1. Supporting NHS Wales to Deliver World Class Healthcare All Wales Stroke Services Improvement Collaborative All Nations Centre, Cardiff 4 th November 2008

2. Dr Anne Freeman Consultant Physician Clinical Lead for AWSSIC

3. Stroke in Wales Where are we now and where are we going?

4. Stroke in Wales: the burden 6,895 stroke/TIA admissions in 2006 4,953 first ever strokes Leading cause of disability 4 th leading cause of death The cost to the nation

5. Stroke Services Improvement Project

6. 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

7. 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 Presumes more patients in Wales dying or suffering serious disability as a result Patients managed on stroke units have better results for key indicators Audit listed 10 recommendations

8. Key indicators 1

9. Key Indicators 2

10. 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

11. RCP Recommendations 1. The recommendations contained within Chapter 5 of the National Service Framework for Older People in Wales should be urgently implemented in full. 2. A National Service Director for Stroke in Wales should be appointed to immediately deal with the major problems this report has identified in the delivery of stroke care 3. Each trust should appoint a clinician with sufficient time to take clinical and managerial responsibility for developing and delivering stroke services. 4. Training posts in stroke medicine should be funded so as to build the infrastructure to enable stroke service development over the next few years 5. Specialist nursing and therapy posts should be expanded, possibly with the introduction of a few consultant posts to help develop these specialties

12. 6. Every hospital should have a geographically defined stroke unit with sufficient beds to provide specialist care for their local population. The unit should provide acute care and rehabilitation 7. Brain imaging should be available to all patients within 3 hours of stroke and plans should be developed to include Thrombolysis services in Wales 8 Accepting the difficulties of providing specialist stroke care in low population density rural settings, consideration should be given to the development of specialist community stroke teams including early supported discharge, able to provide continuing rehabilitation either in a domiciliary or bed based intermediate care setting. 9. All patients in Wales should have access to a neurovascular clinic able to investigate and treat transient ischaemic attacks within seven days of the symptom 10. All trusts managing stroke patients should increase the proportion who spend the majority of their stay on a stroke unit to over 80% by 2008

13. 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

14. WHC (2007) 58 Confirmed that stroke was now a top priority for NHS and social services in Wales Announced that a formal programme of work would be published Prioritised the establishment of stroke units and acute in-patient care Draft 2008/09 AOF target LHBs and social services in each region Submit action plans to deliver NSF standards and achieve the AOF target

15. WHC (2007) 82 Outlined the programme of work Asked the project partnership (SSIP) to carry out a number of tasks Stroke prevention Identify gaps in availability of local resources and services to support risk reduction and develop an action plan to address gaps Improve stroke survival Undertake profession specific audits of key professions Maximise post stroke independent living and quality of life Develop national protocol and quality requirements… for timing and range of rehabilitation assessments and interventions…available on acute specialist stroke unit

16. 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)

17. Effective Services Care Pathway (NPHS) Gap Analysis (NPHS) Action Plan (NPHS) Implement Service Change (NLIAH/NPHS) Evaluate Impact (NPHS)

18. 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

19. Project Workstreams Work Stream A – Care pathway, indicators and outcomes, gap analysis; Assessment of action plans (NPHS) Objectives 1 to 5 Work Stream B - Objective 6, Service Improvement Collaborative (NLIAH) Work Stream C - Objective 7, Workforce development tool (NLIAH) Work Stream D - Objective 8, Symptom awareness campaign (WCfH) Work Stream E – Objective 9, Risk reduction action plan (NPHS)

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

21. Workstream A Care pathway Work had already been undertaken to support the NSF and SAFF targets Team aimed to identify and specify pathways to cover care from symptom onset to maximum possible recovery/death NHS III (2006), Map of Medicine, RCP Audit (2006), RCP Guidelines(2004) Acute emergency and in-hospital care, pre- hospital emergency care, continuing care

22. Service organisation Service structure Specified by BASP Level 1, level 2 and level 3 service Service characteristics NHS III Key characteristics of organisations that provide high quality care and value for money Some overlap with BASP

23. Approach to the 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 DH workforce guidance Review of many Welsh stroke care pathways

24. Stroke units RCP (2007) 9 / 20 had a stroke unit only 5 had both acute and rehab beds. 5 key characteristics of stroke units have been identified – a score of 4+ needed 4 / 9 score 4, 5 / 9 score 5 No units currently met BASP level 1 – NSF minimum

25. 5 stroke unit characteristics consultant physician with responsibility for stroke, MDT meetings at least weekly to plan patient care, formal links with patient / carer organisations, provision of information to patients about stroke, continuing education programmes for staff

26. 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

27. 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

28. 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

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

30. Workforce Guidance DH (2008) issued guidance on stroke staffing levels for Nurses, OT, Physiotherapists, SaLT and Psychologists SSIG, 2007 – aimed to carry out a detailed analysis of workforce availability, by hospital MDT meeting participation RCP, 2007 – audited numbers of WTE staff on stroke units Difficult to determine exactly who the stroke workforce is

31. Work stream D Symptom Awareness WCfH working with Stroke Association

32. 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

33. 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

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

35. Expert Panel – Action plan review WHC (2007) 58 Submit action plans to deliver NSF standards and achieve the AOF target – end March 08 WAG tasked the partnership with establishing an expert panel to review these action plans Now with accompanying spending plans Regional notional allocation totalling £2.25M Recommendations/guidance on how to bid Regional plans to be submitted by 31 March 2008

36. Expert Panel Chair – Paul Tromans (NPHS) External Experts – Dr Tony Rudd, Prof Derrick Wade, Prof Avril Drummond Other members – Dr Anne Freeman, Dr Mushtaq Wani, Trish Hughes, Alun Lloyd, Andrew Lewis, Aled Williams, Mark Vaughan.

37. Process Spending plans received mid-May Expert panel sat late June Unable to make a recommendation based on the plans provided Revised plans were requested by early August Expert panel sat again in early September Recommendations for spending passed to the Minister Letters now gone to service with decisions

38. 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 6-8 months Autumn workshops

40. Welsh Stroke Alliance Thrombolysis and Neuro- Imaging Subgroup Rehabilitation Subgroup Education and Training Subgroup Community Services Subgroup Welsh Association of Stroke Physicians Stroke Nurses Group Welsh Association of Physiotherapy in Stroke Specialist Section for Neurological Practitioners- 0T Speech and Language Therapists in Stroke Medicine 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

41. British Geriatrics Society Welsh Branch Stroke Specialist Interest Group Welsh Association of Stroke Physicians Welsh Stroke Conference (Bhowmick Bursary) Welsh Stroke Bulletin (www.strokeupdate.co.uk)

42. Regional Networks SE Wales Mid and West Wales N Wales Complement Cardiac Networks geographically No funding available to support at present How do they link in with the SSIP?

43. All Wales Stroke Services Improvement Collaborative Three Counties Abertawe Bro Morgannwg Powys North Stroke Services Planning Forum North West Wales North Wales Central North East Wales South Stroke Services Planning Forum Cardiff and Vale Cwm TafGwent Mid and West Wales Stroke Services Planning Forum North Wales Stroke Services Planning Forum South Wales Stroke Services Planning Forum Stroke Services Improvement Programme