to travel further in the first days after loved ones have had a stroke.
This will affect about 14 families a week around Bristol, who will travel an average of 3 miles longer to get to Southmead Hospital, and 5 families a week around Weston, who will travel an average of 27 miles longer to get to Southmead Hospital.
We think this is the right thing to do because:
- more people who have a stroke will survive
- more people who have a stroke will avoid severe disability
- two thirds of members of the public told us it was most important to get the best care in a ‘centre of excellence’
- local people have told us it is important that everyone can access the most specialist services, not just those who live closest
We looked carefully at travel times and people’s feedback when we developed the consultation proposals and will continue to take on board concerns raised during consultation.
Can Southmead Hospital cope with all the people who have a stroke?
At the moment, about 500 people use specialist hospital stroke services at Southmead Hospital each year.
About 1,500 people per year would use the Hyper-Acute Stroke Unit at Southmead Hospital for everyone in Bristol, North Somerset and South Gloucestershire. This is about 23 more people per week cared for at Southmead Hospital compared to now.
Southmead Hospital can cope with the increased numbers as long as we improve our services in the community as we plan, so people can leave hospital and return home more quickly.
Southmead Hospital already has the specialist staff and equipment needed. No building work or upgrades would be needed. However, we would plan to invest in more diagnostic equipment for the Hyper-Acute Stroke Unit. In addition, some staff already providing stroke services at our other hospitals would work at the Hyper-Acute Stroke Unit and Acute Stroke Unit at Southmead Hospital to support this change. Any proposals that could affect staff working conditions will be the subject of a separate employment consultation exercise after a decision is made.
What specialist services could Southmead Hospital offer for all stroke patients on a 24/7 basis?
Southmead Hospital will be able to offer:
- An assessment by a specialist doctor and/or nurse specialist as soon as someone with a suspected stroke arrives at the hospital.
- ‘Clot-busting’ thrombolysis drugs, delivered quickly by specialist clinicians 24/7.
- Assessment for potential mechanical clot removal ‘thrombectomy’ treatment.
- Specialist stroke physician or specialist nurse assessment for neurosurgical treatments 24/7 for faster assessments, improved decision-making and more rapid access to treatment.
- 24/7 on-site support by a registrar and/or nurse specialist for the Hyper-Acute Stroke Unit.
- Specialist remote video telemedicine assessment to guide decisions about stroke treatment at Weston General Hospital and BRI Emergency Departments, and/or transfer to Southmead as needed.
- Emergency advice for Stroke Sub-Acute Rehabilitation Units where a patient may be neurologically deteriorating, for instance suffering a further stroke.
If someone with a suspected stroke takes themselves to a local hospital will there be changes to A&E so that patients are transferred quickly to the stroke unit at Southmead?
Yes. Triage systems will be in place to prioritise the assessment of people arriving with stroke symptoms. This will be supported by improved stroke education and immediate remote advice, with video as needed, from an on-call stroke team at Southmead Hospital to support Weston General Hospital or Bristol Royal Infirmary A&E departments, with urgent transfer to Southmead as appropriate.
Will all stroke survivors have a personalised recovery plan to take them through each stage from HASU to Community care & beyond?
Yes. Everyone who has a stroke will have different needs so assessments are completed by many members of the multi-disciplinary team throughout their recovery journey.
Initially, daily discussions will be held by the team and with the patient and their family to determine the next steps. Setting goals will be integral to the process of rehabilitation and each person will be encouraged and supported to do this with their family and team.
Once someone is able to leave hospital, formal progress discussions will be held less often, but formal personalised care and support plans will be carried out to clarify what long-term needs each person has following their stroke. Each patient will receive a formal review of their needs at 6 weeks and 6 months following their stroke.
Will visiting hours be more flexible to allow for distance to travel to Southmead?
The stroke units at Southmead Hospital would not operate restricted visiting hours. People in the early days after stroke who require hospital care, would be allowed visitors at any time.
How much longer will it take me to get to the Hyper-Acute Stroke Unit by ambulance?
The majority of patients will experience a change of ambulance travel time of between 5 and 10 minutes.
Ongoing hospital care in a stroke ward
Why does the NHS prefer one Acute Stroke Unit at Southmead Hospital for ongoing hospital care?
We think there should be one dedicated Acute Stroke Unit (ASU) co-located with the Hyper-Acute Stroke Unit at Southmead Hospital because:
- people could get all their stroke hospital care in one place, without
- needing to travel to another hospital while they are very unwell
- we will be able to meet national standards to provide high quality care for everyone
- most of the stroke specialists would work together in one place
- this is most affordable
Why is the NHS consulting about having two Acute Stroke Units at different hospitals?
We are consulting about whether to have one Acute Stroke Unit at Southmead Hospital or two Acute Stroke Units – one at Southmead Hospital and one at Bristol Royal Infirmary
We think it would work best to have one stroke ward at Southmead Hospital so people don’t have to travel to another hospital after their immediate care at Southmead Hospital.
But, we are consulting about having stroke wards at two different hospitals because we want to know how this would affect you. We are interested in hearing what you think about the advantages and disadvantages.
What would happen at the Bristol Royal Infirmary if they no longer had a stroke ward?
Bristol Royal Infirmary provides many other highly specialised services and we are doing more work during the consultation period to make sure that those services would not be negatively impacted if Bristol Royal Infirmary did not have a specialist stroke ward. We will also ensure that if a person has a stroke whilst they are in Bristol Royal Infirmary, and they can’t be moved to Southmead due to another medical condition, then they would still be able to access the same excellent care.
Are there any disadvantages of having all care in one hospital?
The main disadvantage of having care all in one hospital is the additional travel to the Hyper-Acute Stroke Unit, but we know this is not as important as getting the right immediate care.
People suffering a stroke will have quicker, more reliable access to brain scanning and stroke unit admission, along with better access to urgent treatments. This would more than make up for the additional time that some people would need to spend in an ambulance travelling to Southmead Hospital.
Overall, more people will survive their stroke, more people will spend less time in hospital, more people will retain their independence and more people will be able to continue their recovery closer to home, more quickly.
Stroke Sub-acute Rehabilitation Units
Why can’t we have 3 Stroke Sub-Acute Rehabilitation Units?
Some people are not ready to go home when they are medically ready to leave hospital. We would provide inpatient rehab units for these people. These units should be close to where people live, so family and friends can visit to provide encouragement and support. We need to balance being close to home with having enough specialist rehab staff to provide the service well, and 7 days a week.
In developing the stroke pathway proposals a large number of different options – including having 3 inpatient rehab units, 1 in each part of the area – have been considered and evaluated. We think it is better to have 2 short stay rehab units because:
- we don’t have enough people with a stroke each year to fill 3 appropriately sized units
- we don’t have enough specialist rehabilitation staff to spread across 3 units
- it would cost £1 million more every year to run 3 units with the same number of beds as in 2 units
Local people have told us, they want to leave hospital quicker and have care at or close to home if possible.
We propose to start rehabilitation whenever people are ready, 7 days a week. Rehabilitation will be available when people are either in hospital or at inpatient rehabilitation units closer to home. In addition, much more rehabilitation and support will be provided to people in their own homes through an integrated Community Stroke Service. This will help people to leave hospital more quickly and we think it is important to invest in this.
What will influence where the Stroke Sub-Acute Rehabilitation Units are?
Our proposals are already to have one inpatient rehabilitation unit on the Weston General Hospital site; this is because we know from population health information that the population of Weston are at high risk of stroke.
We propose having a second unit in either Bristol or South Gloucestershire to spread the services across the area.
The types of things that will be considered when deciding on the location of the second unit are:
- feedback from members of the public and staff during the consultation
- available existing or planned NHS sites
- where most people who have a stroke live, to address population heath needs and health inequalities
- how long it will take people’s families to visit
- parking and access by public transport
- availability of suitable facilities for rehabilitation, such as a gym, therapy space and consultation rooms
- spread of services across the area
Why does the NHS want a Stroke Sub-acute Rehabilitation unit on the Weston General Hospital site when more people have strokes in other areas?
We suggest having a Stroke Sub-acute Rehabilitation unit on the Weston General Hospital site because:
- one third of people who have a stroke in our area each year come from North Somerset
- a higher proportion of the population of North Somerset have a stroke compared to other areas
- North Somerset has a higher number of older people and people more at risk of having a stroke
- it can be time consuming to travel from North Somerset to other areas to visit someone who has a stroke
- it is difficult for family members in North Somerset to travel to other areas using public transport
We propose having another unit somewhere in Bristol or South Gloucester so people from those areas are able to visit friends and family who have a stroke.
What would be the Bed numbers for Acute & Subacute?
- HASU – 20 beds (+1 bed ICU)
- ASU- 22 beds
- SSARU – 42 beds
Are community beds going to be delivering specialist Stroke care? Will there be specialist rehabilitation?
Yes they would be – and yes, there would be specialist beds.
How was the bed numbers modelled?
By length of stay and potential discharges, along with those medically fit for discharge.
Within the Bristol Royal Infirmary we already have patients queuing up for stroke beds, what will happen in the future model with fewer beds?
The bed requirement has been modelled based on assumptions regarding Length of Stay (LOS) and improvements in acute LOS as a result of the increased community services supporting discharge. This has used stroke activity (patient numbers, length of stay etc) reported by each site to understand demand with an assumption then made for growth. Our projections are that if we achieve our community discharge improvements then this will address the issue.
Will this mean potentially increased TIA at BRI?
Yes, provision for transient-ischaemic attack (TIA) services will be bolstered and we are currently working through the modelling to ensure we have the right resource in all areas of BNSSG.
Fifty general rehabilitation beds are currently proposed for the Frenchay reserved site. Can you clarify whether the c.30 stroke rehabilitation beds required are included in this number?
No, the c.30 stroke beds would be additional. If – following consideration of the consultation responses and the detailed decision-making business case – the BNSSG CCG governing body decide to locate the proposed c.30 stroke rehabilitation beds on the Frenchay site, these would be provided in addition to the 50 general rehabilitation beds already proposed for that site.
The pre-consultation business case says there are two options for Acute Stroke Units. Does this mean that everything else has been decided?
No. There is a new NHS National Service Model that all areas in England are trying to achieve, so people can survive and thrive after a stroke. This includes having a Hyper-Acute Stroke Unit to provide the most specialist care immediately, having dedicated Acute Stroke Units with expert staff and having dedicated short stay units providing stroke rehab.
We want to make sure that services in Bristol, North Somerset and South Gloucestershire are just as good as or better than everywhere else in the country.
We developed a ‘Pre-Consultation Business Case’ to summarise all the possible ways to organise specialist stroke services and achieve the National Service Model. Our business case shows how we looked at the options for having a Hyper-Acute Stroke Unit. Then we looked at how we could provide Acute Stroke Units. Finally we focused on how to provide Stroke Sub-Acute Rehabilitation Units. When we put all those elements together, we thought there were two approaches that worked best:
- Having one Hyper-Acute Stroke Unit for immediate care and one Acute Stroke Unit for ongoing care at Southmead Hospital and two Stroke Sub-acute Rehabilitation units.
- Or, having one Hyper-Acute Stroke Unit for immediate care at Southmead Hospital and having two Acute Stroke Units for ongoing care – one unit at Southmead Hospital and one unit at Bristol Royal Infirmary – and two Stroke Sub-acute Rehabilitation units.
No decision has been made yet. We are consulting about all the elements. We want to know:
- What people see as the benefits and challenges from having one acute stroke unit located as part of the Hyper Acute Stroke Unit at Southmead Hospital versus having an acute stroke unit at two locations (one at Southmead Hospital and one ASU at the Bristol Royal Infirmary)
- whether people have a preference and why
- whether people understand the reasons why it is proposed that there is one unit co-located as part of the Hyper Acute Stroke Unit
- Where services should be located for people who need to have rehabilitation in an inpatient community facility. This includes:
- whether people understand why two rather than three sub-acute rehabilitation units are proposed, and what they feel about that
- what people think about having rehabilitation available on the Weston General Hospital site
- where another rehabilitation unit should be located and why
- what factors should be prioritise when deciding on a location
We’re also interested to know what you think of having an Integrated Community Stroke Service, where all teams work together to help people get home quickly and get the rehabilitation and physical and emotional support they need.
How will the proposals affect Weston General Hospital?
The number of beds dedicated to supporting people with stroke on the Weston General Hospital site would stay the same as now. However, instead of providing care immediately after a stroke, these beds would provide inpatient stroke rehab in a Stroke Sub-Acute Rehabilitation Unit.
People who have a stroke while they are receiving care for something else at Weston General Hospital would be transferred to Southmead Hospital.
What do stroke staff think of the proposals?
People working in stroke services have helped to shape our proposals, alongside people who’ve had a stroke and their carers. Health professionals from stroke services led the development of the proposals. People working in voluntary groups supporting people with stroke have also been heavily involved.
We have run workshops and co-design sessions for staff working in stroke services. So far, staff have been supportive.
We are continuing to engage and consult with our staff during the public consultation period and afterwards.
We are planning to have a single stroke workforce across the whole area. That means teams will all work in a consistent way. It will improve career opportunities, training and satisfaction for the stoke workforce.
Will this proposal save money and if so, how much? Or cost more in terms of consultation costs, redundancies, changes, new wards, beds etc?
Our proposed improvements to stroke services for local people would mean a total investment of either £2.9m or £3.4m. This figure depends on whether we provide one or two Acute Stroke Units.
We have modelled the investment needed within the context of reducing waste, maximising efficiency and value for money, and keeping costs down where we are able to.
Our proposals will deliver a more intensive spell of care in the Hyper-Acute Stroke Unit immediately following a stroke, through to a longer, more supported stay in the community, compared to what is provided now.
This will mean we will need fewer stroke beds in our hospitals and enable people to receive an expected four times as many contacts as they do now.
Will all staff currently working in stroke be offered jobs within the proposed changes?
As part of the future delivery of stroke services we anticipate needing more staff than we have now. However, we recognise that teams may be configured differently in order to meet the needs of our proposals.
Staff are being invited to have their say on these proposals as part of the public consultation. There will also be formal engagement with staff before any service changes are implemented.
Has all the data used and conclusions been checked and audited?
Yes, all the data has been checked and validated against the different sources of data that are available for the programme, for example, hospital data, ambulance service data, sentinel stroke national audit programme (SSNAP) data and data from community services. All data has been analysed by a finance and business intelligence group, with representation from all health system partners, to ensure its credibility.
The conclusions have been tested and confirmed with our clinical design group at all stages of development and support has been confirmed through the Healthier Together Directors of Finance, prior to asking the Healthier Together Executive Group to support the proposals.
Will the achievements/success of the changes be assessed in say 2/3/5 years?
A comprehensive list of outcome measures has been developed in partnership with people with lived experience of stroke and with stroke clinicians; these can be read in Chapter 13 of the Pre-Consultation Business Case.
There are some measures that are audited nationally through the sentinel stroke national audit programme (SSNAP) data that we will continue to monitor ourselves against. There are also other additional measures that are important to people which we will review before and after any proposals are implemented so that we can assess whether we have achieved the improvements we expected to see.
How will you know it was worth doing and the right decision?
Ultimately, our aim is for more people survive and thrive after having a stroke in our area. If more people in our area survive their stroke and leave hospital with less disability, we will know we have done the right thing. However, there are other important areas that we believe we will improve, including how people experience stroke care, the level of support that they receive – particularly after leaving hospital – and the quality of the care that they get.
How will these changes be implemented, and what is the timeline?
Subject to the outcome of the public consultation and a decision taken by Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group’s Governing Body, changes to stroke services could be put into place over a 7 month period, starting from April 2022.
How can people who don’t have access to the internet find out more about the proposals?
We want everyone in our area to have the opportunity to have their say on our proposals.
We will be hosting a range of consultation engagement events, where people can hear more about our proposals and Covid-19 restrictions allowing, a number of these events will be face-to-face.
People can call us or write to us find out more about these events or request printed copies of our consultation materials:
- Phone 0117 900 3432
- Write to us at Freepost STROKE CONSULTATION