1. Sentinel Stroke National Audit Programme (SSNAP) Post-acute organisational audit Phase 1: Post-acute stroke service commissioning audit Based on services commissioned on 1 December 2014

2. Participation *Betsi Cadwaladr University Health Board was the only LHB in Wales which did not participate in the audit. Audit participationNumber Participation rate England Clinical Commissioning Groups (CCGs)211211 (100%) Wales Local Health Boards (LHBs)*76 (86%) Northern Ireland Local Commissioning Groups (LCGs)55 (100%) Total223222 (99.6%)

3. Location of participants 5 Local Commissioning Groups (LCGS) Northern Ireland 7 Local Health Boards (LHBs), Wales (1 non participant) 211 Clinical Commissioning Groups (CCGs), England

4. Commissioner (Health Board) characteristics Commissioner (Local Health Board) characteristics (Q2.1- Q2.4) n (%) N = 222 My organisation (Yes/No) Clinical leadership Clinical lead for st r oke in the organisation 172 (77%) Requirement of providers to participate in SSNAP clinical audit Require participation of their acute providers in SSNAP186 (84%) Require participation of their post-acute providers in SSNAP162 (73%) Governance arrangements Commissioners who have a stroke commissioning group e.g. Programme Board for Stroke 125 (56%)

5. Commissioner (Health Board) characteristics Jointly commission with social care (Q2.5) n (%) N = 222 My organisation (Yes/No) Commissioners who jointly commission stroke services with social care. Of these: 83 (37%) commissioned 1 service with social care47/83 (57%) commissioned 2 services with social care22/83 (27%) commissioned 3 services with social care9/83 (11%) commissioned 4 services with social care4/83 (5%) commissioned 5 or more services with social care1/83 (1%) Other community based stroke services (Q2.7) n (%) N = 222 My organisation (Yes/No) CCG/LHB/LCG who have other community based stroke services 56 (25%) Of these:28/56 (50%) named 1 other service 22/56 (39%) named 2 other services 5/56 (9%) named 3 other services 1/56 (2%) named 4 other services

6. Commissioner (Health Board) characteristics Commissioning as part of a consortium (Formal joint commissioning) (Q2.6) n (%) N = 222 My organisation (Yes/No) Organisations which commission as part of a consortium of CCGs/LHBs/LCGs 87 (39%) Of these:31/87 (36%) with one other commissioner 27/87 (31%) with two other commissioners 16/87 (18%) with three other commissioners 3/87 (3%) with four other commissioners 10/87 (12%) with five or more other commissioners

7. Commissioner (Health Board) characteristics Number of participants commissioning each service function CCGs/LHBs/LCGs My organisation (Yes/No) Service function n (%) of CCGs/LHBs/LCGs commissioning the service N = 222 Post-acute inpatient care141 (64%) Outpatient care99 (45%) Early Support Discharge (ESD) team180 (81%) Community Rehabilitation Team (CRT)185 (83%) Domiciliary team (not ESD or CRT)83 (37%) 6 month assessment provider120 (54%) Vocational rehabilitation59 (27%) Psychological support122 (55%) Physiotherapy team168 (76%) Occupational therapy163 (73%) Speech and language therapy173 (78%) Family and carer support147 (66%)

8. All service characteristics The audit identified 716 post-acute stroke services which were commissioned by CCGs, LHBs and LCGs. Each of these services could carry one or more of the following service functions. Service functionNumber Stroke specific services n (%) Generic services n (%) Post-acute inpatient care194170 (88%)24 (12%) Outpatient care154123 (80%)31 (20%) Early Support Discharge (ESD) team207191 (92%)16 (8%) Community Rehabilitation Team (CRT)255202 (79%)53 (21%) Domiciliary team (not ESD or CRT)11083 (75%)27 (25%) 6 month assessment provider139129 (93%)10 (7%) Vocational rehabilitation7063 (90%)7 (10%) Psychological support169150 (89%)19 (11%) Physiotherapy team276224 (81%)52 (19%) Occupational therapy254212 (83%)42 (17%) Speech and language therapy270222 (82%)48 (18%) Family and carer support220187 (85%)33 (15%)

9. All service characteristics * More than one location could be ticked per service Stroke specific services n (%) of all services identified in the audit N = 716 My organisation (n (%) of stroke specific/generic services) Stroke specific561 (78%) Non-stroke specific155 (22%) Location of service* n (%) of all services identified in the audit My organisation (n (%) of services based in each location) Community hospital234 (33%) Patients home477 (67%) Care home235 (33%) ‘Other’ inpatient133 (19%) ‘Other’ outpatient251 (35%)

10. All service characteristics Where services are commissioned from n (%) of all services identified in the audit N = 716 My organisation (n (%) of your service commissioned from each location) Acute trust278 (39%) Community trust262 (37%) Third Sector Provider143 (20%) Private Sector Provider5 (1%) Local Authority1 (<1%) Health Board16 (2%) CCG and Local Authority1 (<1%) Acute and Community trust6 (1%) Third Sector Provider and Council1 (<1%) Health Board and Social Services3 (<1%)

11. All service characteristics: Distribution Commissioners have been assigned a colour based on how many service functions they commission at least one of: My organisation is commissioning: (ENTER NUMBER BETWEEN 1-12) service functions

12. 1. Post-acute inpatient services Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Post-acute inpatient care service Total number of inpatient post- acute services commissioned N = 194 My organisation N n (%) Total194 Stroke specific170 (88%) Non-stroke specific24 (12%) Location of service* n (%) N = 194 My organisation n (%) Community hospital116 (60%) Patients/Carers home88 (45%) Care home56 (29%) ‘Other’ inpatient setting80 (41%) ‘Other’ outpatient setting57 (29%)

13. 1. Post-acute inpatient services Service Details Commissioned from n (%) N = 194 My organisation n (%) Acute trust105 (54%) Community Trust75 (39%) Third sector provider7 (4%) Private sector provider2 (1%) Local Authority1 (1%) Health Board2 (1%) CCG and Local Authority0 (0%) Acute and community trust2 (1%) Third Sector Provider and Council0 (0%) Health Board and Social Services0 (0%)

14. 1. Post-acute inpatient services

15. 2. Outpatient services Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Outpatient care services Total number of outpatient services commissioned N = 154 My organisation N n (%) Total154 Stroke specific123 (80%) Non-stroke specific31 (20%) Location of service* n (%) N = 154 My organisation n (%) Community hospital67 (44%) Patients/Carers home84 (55%) Care home56 (36%) ‘Other’ inpatient setting38 (25%) ‘Other’ outpatient setting96 (62%)

16. 2. Outpatient services Service Details Commissioned from n (%) N = 154 My organisation n (%) Acute trust75 (49%) Community Trust64 (42%) Third sector provider4 (3%) Private sector provider0 (0%) Local Authority0 (0%) Health Board8 (5%) CCG and Local Authority0 (0%) Acute and community trust3 (2%) Third Sector Provider and Council0 (0%) Health Board and Social Services0 (0%)

17. 2. Outpatient services

18. 3. Early Supported Discharge (ESD) Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Early Supported Discharge (ESD) Total number of services commissioned N = 207 My organisation N n (%) Total207 Stroke specific191 (92%) Non-stroke specific16 (8%) Location of service* n (%) N = 207 My organisation n (%) Community hospital69 (33%) Patients/Carers home191 (92%) Care home108 (52%) ‘Other’ inpatient setting45 (22%) ‘Other’ outpatient setting58 (28%)

19. 3. Early Supported Discharge (ESD) Service Details Commissioned from n (%) N = 207 My organisation n (%) Acute trust103 (50%) Community Trust95 (46%) Third sector provider2 (1%) Private sector provider2 (1%) Local Authority0 (0%) Health Board0 (0%) CCG and Local Authority0 (0%) Acute and community trust5 (2%) Third Sector Provider and Council0 (0%) Health Board and Social Services0 (0%)

20. 3. Early Supported Discharge

21. 4. Community Rehabilitation Team Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Community Rehabilitation Team Total number of services commissioned N = 255 My organisation n (%) Total255 Stroke specific202 (79%) Non-stroke specific53 (21%) Location of service* n (%) N = 255 My organisation n (%) Community hospital109 (43%) Patients/Carers home213 (84%) Care home126 (49%) ‘Other’ inpatient setting47 (18%) ‘Other’ outpatient setting92 (36%)

22. 4. Community Rehabilitation Service Details Commissioned from n (%) N = 255 My organisation N n (%) Acute trust96 (38%) Community Trust132 (52%) Third sector provider14 (5%) Private sector provider2 (1%) Local Authority0 (0%) Health Board5 (2%) CCG and Local Authority0 (0%) Acute and community trust6 (2%) Third Sector Provider and Council0 (0%) Health Board and Social Services0 (0%)

23. 4. Community Rehabilitation Team

24. 5. Domiciliary only (not ESD/CRT) Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Domiciliary teams Total number of services commissioned N = 110 My organisation N n (%) Total110 Stroke specific83 (75%) Non-stroke specific27 (25%) Location of service* n (%) N = 110 My organisation n (%) Community hospital43 (39%) Patients/Carers home102 (93%) Care home70 (64%) ‘Other’ inpatient setting18 (16%) ‘Other’ outpatient setting46 (42%)

25. 5. Domiciliary only (not ESD/CRT) Service Details Commissioned from n (%) N = 110 My organisation N n (%) Acute trust41 (37%) Community Trust55 (50%) Third sector provider5 (5%) Private sector provider1 (1%) Local Authority1 (1%) Health Board1 (1%) CCG and Local Authority0 (0%) Acute and community trust3 (3%) Third Sector Provider and Council0 (0%) Health Board and Social Services3 (3%)

26. 5. Domiciliary only (not ESD/CRT)

27. 6. Vocational rehabilitation services Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Vocational rehabilitation services Total number of services commissioned N = 70 My organisation N n (%) Total70 Stroke specific63 (90%) Non-stroke specific7 (10%) Location of service* n (%) N = 70 My organisation n (%) Community hospital35 (50%) Patients/Carers home60 (86%) Care home43 (61%) ‘Other’ inpatient setting18 (26%) ‘Other’ outpatient setting34 (49%)

28. 6. Vocational rehabilitation services Service Details Commissioned from n (%) N = 70 My organisation N n (%) Acute trust33 (47%) Community Trust26 (37%) Third sector provider9 (13%) Private sector provider1 (1%) Local Authority0 (0%) Health Board0 (0%) CCG and Local Authority0 (0%) Acute and community trust1 (1%) Third Sector Provider and Council0 (0%) Health Board and Social Services0 (0%)

29. 6. Vocational rehabilitation services

30. 7. Psychological Support providers Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Psychological support services Total number of services commissioned N = 169 My organisation N n (%) Total169 Stroke specific150 (89%) Non-stroke specific19 (11%) Location of service* n (%) N = 169 My organisation n (%) Community hospital62 (37%) Patients/Carers home120 (71%) Care home78 (46%) ‘Other’ inpatient setting39 (23%) ‘Other’ outpatient setting79 (47%)

31. 7. Psychological Support providers Service Details Commissioned from n (%) N = 169 My organisation n (%) Acute trust73 (43%) Community Trust73 (43%) Third sector provider19 (11%) Private sector provider1 (1%) CCG and Local Authority0 (0%) Both acute and community trust1 (1%) Local Authority0 (0%) Third Sector Provider and Community Hospital0 (0%) Health Board2 (1%) Health Board and Social Services0 (0%)

32. 7. Psychological Support providers

33. 8. Six Month Assessment Providers Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Six month assessment providers Total number of services commissioned N = 139 My organisation N n (%) Total139 Stroke specific129 (93%) Non-stroke specific10 (7%) Location of service* n (%) N = 139 My organisation n (%) Community hospital47 (34%) Patients/Carers home115 (83%) Care home71 (51%) ‘Other’ inpatient setting33 (24%) ‘Other’ outpatient setting63 (45%)

34. 8. Six Month Assessment Providers Service Details Commissioned from n (%) N = 139 My organisation n (%) Acute trust56 (40%) Community Trust58 (42%) Third sector provider17 (12%) Private sector provider1 (1%) Local Authority0 (0%) Health Board1 (1%) CCG and Local Authority0 (0%) Acute and community trust6 (4%) Third Sector Provider and Council0 (0%) Health Board and Social Services0 (0%)

35. 8. Six Month Assessment Providers

36. 9. Physiotherapy services (Single Discipline) Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Physiotherapy services Total number of services commissioned N = 276 My organisation N n (%) Total276 Stroke specific224 (81%) Non-stroke specific52 (19%) Location of service* n (%) N = 276 My organisation n (%) Community hospital109 (39%) Patients/Carers home186 (67%) Care home116 (42%) ‘Other’ inpatient setting61 (22%) ‘Other’ outpatient setting108 (39%)

37. 9. Physiotherapy services (Single Discipline) Service Details Commissioned from n (%) N = 276 My organisation n (%) Acute trust127 (46%) Community Trust124 (45%) Third sector provider7 (3%) Private sector provider4 (1%) Local Authority0 (0%) Health Board8 (3%) CCG and Local Authority0 (%) Acute and community trust6 (2%) Third Sector Provider and Council0 (0%) Health Board and Social Services0 (0%)

38. 9. Physiotherapy services (Single Discipline)

39. 10. Occupational Therapy services (Single Discipline) Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Occupational therapy services Total number of services commissioned N = 254 My organisation N n (%) Total254 Stroke specific212 (83%) Non-stroke specific42 (17%) Location of service* n (%) N = 254 My organisation n (%) Community hospital100 (39%) Patients/Carers home177 (70%) Care home107 (42%) ‘Other’ inpatient setting59 (23%) ‘Other’ outpatient setting90 (35%)

40. 10. Occupational Therapy services (Single Discipline) Service Details Commissioned from n (%) N = 254 My organisation n (%) Acute trust116 (46%) Community Trust116 (46%) Third sector provider5 (2%) Private sector provider4 (2%) Local Authority0 (0%) Health Board7 (3%) CCG and Local Authority0 (0%) Both acute and community trust6 (2%) Third Sector Provider and Council0 (0%) Health Board and Social Services0 (0%)

41. 10. Occupational Therapy services (Single Discipline)

42. 11. Speech and Language Therapy services (Single Discipline) Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Speech and Language therapy services Total number of services commissioned N = 270 My organisation N n (%) Total270 Stroke specific222 (82%) Non-stroke specific48 (18%) Location of service* n (%) N = 270 My organisation n (%) Community hospital112 (41%) Patients/Carers home193 (71%) Care home119 (44%) ‘Other’ inpatient setting56 (21%) ‘Other’ outpatient setting102 (38%)

43. 11. Speech and Language Therapy services (Single Discipline) Service Details Commissioned from n (%) N = 270 My organisation n (%) Acute trust124 (46%) Community Trust111 (41%) Third sector provider17 (6%) Private sector provider4 (1%) Local Authority0 (0%) Health Board8 (3%) CCG and Local Authority0 (0%) Third Sector Provider and Council0 (0%) Acute and community trust6 (2%) Health Board and Social Services0 (0%)

44. 11. Speech and Language Therapy services (Single Discipline)

45. 12. Family and Carer Support service Service Details Stroke specific Location of service * More than one service location could be selected per post-acute team Family and carer support services Total number of services commissioned N = 220 My organisation N n (%) Total220 Stroke specific187 (85%) Non-stroke specific33 (15%) Location of service* n (%) N = 220 My organisation n (%) Community hospital53 (24%) Patients/Carers home173 (79%) Care home77 (35%) ‘Other’ inpatient setting48 (22%) ‘Other’ outpatient setting98 (45%)

46. 12. Family and Carer Support service Service Details Commissioned from n (%) N = 220 My organisation n (%) Acute trust39 (18%) Community Trust47 (21%) Third sector provider126 (57%) Private sector provider0 (0%) Local Authority0 (0%) Health Board0 (0%) CCG and Local Authority1 (<1%) Acute and community trust6 (3%) Third sector provider and Local Authority1 (<1%)

47. 12. Family and Carer Support service

48. Main findings 1. Participation in the SSNAP inaugural organisational audit of post- acute stroke care commissioning has been excellent with 99.6% of responsible bodies providing data. 2. There is widespread variation, both by region and country, in the types of post-acute stroke care currently being provided. 3. The lack of appropriate services being commissioned raises concerns that care home residents may be being denied access to stroke rehabilitation services in some areas.

49. Recommendations 1.All commissioners are recommended to draw up consistent service specifications with their provider organisations and include participation in SSNAP clinical audit as a requirement. 2.All commissioners are recommended to support a 6 month post stroke assessment for all patients as recommended in the National Stroke Strategy and required by the CCG Outcome Indication Set (CCG OIS). 3.All commissioners should be commissioning stroke-specific Early Supported Discharge (ESD). 4.All commissioners are recommended to consider joint health and social care collaboration to address major shortfalls in provision of emotional and psychological support after stroke and vocational rehabilitation. 5.Commissioners are recommended to participate with providers in using SSNAP data as part of a programme of managed quality service improvement.