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.

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 patients
who died within 15
30 days
10
5
0
2004 2006 2008 2010
Year of Audit
Sentinel Stroke Audit 2010. RCP London

7. BUT despite this......

8. The case for changing stroke care
Above Target
London 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

9. 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

10. 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.

11. 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

12. Stroke pathway
Access to leisure,
Stroke Tailored Self care/
Primary Rapid Thromb Employment,
Unit Community Peer support
Prevention 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

13. 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

14. 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

15. 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

16. 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

17. 30-minute blue light ambulance travel time from
the hyper-acute stroke units
The green area shows the areas that are within 30 minutes travel time
(under ambulance blue light conditions) of a proposed HASU

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Journey times
Avg Time from Scene to Hospital
20.00
18.00 Charing Cross
16.00 King`s College
14.00 Northwick Park
Princess Ryl Hosp, Farnborough
12.00
Queens Hospital, Romford
10.00
Ryl London (Whitechapel)
8.00
St Georges, Tooting
6.00 St Thomas`
4.00 University College
Overall Average
2.00
0.00
Apr-10

26. HASU destination on discharge
60%
50%
40%
30%
20%
10%
0%
Home Other Stroke Unit RIP

27. 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

28. Processes of care
Average length of stay
20
18
16
14
12
10
8
6
4
2
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
2009/10 2010/11

29. London stroke survival vs rest of
England
Hazard ratio for survival in London
0.72 95%CI 0.67-0.77 p<0.001

30. Cost-effectiveness analysis of the London Stroke Service:
results based on 6438 strokes per annum
Professor Steve Morris et al
Differences 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 10 years 4,492 3,886
Incremental cost per QALY gained at 10 years Dominant Dominant

31. Cost-effectiveness analysis of the London Stroke
Service: results based on 6438 strokes per annum
Differences 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

32. Cost-effectiveness analysis of the London Stroke
Service: results based on 6438 strokes per annum
Differences 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

33. Sensitivity analysis
Results were qualitatively unchanged after
undertaking 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

34. 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.....

35. 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?