Cross Party Group on Stroke Minutes
Meeting: Cross Party Group on Stroke
Date: 11 December 2018
Venue: Committee Room 5, Ty Hywel, National Assembly
Attendees:
Chair: Dr Dai Lloyd AM (Plaid Cymru)
Speakers:
Ross Whitehead, Assistant Chief Ambulance Services Commissioner, Emergency Ambulance Services Committee
Shane Mills, Director of Quality and Patient Experience, National Collaborative Commissioning Unit
Attendees:
Dr Jill Newman - Director of Performance, Betsi Cadwaladr UHB
Wendy Hooson, Senior Planning Officer, Betsi Cadwaladr
Dr Fiona Jenkins - Chair of the National Stroke Delivery Group, Exec Director of Therapies & Health
Mike Jenkins - Welsh Ambulance Service NHS Trust
David Fitzpatrick - stroke survivor
Nick Cann - stroke survivor, LAS Award winner, ambassador/fundraiser/Committee Member at the Stroke Association
Alexander Smith - Postgraduate Fellow, Cardiff University/Stroke Association
Helen Hak - Occupational Therapist Section for Neurological Practice, Aneurin Bevan UHB
Dr Sue Thomas - Royal College of Nursing
Dr Brendan Lloyd - Exec Director Medical & Clinical Servs, Welsh Ambulance Service NHS Trust
Nesta Lloyd-Jones - Policy & Public Affairs Officer, Welsh Confederation
Stephen Davies - Stroke Implementation Group Co-ordinator
Stephen Ray - National Healthcare Partnership Manager, Bayer Public Limited Company
Niki Turner - HASU Programme Manager, Llandough Hospital
Irina Erchovaia - Research Associate, Cardiff University, stroke survivor
Jason Killens - Chief Executive, Welsh Ambulance Service NHS Trust
Stephen Ray - National Healthcare Partnership Manager, Bayer Public Limited Company
Stephen Davies - Stroke and Neurological Conditions Implementation Groups Coordinator
Mike Jenkins - Regional Clinical Lead, Consultant Paramedic, Welsh Ambulance Service NHS Trust
Marie Evans - Cwm Taf UHB, Planning & Performance
Carol Bott - Director Wales, Stroke Association
Katie Chappelle - Head of Influencing and Communications, Stroke Association
Llinos Wyn Parry - Head of Stroke Support (Mid & North Wales), Stroke Association
Matt O’Grady - Stroke Association, Policy Information and Campaigns Officer, Wales
Jillian Haynes - Stroke Association, PA to Director Wales, Cross Party Group on Stroke Minutes
Apologies:
Llyr Huws Gruffydd AM
Kirsty Williams AM for Brecon and Radnorshire
Sue Beckman - Director NHS Delivery Unit (retired)
Dr Anne Freeman OBE - Hon Consultant ABHB, former Clinical Lead for Stroke, Wales
Nicola Davis-Job - Royal College of Nursing
Philippa Ford MBE - Public Affairs & Policy Manager, Chartered Society of Physiotherapy
Dr Jill Newman - Director of Performance, Betsi Cadwaladr University Health Board
Ross Evans - Stroke Association, Head of Stroke Support
Caroline Walters - Royal College of Speech and Language Therapists
Dr Phil Jones - Clinical Lead for Stroke in Wales
Sheila Tagholm - Wales Advisory Committee Member (Stroke Association), Carer
Kirsty Williams - Assembly Member for Brecon and Radnorshire
Rachel Jenkins - Pfizer
Elin Edwards - External Affairs, Royal National Institute of Blind People
Peter Carr - Executive Director of Therapies and Health Science ABUHB
Carmel Donovan - Integrated Community Services Manager (Bridgend), ABMU
Emma Henwood - Policy & Public Affairs Manager, British Heart Foundation Cymru
1. Welcome, apologies and introductions
Dr Lloyd AM welcomed attendees and introduced Carol Bott as Director Wales, Stroke Association and Katie Chappelle as Head of Influencing & Communications, Stroke Association. Apologies were as listed above.
2. Approval of previous Minutes and update on actions
The Minutes were approved as a true reflection of the content of the meeting. Mr David Fitzpatrick suggested that acronyms should be avoided.
Matt O’Grady stated that the letters as described had been sent to both Health Education and Improvement Wales and local health boards but no replies had been received to date.
3. Presentation: The findings of the Independent Accelerated Programme for Amber Review
Shane Mills stated that the amber review is an independent review. Two issues had been analysed: 1) is there a problem? 2) does delay cause problems? The review had taken six months to complete and included interviews with control centre staff and a survey of the public. The clinical response model was reviewed alongside the models of Scotland and England. The model in Wales appeared to be more target driven, designed to respond to saving life. The public agreed that the quickest emergency response is not always the most appropriate. Mr Mills reported that there was an 11% increase in emergency calls overall, for a range of reasons, and the increase in amber calls was 8%. A clinical desk was set up to answer clinical questions, a facility which is well supported by the public and perceived as an effective service. Harmonisation of opening hours of eg injuries units, was universally agreed as the best practice in Wales, as services varied considerably according to the locality. Service quality measures were considered as crucial in reviewing the patient pathway and also for partnership working with other clinicians. The public agreed that discussions not concluding in an emergency call for an ambulance were acceptable.
Cover for frontline staff during sickness etc was fundamental in maintaining a consistent service and ambulance waiting times outside hospitals is an area for serious consideration. Many patients are seen within 20-30 minutes, but there are cases of people waiting 50-60 hours, so there is work to be carried out in that area to determine the cause(s). Checks should be implemented to ensure that unacceptable waiting times do not occur, and that no harm is inflicted onto the stroke survivor that can be avoided.
What is the definition of ‘harm’? Mr Mills stated that not everyone kept waiting would have a negative experience or come to harm. A poor experience is not the same as harm. Call handlers have a difficult, stressful job and are not well paid. Clinical responses to the review showed that ambulances attended those most in need first, as a priority, and as appropriate.
Discussions:
It was clarified that the increase in calls for ambulances from the public may include calls for ambulances already en route.
Ross Whitehead stated that people sometimes call for advice in order to obtain guidance through the system.
Dr Fiona Jenkins stated that when the national Stroke Delivery Group meetings were operational, representatives from the ambulance service were invited to attend, and they had clarified why stroke was classified as amber, and not red. Amber is a very large category. There was evidence that an effective division could be made within the amber category, with the less serious cases being clinical led.
Mr Whitehead explained that there were two main classifications, ie Amber 1 (high acute, faster response) and Amber 2 (outside thrombolysis). Further differentiation could be made, but available resources is the most important element.
Dr Jill Newman suggested that the 'end to end journey experience' as a whole should be reviewed. The limitations of current systems had meant that the north struggled under the current configuration, and so the question had been asked of health boards how this work should be taken forward.
Dr Brendan Lloyd suggested that it should be understood that the red response, with an eight minute target, invokes multiple responses. The lone paramedic attending an immediate threat to life would send a message to the ambulance control centre to ensure that back-up support from an ambulance was in place as soon as possible. The review of ambulance services by Professor Keith Willett identified perverse behaviours in time-based targets which introduced another level of risk. Amber responses may become a red response at a later point. The end to end study looked at the functional outcomes for patients. The National Stroke Sentinel Audit stated that we should look at these to determine where responses could be improved.
Ross Whitehead suggested that a methodology to look at demographics etc, should be identified, in order to determine how support could be effective. Technical solutions may be required. Various groups were analysing the service to determine the key elements/measures which hold the ambulance service to account.
Dr Sue Thomas asked for clarification about the scope and expertise of the ambulance service and whether it was possible for early stroke treatment to be initiated as part of that service. Dr Brendan Lloyd replied that care measurements are via clinical indication, eg blood sugars/breathing rate/heartbeat etc. Transporting the patient to the stroke unit is the main aim of the service, as access to the correct therapy is vital.
Dr Sue Thomas further enquired whether any studies had been undertaken in bringing the full range of diagnostic and treatment services to the patient. Discussions highlighted the need for a scan before administering any treatment, as for example, thrombolysis may not be appropriate.
Katie Chappelle stated that the Stroke Association’s aim is to work with the ambulance service in order to set appropriate targets to bring the service in line with services in the UK.
Shane Mills suggested that targets can take the focus away from treatment needed; the key question is, what is important and how do we measure it?
Katie Chappelle suggested that there is also a need to educate the public to understand the system; Welsh Ambulance Service NHS Trust should consider working with Public Health Wales on an awareness campaign.
Matt O’Grady stated that all relevant statistics are available for review on www.StatsWales.gov.wales.
Dr Fiona Jenkins reported that a Welsh Ambulance Service NHS Trust representative sits on the Stroke Implementation Group. The National Stroke Group is very welcoming of the Red/Amber/Green status and are satisfied with the categories.
Dr Brendan Lloyd reported that the FAST public health message is used effectively and public awareness for stroke prevention has risen.
Matt O’Grady stated that the Stroke Association welcomes the ‘whole episode’ measure and is satisfied with the current amber classification. He also welcomed the pro-active engagement with those conducting the Review. However, he disputed the assertion there was no evidence for targets. There is evidence which shows that targets are effective when they are used appropriately. He pointed out that targets exist for red category calls for those reasons. Without targets however, the Stroke Association believes there is less of a driver for improvement and there is a risk the only change resulting from the review is how waiting times are measured.
Dr Jill Newman enquired about the response to an amber 1 and amber 2 call out, with regard to thrombolysis patients. The window for thrombectomy, for example, would be wider than the window for thrombolysis. Dr Brendan Lloyd replied that work within national pathways would be led by the experts. It was agreed that intelligent targets should be analysed, but what are those intelligent targets that demonstrate that patients are achieving better outcomes? It validates the job of the emergency call allocators, and hopefully sufficient resources would be available to ensure efficacy.
Matt O’Grady highlighted that there was already significant amounts of evidence which show the harm caused by stroke patients if treatment is delayed and this created further evidence of the need for a target. He also stated that a target would not change capacity, only prioritisation of resources.
David Fitzgerald stated that his family has had a major call on ambulance services and he had observed lines of ambulances waiting to offload patients outside his local hospital on many occasions. Eradicating delays would help the patient experience run more smoothly.
Irina Ercovia stated that, for the patient, the crucial point of measure is when the treatment starts. People often call the emergency services inappropriately. NHS Direct do not give any advice nowadays.
Dr Brendan Lloyd picked up on a point by Matt O’Grady, ie that ‘time based targets do not reduce capacity’, so he suggested that if targets are being analysed, those that are clinically based should be reviewed. Dr Fiona Jenkins stated that technological links between systems would also need to be included in any analysis.
Action: Chair to write a letter to the Cabinet Secretary to highlight the discussion points made and ensure appropriate consideration is given by the Cabinet Secretary.
4. Any other business
No other business was discussed.
5. Next meeting
The next Cross Party Group on Stroke meeting will be held on Tuesday, 12 March at 12:30 which will also be the AGM. The topic will be the Cross Party Group on Stroke’s Annual Work Review. The HEIW will be invited and Dr Phil Jones will update the Group on the Stroke Delivery Plan.