Stroke Care in the UK Tony Rudd

Organisation of Services 120,000 new strokes per year Approx 200 hospitals treating acute stroke patients Most services providing combined acute and rehabilitation services Specialist rehabilitation services in community e.g. Early supported discharge General practitioners doing most of secondary prevention

Stroke: Aggregated Audit Score: Country Comparison

Results: Stroke unit provision – comparison over time Stroke unit in hospital73%79%91%92% Median (IQR) stroke beds 20 (14-27)20 (15-29)24 (16-30)25 (20-34) Specialist community/ domiciliary rehabilitation team 31%27%32%70%

Time from Stroke to Scan

Time of Day Scanning Performed

Thrombolysis Provision Intercollegiate Stroke Working Party

Thrombolysis Service National median: 14 National total: 3284 Thrombolysis Intercollegiate Stroke Working Party

National Initiatives for Change NAO 2005 National Sentinel Audit 2008 NICE and ICWP Stroke Guidelines 2008 Stroke Improvement Programme National Stroke Strategy 2007

Transforming Stroke Care in London

11 In 2004 the Sentinel Stroke Audit showed that stroke services in London were poor… Physiotherapist assessment within 72 hours of admission % Emergency brain scan within 24 hours of stroke % 90% Patients treated in a Stroke Unit % 90% Case for change

12 More strokes occurred in outer London but most providers were in inner London GAPS OVERLAPS The more intense the red the greater number of providers available to provide service to the area.

Story so far 13 The development of the strategy was subject to wide engagement with the model of care agreed by clinicians and user groups HASUs Provide immediate response Specialist assessment on arrival CT and thrombolysis (if appropriate) within 30 minutes High dependency care and stabilisation Length of stay less than 72 hours Stroke Units High quality inpatient rehabilitation in local hospital Multi-therapy rehabilitation On-going medical supervision On-site TIA assessment services Length of stay variable 30 min LAS journey* After 72 hours Discharge from acute phase Community Rehabilitation Services HASUSU * This was the gold standard maximum journey time agreed for any Londoner travelling by ambulance to a HASU 999 New acute model of care

Prophets of doom predictions It would not be possible to implement major system reorganisation in London for a condition as complex as stroke Staffing requirements would not be achievable Patients would not accept being taken to a hospital that is not local to them It would not be possible to transport people within 30 minutes to a HASU Repatriation would fail and HASUs would quickly become full Trusts would fight to retain services Even if acute services work it would fail because it would be impossible to change community services The new model would be unsustainable

15 Following bidding and evaluation a preferred model was agreed and consulted on

London Stroke Care: How is it working? 1 st February 8 Hyperacute (HASU) stroke units opened taking all patients who might be suitable for thrombolysis 19 th July all stroke patients taken to one of the HASUs Over 400 additional nurses and 87 additional therapists recruited to work in stroke care in London by July 2010

17 The number of stroke patients taken by London Ambulance Service to a HASU has been increasing as implementation progresses

18 Performance data shows that London is performing better than all other SHAs in England Thrombolysis rates have increased since implementation began to a rate higher than that reported for any large city elsewhere in the world % of patients spending 90% of their time on a dedicated stroke unit % of TIA patients’ treatment initiated within 24 hours 12% 10% 3.5% Feb – Jul 2009Feb – Jul 2010AIM

19 Efficiency gains are also beginning to be seen Average length of stayHASU destination on discharge The average length of stay has fallen from approximately 15 days in 2009/10 to approximately 11.5 days in 20010/11 YTD This represents a potential saving of approximately [DN - insert figure] Approximately 35% of patients are discharged home from a HASU. The estimate at the beginning of the project was 20%.

London Stroke Care: How is it working? No significant problems with repatriation to SUs. Good exchange of patient information. Significantly improved quality of care in SUs Evidence of constructive collaboration between hospitals – SU Consultants joining HASU rotas and participating in post-take rounds and educational meetings Very positive anecdotal patient feedback

Areas where issues remain Community services in many areas still insufficient – Early supported discharge – Longer term rehabilitation – Vocational rehabilitation Collecting data to prove the model is worth it

The Future Reorganisation of health care in UK with less central control – Abolition of strategic health authorities – General practitioners commissioning care May mean that major changes to stroke care will be difficult Probably funding cuts