On Good Friday 2013, Shani Shamah, a 56-year-old mother of four, was in her North London kitchen making some food for her mother, who had had a hip replacement. Her son was home from university for Easter and everything seemed calm.
All at once, she told Apolitical, ‘I felt as if I were foaming at the mouth. It’s a very strange feeling and hard to explain. But it was like when you see a werewolf in a film – that’s how it felt. I went to lie down, my husband came in and I just wasn’t making any sense. He said, “You’re having a stroke,” because luckily he’d seen an ad about it on TV the night before. I said, “Don’t be so stupid.’ But he ignored me and called 999.’
An ambulance was there within a matter of minutes – Shamah, pictured, believes they were having a cigarette break round the corner – and hurtled her, under blue lights and sirens, to the new Hyper-Acute Stroke Unit at Northwick Park Hospital. The treatment she received there probably saved her life.
Access to this treatment was made possible by a visionary re-organisation of healthcare for London’s eight million inhabitants, pushed through to raise appalling standards of care in the teeth of embittered opposition.
How this was achieved is a study in the tactics, toughness and sheer resolve required from public servants to turn an audacious idea into reality on a scale that affects millions. It is also a sobering insight into how narrow the window of opportunity for change can be.
Making stroke care both equal and acceptable meant closing units all over London, including the only unit that met national standards. That hospital, St Thomas’s, is across the river from the Palace of Westminster, and is where Members of Parliament would be treated. Still, with a considered strategy and an irrefutable case for change, that unit was shut, demonstrating that an ever-more-overstretched service can enact systemic change to provide ‘more for less’. The model is now being copied elsewhere in Britain as it tries to create a National Health Service that can provide high-quality treatment for an ageing population that needs ever more of it.
How it got done – and who did it
The Chief Executive of London’s Strategic Health Authority at the time was Ruth Carnall, now Dame Ruth Carnall, who trained as an accountant and began working in the NHS in 1977. This body covering the whole of London was only set up in 2005, the year she became its leader, and was disbanded in 2013, the year Shani Shamah’s life was saved by one of the hyper-acute units it instituted.
England’s National Clinical Director for Stroke, Professor Tony Rudd, told Apolitical, ‘It was Ruth who really pushed it through, it was her strong leadership that did it.’
We decided not to try and eat an elephant
She set out to address not stroke particularly, but one of London’s perennial problems: badly skewed inequalities of care in different parts of the city. Hospitals are concentrated in the centre at the expense of the periphery, something first identified as needing reform in a House of Lords report from 1892. That is not a typo.
Dame Carnall told Apolitical that she now realises the pivotal decision was not to try to address all that was wrong, not ‘to try and eat an elephant’, but to isolate a few priorities into which time, money and energy could most effectively be concentrated. A study she commissioned from Professor Ara Darzi – now Professor the Lord Darzi – showed that stroke was a promising candidate.
The case for change
Stroke is the second-biggest killer in London and of people over 60 worldwide. It is also London’s leading cause of avoidable disability. At that time, it struck 11,000 people in the city each year and London had the worst outcomes of any capital in the EU. Only one hospital in the city, St Thomas’s, met the UK’s standards of care, and even those were far short of standards in the EU and America. Dame Carnall, pictured, describes London’s performance then as ‘pathetic’.
But what made it a better target than other possibilities like mental health, primary care, urgent care and paediatrics was that, unlike in those areas, the gold standard of treatment was not in doubt.
The crux is speed. Stroke cuts blood supply to the brain, but can happen in two ways – by clot or by bleeding. In the former case, you can give clot-busting thrombolysis, but giving that to a person with a bleed could kill them. To establish which it is, you need to do a brain scan. But for thrombolysis to be effective, it must be given as soon as possible. Every minute counts. In the NHS, it is only licensed for use in the first four and a half hours, and even that is an extension.
So the gold standard is ‘essentially very fast access to detailed scanning, followed by thrombolysis, if you’ve got a clot, or neurosurgery, and the ability then to provide intensive treatment and rehabilition with highly qualified support services. So very fast access to specialist centres 365 days a year, 24 hours a day.’
As Shani Shamah, who has written a fundraising book about her experience, describes it, ‘When I arrived at the hospital, the ambulance had called ahead, the doors were open, the stroke team were ready, I went straight into the HASU. Everything happened so fast I would almost have liked a break to ask questions.’
Achieving that standard in a financially feasible way meant closing dozens of stroke units and centralising care into a few Hyper-Acutes. As Dame Carnall says: ‘The model of care wasn’t difficult to define, the thing that was difficult was to decide: how many HASUs should we have? And how should those centres connect such that the whole of London’s population is within half an hour of blue-light access?’
They concluded that they needed eight and, by analysing travel times, where they should be. That meant putting elite units in bad hospitals and closing the best-forming unit in London, at St Thomas’s. Then the fight began.
The fight, and why it was won
Opposition came in many forms. Members of Parliament resisted the closure of stroke units in their constituencies. Clinicians resisted being told they would have to specialise at the expense of other work.
There was resistance from doctors who opposed closing the flagship unit at St Thomas’s. Dame Carnall remembers them asking, ‘“Why is eight the magic number? Why can’t we have nine?” The reason you can’t have nine is that there are several that have got a case to be the ninth, and that would mean we’d probably end up with 14. Then you’re talking about dispersing a specialised service into too many different centres, and they’d never be able to support the quality of staff and everything else that you need.’
Dame Carnall identifies four elements that allowed her and her team to overcome this opposition:
1) A watertight case for change
Although she emphasises that it was vital to have a persuasive narrative as well as just statistics, she says: ‘It was like a gateway process; do you agree that Lord Darzi’s report is a good case for change? “Yes.” Do you agree that we can’t do it all? “Yes.” Do you think we should prioritise? “Yes.” Is this a reasonable process of prioritisation: where are we killing people unnecessarily, where are people suffering disabilities and where do we know what good looks like, do you think it’s in these areas? “Yes we do.”
‘The whole thing is like a series of gates. Do you agree that this is the model of care? “Yes.” Do you agree we should have eight HASUs (here’s the evidence). “Yes.” OK, these are the eight then. “No.” And that’s self-interest.’
2) A powerful alliance
The most important allies were clinicians like Lord Darzi who could make the case and bring along ‘laggard’ colleagues. But Dame Carnall’s team also secured the support of patients’ groups, particularly the Stroke Association, and the heads of local administrations. As the alliance grew, so did its momentum.
There were pivotal figures, such as Professor Tony Rudd, who ran that flagship stroke unit at St Thomas’s and had invested his entire career in it. Says Dame Carnall, ‘Tony decided that he would become clinical director for the programme, having been the leader of the best-performing hospital and one that was, as it were, losing out. The fact that he was committed was a tipping point.’ He is now clinical director for stroke nationwide (as well as a Commander of the British Empire) and is known, to his displeasure, as ‘England’s stroke tsar’.
Winning over individuals was also essential further down the line. One problem was that some of the chosen hospitals, such as Bromley, in the south of the city, were so bad they could not recruit the high-performing staff needed. ‘So we asked one of the most capable, most prominent stroke leaders in London, Diane Ames, who was close to retirement, if she would go to Bromley and be the director there. That was a massive ask, because she was like, “Where is Bromley? I usually work in a big teaching hospital and have a massive entourage and have got a fantastic set-up here and I’m about to retire, and you want me to go where?’ But she went, and others followed to work with her.
3) Upfront investment to show commitment
Centralisation has been shown to save money overall, but to get things moving, the Health Authority ‘top-sliced’ a total of £20million from subsidiaries to put into it. Doing so again brought in supporters because they realised, ‘we were actually going to go through it’.
4) Uncompromising leadership
Dame Carnall’s view is that any compromise on the essence of what they were trying to achieve, such as on having precisely eight units, would have been fatal. Her team also created polyclinics for primary care, but failed to achieve what they did in stroke. ‘We let go of the control and the result was that implementation was really weak. People rebadged things they’d already got or explained why it wasn’t going to work there, so the effort and the impact dissipated.’
As an example of the necessary stick-to-your guns robustness, they told hospitals, ‘We will have a stroke tariff and hospitals won’t get that tariff unless they demonstrate a) that they’ve committed the investment, b) that they’re providing the specialised training and c) that they’re delivering the access 365 days a year. If they don’t do all those things, they won’t get the money.’
We didn’t have the authority to just say, ‘This is what I want’
When doctors in a part of north London thought they could carry on without taking any notice, ‘which a lot of people thought’, another group of clinicians was mobilised to tell them, ‘You have to participate, and if you don’t, you won’t be working in stroke care any more.’
She emphasises that, ‘Our authority wasn’t that strong actually. We didn’t have the global authority to just say, “This is what I want and therefore you’ll do it.” That’s why the case for change and the clinical leadership were so important.’
Perhaps the best example of her focus and toughness is her response to the criticism that the project sucked clinical talent away from other parts of the country: ‘That’s not my problem.’ On the other hand, to the suggestion that two years was quite fast for a consultation, she said, ‘Not if you’re one of the 400 people that died while it was all going on.’
The aftermath, and the future
For London, the result of this struggle is clear. The first HASU opened in 2010 and the average journey time to one in an ambulance is now 14 minutes. A study in the British Medical Journal concluded that 96 Londoners each year owe their lives to centralisation. As Professor Tony Rudd put it, ‘No patient has ever said, “Take me back to my crap local hospital.”’
For Dame Carnall, her working life is now outside the NHS. She left when the Strategic Health Authority was disbanded by Health Minister Andrew Lansley, who wanted to use market forces instead of top-level strategy to determine the future of care. She now runs a consultancy firm with other ex-public servants, and misses her days in the NHS. She says that, if it hadn’t been for her job disappearing, ‘I never would have left.’
We’re facing a crisis
For healthcare in Britain, this centralisation provided not only an inspiration in what could be achieved, but also a model of how to provide high-quality treatment for a population that requires ever more for less money. Professor Rudd says, ‘We’re facing a crisis. We can’t afford to pay for specialist care in 180 hospitals in England. And there remains unacceptable variation in the quality of care. We need to have a huge shift. It’s something that needs to happen. It’s about developing a whole pattern of care and the new models in vanguard sites are really important.’
One of those sites has just opened in the north of England. The Cramlington hospital in Northumbria has an analogous centralisation of emergency specialists and equipment. Patients from the area are now driven past their local hospitals to get to it. Although it is too early to see results, Professor Sir Bruce Keogh, the national medical director, has said, ‘This hospital will have the right people, at the right place, with the right equipment. It is a glimpse of the future.’
(Picture credit: Flickr/Kenjonbro)