Stroke Services Improvement Project

Improving Stroke Care in Wales

How did this all start?Where are we now? Where are we going?

Where did this all start?

RCP National Sentinel Audit 2006Published May 2007Tony Rudd – Media – ‘Scandalous’

Stroke services in Wales need urgent attentionUnacceptably low rates of stroke unit admissionMore patients in Wales dying or suffering serious disability as a resultAudit listed 10 major recommendations

Key indicators 1

% Compliance England Wales

Treated in SU 64 28

>50% SU 56 22

Swallow 24/ 24 67 55

CT 24/ 24 43 38

Aspirin 71 76

Physio 72/ 24 72 54

% Compliance England Wales

Treated in SU 64 28

>50% SU 56 22

Swallow 24/ 24 67 55

CT 24/ 24 43 38

Aspirin 71 76

Physio 72/ 24 72 54

Key Indicators 2

% Compliance England Wales

OT 7/ 7 69 50

Weighed 57 54

Mood Assessed 54 53

Anti-Thrombotic

100 100

Rehab Goals 76 70

HV 64 53

Average 66 54

% Compliance England Wales

OT 7/ 7 69 50

Weighed 57 54

Mood Assessed 54 53

Anti-Thrombotic

100 100

Rehab Goals 76 70

HV 64 53

Average 66 54

• 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

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

Program of Work

Identify gaps in service/pathway development March 08

Co-location of beds May 2008Stroke Units May 2009Thrombolysis 2010TIA assessment 2009Early supported discharge 2011

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

Project Structure

Project BoardChaired by Mike Harmer, Deputy CMO

Project Management TeamLed by Cerilan Rogers, Director NPHS

Project AssuranceClinical Reference Group (Welsh Stroke Alliance)Policy Reference Group (Jan Smith, Denise Richards, Sarah Watkins, Owen Crawley)

Project Objectives1. Care Pathway2. Indicators and Outcomes3. Gap Analysis4. Action Plan

• Development• Overseeing of implementation

5. Mechanism for assessing development proposals6. Service Improvement Collaborative7. Workforce Development Tool8. Symptom Awareness Campaign9. Action Plan to address gaps in risk reduction

resources and services

All Wales Stroke Services Improvement Collaborative

WorkstreamsWork Stream

Objective(s)

A(NPHS)

1. Care Pathway; 2. Indicators and Outcomes; 3. Gap Analysis; 4a Action Plan (development); 4b Action Plan (overseeing of implementation); 5 Mechanism for Assessing Development Proposals

B(NLIAH)

6. Service Improvement Collaborative

C(NLIAH)

7. Workforce Development Tool

D(WCfH)

8. Symptom Awareness Campaign

E(NPHS)

9. Action Plan to address gaps in resources and

services to support risk reduction

Welsh Association of Stroke Physicians Stroke Nurses AllianceWelsh Association of Physiotherapy in Stroke Specialist Section for Neurological Practitioners- 0TSpeech and Language Therapists in StrokeDieteticsNeuro-psychologyStroke AssociationOPANRadiologyPathology/Laboratory ServicesClinical PhysiologyNeurologyNeuro-rehabilitationVascular SurgeryCardiac NetworkNeurosurgeryAccident and Emergency MedicineGeneral PractitionersLHB/commissioners Welsh Ambulance ServicePatient groups; 1. Stroke Survivors: 2. CarerVocational Support for Stroke Survivors of working ageSocial ServicesPsychiatry/PsychogeriatricsPalliative CarePharmacy/therapeuticsNPHSNLIAHWCfHWAGPathways Development and Map of Medicine

Progress to Date

Workstream A

• Care pathway, indicators and outcomes, gap analysis

• Deadline 30 March 2008• Team included representatives of all key

professions involved in stroke care• 102 page report produced – on target –

just!

Workstream A• Care pathway

• Team aimed to identify and specify pathways to cover care from symptom onset to maximum possible recovery/death

Drew on info from variety of sources:

• NHS III (2006), Map of Medicine, RCP Audit (2006), RCP Guidelines(2004)

• Acute emergency and in-hospital care, pre-hospital emergency care, continuing care

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

Adopted Map of Medicineplus

RCP pre-hospitalPalliative care/End of life

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/NHS III• DH workforce guidance• Review of many Welsh stroke care

pathways

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

Work stream B

NLIAHService 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

Collaborative program

Workstream C

Workforce development – NLIAHWorkshop 10th October 2008

Identifying skills needed to deliver careCross profession careRole Redesign

• Local HR must put stroke as priority in the workforce submissions for next March

• New ‘whole system workforce plan’ for next year – new way of workforce planning

• T and D – essential element• Need to link in with the work of the UK Stroke

Training Forum –Welsh representation• Steering group

• 4 subgroups (Raising Awareness and Information, Time is Brain, Life after Stroke, Implementation)

• Draft Dec 08, Consultation Jan – Mar 09, Final framework June 09

Work stream D Symptom Awareness

WCfH working with Stroke AssociationAwareness Raising

Project Communication

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

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

Work stream E – Risk Reduction

• Work stream lead has been appointed - Fiona Kinghorn

• Team being established• Will look at primary prevention/health

promotion

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 8 - 9 months• Innovative projects• Autumn workshops

Regional Networks/Planning Forums

Development• SE Wales• Mid and West Wales• N Wales

• No funding available to support at present

• How do they link in with the SSIP?