1. Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business support to London’s NHS. Healthcare for London’s stroke rehabilitation commissioning guidance: an introduction Dr Tony Rudd London Stroke Clinical Director

2. Lecture outline Background Brief review of evidence Key elements for a comprehensive stroke service

3. National Stroke Strategy, DH, 2007 “For those who have had a stroke and their relatives and carers, whether at home or in care homes, to achieve a good quality of life and maximise independence, well-being and choices”.

4. Approximately 54 people will have a stroke. 6000 per year with lasting disability. Everyday in London…

5. Stroke pathway Learning to live with a disability Living with a disability Quality information for users and carers Quality information for professionals A workforce skilled in working with people with stroke Acute phase recovery Access to leisure, employment, other opportunities Rapid detection Thromb -olysis Stroke Unit care Tailored Community rehab Self care/ Peer support Sign posting Primary Prevention Preventing a further stroke or TIA

8. Chapters in rehabilitation commissioning guide Inpatient rehabilitation Community rehabilitation Early supported discharge Support structures Regular review

9. Stroke Unit care Every PCT commissions inpatient rehabilitation that is available for all stroke patients. This should start as soon as possible and continue for as long as required. This service must meet all of the performance standards.

12. 20 trials, n=2686 Significant effect on activities of daily living in first 6 months after stroke No ceiling effect for therapeutic intensity 16 additional hours Effects of augmented exercise therapy time after stroke Kwakkel et al, 2004

13. Community rehabilitation Every PCT should commission a community rehabilitation service for stroke patients, delivered by staff with stroke specialist skills. Service configuration should be locally determined and the service must meet all of the performance standards.

14. Outpatient Service Trialists Personal ADL

15. Outpatient Service Trialists Extended ADL

16. –47% of equipment never used (Gitlin et al, 1996) –Lack of information on availability (Mann et al, 1995) –Stroke patients using more equipment / environmental adaptations and significantly more independent at one year after stroke (Logan et al, 1995) Equipment and environmental adaptations

17. Simple, inexpensive AND effective

18. Community rehabilitation Key gap: A lack of timely access to a community rehabilitation team can lead to delays within rehabilitation causing a loss of improvements gained during rehabilitation. Priority for development: Every PCT should ensure access to a responsive stroke specialist community rehabilitation service.

19. Early supported discharge (ESD) Every PCT should commission an early supported discharge service for people who would benefit. This service should include staff with specialist stroke skills and must meet all of the performance standards.

20. Early supported discharge services Eight trials (data from seven) from UK, Norway, Sweden, Australia, Canada, USA Heterogeneity of services Average reduction in hospital length of stay by 9 days (95% CI 5-15; P<0.0001) Apparent reductions (P<0.01) in death/ institutional care and death/dependency Modest reduction in costs? ESD trialists (2001)

22. Early supported discharge services Not applicable to all stroke patients Can accelerate discharge home Appear to improve subsequent recovery Best results with ESD services coordinated and provided by a multidisciplinary rehabilitation team ESD trialists (2001)

23. Early supported discharge Key gap: Many London hospitals do not have access to ESD; ESD services that do exist may operate in isolation without a fully developed community stroke rehabilitation service, resulting in poor exit strategies from the rehabilitation pathway. Priority for development: An ESD service must be seen as an addition to a community stroke rehabilitation service. An ESD service should be appropriately resourced to offer the same intensity of rehabilitation as an inpatient stroke service.

24. Support services Everyone who has had a stroke, and their carers, should have: 1.A key support worker such as a family support worker or community matron to provide: navigation and advocacy; a link with the inpatient and community rehabilitation teams and other care providers. 2.A designated person from health or social care who is the key contact for the patient and carer whilst in each setting, such as a therapist, social worker, or healthcare assistant.

25. Support services Key gap: There is a lack of collaboration between health and social care provided services leading to confusion for patients, families, carers and staff regarding access to services and support. Priority for development: Every PCT should work collaboratively to develop support roles that cover the whole stroke pathway in order for patients, families, carers and staff to have access to services and support.

26. Regular review For the first 12 months following stroke, all people who have had a stroke and their carers should have a regular review and assessment of ongoing medical, social and emotional needs as both an inpatient and in the community.

27. Regular review Key gap: There is no specific follow up programme in place for stroke patients. Priority for development: Every PCT should ensure participation of all services along the pathway, including GPs and social care, with respect to ongoing management.