1. Reorganisation of Stroke Services in Greater Manchester 2006-15
challenges and opportunities in providing a centralised service
Professor Pippa Tyrrell

2. SINAP and SSNAP Reports
15 years of policy making…………
SINAP and SSNAP Reports
2015
2000

3. The Ambition:
That every citizen of Greater Manchester presenting with stroke/TIA symptoms shall have equal access to a fully integrated, evidence-based hyper-acute and acute specialist stroke care pathway

4. The Plan: 2010
Positive FAST test within 24 hours to stroke centre

5. Stroke care before 2010 Suspected stroke Local A&E Stroke unit or ward
Geographic variation between centres
Some providing thrombolysis some not
Suspected stroke
Local A&E
Stroke unit or ward
Very different results on RCP Sentinel Audit, inequity of service across GM
Emphasise variability of stroke services pre-reconfiguration
Key contrast: in London, all patients go to a HASU for care, whereas in Manchester, only patients presenting within 4h
GM: only patients presenting within 4 hours of stroke taken to CSC/PSC; otherwise taken to nearest DSC
London: ALL go to HASU (24/7), then after 72 hours transferred to the community or to an SU near to home
Before
12 stroke services
30 stroke services
After
1 CSC, 2 PSCs, 11 DSCs
8 HASUs, 24 SUs; 5 services closed
Community
rehab

6. Proposal for stroke care after the changes
Suspected stroke
1 Comprehensive Stroke Centre
24/7
Hyper Acute Stroke Unit
Stroke Unit
2 Primary Stroke Centres
7-7 M-F
Emphasise variability of stroke services pre-reconfiguration
Key contrast: in London, all patients go to a HASU for care, whereas in Manchester, only patients presenting within 4h
GM: only patients presenting within 4 hours of stroke taken to CSC/PSC; otherwise taken to nearest DSC
London: ALL go to HASU (24/7), then after 72 hours transferred to the community or to an SU near to home
Before
12 stroke services
30 stroke services
After
1 CSC, 2 PSCs, 11 DSCs
8 HASUs, 24 SUs; 5 services closed
Community
rehab
This is effectively the model that London adopted

7. What actually happened: Stroke care in Manchester after the changes
Suspected stroke
Under
4 hrs
Over
4 hrs
1 FT CE refused to cooperate with changes unless 24hour changed to 4 hour: revenue concerns
Comprehensive Stroke Centre
Primary Stroke Centres
District Stroke Centres
Emphasise variability of stroke services pre-reconfiguration
Key contrast: in London, all patients go to a HASU for care, whereas in Manchester, only patients presenting within 4h
GM: only patients presenting within 4 hours of stroke taken to CSC/PSC; otherwise taken to nearest DSC
London: ALL go to HASU (24/7), then after 72 hours transferred to the community or to an SU near to home
Before
12 stroke services
30 stroke services
After
1 CSC, 2 PSCs, 11 DSCs
8 HASUs, 24 SUs; 5 services closed
Community
rehab

8. What worked? Detailed pathway mapping Paramedic engagement
Clinician and PPI engagement
Ambition to change and improve
Clear about “what”
Not so clear about “how”

9. Pre SINAP/SSNAP data was inaccurate, confusing and mostly wrong!
What was difficult?
Calculating the numbers pre SINAP/SSNAP!
Pre SINAP/SSNAP data was inaccurate, confusing and mostly wrong!

10. What was difficult? Last minute model change caused confusion
4 hour cut off difficult for paramedics
Model dependent on onset time
Distinction made between thrombolysis and other aspects of acute stroke care

11. Measuring Change
SINAP started with full roll out of GM model in June 2011
GM network fully supported SINAP/SSNAP participation across the city
High quality data supporting changed model
Provides prospective data from roll out but no retrospective data

13. How did we measure outcomes pre and post model change?
Innovations in major system reconfiguration in England: a study of the effectiveness, acceptability and processes of implementation of different models of stroke care
NIHR HS&DR collaborative study between UCL, University of Manchester, King’s Health and University of Cambridge to compare London and Manchester reorganisations with the rest of England: did the change work?

14. Study details Project funded 1st September 2011 – 31st March 2016
Retrospective study of London and Manchester ‘A’
Contemporaneous study of Manchester ‘B’, and planned/under discussion changes across East of England and Midlands
Contemporaneous study of sustainability of London

15. What did we do?
Compared what happened to stroke patients in London and Manchester…
before and after reconfiguration…
with the average for the rest of England

16. Research questions
What are the key processes and factors influencing the development and implementation of the reconfigurations?
To what extent have system changes delivered improvements in clinical processes and outcomes?
How do stakeholders (patients/carers, commissioners, staff delivering care) view the changes?
Have changes delivered value for money?
How is service reconfiguration influenced by the wider context of major structural change in the NHS?

17. Legend Decision to change Set priorities of change
Decision on which model to implement
Governance; buy-in
Implementation approach/plan
Implementation of model
Revisions to model and approach in light of ongoing monitoring of outcomes
Effectiveness of design
Completeness; adherence
Change or not:
clinical processes
Provision of evidence-based care
Change or not:
clinical outcomes
Investigated through qualitative analysis
Investigated through quantitative analysis
Legend
Care provided and impact on outcomes
Was change
cost-effective?

18. Implementation and sustainability
Decision to change
What works at what cost?
Controlled before and after design
Control = rest of England
Clin outcomes: HES/ONS data
Clin processes: National audit data (Sentinel/SINAP/SSNAP)
Cost data
Decision on which model to implement
Implementation of model
Change or not:
clinical processes
Implementation and sustainability
Governance level: interviews, observations, documentary analysis
Service-level: interviews with clinicians, management, patients & carers
[incl. with service ‘winners’ and ‘losers’]
Change or not:
clinical outcomes
Was change
cost-effective?

19. Findings: clinical outcomes
Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014
Controlled before and after analysis: Greater Manchester, London, Rest of England (control)
Risk adjusted mortality and LoS reduced everywhere
LoS reduced significantly more in Greater Manchester and London than in the rest of England
London mortality reduced significantly more in than in the rest of England – but no equivalent effect in Greater Manchester

20. Progress: dissemination
Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014;349:g4757

21. Progress: dissemination
Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014;349:g4757

22. Progress: dissemination
Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014;349:g4757

23. Progress: dissemination
Morris et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014;349:g4757

24. How did we do the research?
We used HES data for stroke patients admitted between January 2008 and March 2012
We looked at:
Mortality from any cause at any location at 3, 30 and 90 days
Length of hospital stay

25. Information from Hospital Episode Statistics database
Anonymous information about every patient
Diagnosis, age, sex etc
Information about deaths from Office for National Statistics

26. Stroke patients included in the study
admissions for stroke
17,650 patients in Greater Manchester
33,698 patients in London
207,567 patients in the rest of England living in urban areas

27. Statistical analysis First step:
Calculated expected and actual risk of death at 3, 30 and 90 days, and length of stay adjusting for age, gender, stroke diagnosis, Charlson index, ethnicity, deprivation, rurality
These were aggregated to create a dataset of the actual percentage of patients who died and the expected percentage by admitting hospital and quarter
Second step:
Between-region difference-in-differences adjusting for admitting hospital and time period

28. Why we used this approach
So – does the difference between e.g. London and RoE stay the same following reconfiguration?

29. Mortality at 3 days

30. Mortality at 30 days

31. Mortality at 90 days

32. Length of stay

33. Main result: overall
Risk-adjusted mortality and length of hospital stay fell in Greater Manchester, London and the rest of England during the study period

34. Main results: London
In London significantly larger absolute reduction in risk-adjusted mortality at 3, 30 and 90 days after admission compared with the rest of England:
3 days: -1.0 percentage points (95% CI, -1.5 to -0.4; P<0.001)
30 days: -1.3% (95% CI, -2.2 to -0.4; P=0.005)
90 days: -1.1% (95% CI, -2.1 to -0.1; P=0.03)
The absolute difference represents a relative reduction in mortality of 5% at 90 days, which equates to 96 fewer deaths per year
There was a significant reduction in length of hospital stay of -1.4 days (95% CI, -2.3 to -0.5) over and above the reduction seen in the rest of England

35. Main results: Greater Manchester
In Greater Manchester there was no impact on mortality over and above the change seen in the rest of England
There was a significant reduction in length of hospital stay by -2.0 days (95% CI, -2.8 to -1.2)
We speculate reasons for the non-significant effect on mortality in Greater Manchester were that fewer people received HASU-based care

36. 50 excess stroke deaths a year in Manchester
Headline Result
50 excess stroke deaths a year in Manchester

37. Strengths of study Large national dataset
Robust quasi-experimental design

38. Limitations No information on stroke severity
Could not measure impact on quality of life, disability, neurological and functional impairment
No information for pre-hospital period
No information on cost-effectiveness

39. Conclusions
Centralising stroke care so it is provided in specialist units in a reduced number of hospitals can improve quality of care for patients
But important that all stroke patients are taken to specialist units – not just a selection
These systems worked in urban areas but they might not work in rural areas where travel times would be too great

40. Why did mortality not fall in Manchester?
Wrong dose:
Many acute strokes missing out
on specialist acute care because of
4 hour time limit
Poor compliance:
Confusion over onset time
meant even those <4h were often
ending up in DGH

41. How could we have done it better?
Did we have the right people involved in the discussions?
What’s the PPI role?
Political will
Can we learn from history?
More than just physicians
PPI needs to co-design not just agree proposals
How do you get everyone on board in a “consensual” NHS?
Need evidence to guide system change: learn from our mistakes!

42. What’s happening now?
All change again in GM to London type model from 30 March 2015
Taken 4 years to move from recognition of a problem to implementation
Research findings and publicity pushed decision making

43. Centralised stroke services could save up to 50 patients per year under £2m NHS shake-up
Patient quote: “I think it’s fantastic that everyone in the area
who has a stroke will now be able to go straight to a specialist centre”.
March 2015

44. Thanks to Greater Manchester Stroke Network
Salford Royal Foundation Trust
HS&DR study team at UCL, King’s London, University of Manchester especially Naomi Fulop, Steve Morris and Angus Ramsay
SSNAP Team at RCP
Patients, carers and staff who have contributed to system change and its evaluation