1. Stroke Services Improvement Project

2. Improving Stroke Care in Wales How did this all start? Where are we now? Where are we going?

3. Where did this all start? RCP National Sentinel Audit 2006 Published May 2007 Tony Rudd – Media – ‘Scandalous’ Stroke services in Wales need urgent attention Unacceptably low rates of stroke unit admission More patients in Wales dying or suffering serious disability as a result Audit listed 10 major recommendations

4. Key indicators 1

5. Key Indicators 2

6. RCP (2007) recommended that The Assembly Government, Commissioners, Managers and Clinicians should urgently address the growing divide in quality of stroke care between Wales and the rest of the UK. The highest priority should be given to the development of specialist stroke services, both in hospital (with full provision of stroke units) and the community

7. And then…………… CMO – Report for WMC Presented early June 2007 WSC – Tony Rudd presented the Welsh Audit results mid June 2007 Health Minister meeting end June 2007 Program of Work to be developed

8. Program of Work Identify gaps in service/pathway development March 08 Co-location of beds May 2008 Stroke Units May 2009 Thrombolysis 2010 TIA assessment 2009 Early supported discharge 2011

9. Partnership between NPHS, NLIAH and WCfH Cerilan Rogers, Mark Dickinson, Sarah Jones, Nigel Monaghan Alan Willson, Michelle Price Anne Freeman, Mushtaq Wani Stephen Griffiths Jo Menzies Trish Hughes, Leighton Veale

10. Project Structure Project Board Chaired by Mike Harmer, Deputy CMO Project Management Team Led by Cerilan Rogers, Director NPHS Project Assurance Clinical Reference Group (Welsh Stroke Alliance) Policy Reference Group (Jan Smith, Denise Richards, Sarah Watkins, Owen Crawley)

11. Project Objectives 1.Care Pathway 2.Indicators and Outcomes 3.Gap Analysis 4.Action Plan Development Overseeing of implementation 5.Mechanism for assessing development proposals 6.Service Improvement Collaborative 7.Workforce Development Tool 8.Symptom Awareness Campaign 9.Action Plan to address gaps in risk reduction resources and services

12. All Wales Stroke Services Improvement Collaborative Workstreams Work Stream Objective(s) A (NPHS) 1. Care Pathway; 2. Indicators and Outcomes; 3. Gap Analysis; 4a Action Plan (development); 4b Action Plan (overseeing of implementation); 5 Mechanism for Assessing Development Proposals B (NLIAH) 6. Service Improvement Collaborative C (NLIAH) 7. Workforce Development Tool D (WCfH) 8. Symptom Awareness Campaign E (NPHS) 9. Action Plan to address gaps in resources and services to support risk reduction

14. Welsh Stroke Alliance Thrombolysis and Neuro- Imaging Subgroup Rehabilitation Subgroup Education and Training Subgroup Community Services Subgroup Welsh Association of Stroke Physicians Stroke Nurses Alliance Welsh Association of Physiotherapy in Stroke Specialist Section for Neurological Practitioners- 0T Speech and Language Therapists in Stroke Dietetics Neuro-psychology Stroke Association OPAN Radiology Pathology/Laboratory Services Clinical Physiology Neurology Neuro-rehabilitation Vascular Surgery Cardiac Network Neurosurgery Accident and Emergency Medicine General Practitioners LHB/commissioners Welsh Ambulance Service Patient groups; 1. Stroke Survivors: 2. Carer Vocational Support for Stroke Survivors of working age Social Services Psychiatry/Psychogeriatrics Palliative Care Pharmacy/therapeutics NPHS NLIAH WCfH WAG Pathways Development and Map of Medicine

15. Progress to Date

16. Workstream A Care pathway, indicators and outcomes, gap analysis Deadline 30 March 2008 Team included representatives of all key professions involved in stroke care 102 page report produced – on target – just!

17. Workstream A Care pathway Team aimed to identify and specify pathways to cover care from symptom onset to maximum possible recovery/death Drew on info from variety of sources: NHS III (2006), Map of Medicine, RCP Audit (2006), RCP Guidelines(2004) Acute emergency and in-hospital care, pre- hospital emergency care, continuing care

18. Review of Welsh Stroke ICPs SSIG, 2007 – Stroke ICPs in 11/20 Availability does not guarantee use Most ICPs begin at admission to hospital/a ‘stroke bed’ and end at discharge from secondary care Care pathways are more likely to be used where there are co-located beds Main barriers to use:- Lack of enthusiasm and motivation associated with a lack of infrastructure Exceptions North West Wales NHS Trust Bro Morgannwg

19. Adopted Map of Medicine plus RCP pre-hospital Palliative care/End of life

20. Gap Analysis RCP (2007) – Results of the 2006 National Sentinel Audit Stroke Special Interest Group (SSIG, 2007) – ‘Review of secondary care stroke services in Wales’, carried out in 2006 BASP service specification guidance/NHS III DH workforce guidance Review of many Welsh stroke care pathways

21. Gap Analysis - Conclusions Gaps in service specification are considerable Workforce issues are not dissimilar to the rest of the UK Care Pathway coverage is limited and pathways are rarely used

22. Work stream B NLIAH Service Improvement Collaborative  Identifying bundles of care that are linked to quality improvements  Identifying sources of information to allow stroke teams to monitor their own progress

24. Collaborative program

25. Workstream C Workforce development – NLIAH Workshop 10 th October 2008 Identifying skills needed to deliver care Cross profession care Role Redesign

26. Local HR must put stroke as priority in the workforce submissions for next March New ‘whole system workforce plan’ for next year – new way of workforce planning T and D – essential element Need to link in with the work of the UK Stroke Training Forum –Welsh representation Steering group 4 subgroups (Raising Awareness and Information, Time is Brain, Life after Stroke, Implementation) Draft Dec 08, Consultation Jan – Mar 09, Final framework June 09

27. Work stream D Symptom Awareness WCfH working with Stroke Association Awareness Raising Project Communication

28. Awareness Raising Campaign scoping membership to the group preparing bid for a budget for the campaign – submit Dec 2008 developing two communication strategies for the awareness raising campaign: the service, the public liaising with DoH about their stroke awareness campaign launching campaign March 2009

29. Project communications The SSIP intranet site live since 8 October (nww.stroke.wales.nhs.uk) Feedback on the site has been positive The site is undergoing further developments - namely building a presence for the Collaborative and the development tools (both NLIAH) A SSIP newsletter will be developed and disseminated through contacts in Late Nov/early Dec

30. Work stream E – Risk Reduction Work stream lead has been appointed - Fiona Kinghorn Team being established Will look at primary prevention/health promotion

31. Next steps Profession specific audits Interim RCP audit Spring 2009 Monitoring of progress towards AOF Need to set AOF targets for 2009/10 Intelligent Targets Group SIC work over next 8 - 9 months Innovative projects Autumn workshops

32. Regional Networks/Planning Forums Development SE Wales Mid and West Wales N Wales No funding available to support at present How do they link in with the SSIP?

33. Workstream A Stroke Services Improvement Programme Mid and West Stroke Services Planning Forum Three Counties Stroke Services Planning Group Abertawe Bro Morgannwg Stroke Services Planning Forum Powys Stroke Services Planning Forum North Stroke Services Planning Forum North West Wales Stroke Services Planning Forum North Wales Central Stroke Services Planning Forum North East Wales Stroke Services Planning Forum South Stroke Services Planning Forum Cardiff and Vale Stroke Services Planning Forum Cwm Taf Stroke Services Planning Forum Gwent Healthcare Stroke Services Planning Group