Written Ministerial Statement

The content of this written ministerial statement is as received at the time from the Minister. It has not been subject to the official reporting (Hansard) process.

Department of Health - Reshaping stroke care consultation analysis and stroke action plan, orthopaedics rebuild and future of the Republic of Ireland reimbursement scheme

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Published at 12.00 noon on Monday 20 June 2022.


Mr Swann (The Minister of Health): The purpose of this statement is to update members on two key priorities for my Department; the reform of stroke services; and the recovery of elective orthopaedic services, in Northern Ireland.

Regarding Stroke Services, Members will be aware that my Department published the consultation document ‘Reshaping Stroke Care: Saving Lives, Reducing Disability’ in March 2019 and consulted on seven proposed commitments to improve stroke services both in hospital and in the community. These commitments included the establishment of a network of Hyper Acute Stroke Units (HASUs) and Acute Stroke Units (ASUs), with a number of potential future hospital sites where HASUs and ASUs could be located identified in the consultation document.

Today I am publishing the consultation analysis of the responses to Reshaping Stroke Care. My Department received over 19,500 responses to the consultation and over 1,600 people attended the seven public consultation events. Working in partnership with some local charities my Department also held six meetings with stroke survivors and carers to learn from their lived experience.

I want to thank each and every person who gave up their time and participated in the consultation and assure them that I have given very careful consideration to the issues raised in the consultation.

Responses to the consultation were supportive of many of the commitments and supported the need for staff to have the opportunity to build and develop their specialist expertise, and that delivering better outcomes should take priority over additional travel time.

It is clear, however, that in respect of measures to address travel time, and the location of future HASUs and ASUs, there is concern about the potential impact on those who would travel further for treatment under the options outlined in Reshaping Stroke Care. I also share those concerns.

I have also looked again at the evidence base underpinning the options outlined in Reshaping Stroke Care, particularly in light of developments since the consultation closed in 2019. It is clear to me that there are areas where the evidence base requires further strengthening and refinement to ensure that all relevant issues are considered in identifying future HASU and ASU sites. These include:

  • An assessment of the impact of our ageing population – the number of people aged 65 and over is projected to increase by more than 50% over the next 25 years. With the majority of strokes occurring in people aged 65 and over, we must ensure that our planning reflects both current and future demand for services. This is in the context of the number of stroke admissions increasing from an average of 2,800 in the period 2013-2017 to over 3,000 in 2022;
  • An assessment of the impact of stroke mimics – it is estimated that 25% of admissions to Stroke Units are subsequently identified as stroke mimics;
  • We need to build on the current evidence base for HASUs to include ASUs which are  key to ensuring effective patient flow;
  • Critically, there must be an assessment of the cost and feasibility of implementation of developing HASUs or ASUs at potential future locations.

In the time since the consultation closed, the Health Service has faced – and met - the colossal challenge of responding to the coronavirus pandemic. Due to the need to prioritise the response to the pandemic, announcing the way forward on stroke care was delayed. Given the huge response to the previous consultation, and the strength of feeling of local communities, it was vital that sufficient time was taken to properly consider those concerns.

Having now done so, I am pleased to publish the Reshaping Stroke Care Action Plan setting out the next steps in the reform of stroke services. The Action Plan builds on the improvements already delivered by the Stroke Network including the move to a seven day thrombectomy service in 2020, with over 80 people benefitting from this potentially life changing service at weekends since the service was expanded. Improvements have also been made in other areas including a reduced Door to Needle time for thrombolysis while a Long Term Support specification has been developed to underpin support for stroke survivors and carers.

The Action Plan is an ambitious, multi-year programme of reform which will address the commitments in Reshaping Stroke Care. By the end of this year, I want to see Early Supported Discharge available in all Trusts, all stroke survivors receiving a six month review of their needs, and technology rolled out to hospitals to assist in the interpretation of scans.

In 2023, implementation of the Action Plan will see the establishment of a seven day access to specialist assessment for Transient Ischemic Attack (TIA or ‘mini’ stroke); implementation of measures to address ongoing variation in the provision of thrombolysis; the identification of a preferred option for the establishment of HASUs and ASUs and the completion of a workforce review.

Looking ahead to 2024, I expect to see further improvements with the expansion of the thrombectomy service to a 24/7 service and the implementation of new pathways for referrals to clinical psychology and mental health services.

Many of the actions in the Action Plan involve an initial scoping exercise to identify the gap between current services and what is needed to develop that service to the desired level. As part of that process, we will be considering both how best to make use of current resources as well as the need for additional funding where required.

While I have no doubt as to the need for further investment in stroke services, it would be remiss of me not to note the wider financial context and the pressing demands for extra funding across many areas of health and social care. I am on record as warning that funding pressures in health may be significant by the second half of 2022/23. The financial situation will undoubtedly be constrained whatever the final budget settlement and my Department’s ability to plan strategically is being significantly impaired by the ongoing budgetary uncertainty.

While the financial context does present a challenge, I want to reassure the Assembly and the wider stroke community that the implementation of this Action Plan is a key commitment for my Department. Put simply, we can and must do more to prevent strokes, and we must do better for stroke patients and their carers. Implementation of this Action Plan will enable us to do just that.

Regarding elective orthopaedics, I am pleased to announce plans to rebuild elective orthopaedic services across Northern Ireland.

Waiting times for elective orthopaedic procedures in Northern Ireland are unacceptable with some of the longest waits in the UK. It is not right that a patient have to wait many years for a new hip or a joint, waits which are often marred by suffering pain and discomforts.

Despite the current focus on service rebuilding, elective orthopaedic activity remains below pre-pandemic levels. Going forward we must both increase our activity levels and ensure we work smarter – all with the focus improve outcomes for our patients.

It is for this reason that earlier year my Department commissioned an independent external review of the orthopaedic service, to understand what actions can be taken now, in the short term, to ensure patients can be treated as quickly as possible. The review was undertaken by a team from the NHS Improvement Programme, Getting It Right First Time (GIRFT), and it has been clinically led and co-produced with input from key stakeholders across the health and social care system. I would like to extend my sincere thanks to all who contributed to this.

I am pleased to tell you that this review is now complete. The report details 21 recommendations, all of which have been accepted by the Department. The recommendations and the Department’s response to each recommendation is published on the Department’s website. Work is well underway to implement these as quickly as possible.

In that context, I am planning to focus elective orthopaedic services across all of the existing orthopaedic units, through the creation of Elective Orthopaedic Hubs at Musgrave Park Hospital in Belfast HSC Trust, and within the Southern and Western HSC Trusts. These Hubs will provide a regional core for orthopaedic services to reduce waiting lists and will include ring-fenced staff and beds. Going forward, the hub model will allow the move towards single waiting lists and ensure that specialist services are available to those who need treatment, when they need the treatment.

I am also pleased to announce the establishment of a new Elective Orthopaedic Surgery Recovery Board to drive forward the rebuilding of elective orthopaedic surgery services. The Board will help share best practice across Northern Ireland, provide a challenge function to ensure we learn from each other and provide oversight for the scaling up of elective orthopaedic activity and implementation of the Report’s actions across Trusts.

As we emerge from the full rigours of the pandemic, we are in a position where we can begin to set the foundations for the future and build the service back better. It is also my intention that the Orthopaedic Network will provide clinical leadership of the recovery of the service, with direct links to the new Recovery Board.

I am fully committed to ensuring that elective orthopaedic activity is scaled up as quickly as possible in the coming months. To ensure that our patients receive the care they need, I expect that Musgrave Park Hospital will be restored to pre-COVID levels by 1 November 2022, and that services at other sites are restored as quickly as possible.

I welcome the findings of the review, and through collaborative working across Trusts, I am confident that we can successfully rebuild the service and ensure that patients receive much needed orthopaedic treatment as quickly as possible.

Finally, one issue which some Members, clinicians and patients have sought clarity on is the future of the Republic of Ireland Reimbursement Scheme. In June 2021 I announced the creation of the scheme for a 12 month period to further support patients on a Northern Ireland waiting list.

The scheme has been very successful, with significant patient interest. From July 1st 2021 to the end of April 2022 there were 2,842 applications received and 2,246 applications already approved. By comparison in the 2020-21 year, prior to the introduction of the new scheme there were 1,466 applications to use the previous Cross Border Healthcare Directive throughout the EU, of which 886 were for the provision of services in RoI.

Some 89% of the applications to date to the ROIRS relate to orthopaedics, the vast majority of which relate to hip and knee replacements. Therefore the scheme has provided valuable orthopaedic capacity as the service locally rebuilds.

As HSC capacity is continuing to grow I have therefore taken the decision to extend the ROIRS by allocating a further £5m to permit its continued utilisation beyond the previously set timeframe to the end of this month. Again this is funding that I do not currently have in my Department’s baseline so it is a decision that I have taken at risk, however given the obvious benefits of the scheme it was one I felt was necessary as essential HSC capacity continues to become increasingly available over the coming weeks and months.