1. Implementation Options – Stroke

2. Implementation commences Current stroke services in London are of variable quality – under the new model, all stroke services will be required to meet agreed clinical and quality standards. The process of implementation will start from the date of the JCPCT decision to designate stroke and major trauma services. This will include recruiting and training staff, updating facilities and developing linkages between designated providers and with networks. The new service will be introduced from April 2010 with a step-change in the quality of services being delivered from the outset, and commitment to an improvement plan and monitoring of the achievement of key results within the first 12 months

3. The external evaluator panel scores showed that only one potential HASU and 3 potential Stroke Units would be able to meet all essential ‘launch criteria’ by October 2009 Most commonly, organisations failed to meet criteria related to recruitment of staff, thrombolysis and management pathways Assessor scores indicate that many more stroke units would be able to fully meet the quality standards by April 2010. This will enable a London wide synchronised launch of new SU arrangements, and diversion from de-designated units at that time. Assessor scores also indicate that more potential HASUs would be able to meet or partially meet the ‘A criteria’ by April 2010. HASU implementation will need to be a staged process. Transition: from April 2010

4. Issues for implementation There will be a transition period before the new service model can be fully implemented Some organisations will require significant support to achieve HASU standards in a timely manner Even the best performing units have some significant issues to resolve before go live

5. Workforce The biggest challenge to implementation is satisfying the workforce requirements of the new model. For HASUs and Stroke Units, the bids indicated the following approximate requirements for new services: 570 wte nurses (80:20 skilled / unskilled) 200 wte therapists (PT, OT, S&LT) 16 wte consultants (+ junior medical staff) There is a risk that the available workforce will be consumed by early implementers, leaving later implementers unable to recruit to posts. This could potentially delay their ability to meet designation criteria.

6. HASU Transition Managing the roll-out of HASU operation and transitional issues will require detailed multi-stakeholder planning Detailed planning will take place during consultation Provider, commissioner, user and ambulance service perspectives are different, and must all be managed. Controlled, managed changes to patient flows are critical, so key issue is to manage opening of new HASU capacity, aligning with ambulance diversion and decommissioning existing capacity (A&E and early SU)

7. Implementation support: what are the challenges? Common themes Poor planning for workforce requirements inc. lack of clear recruitment plans across all specialties, but special concern about Consultant and nursing posts. Poor understanding of requirements to meet the designation criteria, with over- optimism in when changes could be delivered. Apparent lack of management support for the application demonstrated by poor support in business case, including financial impact and lack of commitment to organisational change. Poor understanding of capacity needs of organisation to meet demands of providing a stroke service. Poor understanding of challenges facing organisation to deliver improved stroke care. Lack of leadership capacity required to make and sustain changes and drive quality improvement The bid evaluations shows that similar challenges affect both those who failed the bid overview assessment and those who passed with a score of three. The difference is in those organisation’s ability to address those challenges without external support.

8. ‘Step change’ at weaker providers If weaker providers are to be included in recommendations, JCPCT must be assured that quality standards will not be compromised. The quality assessment of the weaker bids will be shared with the local commissioners, so as to inform the assessment of each unit’s ability to step up to the required standard, the time required and the preferred commissioning approach. There is a continuing commitment to ensuring that all services meet the quality standards set out. In order to achieve this, robust plans will need to be developed to ensure that these services meet the standards required. Services will not be commissioned from weaker providers until clear and robust plans are in place.

9. Step change at weaker providers All providers‘Below the line’ providers Commissioner leadership PCTs commission, monitor and manage performance against the new specification Formal governance and project management with clear PCT accountability Planning and implementation Plans agreed with commissioners and network External support Proper resourcingTariff incentivises and shares risk Peer review and support Peer assessment to support implementation planning Network participation Formal partnership with high quality stroke provider (potentially, direct involvement in provision) SupportNetworkImplementation team