Midlands and East Cluster Review A Vehicle for Service Improvement

Damian JenkinsonInterim National Clinical Director for StrokeDepartment of Health

• Clear process

• Service specification to high aspirations for whole stroke pathway

• No prescription of model or configuration to deliver stroke services

• External Expert Advisory Group

D) Includes:i. Early Supported

Discharge (ESD)ii. Stroke specialist

community rehabilitation

C) Includes:i. Hyper-acute servicesii. Acute services (including

in-hospital rehabilitation)iii. TIA servicesiv. Tertiary care services e.g.

Vascular and neuro-surgery

Addressing Quality and ProductivityMidlands and East Review of Stroke Services

4

SHMI 2010/11

Yorkshire and the Humber Strategic Health Authority 112.1

West Midlands Strategic Health Authority 109.8

East Midlands Strategic Health Authority 104.8

North West Strategic Health Authority 105.2

North East Strategic Health Authority 104.5

South East Coast Strategic Health Authority 104.4

East of England Strategic Health Authority 103.1

South Central Strategic Health Authority 98.4

South West Strategic Health Authority 95.6

London Strategic Health Authority 75.9

Source: HES – SHMI downloaded October 2011

Summary Hospital Level Mortality Indicator for Stroke 2010/11

Regional Cluster Stroke PerformanceNational Vital SignsStroke - % spending 90% on Stroke Unit

Q1 11/1

2

Q2 11/1

2

Q3 11/1

2

Q4 11/1

2

Stroke – Higher risk

TIAs treated

within 24 hours

Q1 11/12

Q2 11/1

2

Q3 11/1

2

Q4 11/1

2

ENGLAND 77.8%

81.6%

82.8%

81.7%

ENGLAND 68.8% 70.1%

70.5%

71.2%

Midlands & East

74.8%

81.1%

81.5%

80.4%

Midlands & East

65.0% 63.4%

65.7%

66.2%

East Midlands

71.5%

77.2%

80.7%

78.0%

NHS East Midlands

73.2% 62.0%

66.4%

71.9%

West Midlands

76.0%

82.7%

84.5%

81.1%

NHS West Midlands

64.4% 66.7%

72.5%

65.4%

East of England

76.4%

82.8%

79.3%

81.2%

NHS East of England

54.5% 61.2%

54.7%

60.8%

Targets: 80% of patients spending over 90% of they stay on a stroke unit 60% of high risk TIA patients scanned and treated in under 24 hours

NHS Midlands and EastRange in Vital Sign Performance

TIA % treated within 24 hours: Q4 2011- 12

0%

20%

40%

60%

80%

100%

No

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Wav

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No

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Stroke 90% of stay on stroke unit: Q4 2011-12

0%

20%

40%

60%

80%

100%

Telfo

rd a

nd W

reki

n PC

T

Notti

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m C

ity

PCT

Nor

th E

ast

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T

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rt o

f Bir

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msh

ire

Sout

h W

est

Esse

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T

Sout

h Es

sex

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h Ea

st E

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ire

Coun

ty

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ast

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pton

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Shro

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re C

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T

Stok

e on

Tre

nt P

CT

Her

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re P

CT

Nor

tham

pton

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ilton

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ords

hire

Sout

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affor

dshi

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CT

Nor

th S

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ire

PCT

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lk P

CT

Wes

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erci

a

Nor

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Dud

ley

PCT

Wal

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Teac

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PCT

Pete

rbor

ough

PCT

Wes

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sex

PCT

Sand

wel

l PCT

Der

bysh

ire

Coun

ty P

CT

NH

S M

idla

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& E

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k Co

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Cove

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T

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n

War

wic

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re P

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Leic

este

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re C

ount

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d

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folk

PCT

B'ha

m a

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olih

ull

Milt

on K

eyne

s

Leic

este

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re

Der

bysh

ire

Cam

brid

gesh

ire

&

Nor

folk

& W

aven

ey

Leic

este

r Ci

ty P

CT

Bedf

ords

hire

PCT

Bedf

ords

hire

& L

uton

Luto

n PC

T

Mid

Ess

ex P

CT

Wol

verh

ampt

on C

ity

PCT

Cam

brid

gesh

ire

PCT

Wor

cest

ersh

ire

PCT

Der

by C

ity

PCT

Gre

at Y

arm

outh

and

Sout

h Bi

rmin

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PCT

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ull P

CT

Linc

olns

hire

Tea

chin

g PC

T

Target 80%

Target 60%

SSNAP OrganisationalAudit 2012

SSNAP OrganisationalAudit 2012

• NHS M&E covers a quarter of the country; an area the size of Belgium

• Major variation in geographical and demography

• Complete the review before SHA’s abolition March 2013

• Pace at a time of major organisational change:– abolition of stroke networks, PCTs, SHA– transition to CCG commissioning– development of strategic clinical networks, Area Teams– agreeing ownership beyond NHS ‘transition’

• Expectation of no additional financial pump priming

Challenges to The Review

Service SpecificationMidlands and East Review of Stroke Services

Service SpecificationMidlands and East Review of Stroke Services

Performance Standards

 <6

months6-12

Months>18

months

1. Percentage of all stroke patients admitted to hyper acute unit within 4 hours of arrival to hospital (SSNAP)

90%    

1. Percentage of patients seen and assessed within 30mins of admission by a specialist in stroke (SSNAP)

90% 95%  

1. Percentage of appropriate patients having thrombolysis within 60 mins of entry (door to needle time) (SSNAP)

85% 90% 95%

1. Percentage of appropriate patients having thrombolysis within 45 mins of entry (door to needle time) (SSNAP)

    90%

1. Percentage of appropriate patients having thrombolysis within 30 mins of entry (door to needle time) (SSNAP)     50%

Performance StandardsMidlands and East Review of Stroke Services

Does Size Matter?

Stroke onset-arrival times by thrombolysis volume, as a proportion of all patients admitted with ischaemic stroke

SINAP 2012: 4347 receiving tPA (10.3% of

42,024 patients with acute ischaemic

stroke admitted to 80 hospitals).

78 min 72 min 50 min MEDIAN

Does Size Matter?

Bold Solutions to Large Scale ProblemsLondon 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 0.72 95%CI 0.67-0.77 p<0.001

Cost-Effectiveness of London Stroke ServiceBased on 6438 strokes per annumDifferences in Unadjusted Adjusted

Differences in total costs at 30 days 3,307,677 3,763,472

Differences in total deaths at 30 days -214 -68

Differences in total QALYs at 30 days 51 44

Incremental cost per death averted at 30 days 15,451 55,371

Incremental cost per QALY gained at 30 days 64,478 86,106

Differences in total costs at 90 days -5,393,533 -3,544,210

Differences in total deaths at 90 days -238 -98

Differences in total QALYs at 90 days 112 86

Incremental cost per death averted at 90 days Dominant Dominant

Incremental cost per QALY gained at 90 days Dominant Dominant

Differences in total costs at 10 years -21,318,180 -22,786,954

Differences in total QALYs at 90 days 4,492 3,886

Incremental cost per QALY gained at 10 years Dominant Dominant

T0 - T1 T1 - T2 T2 - T3 T3 - T4

Stroke Patient Conveyance PathwayPathway sub-process

T1T0 T2 T3 T4

Emergency call

Stroke event

Ambulance at scene

Ambulance leaves scene

Arrival at hospital

• Act F.A.S.T. campaign

• Telemedicine

• Ambulance dispatch locations

• Location of nearest RVV/ambulance

• Interventions at the scene

• Need to wait for double-staffed ambulance

• Patient location

• HASU configuration

• Traffic density

Call to door time

19

High Level EEAG Appraisal Criteria

A. Clinically sustainable and future proofed

B. Whole stroke patient pathway

C. Equitable access irrespective of socio economic status

D. Coproduced: health and social care; for people outside area

E. Services accessible by residents and travellers

F. All needed services of equal importance e.g. medical, nursing, therapy, psychological support etc

G. Plans will improve stroke mortality; patient's quality of life; and patient’s and carer’s experience of care

H. Services are cost effective and financially sustainable

Concluding Proposals

• From 45 acute stroke providers…• To 30 HASUs, with EEAG recommendations to

reduce to 25 HASUs• Challenges of rurality and access in 60min travel

time

• Commissioner led proposals• NCB Area Teams engaged to support performance

management of implementation• Implementation support :new Strategic Clinical

Networks

Summary of Proposed Locations

Making It Happen

Handover Legacy Pack

• Area Teams• Clinical Senates• CCGs• Strategic Clinical

Networks• NHS IQ• AHSN• Health and

Wellbeing Boards

Making It Happen

New Policy

Early Supported Discharge

Challenge

ESD where appropriate, Extend provision from 20% to

40%

Improvements

1080 pa fewer deaths dependencies, cost neutral

Levers

NHS IQ to promote

SSNAP audit

Acute Stroke

Acute Cardiac

Acute PAD

Specialist Stroke Rehab

Specialist Cardiac Rehab

Specialist PAD Rehab

TIA

CardiovascularRehab

ESD

Community Stroke Team

Specialist TIA Assessment

Rehabilitation Access and Uptake

? CVD Educational Framework ?

Challenge

Improve provision and access

Improvements

QoL

Patient experience

Cost saving at 2 years

Levers

QIPP

SSNAP audit

Access to Psychological Support

Long Term CareIntegration is Key

Patient & Carer Experience

EmpowermentSelf-management

Secondary specialist

careRecovery/Rehabili-

tation

Identify/Monitor

need

PreventingDependency/

need

Monitor/manage

needs

Specialist/Broader rehab

End of LifeCare

Assess/Monitor

need

CVD risk assess and

treat Other routes ineg HC

JointCare

Planning

Midlands and East Cluster Review A Vehicle for Service Improvement

Damian JenkinsonInterim National Clinical Director for StrokeDepartment of Health