Future Fit – Or Fundamentally Flawed?

Shropshire’s Health bosses have launched a new charm offensive to try and convince us that closing down one of our A&Es and acute hospitals is a good idea. They’ve got a lot of work to do if their first contribution to the new strategy is anything to go by!

A few days ago, the Future Fit website published an important article[i]. They say ‘The following blog provides the views of the three clinicians leading NHS Future Fit in Shropshire and Telford & Wrekin. It is a discussion on the balance between travel time access and clinical outcomes in advance of the planned future consultation on the reconfiguration of hospital services within the county. It is from Dr Stephen James, Clinical Director of Information and Enhanced Technologies, Shropshire Clinical Commissioning Group; Dr Michael Innes, from Telford and Wrekin Clinical Commissioning Group; and Dr Edwin Borman, Medical Director at The Shrewsbury and Telford Hospital NHS Trust’.

Unfortunately, these three leading clinicians make an astonishingly basic error that could put lives at risk. Part of their justification for increasing the journey times to A&E is that paramedics will treat patients with clot busting drugs, so the time taken to get to hospital doesn’t matter. They say, ‘With the professional support of a paramedic comes the opportunity to start treatment at the scene, bringing care closer to people and reducing time to treatment. Increasing amounts of evidence, especially from rural Scotland, have demonstrated that this can actually improve care further. For example, people living further away from a hospital can have clot-busting treatment administered at home faster than those conveyed to hospital… This is particularly relevant for the county of Shropshire and beyond, where travel times and distance can be significant.’

Dr James, Dr Innes and Dr Borman are making an extraordinarily serious error here that would put patients’ lives at risk. Julia Evans, Secretary of Shropshire and Telford and Wrekin, is an A&E nurse.  We asked her to explain why this model of care would be catastrophic for patients. We checked her analysis with a doctor and a paramedic who are supporters of Shropshire and Telford and Wrekin Defend Our NHS. We’ve checked the guidance from NICE, the national body that maintains quality standards and produces care pathways for the NHS. Good clinical practice is overwhelmingly clear. The three clinical leaders of Future Fit are about as wrong as they could be on clot busting treatment.

Strokes. Thrombolysis (‘clot busting’) is an important treatment for ischaemic strokes – strokes where there is a blood clot in an artery in the brain. But there are two kinds of stroke – brain haemorrhage (a bleed in the brain) can look the same as a stroke caused by a blocked artery. It’s essential that the type of stroke is properly diagnosed with a head scan in hospital before clot busting drugs are given[ii]. If a paramedic gives clot busting drugs to a patient with a brain haemorrhage, this can directly cause severe brain damage or death. That’s why paramedics DON’T give clot busting medication. A&E nurse Julia Evans explained, ‘The national guidance from NICE is that a patient can only be given a clot busting drug after brain imaging – a scan to diagnose the type of stroke. Without that, the risks are far too great. It’s extraordinary that the clinical leaders of Future Fit are making a mistake as dangerous as this. They might want to go away and read the national guidance. They certainly need to’.

Heart attacks. The other use of clot busting drugs is for a heart attack caused by a blood clot blocking a coronary artery. It’s not the best treatment anymore.  Clinical practice has moved on[iii]  [iv]– even if the clinical leads for Future Fit have not. Julia Evans explained, ‘There are two treatments for ‘STEMI’, heart attacks where a coronary artery is blocked. Giving a clot busting drug is a valid treatment, but it’s certainly not the best one. The NICE national guidance spells out that a more effective treatment is a procedure called primary angioplasty, also known as primary PCI. A specialist doctor unblocks the coronary artery with a balloon and inserts a stent to keep the artery open. It’s an amazing technique and it saves lives. It has to be done quickly, to save heart muscle, and it isn’t done directly after giving clot busting drugs. This is where the best outcomes are achieved by getting patients to hospital quickly and treating them with an angioplasty and stent as soon as possible. If the doctors running Future Fit think paramedics should be giving clot busting treatment for heart attacks, they’re either making a foolish mistake – or even worse, they’re accepting that second best treatment is good enough for local people. I find this quite frightening’.

Gill George, speaking for Shropshire and Telford and Wrekin Defend Our NHS commented, ‘It’s astonishing how much nonsense is being spouted to try and justify closing down one of our A&Es and hospitals – but this particular mistake is a really shocking one. They keep telling us that Future Fit is “clinically led” but that’s not reassuring when clinicians can make errors as basic as this. We would welcome an explanation and an apology’. Ms George added, ‘The reality is that Future Fit is about saving money. The Princess Royal and the Royal Shrewsbury serve more than half a million people across two thousand square miles. The experts at the Royal College of Emergency Medicine recommend against closing A&Es in rural areas. We need both our A&Es and both our hospitals’.

[i] The Future Fit blog is here: http://nhsfuturefit.org/our-news/blog/80-auto-generate-from-title (accessed 28/02/16). We attach a pdf of the article as we have told Clinical Commissioning Group leads (Brigid Stacey and David Evans) of this error, and anticipate some hasty re-writing.

[ii] NICE is the national standards body for the NHS, producing up to date evidence based guidelines for the treatment of most conditions. Guidance on acute stroke care is here: http://www.nice.org.uk/guidance/cg68/chapter/1-Guidance (accessed 28/02/16). Sections 1.3 and 1.4 on treatment of acute stroke are most relevant. It makes it clear that clot busting drugs should only be given following brain imaging, and should only be used by ‘physicians trained and experienced in the management of acute stroke’.

[iii] The NICE quality standard on the management of acute STEMI (myocardial infarction where the artery is completely blocked by a clot) is here: https://www.nice.org.uk/guidance/qs68/chapter/Quality-statement-6-Primary-PCI-for-acute-STEMI (accessed 28/02/16). Clot busting treatment for myocardial infarction is known as ‘fibrinolysis’. The standard explains that primary PCI (angioplasty and stent) is a better treatment than clot busting drugs – but must be initiated quickly:  ‘Primary PCI is a form of reperfusion therapy which should be done as soon as possible. This is because heart muscle starts to be lost once a coronary artery is blocked and the sooner reperfusion therapy is delivered the better the outcome for the patient. If too much time elapses the benefits of primary PCI may be lost. Because of the difficulty in timely delivery, in some areas primary PCI is no longer the preferred coronary reperfusion strategy over fibrinolysis. However, when performed early, primary PCI is more effective’.

[iv] The NICE guidelines at http://www.nice.org.uk/guidance/cg167/chapter/1-recommendations (accessed 28/02/16) confirm this approach (section 1.1.4), stating that clinicians should: ‘Offer coronary angiography, with follow-on primary PCI if indicated, as the preferred coronary reperfusion strategy for people with acute STEMI if: presentation is within 12 hours of onset of symptoms and primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given’.