Tony Rudd: the legacy of NHS London - stroke programme

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Tony Rudd gives a background to stroke care in London and looks at how NHS London’s stroke programme has made a difference for people in the capital.

Tony Rudd gives a background to stroke care in London and looks at how NHS London’s stroke programme has made a difference for people in the capital.

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  • In complete opposite to major trauma, most cases of stroke occur in the suburbs – where older people tend to live. The next two most important factors in stroke are i) ethnicity (there is a 60% greater incidence of stroke within the black African and black Caribbean populations than the white population and ii) social deprivation. However the actual numbers of people from BME communities having a stroke are not as high as would be expected as there are fewer older black and minority ethnic people in London.
  • Overview of stroke pathway Timescale different for individual patients Underpinning themes Three main phases- transition through theme is a vital element we need to manage

Transcript

  • 1. The Legacy of NHS London Stroke Tony Rudd London Stroke Clinical Director
  • 2. St Thomas’ Hospital
  • 3. St Thomas’ Hospital stroke care in 1988 Patients admitted under care of any of 17 general physicians to any one of 15 wards Very little happened acutely Brain scans difficult to obtain and therefore rarely done Referred to geriatricians for rehabilitation – long wait No stroke specialist service either in hospital or community
  • 4. Sentinel Stroke Audit 2010. RCP London
  • 5. 30 Day Mortality Over Time 30 25 20 % of patientswho died within 15 30 days 10 5 0 2004 2006 2008 2010 Year of Audit Sentinel Stroke Audit 2010. RCP London
  • 6. BUT despite this......
  • 7. The case for changing stroke care Above TargetLondon Stroke Units Sentinel Audit Comparison 2004 and 2006 Below Target Target 91 90 89 88 88 86 84 83 80 80 90 77 76 76 75 72 71 71 71 70 70 68 68 66 65 65 62 61 60 London Stroke Providers against 55 51 49 45 Sentinel Audit 12 key indicators 2006 25 25 24 21 21 Change in London 19 19 Stroke Providers against Sentinel 14 Audit 12 key 12 12 indicators 9 9 8 2006 vs 2004 6 6 5 scores 4 4 2 1 0 -1 -3 -3 -4 -4 -5 -7 -9 -12
  • 8. The scale of the problem of stroke in London• Second biggest killer and most common cause of disability• Population >8 million• 11,500 strokes a year in London – 2,000 deaths
  • 9. Availability of potential stroke providers Theoretical Catchments Area Overlap for current Stroke Providers 12 to 14 Providers Overlapping 10 to 12 Providers Overlapping 8 to 10 Providers Overlapping 6 to 8 Providers Overlapping 4 to 6 Providers Overlapping 2 to 4 Providers Overlapping • The more intense the red the greater number of providers available to provide service to the area. • There is always at least two providers available to any give area.
  • 10. Decision to reorganise care National Stroke Strategy National Stroke Audit Darzi review of medical care in London Lobbying from London Stroke community Ruth Carnall and SHA choosing stroke and major trauma  Clear case for change  Good evidence as to what should be done  A clinical community wanting to see change
  • 11. Stroke pathway Access to leisure, Stroke Tailored Self care/ Primary Rapid Thromb Employment, Unit Community Peer supportPrevention detection -olysis Other care rehab Sign posting opportunities Quality information for users and carers Quality information for professionals A workforce skilled in working with people with stroke Preventing a further stroke or TIA Acute phase recovery Learning to live with a Living with a disability disability
  • 12. Process for implementing change Agreement from all London PCTs and formation of JCPCT to support the process and to invest additional £20m/annum Project board with representation from commissioners, networks, clinicians, managers, patients, voluntary groups Whole system reorganisation Split care into hyperacute, acute, transient ischaemic attack and community care
  • 13. Process for implementing change Setting the standards based on evidence Development of range of models – consultation with professionals Agreement that additional funding paid as enhanced tariff if quality standards met Agreement on splitting tariff Setting of stages of quality standards with increasing proportions of enhanced tariff paid at each level
  • 14. Process for implementing change Bidding process for delivery of HASU, SU and TIA care. Requiring close collaboration between managers and clinicians from each provider External review of applications Final decision on allocation of services made by SHA based on geography more than quality
  • 15. Final model 8 HASUs each with their own SUs  124 HASU beds Further 16 SUs 24 TIA services Repatriation where needed up to 72 hours (longer if too unstable to transfer). Financial incentives to move rapidly after referral 400 additional nurses needed and about 100 therapists
  • 16. 30-minute blue light ambulance travel time from the hyper-acute stroke unitsThe green area shows the areas that are within 30 minutes travel time(under ambulance blue light conditions) of a proposed HASU
  • 17. Standards Predefined minimum rotas for doctors Requirement at least daily consultant rounds on HASUs Minimum staffing levels for therapists and nurses About 60 criteria against which quality of care measured
  • 18. Implementation of plan London Stroke and Cardiac Board Role of networks and clinical director  Supporting change  Inspecting services with commissioners to decide if eligible for enhanced tariff  Education/training  Daily activity and performance management• Development of local leaders• Obligation to submit continuous audit
  • 19. Successes All HASUs now fully open and working effectively All SUs passed A1 and A2 criteria Virtually all patients directly accessing high quality acute care  Admission to HASU  Thrombolysis where appropriate  Consultant led specialist medical care, stroke specialist nursing care and early access to stroke therapists from the beginning
  • 20. Successes Excellent collaboration between clinicians across London Innovative training initiatives Closer collaboration between managers, paramedics, hospital clinicians, community clinicians, network staff and commissioners working in stroke than ever achieved before Good patient feedback
  • 21. Workforce initiatives E-learning programme nearly complete (Imperial College) Simulation centre courses developed and running at 4 of SIM Centres in London  Senior doctors and nurses  Band 5 nurses and junior doctors Conferences for paramedics Competencies developed for HASU and SU nurses
  • 22. Early supported discharge Most areas now have access to a service or at the stage of commissioning a service Longer term rehabilitation  Service provision variable
  • 23. Evaluation of the reconfiguration Process data from  London Ambulance Service  SINAP  London Minimum Dataset  Vital signs data SDO NIHR funded study NHS London Health Economic study
  • 24. Journey times Avg Time from Scene to Hospital20.0018.00 Charing Cross16.00 King`s College14.00 Northwick Park Princess Ryl Hosp, Farnborough12.00 Queens Hospital, Romford10.00 Ryl London (Whitechapel) 8.00 St Georges, Tooting 6.00 St Thomas` 4.00 University College Overall Average 2.00 0.00 Apr-10
  • 25. HASU destination on discharge60%50%40%30%20%10%0% Home Other Stroke Unit RIP
  • 26. Processes of care Thrombolysis rates 18%16%14% 14%12% 12%10%8% 10%6%4% 3.5%2%0% Feb-July 2009 Aim Feb-July 2010 Jan-March 2011 Jan-July 2012
  • 27. Processes of care Average length of stay20181614121086420 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 2009/10 2010/11
  • 28. London stroke survival vs rest of England Hazard ratio for survival in London 0.72 95%CI 0.67-0.77 p<0.001
  • 29. Cost-effectiveness analysis of the London Stroke Service: results based on 6438 strokes per annum Professor Steve Morris et alDifferences in Unadjusted AdjustedDifferences in total costs at 30 days 3,307,677 3,763,472Differences in total deaths at 30 days -214 -68Differences in total QALYs at 30 days 51 44Incremental cost per death averted at 30 days 15,451 55,371Incremental cost per QALY gained at 30 days 64,478 86,106Differences in total costs at 90 days -5,393,533 -3,544,210Differences in total deaths at 90 days -238 -98Differences in total QALYs at 90 days 112 86Incremental cost per death averted at 90 days Dominant DominantIncremental cost per QALY gained at 90 days Dominant DominantDifferences in total costs at 10 years -21,318,180 -22,786,954Differences in total QALYs at 10 years 4,492 3,886Incremental cost per QALY gained at 10 years Dominant Dominant
  • 30. Cost-effectiveness analysis of the London Stroke Service: results based on 6438 strokes per annumDifferences in Unadjusted AdjustedDifferences in total costs at 30 days 3,307,677 3,763,472Differences in total deaths at 30 days -214 -68Differences in total QALYs at 30 days 51 44Incremental cost per death averted at 30 days 15,451 55,371Incremental cost per QALY gained at 30 days 64,478 86,106Differences in total costs at 90 days -5,393,533 -3,544,210Differences in total deaths at 90 days -238 -98Differences in total QALYs at 90 days 112 86Incremental cost per death averted at 90 days Dominant DominantIncremental cost per QALY gained at 90 days Dominant DominantDifferences in total costs at 10 years -21,318,180 -22,786,954Differences in total QALYs at 90 days 4,492 3,886Incremental cost per QALY gained at 10 years Dominant Dominant
  • 31. Cost-effectiveness analysis of the London Stroke Service: results based on 6438 strokes per annumDifferences in Unadjusted AdjustedDifferences in total costs at 30 days 3,307,677 3,763,472Differences in total deaths at 30 days -214 -68Differences in total QALYs at 30 days 51 44Incremental cost per death averted at 30 days 15,451 55,371Incremental cost per QALY gained at 30 days 64,478 86,106Differences in total costs at 90 days -5,393,533 -3,544,210Differences in total deaths at 90 days -238 -98Differences in total QALYs at 90 days 112 86Incremental cost per death averted at 90 days Dominant DominantIncremental cost per QALY gained at 90 days Dominant DominantDifferences in total costs at 10 years -21,318,180 -22,786,954Differences in total QALYs at 90 days 4,492 3,886Incremental cost per QALY gained at 10 years Dominant Dominant
  • 32. Sensitivity analysisResults were qualitatively unchanged afterundertaking sensitivity analysis on the following: • Stroke mimics • LOS in the HASU • Unit cost per day in the HASU • LOS in ICU • Neurosurgery rates • Discharge destinations
  • 33. What next? Much more work on latter part of pathway Development of similar model in Midlands and East of England and review of Manchester model Keeping going.....
  • 34. How do we stop everything unravelling? How do we persuade CCGs to continue the enhanced tariff? How do we keep control of quality and stop trusts cutting resources? How do we maintain the close relationship that has developed between commissioners and providers that has been fostered by networks? Who will retain oversight and retain responsibility for London stroke?