Midlands and East Cluster Review A Vehicle for Service Improvement Damian Jenkinson Interim National Clinical Director for Stroke Department of Health

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 D) Includes: i.Early Supported Discharge (ESD) ii.Stroke specialist community rehabilitation C) Includes: i.Hyper-acute services ii.Acute services (including in-hospital rehabilitation) iii.TIA services iv.Tertiary care services e.g. Vascular and neuro-surgery Addressing Quality and Productivity Midlands and East Review of Stroke Services

4 SHMI 2010/11 Yorkshire and the Humber Strategic Health Authority West Midlands Strategic Health Authority East Midlands Strategic Health Authority North West Strategic Health Authority North East Strategic Health Authority South East Coast Strategic Health Authority East of England Strategic Health Authority 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 Summary Hospital Level Mortality Indicator for Stroke 2010/11

Regional Cluster Stroke Performance National Vital Signs Stroke - % spending 90% on Stroke Unit Q1 11/1 2 Q2 11/1 2 Q3 11/1 2 Q4 11/1 2 Stroke – Higher risk TIAs treated within 24 hours Q1 11/12 Q2 11/1 2 Q3 11/1 2 Q4 11/1 2 ENGLAND77.8 % 81.6 % 82.8 % 81.7 % ENGLAND68.8%70.1 % 70.5 % 71.2 % Midlands & East 74.8 % 81.1 % 81.5 % 80.4 % Midlands & East 65.0%63.4 % 65.7 % 66.2 % East Midlands 71.5 % 77.2 % 80.7 % 78.0 % NHS East Midlands 73.2%62.0 % 66.4 % 71.9 % West Midlands 76.0 % 82.7 % 84.5 % 81.1 % NHS West Midlands 64.4%66.7 % 72.5 % 65.4 % East of England 76.4 % 82.8 % 79.3 % 81.2 % NHS East of England 54.5%61.2 % 54.7 % 60.8 % 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

NHS Midlands and East Range in Vital Sign Performance Target 80% Target 60%

SSNAP Organisational Audit 2012

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

Service Specification Midlands and East Review of Stroke Services

Performance Standards <6 months 6-12 Months >18 months 1.Percentage of all stroke patients admitted to hyper acute unit within 4 hours of arrival to hospital (SSNAP) 90% 1.Percentage of patients seen and assessed within 30mins of admission by a specialist in stroke (SSNAP) 90%95% 1.Percentage of appropriate patients having thrombolysis within 60 mins of entry (door to needle time) (SSNAP) 85%90%95% 1.Percentage of appropriate patients having thrombolysis within 45 mins of entry (door to needle time) (SSNAP) 90% 1.Percentage of appropriate patients having thrombolysis within 30 mins of entry (door to needle time) (SSNAP) 50% Performance Standards Midlands and East Review of Stroke Services

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

78 min 72 min50 minMEDIAN Does Size Matter?

Bold Solutions to Large Scale Problems London 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

London Stroke Survival is Higher Than Rest of England Hazard ratio for survival in London %CI p<0.001

Cost-Effectiveness of London Stroke Service Based on 6438 strokes per annum Differences inUnadjustedAdjusted Differences in total costs at 30 days3,307,6773,763,472 Differences in total deaths at 30 days Differences in total QALYs at 30 days5144 Incremental cost per death averted at 30 days15,45155,371 Incremental cost per QALY gained at 30 days64,47886,106 Differences in total costs at 90 days-5,393,533-3,544,210 Differences in total deaths at 90 days Differences in total QALYs at 90 days11286 Incremental cost per death averted at 90 daysDominant Incremental cost per QALY gained at 90 daysDominant Differences in total costs at 10 years-21,318,180-22,786,954 Differences in total QALYs at 90 days4,4923,886 Incremental cost per QALY gained at 10 yearsDominant

T 0 - T 1 T 1 - T 2 T 2 - T 3 T 3 - T 4 Stroke Patient Conveyance Pathway Pathway sub-process T1T1 T0T0 T2T2 T3T3 T4T4 Emergency call Stroke event Ambulance at scene Ambulance leaves scene Arrival at hospital 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 Patient location HASU configuration Traffic density Call to door time

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

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

Summary of Proposed Locations

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

Making It Happen

New Policy

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

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

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

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

Midlands and East Cluster Review A Vehicle for Service Improvement Damian Jenkinson Interim National Clinical Director for Stroke Department of Health