Midlands and East Cluster Review A V ehicle for S ervice Improvement

1. Midlands and East Cluster Review AVehicle for Service Improvement Damian Jenkinson Interim National Clinical Director for Stroke Department of Health

2. Addressing Quality and ProductivityMidlands and East Review of Stroke Services • Clear process • Service specification to high aspirations for whole stroke pathway • No prescription of model or configuration to deliver stroke services • External Expert Advisory Group • C) Includes: • Hyper-acute services • Acute services (including in-hospital rehabilitation) • TIA services • Tertiary care services e.g. Vascular and neuro-surgery • D) Includes: • Early Supported Discharge (ESD) • Stroke specialist community rehabilitation

4. Summary Hospital Level Mortality Indicator for Stroke 2010/11 SHMI 2010/11 Yorkshire and the Humber Strategic Health Authority 112.1 West Midlands Strategic Health Authority 109.8 East Midlands Strategic Health Authority 104.8 North West Strategic Health Authority 105.2 North East Strategic Health Authority 104.5 South East Coast Strategic Health Authority 104.4 East of England Strategic Health Authority 103.1 South Central Strategic Health Authority 98.4 South West Strategic Health Authority 95.6 London Strategic Health Authority 75.9 Source: HES – SHMI downloaded October 2011

5. Regional Cluster Stroke PerformanceNational Vital Signs Targets: 80% of patients spending over 90% of they stay on a stroke unit 60% of high risk TIA patients scanned and treated in under 24 hours

6. NHS Midlands and EastRange in Vital Sign Performance Target 80% Target 60%

7. SSNAP OrganisationalAudit 2012

8. SSNAP OrganisationalAudit 2012

9. NHS M&E covers a quarter of the country; an area the size of Belgium Major variation in geographical and demography Complete the review before SHA’s abolition March 2013 Pace at a time of major organisational change: abolition of stroke networks, PCTs, SHA transition to CCG commissioning development of strategic clinical networks, Area Teams agreeing ownership beyond NHS ‘transition’ Expectation of no additional financial pump priming Challenges to The Review

10. Service SpecificationMidlands and East Review of Stroke Services

11. Service SpecificationMidlands and East Review of Stroke Services

12. Performance StandardsMidlands and East Review of Stroke Services

13. Does Size Matter? SINAP 2012: 4347 receiving tPA (10.3% of 42,024 patients with acute ischaemic stroke admitted to 80 hospitals). Stroke onset-arrival times by thrombolysis volume, as a proportion of all patients admitted with ischaemic stroke

14. Does Size Matter? 78 min 72 min 50 min MEDIAN

15. Bold Solutions to Large Scale ProblemsLondon Stroke Service 30-Minute Blue Light Ambulance Travel Time from the Hyper-Acute Stroke Units • Population >8million • 11,500 strokes a year in London – 2,000 deaths • Commitment to whole system redesign

16. London Stroke Survival is Higher Than Rest of England Hazard ratio for survival in London 0.72 95%CI 0.67-0.77 p<0.001

17. Cost-Effectiveness of London Stroke ServiceBased on 6438 strokes per annum

18. Stroke Patient Conveyance PathwayPathwaysub-process Call to door time T0 T1 T2 T3 T4 Emergency call Ambulance at scene Arrival at hospital Stroke event Ambulance leaves scene T0 - T1 T1 - T2 T2 - T3 T3 - T4 • Patient location • HASU configuration • Traffic density • Act F.A.S.T. campaign • Telemedicine • Ambulance dispatch locations • Location of nearest RVV/ambulance • Interventions at the scene • Need to wait for double-staffed ambulance

19. High Level EEAG Appraisal Criteria Clinically sustainable and future proofed Whole stroke patient pathway Equitable access irrespective of socio economic status Coproduced: health and social care; for people outside area Services accessible by residents and travellers Allneeded services of equal importance e.g. medical, nursing, therapy, psychological support etc Plans will improve stroke mortality; patient's quality of life; and patient’s and carer’s experience of care Services are cost effective and financially sustainable 19

20. Concluding Proposals • From 45 acute stroke providers… • To 30 HASUs, with EEAG recommendations to reduce to 25 HASUs • Challenges of rurality and access in 60min travel time • Commissioner led proposals • NCB Area Teams engaged to support performance management of implementation • Implementation support :new Strategic Clinical Networks

21. Summary of Proposed Locations

22. Making It Happen • Handover Legacy Pack • Area Teams • Clinical Senates • CCGs • Strategic Clinical Networks • NHS IQ • AHSN • Health and Wellbeing Boards

23. Making It Happen

25. New Policy

26. Early Supported Discharge Challenge ESD where appropriate, Extend provision from 20% to 40% Improvements 1080 pa fewer deaths dependencies, cost neutral Levers NHS IQ to promote SSNAP audit

27. Rehabilitation Access and Uptake TIA Specialist TIA Assessment ESD Acute Stroke Community Stroke Team Acute Cardiac Specialist Stroke Rehab Acute PAD Cardiovascular Rehab Specialist Cardiac Rehab Specialist PAD Rehab ? CVD Educational Framework ?

28. Access to Psychological Support Challenge Improve provision and access Improvements QoL Patient experience Cost saving at 2 years Levers QIPP SSNAP audit

29. Long Term Care Integration is Key Patient & Carer Experience Empowerment Self-management CVD risk assess and treat Joint Care Planning Monitor /manage needs Specialist/ Broader rehab Preventing Dependency/ need End of Life Care Recovery/ Rehabili- tation Identify/ Monitor need Assess/ Monitor need Other routes in eg HC Secondary specialist care

30. Midlands and East Cluster Review AVehicle for Service Improvement Damian Jenkinson Interim National Clinical Director for Stroke Department of Health