Improving stroke services in West Sussex

• West Sussex (Coastal) Stroke Decision Making Business Case November 2023
• Appendix 1 Stakeholder Engagement Duty
• Appendix 2 Sussex Prevention Programme
• Appendix 3 Independent ORS Public Consultation Report

We want everyone to benefit from safe, effective, and high-quality stroke services when they need them, and whilst we are proud of the safety and quality of the stroke services we offer currently, we know we need to further improve outcomes and experiences for patients.

For the past two years we have been working to carry out a comprehensive review of stroke services in the coastal area of West Sussex, which covers the population of Adur, Arun, Chichester, Worthing and south of Horsham.

The review has been led by clinicians from stroke services, GP practices and the ambulance service and it has helped to identify improvements we need to make to provide the best care to the people who live, work and visit our communities. The improvements are needed to also ensure we are meeting national guidelines for the treatment of stroke.

As a result, we have developed proposals, based on evidence and feedback from the skilled people who work in our hospitals, community services and GP practices, which set out how we can best deliver high quality care now and for the future.

In developing the proposals, we also spoke directly to people who use our services, their carers and families, the Stroke Association, Healthwatch West Sussex, the local voluntary and community sector, and members of our communities who experience health inequalities.

Their feedback helped to shape our proposals and ensure that we have considered how local people experience services now, and how this could be further improved.

Our proposal is to create an Acute Stroke Centre (ASC) for the coastal area of West Sussex and locate it at St Richard’s Hospital in Chichester. 

This option would bring many benefits to local people, including:

• access to specialist stroke services 24 hours a day, seven days a week;
• a reduction in deaths from stroke;
• fewer people living with long-term disability following stroke;
• fewer people losing their independence and being admitted to nursing or care homes;
• and shorter stays in hospital.

It would also support a more resilient workforce and give them a better opportunity to develop their skills to improve standards and continuity of care.

To make the changes, and realise these benefits, it would mean Worthing Hospital no longer receives people who are experiencing a stroke. This would lead to an increase in the number of people with a stroke going to the proposed Acute Stroke Centre at St Richard’s Hospital in Chichester and the Comprehensive Stroke Centre at Royal Sussex County Hospital in Brighton. 

Working together as a network, the two stroke centres would ensure everyone in the coastal area of West Sussex is within a 60-minute ambulance journey to a stroke centre staffed by the right specialists, 24 hours a day, seven days a week. Our analysis of ambulance journey times shows that most ambulance journeys are under 45 minutes.

Rehabilitation services for people who have had a stroke will still be available across West Sussex, either in their home or in a healthcare setting.

A detailed review of stroke services began in 2018. Clinicians from stroke services, general practice (GP practices) and the ambulance service led the review and have helped to develop the proposals in this document. 

The review identified areas where hospital-based stroke services could be further improved and from there, a number of options were developed to set out how those improvements could be made. There has been a detailed process to consider these options before proposing the option that we are now consulting on.

Throughout the process we have engaged with patients, carers, the public, staff and other stakeholders to help shape our plans. 

Over the course of this work we looked at:

• A long list of six options that considered different options for Acute Stroke Centres in West Sussex
• A short list of four site options
• The recommended option for consultation

Against each option, we considered travel times, how many stroke patients each unit would see, staffing requirements and the impact on wider partners and other systems to ensure we meet national standards and offer the best outcomes for people needing hospital-based stroke services.

You can find out more about the proposed changes from the reports and documents listed below:

• See full information about the proposals and consultation
• Pre-Consultation Business Case (PCBC) – Improving stroke services in West Sussex
  • Appendix 1: Stroke Case for Change
  • Appendix 2: West Place-based Plan
  • Appendix 3: LTP ambitions update and transformation priorities
  • Appendix 4: West Sussex Prevention Programmes
  • Appendix 5: West Sussex Stroke Programme Equality and Health Inequalities Impact Assessment (EHIA)
  • Appendix 6: Acute Stroke Centre EHIA
  • Appendix 7: University Hospitals Sussex NHS Foundation Trust (UHSx) Green Plan
  • Appendix 8: West Sussex Rehabilitation further direction against National Stroke Model
• Quality Impact Assessment (QIA)
• West Sussex Stroke Communications and Engagement Plan

University Hospitals Sussex NHS Foundation Trust (UHSussex) currently provides hospital-based stroke care from three hospitals:

• Royal Sussex County Hospital (RSCH) in Brighton,
• St Richard’s Hospital in Chichester and
• Worthing Hospital.

UHSussex also works in partnership with Sussex Community NHS Foundation Trust (SCFT) to provide recovery and rehabilitation services for people who have experienced a stroke.

Some West Sussex residents who experience a stroke may also use hospital-based stroke services at East Surrey Hospital in Redhill, Queen Alexandra Hospital in Portsmouth or in some cases Southampton General Hospital. Both the Queen Alexandra Hospital and East Surrey Hospital are Acute Stroke Centres, while RSCH and Southampton General are Comprehensive Stroke Centres. 

St Richard’s Hospital in Chichester and Worthing Hospital provide acute stroke care but are not Acute Stroke Centres, so do not meet the national model.

We know that hospital staff at St Richard’s Hospital in Chichester and Worthing Hospital provide the best service they can for people who have a stroke, and we are proud of the high-quality care our clinical teams provide to patients.

However, we need to address some challenges to current services to ensure we are meeting the needs of local people. Keeping services the way they are will not help us make the improvements that are required. To meet the needs of people now and in the future, we need to change how stroke services are delivered.

Some of the challenges we currently face are:

• Both St Richard’s Hospital and Worthing Hospital see fewer patients that the recommended minimum of 600 stroke patients a year;
• Although both hospitals receive stroke patients 7 days a week (patients being admitted), there is a lack of consultant cover at weekends;
• There is a transient ischemic attack (TIA or sometimes known as “mini-stroke”) service but it only runs on weekdays, rather than being a seven day service; 
• Acute rehabilitation also runs on weekdays, rather than being a seven day service;
• Scanning support services are not always available, particularly out of hours;
• The specialist nursing ratios on the stroke wards do not meet the expected national standards.

The primary aim of our stroke review is to ensure that anybody who has a stroke, day or night, anywhere across the coastal area of West Sussex, and the surrounding area, has the best chances of survival and recovery. 

National best practice is to have Comprehensive Stroke Centres (CSCs) and Acute Stroke Centres (ASCs) that are staffed by teams of stroke specialists around the clock and have consultants on the unit seven days a week, with access to all the equipment they need for diagnosing and treating stroke patients. 

Patients should be taken to these units directly to receive specialist stroke care as soon as possible after having a stroke. We want all our emergency stroke services to meet national quality standards and offer patients the best care. 

Looking ahead, we want stroke services in Sussex to be forward thinking and at the forefront of evidence-based care, with the best staff able to offer the latest developments in stroke treatment.

To achieve this, we need to make changes to the way services are organised, and through this consultation we are seeking your views on our proposal for this new service model.

What are you proposing to change?

We want to ensure that anybody who has a stroke, day, or night, has the best chances of survival and recovery anywhere across the coastal area of West Sussex, as well as more widely in Sussex.

We want all our stroke services to meet the national quality standards and offer patients the best care. Looking ahead, we want stroke services in Sussex to be forward thinking and at the forefront of evidence-based care, with the best staff able to offer the latest developments in stroke treatment.

Currently hospital-based stroke services are not set up in a way in the coastal area of West Sussex to meet national standards or to offer the level of care we want to provide to local people.

Therefore, we need to make changes to the way hospital-based services are organised, and through this consultation we are seeking your views on our proposal for this new service model.

Our proposal is to create an Acute Stroke Centre (ASC) for the coastal area of West Sussex and locate it at St Richard’s Hospital in Chichester.

With the existing Comprehensive Stroke Centre (CSC) at the Royal Sussex County Hospital in Brighton, providing support and services for people living in the east of the coastal West Sussex area, this would mean people across West Sussex would have access to specialist care, 24 hours a day and seven days a week. Rehabilitation services for people who have had a stroke would be available across West Sussex, either in their home or in a hospital setting.

This would mean Worthing Hospital would no longer be a place that people experiencing stroke would be taken for care.

How was this proposal developed?

We have been reviewing stroke services in the coastal area of West Sussex for the last two years.

This review identified the areas where improvements were needed to hospital-based stroke services so we can offer the level of care we want to local people.

As a result, during the review we looked at:

• A long list of six different options for how an Acute Stroke Centre could be set up in West Sussex
• A short list of four options

From the consideration of these, our recommended option was formed.

Read more about how the options were considered in the consultation document.

Clinical model

With demand for stroke services increasing, don’t we need more specialist acute stroke units, not fewer?

Currently, patients suspected of having a stroke that come into either St Richard’s Hospital in Chichester or Worthing Hospital are clinically assessed and treated. However, different treatments are offered at each site, and neither site provides a service that is 24 hours a day, seven days a week, with stroke specialists available at all times. This means our services do not meet national guidelines.

To offer the level of care we want to for local people and to meet national standards, we need to establish an Acute Stroke Centre. An Acute Stroke Centre offers 24/7 stroke services and is a specialist acute stroke service.

Nationally the recommendation is for a network of Acute Stroke Centres and Comprehensive Stroke Centres working together to provide specialist services to local populations. (Excluding thrombectomy and neurosurgery).

Our proposal is to create an Acute Stroke Centre for the coastal area of West Sussex and locate it at St Richard’s Hospital in Chichester.

With the existing Comprehensive Stroke Centre at the Royal Sussex County Hospital in Brighton, providing support and services for people living in the east of the coastal West Sussex area, this would mean people across West Sussex would have access to specialist care, 24 hours a day and seven days a week.

Rehabilitation services for people who have had a stroke would still be available across West Sussex, either in their home or in a hospital setting.

Therefore, this is about creating specialist stroke services in a way that would enhance what is currently available in the coastal area of West Sussex.

With fewer sites, would I have to wait longer to receive my care?

Absolutely not, the aim of this work is to improve patient access to acute stroke specialist services, 24 hours a day, seven days a week.
Our proposal would mean that people in the coastal area of West Sussex would be able to receive acute specialist stroke care any hour of the day, any day of the week. Currently this isn’t available in the area.

For some people it may mean that the ambulance will have to travel slightly further to reach Chichester or Brighton, but we know that everyone would be able to get to one of these specialist services within 60 minutes – and the majority within 45 minutes. This is a very important timescale to adhere to. As this will be met the benefits of being received by a specialist team at any time of the day, is clinically more important than an increase in time travelled to receive the specialist service and start the appropriate treatment as quickly as possible.

Why can’t we have acute stroke services at both hospitals?

It is not possible to have two Acute Stroke Centres in the coastal area of West Sussex. This was one of the options that was originally considered but it was identified that this would not be possible.

To develop two Acute Stroke Centres would require a significant staffing requirement to be able to offer an enhanced level of service at both sites. There is currently a national shortage of stroke consultants and other specialist staff, including specialist nurses and allied health professionals. To run two Acute Stroke Centres would require a full team of specialist stroke staff at both sites, and there currently isn’t the level of staff available to be able to create these teams.

There is also a recommended number of stroke cases that a specialist service should expect to see and treat. We have looked at the current numbers of strokes and predicted cases for the coastal area of West Sussex. If these people would go to services at both Chichester and Worthing, as well as Brighton, the coastal West Sussex services would see fewer stroke cases than the recommended minimum activity levels and this would have an impact on the quality of care, and on costs.

I have concerns over bed availability at hospital sites receiving acute stroke patients – what plans have you put in place to ensure bed availability does not become an issue?

Our proposals include not only additional investment in staff, but also additional beds at both the proposed new Acute Stroke Centre in Chichester and the new Louise Martindale building at the Royal Sussex County Hospital in Brighton as part of its Comprehensive Stroke Centre.

There would be 11 additional beds at the Acute Stroke Centre in St Richard’s Hospital in Chichester and 14 additional beds in Brighton. Overall, this is also an increase of three beds to the overall stroke bed capacity for the area.

There will be no reduction of beds in Worthing.

Our proposed changes would not only mean a slight increase in beds – they would also enable improvements in access to specialists, quality of services and service resilience.

How do health services decide which hospital to take an acute stroke patient to?

The decision about where to take someone with an acute stroke would be made by the paramedics, in liaison with the stroke clinicians via telemedicine.

Telemedicine allows medical professionals to communicate using digital video cameras, smartphones, tablets, and other technology. With stroke diagnosis and treatment, doctors who have advanced training in treating strokes can use telemedicine to treat people who have had strokes in another location.

These stroke experts work with the person’s local emergency medicine doctors to recommend diagnosis and treatment that can be given in their own community. This would be the case for patients self-presenting at Worthing A&E or any patients experiencing a stroke whilst an in Worthing Hospital.

The decision about which stroke centre an acute stroke patient is taken to might be affected not only by location but also if health professionals think the person might need to go to a Comprehensive Stroke Centre, where there is immediate access to the mechanical thrombectomy.

Thrombectomy is the surgical removal of a blood clot and is effective in preventing and reducing long-term disability in people with severe strokes. In future anyone suspected of having a stroke would go to an 24/7 Acute Stroke Centre (not currently available) or Comprehensive Stroke Centre based on their clinical need.

What is the difference between Hyper Acute and Acute stroke care?

Urgent stroke care has traditionally been split into two phases: Hyper-acute and Acute.

The hyper-acute phase starts with the onset of symptoms and lasts from one to three days. During this time, specialist assessment, imaging and interventions take place to treat the stroke and reduce the impact of the brain attack as much as possible. Interventions could include using medicine to thin blood clots or a procedure known as thrombectomy which is the mechanical removal of a blood clot.

The acute phase immediately follows the hyper-acute phase and it consists of the time a patient spends in hospital recovering and receiving hospital-care for their stroke. This typically lasts from seven to ten days while the patient receives specialist nursing, therapeutic and medical care. After this, a rehabilitation phase begins.

What would happen if you take a loved one to Worthing A&E with symptoms of a stroke? 

Under the proposal, patients with a suspected stroke would be assessed and stabilised at Worthing A&E and blue-lighted by ambulance to the most appropriate specialist stroke unit, either at St Richard’s Hospital or Royal Sussex County Hospital (RSCH). 

Five years ago, the stroke service at Princess Royal Hospital (PRH) moved to RSCH to support the delivery of a seven-day service. Patients who arrive at A&E at PRH with a suspected stroke now are taken by ambulance to RSCH. Evidence shows that outcomes for patients have improved since this service was reconfigured to provide seven-day specialist stroke care, including therapeutic support.

Who decides where patients would go? 

The attending ambulance service team determines which hospital a patient is taken to. They follow a standard operating procedure that helps to determine the best option for the patient at that time, depending on where they are as well as assessment. 

Additionally, it is hoped a telemedicine service will be introduced in Sussex that will enable paramedics to talk by video-link directly to hospital-based specialist stroke clinicians who could help to determine which hospital would be the best receiving unit for a patient.

For example, some patients may benefit from going straight to a Comprehensive Stroke Centre if their stroke event could be treated with a thrombectomy procedure. 

Travel

Would I have to travel further to receive my care?

We have carried out extensive mapping of the travel times across the coastal area of West Sussex for the preferred option. In particular, we have looked at ambulance travel times (specifically when someone is taken to a hospital in an emergency vehicle using blue flashing lights) as we recognise that for strokes, the majority of patients travel to hospital by ambulance following a 999 call.

The proposed model would ensure that all patients across the coastal area of West Sussex arrive at the Acute Stroke Centre well within the recommended 60 minutes. South East Coast Ambulance Service (SECAmb) has been integrally involved in all stages of our review of stroke services, and in the development of our proposals.

The data and modelling we used when developing our proposals – conducted by the Academic Health Science Network, with additional analysis by an independent organisation – indicates that no patient journey would take more than 45 minutes to get to St Richard’s Hospital in Chichester or the Comprehensive Stroke Centre at Royal Sussex County Hospital in Brighton.

Although the numbers are low, individuals from the Southern end of the RH13 and RH14 would have the longest projected travel times (around 45.1 minutes).

The biggest impacts relate to areas which are either in or adjacent to Worthing, such as BN11 and BN14. They would see an average increase +27.38 in BN11 and BN14 an average increase +22.62 compared to current in travel times.

The other aspect of travel time is the impact our proposals would have on friends, family and carers visiting people in hospital.

Throughout the public consultation we will talk to local people and communities to explore ways we could best mitigate extended travel times, whether through transport offers or on-site facilities.

We know that our proposal would mean that some people would need to travel further for their care. It also means that some of their carers, families and friends may also have to make longer journeys to visit them in hospital.

However, the positive health outcomes of being treated at an Acute Stroke Centre outweigh a slightly longer journey. This would only be for the initial hospital-based care, as then rehabilitation would take place across West Sussex in a range of settings, which could be closer to, or in, a person’s home.

Do your proposals mean more ambulance journeys will be required?

People suspected of having a stroke would just potentially go to a different hospital by ambulance than they would have done before. However, some people who self-present and are found to be having a stroke would have to be conveyed by ambulance to a different hospital. However, the use of telemedicine may have the potential to reduce the number of these journeys. The number could also change due to population growth factors, but not because of our proposals to improve stroke services in West Sussex.

Staff and workforce

Do you have staff capacity to operate a specialist Acute Stroke Centre 24 hours, 7 days a week?

Staffing is a key element of the proposal for an Acute Stroke Centre.
To provide the level of service we want for local people, we need to have the right level of specialist staff.

It is important to make the best use of the resources that we already have across stroke services at University Hospitals Sussex. Our proposals would help us retain and develop our current staff and create an environment where we could recruit to additional posts.

Our proposal would also mean a significant investment in staffing including stroke consultants, specialist nurses and allied health professionals such as physiotherapists, speech and language therapists, occupational therapists, and psychologists.

What will be the impact on existing staff? Have they been involved?

Our proposals have been developed by clinical staff at all stages of their development. Members of staff across both hospitals are being given opportunities to continue to contribute their feedback and ideas.

Depending on the outcome of the consultation there would be a formal HR process to manage any changes and support those members of staff who are affected.

Future-proofing stroke services

How is the new Acute Stroke Centre going to cope with future increases in stroke cases, especially given the increasing ageing population in West Sussex?

We have looked very carefully at the way the population is going to change over the next five to ten years.

Stroke numbers vary year to year but generally they do not rise quickly. However, we do have a growing elderly population, which does increase the risk of the number of strokes. To account for this we have planned for an increase of 2% each year for the next five years as we have considered our options for hospital-based stroke care.

It is important that we have hospital-based services that can treat anyone who needs emergency stroke care in the coastal area of West Sussex. We are confident our proposal would ensure that everyone would be able to receive the best possible care, 24/7 now and for the future.

It is also important that we focus on preventing strokes, including the supporting people make changes to lifestyle factors that increase the risk of a stroke, and effective use of medicines that prevent them. This work is a real focus for health and care partners across the whole of Sussex.

Other FAQs

What other developments in stroke services have taken place?

There has been good progress in tackling many factors associated with strokes, such as managing high blood pressure, high cholesterol, diabetes, and outcomes from behaviour change support, such as helping people to stop smoking and reduce how much alcohol they drink.

Recent service developments for the coastal area include:

• Atrial fibrillation is an irregular heartbeat that is sometimes very fast. This is the most common type of irregular heart rhythm with more than one million people in the UK living with the condition. People with atrial fibrillation have a five-fold increased risk of stroke. Across Sussex, services to identify and treat people with atrial fibrillation are now being provided by local GP practices.
• Early supported discharge enables stroke patients to leave hospital earlier through the provision of therapy and rehabilitation in the community, often in people’s own homes, at a similar level to the care provided in hospital. This service is due to start in the coastal area of West Sussex in early 2023. It is already in place in the rest of West Sussex.
• Life after stroke service provides the ongoing personalised care and support that people need to rebuild their lives and minimise risk of future strokes. This service has not previously been in place in the coastal area of West Sussex and started in autumn 2022. It was already in place in the rest of West Sussex. It provides support for long-term needs through timely access to information and community-based support and enables people to manage their condition(s) as independently as possible.

What happens to patients in Crawley and North West Sussex now and will they benefit from the proposed changes to acute stroke services?

We are not consulting on changes to the current stroke services for the population in the northern part of West Sussex (Crawley and surrounding area).

People in this area mostly go to Surrey and Sussex Healthcare NHS Trust in East Surrey, which already has an Acute Stroke Centre. They are already working in the way we are proposing for Coastal West Sussex.

In addition, Early Supported Discharge for Stroke services are already in place in North West Sussex. These services are now being introduced in the Coastal West Sussex area.

What will be the impact on other services at Worthing Hospital if stroke services are no longer provided there?

The proposed change to stroke services would not affect other services at Worthing hospital.

Training and development opportunities would be in place for staff based at Worthing hospital to maintain skills around managing strokes.

How would tele-medicine work? 

Tele-medicine for stroke patients is currently being piloted in East Sussex and Kent. The Sussex Integrated Stroke Delivery Network will review the findings of these pilots to determine how this service could be developed across Sussex. In other areas where tele-medicine for stroke has been introduced, it has been shown that providing a means for hospital-based stroke specialists to talk to paramedics and review patients by a video-link has improved outcomes for patients.

When would the ASC happen if agreed? 

The timing depends on the outcome of the public consultation as well as a number of other factors, such as recruitment of specialist staff and the building programme required to expand the number of beds available.

If the public consultation response raises new issues to be considered, then time will be allocated to work these through.

If the outcome of the consultation does not raise significant new issues to be addressed, then NHS Sussex and University Hospitals Sussex will develop a Decision-Making Business Case and seek approval for the proposal from NHS Sussex partners and regulatory authorities. This could potentially happen as early as June/July 2023 – dependent on work required and outcome of consultation. 

The final decision to proceed with the proposal would be made by the NHS Sussex Integrated Care Board (ICB). The ICB‘s decision would then be discussed at the West Sussex Health and Adult Social Care Scrutiny Committee (HASC).

This could potentially happen as early as August/September 2023 – dependent on work required and outcome of consultation. If agreed, transition to an implementation phase could take place from September 2023. Change of service is therefore not likely to occur until 2024 at the earliest.

In addition to the governance arrangements above, it would be necessary to ensure the staffing arrangements for the Acute Stroke Centre are met before any change of service could proceed. Furthermore, other factors could also influence the timeline, such as delays to the building programme.