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NHS England conducted an Urgent and Emergency Care Review in 2013, which sets out how the NHS plans to cope with the ever increasing pressure on emergency services. These services need to be designed so that patients with life threatening conditions, such as heart attack and stroke, get the quickest treatment possible. Evidence shows such patients have the best chance of surviving and suffer less disability, the more quickly they can be treated.
The Review proposes redesigning existing acute services to develop a network of Specialist Emergency Centres to provide care for heart attack and stroke. At such centres, teams of specialists are available around the clock to deal with these conditions where time is critical. By having fewer but larger units, clinicians at these centres see more patients and become experts in their field, providing higher quality services and maximising good outcomes.
In cities such as London and Manchester, where stroke services have been reorganised into specialist units, more people receive emergency clot-busting treatment (thrombolysis) and more people survive their stroke. However, centralising services in more rural locations is expected to have a mixed effect; improving services within hospitals, which become centres of clinical excellence but potentially delaying time-critical treatment for those patients who may have to travel further for treatment. On the other hand, where there are lots of smaller local services, some patients’ travel times may be reduced but differences in the quality of service may be found between units.
This project aimed to use modelling to better understand the trade-offs between improved in-hospital services and increased ambulance travel times in the mixed urban/rural communities of the South West of England.
Computer modelling was used to try and determine the best configuration of hospitals to provide heart attack and stroke services for nearly five million people across the South West of England, from Gloucester to the Isles of Scilly. The model tried to balance the need for services to be large enough to provide round the clock specialist emergency treatment, with the need for these services to be close enough to where people live so they can get fast treatment for a heart attack or stroke.
The main aim of the project was to investigate the relationship between the number of hospitals in the South West and key performance criteria, including:
Transfer times to hospital.
Time from onset of stroke/heart attack to treatment (with improved in-hospital arrival-to-treatment times in centralised centres of clinical excellence).
Number of admissions per hospital per year (substitute for measuring experience and clinical excellence) and ability to meet recommended minimum admissions/year.
Predicted clinical outcome (disability-free patients for stroke and one-year mortality for heart attack).
Cath lab load/utilisation.
Ambulance time required (centralisation increases ambulance time required).
In addition, the best locations of hospitals for any given number of hospitals, including providing a range of possible near-equivalent scenarios, was investigated.
The results of the computer modelling suggest that currently, for some people, their local service is too small to be able to deliver round the clock specialist treatment for heart attack and stroke. Possible alternative configurations suggested by the model include reducing the number of hospitals providing emergency heart attack treatment from ten to a minimum of six. Whilst the number of emergency stroke centres could be reduced from the current fourteen to eight.
There are advantages and disadvantages to reducing the number of centres for emergency heart attack and stroke treatment. Patients are more likely to be cared for by a specialist in their condition, with evidence from London’s specialist units suggesting this improves their chances of survival. In addition, larger specialist centres treat enough patients with these conditions to become clinically excellent at providing treatment. The main disadvantage of having fewer centres is that in some parts of the South West, particularly areas of North Devon and Wiltshire, people would have to travel further to receive this specialist treatment.
Modelling the case for specialist stroke centres:
A key treatment for acute ischaemic stroke is thrombolysis, which significantly increases the chances of surviving free of disability. With 8 acute stroke centres, rather than the current 14, average onset-to-thrombolysis time could be reduced by 8 minutes and maximum onset-to-thrombolysis time could be reduced by 20 minutes, if all centralised centres could deliver 45 minutes door-to-treatment times (achieved by all London’s centralised stroke centres). The clinical benefit (number of additional patients with no significant disability per 100 clinically eligible patients thrombolysed) increases from 10.2 using 14 units with current door-to-needle times to 10.6 when reconfigured into 8 units delivering 45 minutes door-to-treatment times. With 8 centres delivering 45 minutes door-to-treatment times, 77% of patients would be expected to experience faster onset-to-thrombolysis time, with the remaining 23% of patients experiencing slower onset-to- thrombolysis time.
The Strategic Clinical Network will make recommendations to the Clinical Commissioning Groups (CCGs) for service reconfiguration in the South West based on the results of this work. These will include recommending they:
1. Conduct a consultation with patients and the public on the implication of the options, and critically on the balance to be struck between the concentration of expertise in Specialist Emergency Centres and issues relating to geographical access. This is particularly relevant for NHS Northern, Eastern and Western (NEW) Devon CCG and for NHS Wiltshire CCG, where the geographical impact of consolidation is greatest.
2. Agree a timeline and arrangements for collaborative commissioning in order to progress through the decision-making process laid out in the recently updated 2015 NHS England policy ‘Planning, Assuring and Delivering Service Change for Patients’.
There is the potential for the reconfiguration of stroke and heart attack services in the South West, based on this patient centred modelling approach, to lead to improved net clinical outcomes for patients.
The project was extended to allow PenCHORD to carry out more detailed analysis about the impact of 6 potential configurations of emergency centres, for each hospital and Clinical Commissioning Group in the South West.
Computer modelling provided evidence of how the different scenarios would affect each hospital and CCG, including the impact on:
Allen M, Pearn K, Monks T, Bray BD, Everson R, Salmon A, James M, Stein K. Can clinical audits be enhanced by pathway simulation and machine learning? An example from the acute stroke pathway BMJ Open 2019;9:e028296.