Reorganisation of Stroke Services in Greater Manchester 2006-15 challenges and opportunities in providing a centralised service Professor Pippa Tyrrell

SINAP and SSNAP Reports 15 years of policy making………… SINAP and SSNAP Reports 2015 2000

The Ambition: 2006-10 That every citizen of Greater Manchester presenting with stroke/TIA symptoms shall have equal access to a fully integrated, evidence-based hyper-acute and acute specialist stroke care pathway

The Plan: 2010 Positive FAST test within 24 hours to stroke centre

Stroke care before 2010 Suspected stroke Local A&E Stroke unit or ward Geographic variation between centres Some providing thrombolysis some not Suspected stroke Local A&E Stroke unit or ward Very different results on RCP Sentinel Audit, inequity of service across GM Emphasise variability of stroke services pre-reconfiguration Key contrast: in London, all patients go to a HASU for care, whereas in Manchester, only patients presenting within 4h GM: only patients presenting within 4 hours of stroke taken to CSC/PSC; otherwise taken to nearest DSC London: ALL go to HASU (24/7), then after 72 hours transferred to the community or to an SU near to home Before 12 stroke services 30 stroke services After 1 CSC, 2 PSCs, 11 DSCs 8 HASUs, 24 SUs; 5 services closed Community rehab

Proposal for stroke care after the changes Suspected stroke 1 Comprehensive Stroke Centre 24/7 Hyper Acute Stroke Unit Stroke Unit 2 Primary Stroke Centres 7-7 M-F Emphasise variability of stroke services pre-reconfiguration Key contrast: in London, all patients go to a HASU for care, whereas in Manchester, only patients presenting within 4h GM: only patients presenting within 4 hours of stroke taken to CSC/PSC; otherwise taken to nearest DSC London: ALL go to HASU (24/7), then after 72 hours transferred to the community or to an SU near to home Before 12 stroke services 30 stroke services After 1 CSC, 2 PSCs, 11 DSCs 8 HASUs, 24 SUs; 5 services closed Community rehab This is effectively the model that London adopted

What actually happened: Stroke care in Manchester after the changes Suspected stroke Under 4 hrs Over 4 hrs 1 FT CE refused to cooperate with changes unless 24hour changed to 4 hour: revenue concerns Comprehensive Stroke Centre Primary Stroke Centres District Stroke Centres Emphasise variability of stroke services pre-reconfiguration Key contrast: in London, all patients go to a HASU for care, whereas in Manchester, only patients presenting within 4h GM: only patients presenting within 4 hours of stroke taken to CSC/PSC; otherwise taken to nearest DSC London: ALL go to HASU (24/7), then after 72 hours transferred to the community or to an SU near to home Before 12 stroke services 30 stroke services After 1 CSC, 2 PSCs, 11 DSCs 8 HASUs, 24 SUs; 5 services closed Community rehab

What worked? Detailed pathway mapping Paramedic engagement Clinician and PPI engagement Ambition to change and improve Clear about “what” Not so clear about “how”

Pre SINAP/SSNAP data was inaccurate, confusing and mostly wrong! What was difficult? Calculating the numbers pre SINAP/SSNAP! Pre SINAP/SSNAP data was inaccurate, confusing and mostly wrong!

What was difficult? Last minute model change caused confusion 4 hour cut off difficult for paramedics Model dependent on onset time Distinction made between thrombolysis and other aspects of acute stroke care

Measuring Change SINAP started with full roll out of GM model in June 2011 GM network fully supported SINAP/SSNAP participation across the city High quality data supporting changed model Provides prospective data from roll out but no retrospective data

How did we measure outcomes pre and post model change? Innovations in major system reconfiguration in England: a study of the effectiveness, acceptability and processes of implementation of different models of stroke care NIHR HS&DR collaborative study between UCL, University of Manchester, King’s Health and University of Cambridge to compare London and Manchester reorganisations with the rest of England: did the change work?

Study details Project funded 1st September 2011 – 31st March 2016 Retrospective study of London and Manchester ‘A’ Contemporaneous study of Manchester ‘B’, and planned/under discussion changes across East of England and Midlands Contemporaneous study of sustainability of London

What did we do? Compared what happened to stroke patients in London and Manchester… before and after reconfiguration… with the average for the rest of England

Research questions What are the key processes and factors influencing the development and implementation of the reconfigurations? To what extent have system changes delivered improvements in clinical processes and outcomes? How do stakeholders (patients/carers, commissioners, staff delivering care) view the changes? Have changes delivered value for money? How is service reconfiguration influenced by the wider context of major structural change in the NHS?

Legend Decision to change Set priorities of change Decision on which model to implement Governance; buy-in Implementation approach/plan Implementation of model Revisions to model and approach in light of ongoing monitoring of outcomes Effectiveness of design Completeness; adherence Change or not: clinical processes Provision of evidence-based care Change or not: clinical outcomes Investigated through qualitative analysis Investigated through quantitative analysis Legend Care provided and impact on outcomes Was change cost-effective?

Implementation and sustainability Decision to change What works at what cost? Controlled before and after design Control = rest of England Clin outcomes: HES/ONS data Clin processes: National audit data (Sentinel/SINAP/SSNAP) Cost data Decision on which model to implement Implementation of model Change or not: clinical processes Implementation and sustainability Governance level: interviews, observations, documentary analysis Service-level: interviews with clinicians, management, patients & carers [incl. with service ‘winners’ and ‘losers’] Change or not: clinical outcomes Was change cost-effective?

Findings: clinical outcomes Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014 Controlled before and after analysis: Greater Manchester, London, Rest of England (control) Risk adjusted mortality and LoS reduced everywhere LoS reduced significantly more in Greater Manchester and London than in the rest of England London mortality reduced significantly more in than in the rest of England – but no equivalent effect in Greater Manchester

Progress: dissemination Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014;349:g4757

Progress: dissemination Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014;349:g4757

Progress: dissemination Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014;349:g4757

Progress: dissemination Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014;349:g4757

How did we do the research? We used HES data for stroke patients admitted between January 2008 and March 2012 We looked at: Mortality from any cause at any location at 3, 30 and 90 days Length of hospital stay

Information from Hospital Episode Statistics database Anonymous information about every patient Diagnosis, age, sex etc Information about deaths from Office for National Statistics

Stroke patients included in the study 258 915 admissions for stroke 17,650 patients in Greater Manchester 33,698 patients in London 207,567 patients in the rest of England living in urban areas

Statistical analysis First step: Calculated expected and actual risk of death at 3, 30 and 90 days, and length of stay adjusting for age, gender, stroke diagnosis, Charlson index, ethnicity, deprivation, rurality These were aggregated to create a dataset of the actual percentage of patients who died and the expected percentage by admitting hospital and quarter Second step: Between-region difference-in-differences adjusting for admitting hospital and time period

Why we used this approach So – does the difference between e.g. London and RoE stay the same following reconfiguration?

Mortality at 3 days

Mortality at 30 days

Mortality at 90 days

Length of stay

Main result: overall Risk-adjusted mortality and length of hospital stay fell in Greater Manchester, London and the rest of England during the study period

Main results: London In London significantly larger absolute reduction in risk-adjusted mortality at 3, 30 and 90 days after admission compared with the rest of England: 3 days: -1.0 percentage points (95% CI, -1.5 to -0.4; P<0.001) 30 days: -1.3% (95% CI, -2.2 to -0.4; P=0.005) 90 days: -1.1% (95% CI, -2.1 to -0.1; P=0.03) The absolute difference represents a relative reduction in mortality of 5% at 90 days, which equates to 96 fewer deaths per year There was a significant reduction in length of hospital stay of -1.4 days (95% CI, -2.3 to -0.5) over and above the reduction seen in the rest of England

Main results: Greater Manchester In Greater Manchester there was no impact on mortality over and above the change seen in the rest of England There was a significant reduction in length of hospital stay by -2.0 days (95% CI, -2.8 to -1.2) We speculate reasons for the non-significant effect on mortality in Greater Manchester were that fewer people received HASU-based care

50 excess stroke deaths a year in Manchester Headline Result 50 excess stroke deaths a year in Manchester

Strengths of study Large national dataset Robust quasi-experimental design

Limitations No information on stroke severity Could not measure impact on quality of life, disability, neurological and functional impairment No information for pre-hospital period No information on cost-effectiveness

Conclusions Centralising stroke care so it is provided in specialist units in a reduced number of hospitals can improve quality of care for patients But important that all stroke patients are taken to specialist units – not just a selection These systems worked in urban areas but they might not work in rural areas where travel times would be too great

Why did mortality not fall in Manchester? Wrong dose: Many acute strokes missing out on specialist acute care because of 4 hour time limit Poor compliance: Confusion over onset time meant even those <4h were often ending up in DGH

How could we have done it better? Did we have the right people involved in the discussions? What’s the PPI role? Political will Can we learn from history? More than just physicians PPI needs to co-design not just agree proposals How do you get everyone on board in a “consensual” NHS? Need evidence to guide system change: learn from our mistakes!

What’s happening now? All change again in GM to London type model from 30 March 2015 Taken 4 years to move from recognition of a problem to implementation Research findings and publicity pushed decision making

Centralised stroke services could save up to 50 patients per year under £2m NHS shake-up Patient quote: “I think it’s fantastic that everyone in the area who has a stroke will now be able to go straight to a specialist centre”. March 2015

Thanks to Greater Manchester Stroke Network Salford Royal Foundation Trust HS&DR study team at UCL, King’s London, University of Manchester especially Naomi Fulop, Steve Morris and Angus Ramsay SSNAP Team at RCP Patients, carers and staff who have contributed to system change and its evaluation