Tom Penman Head of Stroke Services Tower Hamlets Community Health Services Sue Perkins Commissioning Manager for Long Term Conditions NHS Tower Hamlets

Every PCT should commission a community rehabilitation service for stroke patients delivered by staff with stroke specialist skills Service configuration should be locally determined and the service must meet all of the performance standards

▪ Tower Hamlets demographics … ▪ Deprived ▪ Overcrowded ▪ Diverse ▪ Young ▪ Growing population ▪ High unemployment ▪ 20% families live on less than £15,000 And our health our needs assessment tells us … ▪ Low life expectancy ▪ Health inequalities (male life expectancy vs national average) ▪ High burden of cardiovascular disease ▪ Health inequalities within the borough But … ▪ Ranked 1st nationally for economic growth

▪ Approx 2,000 residents on GP stroke registers ▪ Absolute number of deaths from stroke low compared to London (young population)..but.. ▪ Deaths in under 75s (“preventable”) from Stroke third highest in London ▪ Death rates in under 65s fourth highest in London ▪ Highest hospital admission rates for Stroke in London Health Needs Assessment – Stroke in North East London

Parts of the jigsaw in place in 2008 Agreed, mapped Stroke pathway Service development & innovation driven by staff Staff working across acute and community pathway Inpatient community rehabilitation ward Multi-disciplinary Community Stroke Team (CST) established Stroke a priority area - Commissioning Strategic Plan Missing pieces 1.Capacity of CST and inpatient rehabilitation 2.Accountability for stroke pathway 3.Clear service specification for community rehab team and structured Performance Monitoring process 4.Ongoing patient and public involvement 5.Clear link to prevention

Team Manager 0.5 WTE Occupational Therapist B7 Occupational Therapist B6 Physiotherapist B7 Physiotherapist B6 Speech & Language B7 part-time Therapy Assistant B3 Bengali Therapy Link Worker Clinical Psychologist 0.6 WTE Post discharge 12 week input

Consultant Junior Dr FY2 Registrar Nursing (not all stroke specialist) Speech and Language Therapy Occupational Therapy Psychology & Dietician Physiotherapy Some staff shared across Acute Stroke Unit, or across Older People’s Ward, or all Community Intermediate Care & Rehab services

Further pathway reviewFrom patient perspective & against Stroke Strategy Stakeholder involvementStaff interviews, ward observations, discovery interviews, Local Authority engagement To develop a “vision” for the service Skill mix reviewIdentified need for more specialist nursing staff & nursing clinical leadership role JSNATo add to PHAST data re. admissions, expected prevalence, current inequalities Investment and redesign needed Early Supported Discharge Pathway available to stroke survivors without an acute admission Post 12 week follow up Specialist vocational rehab service

Head of Stroke Services, Clinical Nurse Specialist – leadership and management accountability POSTRATIONALE Head of Stroke ServicesManagement accountability for stroke pathway, service development, strategic leadership Clinical Nurse SpecialistClinical leadership across acute, inpatient rehabilitation and community Patient Facilitator & Family Support Worker Champion stroke survivor, family, carer voice Guide through pathway Non clinician point of contact ESD team Physio, OT, Speech & Language, RSW, Dietitian Appropriate frequency & intensity of rehab 7 day a week service Health and social care interventions ESD to target 20% of admissions Vocational Rehabilitation Support for people to remain in, or return to work or meaningful occupation

Maximum time a patient waited for 1 st clinical contact % of clients with goals / care plans agreed Quality & Outcomes % appointments cancelled by the service % seen within 30 mins of appointment time Patient / User Experience # of referrals and discharges # of clinical and non-clinical contacts Performance & Activity % of vacancies Staffing % of staff up to date with safeguarding children and adults training Statutory compliance Use of London Stroke Strategy measures # patients being case managed Service Specific criteria

Agreed patient pathwayFrom prevention, through acute, out to community, ongoing care Performance Management process Performance Dashboards, quarterly reviews for CST and inpatients HfL performance monitoring link Governance structureImportant for multidisciplinary teams working across a number of settings Link to Prevention Role of CHD Nurse Specialists and Vascular Strategic Board Clear Service Specification Department of Health new contract template

Where does community rehab start and stop e.g. in-reach The role of Local Authority commissioner and LA Stroke funding How to commission for a pathway rather than for a care setting How to capture data for performance monitoring How to engage primary care in what we develop How to “share” savings in social care package costs

Where does community rehab start and stop e.g. in-reach The role of Local Authority and / or third sector providers How to engage primary care and the role of GPs in rehab Can we combine uni- disciplinary budgets for a multidisciplinary service How to capture data for performance monitoring Who manages new posts across disciplines e.g. Rehab Support Workers How does the service work with more general reablement teams

Additional resources sometimes distract from bigger issues Transitions can be improved (acute to community and community to long term support) without investment Stroke Networks have information about best practice Important to engage GPs – 12 month follow up Be clear what you want to commission (service specification) Meaningful PPI is difficult in short timescales and needs to be embedded in whole process Establish an explicit performance management process