1. The Challenge for Small Stroke Units Dr Phil Jones Ceredigion Division, Hywel Dda

2. The Ceredigion Challenge Catchment population around 100,000 Catchment population ranges from South Gwynedd to South Ceredigion and across to Rhayader Annual stroke admissions about 120 Plus attendances at rapid access stroke service

3. The Ceredigion Challenge Travel Times to admitting DGH (Bronglais, Aberystwyth) variable: short for local patients 2 hours plus for more distant residents

4. The Ceredigion Challenge Local service infrastructure: 4 acute monitoring beds 11 rehabilitation beds in BGH Staffing Physio, OT, SALT, nursing staff, consultant others as required

5. The Ceredigion Challenge What we don’t have: Specialist nurse/therapist Community based stroke service Thrombolysis service Commissioned services for stroke patients

6. The Ceredigion Challenge Participation in Sentinel audit since inception. Organisational change as far as possible.

7. The Ceredigion Challenge How did we do in the 2006 RCP Audit?

8. Standards 1 + 2 1 More than 50% of stay is in Stroke Unit We do not have a designated stroke unit, we are classed as stroke and rehabilitation. We do not have a designated stroke unit, we are classed as stroke and rehabilitation. 2 Treated in Stroke Unit at some point during stay 25% treated outside of Ystwyth 25% treated outside of Ystwyth 75% treatment included stay on Ystwyth 75% treatment included stay on Ystwyth

9. Assessment and Diagnosis Standards 3+4 Assessment and Diagnosis Standards 3+4 3 Swallowing assessed within 24 hours of admission National Average 66% National Average 66% Our site 88% Our site 88% 4 Brain scan within 24 hours of stroke National Average 42% National Average 42% Our Site30% (median = 27 hours) Our Site30% (median = 27 hours) (within 3 hours = 10%) (within 3 hours = 10%) Brain scan within 24 hours of admission National Average 53% National Average 53% Our Site74% Our Site74%

10. Secondary Prevention (10 and 5) 5 Receiving aspirin by 48 hours after stroke National Average60%Our Site83% National Average60%Our Site83% 10 on any antithrombotic agent by discharge National average 100%Our site 100% National average 100%Our site 100% On 1 or more antihypertensives by discharge National Average88%Our Site91% National Average88%Our Site91% On warfarin for AF by discharge National Average92%Our Site100% National Average92%Our Site100% On lipid lowering therapy by discharge National Average79%Our Site69% National Average79%Our Site69%

11. Multidisciplinary Assessment (6 + 7) 6 PT assessment within 72 hours of admission National Average 71% Our Site63% National Average 71% Our Site63% 7 OT assessment within 7 days of admission National Average 68%Our Site57% National Average 68%Our Site57% Communication assessed by SALT within 7/7 National Average 69%Our Site79% National Average 69%Our Site79% Social Work Assessment within 7/7 of referral National Average 56% Our Site14% National Average 56% Our Site14%

12. Risk factor management Underlying cause for stroke identified National Average73%Our Site88% National Average73%Our Site88% Smoking Cessation (N=1) National Average79%Our Site100% National Average79%Our Site100% Alcohol Reduction (N=1) National Average80%Our Site0% National Average80%Our Site0% Exercise (N=6) National Average41%Our Site50% National Average41%Our Site50% Diet (N=16) National Average42%Our Site25% National Average42%Our Site25%

13. Research Patients entered into research trial National Average3%Our Site20% National Average3%Our Site20%

14. The Thrombolysis Challenge 100% of stroke patients require the basic assessment and rehabilitation services at a local level. 2006 RCP audit shows that 0.2% of patients were thrombolysed in that round of audit. 40 sites across Engalnd and Wales offered the services, 25% did not thrombolyse in 12 months. 2 patients were thrombolysed in Wales. We must not confuse the thrombolysis issue with the holistic management of stroke.

15. Ceredigion Position Emergency services: Consultant led 0900-1700. Speciality doctor led 1700-0900 and at weekends. Rapid local access to CT scanning services in hours and out of hours. Provision of acute monitoring facilities. Complete lack of commissioning intent.

16. The NHS in Wales Challenge NHS ethos of care is free at point of delivery and local access to services. Moving away from the “post-code” lottery. The challenge for the NHS in Wales is to support these principles through support for local care where it can be effectively delivered. The SITS-MOST data demonstrates that experience and high volume of activity does not confer a significant advantage in the area of thrombolysis.

17. Conclusion The challenges facing smaller stroke units are different to those facing larger stroke units. Where is the evidence that smaller stroke units provide an inferior level of care to larger stroke units?

18. Services should be judged/commissioned on quality not quantity