Learning from the Stroke Pathway Principles for Success Damian Jenkinson

30 Day Stroke Mortality Over Time SINAP = Stroke Improvement National Audit Programme SSNAP = Sentinel Stroke National Audit Programme

Newly Institutionalised Rate Over Time Bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb Nnnnnnnnnnnnnnnn bbbbbbbbbbbbbb

Stroke Care Over a Decade

National Audit Office 2005 Value for Money of the Nation’s Stroke Services

A Comprehensive Stroke Service C) Includes: i.Hyper-acute services ii.Acute services (including in- hospital rehabilitation) iii.TIA services iv.Tertiary care services e.g. Vascular and neuro-surgery D) Includes: i.Early Supported Discharge (ESD) ii.Stroke specialist community rehabilitation E) Includes: i.Follow up i.6 weeks ii.6 months iii.Annually ii.Integrated health and social care team plan Research Information Patient, public and carer involvement

The Recent Journey 2007 Stroke Quality Standard Vital Signs Best Practice Tariff Eleven process standards Indicators along the pathway More emphasis on prevention and on long term care CCGs accountable for OIS NHS Outcomes Framework 2011/12 The Mandate CCG Outcomes Indicator Set

CCG Outcome Indicators 2014/15

Knowing Where You Are SSNAP Case ascertainmentAudit compliance

In first year 9864 more people reached hospital faster 642 had reduced disability through thrombolysis Payback of £3.16 for each £1 spent FAST Public Awareness Campaign Significant increase in those intending to call 999: 87% seeing weak face 46% seeing weak arm 74% hearing abnormal speech

Thrombolysis Provision

Bold Solutions to Large Scale Problems London Stroke Service 30-Minute Blue Light Ambulance Travel Time from the Hyper-Acute Stroke Units Population >8million 11,500 strokes a year in London – 2,000 deaths Commitment to whole system redesign

London Stroke Survival is Higher Than Rest of England Hazard ratio for survival in London %CI p<0.001

Reconfiguring Acute Care stroke admissions per year 45 minute travel time consultants with stroke expertise on rota Daily specialist ward rounds HASU-grade staffing levels 100% patients continuous physiological monitoring 95% patients admitted directly to HASU from A&E 100% urgent patients scanned next slot and all within 24 hours 50% appropriate patients thrombolysed within 30 mins; 90% within 45 mins of arrival

Early Supported Discharge (ESD) and Community Stroke Teams (CST) CQC 2011: ‘overall picture of inconsistency, waits between transfer home and commencing community rehabilitation and lack of specialists’ SSNAP 2014 ESD: 25% transferred to ESD CST: 21% transferred to CST Only 14% patients with post acute rehabilitation registered on SSNAP Fear of costs of ‘double running’

Many staff in traditional unidisciplinary roles No nationally-recognised stroke- specialist courses or competences for nurses or Allied Health Professionals Quality-assured framework for staff education based on the needs of patients at all stages of care pathway Endorsement process to assure trainees and employers Shaping the Workforce

Stroke Research Network Patient Recruitment RCT Target Target Building Stroke Research Capacity

Making It Happen CCGs Health and Wellbeing Boards Strategic Clinical Networks Area Teams Clinical Senates NHS IQ Academic Health Science Networks

1.Political priority 2.Co-produced National Policy 3.Raised Awareness 4.Leadership 5.National Audit 6.Whole-System Engagement 7.Networks 8.Metrics Learning from the Stroke Pathway Principles for Success