Centralising stroke services in Greater Manchester - lessons learnt Sarah Rickard, Network Manager @GMStrokeODN www.gmsodn.org.uk

2010 2011 2014 2015 2016 2017 Partial centralisation of acute care in GM, full centralisation in London Internal review of pathway concludes further change is needed NIHR research demonstrates superiority of full centralisation PAT rationalises stroke services to one site Work to improve community services commences GM implements full centralisation Greater Manchester began centralising its stroke services in 2010. It introduced a partially centralised model delivering hyper acute care at three Hyper Acute Stroke Units (Salford Royal, Stepping Hill and Fairfield General) for patients presenting within <4 hours of onset with everyone else taken to their local stroke unit called District Stroke Centres. At the same time, London moved to a fully centralised pathway where all patients were taken directly to a HASU. An NIHR research project examined the impacts of the two differing models and showed the London model was superior in terms of mortality. Following a local review in 2011, national audit data and the publication of this evidence, it was recommended that GM moved to the fully centralised model, which went live in March 2015. The ODN was established in the summer of that year and initially focused on supporting the pathway to ensure its sustainability and high performance. During the last 3 years, the region has also reduced its stroke units to concentrate the quality of care, with Pennine Acute rationalising its services to one site in 2014, and Macclesfield’s unit closing in 2016. ODN reviews of the redesigned hospital pathway at 1 and 2 years has shown significant improvements in the quality of care provided to all GM residents, with everyone now having access to 7 day 24/7 hyper acute care that is A rated by the national stroke audit. The network is now focused on ensuring that community rehabilitation is as equitable and of a similar high standard throughout the region. ODN established Macclesfield stroke unit closes Annual review of acute pathway shows improvement GM achieves ‘A’ acute care for all residents

GM stroke providers 3 Hyper Acute Stroke Units 6 District Stroke Centres 16 community rehabilitation teams The region is served by 3 HASUs and 6 DSCs, with Salford open overnight serving the whole of GM and all stroke units are commissioned using a standard service specification with associated quality standards. We are actively considering how we could further reduce the number of units to help ensure services can be sustained in the longer term as staffing issues become more critical. Our specialist community rehabilitation services are much more variable, with 16 separate teams serving 12 CCGs.

Pathway strokes

Acute pathway performance PAT re-organisation GM full centralisation   2014 2015 2016 2017 CCG Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jul Aug-Nov Dec 16-Mar 17 Eastern Cheshire D C B A Bolton X Bury Central Manchester Heywood, Middleton & Rochdale North Manchester Oldham Salford South Manchester Stockport Tameside & Glossop Trafford Wigan Borough One of the roles of the ODN is to monitor and support improvements in the stroke acute pathway. The most recent national audit data shows: GM now has best scoring hospital stroke pathway in the country Stroke patients in all 13 CCGs receive ‘A’ rated care All 3 HASUs are rated ‘A’ and in the top 10 units in the country (out of 224) An ODN audit of patient flow in 2017 showed the pathway has broadly stabilised with 93% of all GM admissions via a HASU with 94% of stroke patients admitted to a stroke ward There have been some changes in the last year: Increased proportion of stroke patients presenting <4hours at HASUs – more people now eligible for thrombolysis at HASUs Large decrease in stroke assessments in DSC A&Es and admission at DSCs Large increase in directly admitted stroke patients at DSCs placed on non-stroke wards – often due to internal bed management issues Reduction in non-strokes (stroke mimics or Transient Ischaemic Attacks) admitted to HASU stroke wards – better detection, triage and management of patients by stroke services freeing up stroke beds for stroke patients ODN benchmarking of compliance with the 2016 National Clinical Guideline for Stroke showed compliance of teams with their relevant recommendations as HASUs - 91%; DSCs 93%. Areas of non-compliance (e.g. access to clinical psychology) were usually due to lack of or insufficient local commissioning.

Review at 2 years Significant decrease in stroke assessments and admissions at District Stroke Centres 9% increase in proportion of strokes <4hours time of onset at HASUs 94% of stroke patients admitted to a stroke ward Significant reduction in stroke mimics assessed in A&E and admitted to HASU stroke wards in Year 2 Significant increase of directly admitted stroke patients at DSCs treated on non-stroke wards in Year 2

Key learning Realistically model changes in patient flow and consider future developments e.g. IAT, ICH pathways Minimise number of stroke units (and community teams) to future proof quality of care and improve efficiency Redesign community services at the same time Measure impacts across whole patient journey

Key learning Collaboratively agree SOPs to support pathway Agree at CEO level robust processes to ensure timely repatriation of strokes and mimics Ensure sufficient support to manage increased patient flow at HASUs Improve recognition of stroke to reduce burden of false positives at HASUs Ensure ASUs still able to treat direct admissions appropriately Consider pathway exclusions (e.g. time of onset cut off) and referral pathways (carotid artery etc)

Critical success factors Decision to centralise based on robust evidence Collaborative approach built relationships and trust over time Include patient voice Effective use of data to demonstrate impacts Network support for change management

Who are we? Established in July 2015; pump primed by SCN and now provider funded (~£200k/annum) Only Stroke ODN in the country Non-statutory body constituted from all public sector stroke provider organisations across Greater Manchester, including NWAS Providers, in partnership with the Host, are collectively responsible for delivery of the functions of the network

Established in 2015 and funded by providers of stroke care Small team Our vision

Hospital Clinical Lead Community Clinical Lead Meet the team Sarah Rickard Manager Chris Ashton Co-ordinator Dr Jane Molloy Hospital Clinical Lead Tracy Walker Community Clinical Lead Supported by Administrator Lisa Chadwick; shared with Neuro Rehab ODN

Continuous improvement Mortality Patient information Stroke unit capacity Community services Service developments TIA services Shared clinical SOPs Measuring performance ICH pathway Regional IAT service Sector Forums Audit Patient flow Training & Education Competency frameworks Training programme Annual conference Induction training Online training Teaching at universities Secondary prevention Cardiology services SaLT Rehabilitation Life after stroke Vocational rehabilitation Driving Use of assessments

sarah.rickard@srft.nhs.uk www.gmsodn.org.uk @GMStrokeODN