1. Centralising stroke services in Greater Manchester - lessons learnt
Sarah Rickard, Network Manager
@GMStrokeODN

2. 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 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 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

3. 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.

4. Pathway strokes

5. 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.

6. 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

7. 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

8. 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)

9. 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

10. 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

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

12. 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

13. 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

14.
@GMStrokeODN