1. Professor Roger Boyle March 2009
The National Stroke Strategy - Direction of travel and quality markers for stroke rehabilitation service development in England
Professor Roger Boyle
March 2009

2. Why stroke matters Burden of disease Costs
>110,000 strokes each year (rule of thirds)
>20,000 Transient Ischaemic Attacks (TIAs or ‘mini strokes’)
At least 300,000 living with significant post-stroke disability (single largest cause of adult disability)
Third most common cause of death
1 in 4 people affected are under 65
People of South Asian and African Caribbean origin at significantly higher risk
Costs
£2.8 billion direct care costs
£1.8 billion due to lost productivity and disability
£2.4 billion informal care costs
2.6 million bed days per year

3. Positioning Ministers (particularly Secretary of State) NHS Board
NHS Chief Executive
Directors of Commissioning and Performance
Chief Executives and medical directors of the Ambulance Trusts
All Party Parliamentary Group
Stakeholders
Next Stage Review – High Quality Care for All

6. Working together Hyper-acute stroke service
24-hour cover by stroke specialists
24-hour radiological support
Neuroscience centre
Likely to benefit from interventions
Link to neighbouring network
Transfer to acute stroke unit after hours
Likely to benefit from specialist care
Acute/Rehabilitation Unit Combined
Acute Stroke Unit
Early Supported Discharge Teams
Stroke Rehabilitation Units
Community Stroke Teams

7. 11,000 people suffer a stroke each year
In London stroke is:
Second commonest cause of death
The commonest cause of disability
11,000 people suffer a stroke each year
One person every hour
One in six die

8. Dr Chris Streather
Rachel Tyndall

9. Supporting the strategy
Mandated for every PCT within the Operating Framework
‘Tier 1’ priority
Central finance over 3 years (£105 million)
Training (£16 m)
Raising awareness (£12 m)
Developing innovative practice (£77 m)
£32 m to the NHS
£45 m to social care

10. Implementation agenda
Money to SHAs (circa £2.4 million)
Money to local authorities (circa £100k each year for three years)
Problem solving small grants fund
Awareness campaign
NHS staff and the public
National Training Forum (30 doctor training places)
Communication plan
Evaluation
Development of the stroke networks and the stroke improvement programme

13. Publish quality performance Recognise and reward quality
The Quality Framework in “High Quality Care for All”
Bring clarity
to quality
Measure quality
Publish quality performance
Recognise and reward quality
Raise standards
Safeguard quality
Stay
ahead
Quality Standards
NHS Evidence
Metrics – local, national, international
QOF indicator development
Clinical dashboards
Quality accounts
NHS Choices
International measures and NQB report
CQC role
CQUIN
Multi-year and best practice tariff work
CEAs
QOF
Clinical voice at every level inc NQB
SHAs – Medical Directors and CABs
PCTs – WCC clinical engagement
NICE fellowship programme
CQC role
Regulation extended to primary care
NQB
SHA duty to innovate
Innovation funds and prizes
AHSCs
HIECs 13

14. Vital Signs
% stroke patients who spend 90% of their time in hospital in a stroke unit
% of high risk TIA patients who are treated within 24 hours

15. Audit as a lever for change
Sentinel Audit sets the standard
Expansion to a ‘MINAP’ style process for acute care planned
Expansion for extension into primary and community care under consideration

17. Total Organisational Score – 2006 & 2008 – Average Score for Trust/Hospital Stroke Services by SHA (National Sentinel Audit of Stoke 2008, RCP London)

19. Life after stroke - Key facts
At present only around half of individuals who have experienced stroke receive the rehabilitation to meet their needs in the first six months after discharge from hospital, falling to around one fifth in the following six months

20. Life after stroke – Key facts
Three- quarters of younger individuals want to return to work
One third of individuals develop depression
One third of individuals experience communication difficulties
About one third of individuals will die of their stroke – not immediately but within three months

21. QM 10 High-quality specialist rehabilitation
People who have had strokes access high-quality rehabilitation and, with their carer, receive support from stroke-skilled services as soon as possible after they have had a stroke, available in hospital, immediately after transfer from hospital and for as long as they need it.

22. Multi-faceted stroke rehabilitation
Mobility and movement
Communication
Everyday activities, dressing, washing, meal preparation
Depression and distress
Swallowing
Nutrition
Cognitive difficulties
Visual disturbances
Continence
Relationships and sex

23. QM11 End-of-life care
People who are not likely to recover from their stroke receive care at the end of their lives which takes account of their needs and choices, and is delivered by a workforce with appropriate skills and experience in all care settings

24. QM 12 Seamless transfer of care
A workable, clear discharge plan that has fully involved the individual (and their family where appropriate) and responded to the individual's particular circumstances and aspirations is developed by health and social care services, together with other services such as transport and housing.

25. QM 13 Long-term care and support
A range of services are in place and easily accessible to support the individual long-term needs of individuals and their carers.

26. QM 14 Assessment and review
People who had strokes and their carers, either living at home or in care homes, are offered a review from primary care services of their health anc social care status and secondary prevention needs, typically within six weeks of discharge home or to a care home and again six months after leaving hospital.
This is followed by an annual health and social care check, which facilitates a clear pathway back to further specialist review, advice, information, support and rehabilitation where required

27. QMs 15 and 16 Participation in community life Return to work
People who have had a stroke, and their carers, are enabled to live a full life in the community
Return to work
People who have had a stroke, and their carers, are enabled to participate in paid supported and voluntary employment

29. Sentinel Audit 2008

30. Team meetings

31. Patient access to management plan
Variable but improving access to informative literature on the wards

32. Knowledge gaps State of community-based services
Availablility
Quality
Extent of partnership working between health and social care
Patient and carer experience beyond hospital discharge

33. Conclusions Plenty still to do
Plenty for everyone whatever the setting
Challenges are considerable beyond the acute phase