The National Stroke Strategy Direction of travel and quality
markers for stroke rehabilitation
service development in England
Professor Roger Boyle
March 2009
Why stroke matters
• Burden of disease
– >110,000 strokes each year (rule of thirds)
– >20,000 Transient Ischaemic Attacks (TIAs or ‘mini strokes’)
– At least 300,000 living with significant post-stroke disability
(single largest cause of adult disability)
– Third most common cause of death
– 1 in 4 people affected are under 65
– People of South Asian and African Caribbean origin at
significantly higher risk
• Costs
–
–
–
–
£2.8 billion direct care costs
£1.8 billion due to lost productivity and disability
£2.4 billion informal care costs
2.6 million bed days per year
Positioning
• Ministers (particularly
Secretary of State)
• NHS Board
• NHS Chief Executive
• Directors of Commissioning
and Performance
• Chief Executives and medical
directors of the Ambulance
Trusts
• All Party Parliamentary Group
• Stakeholders
• Next Stage Review – High
Quality Care for All
Working together
Hyper-acute stroke service
24-hour cover by stroke specialists
24-hour radiological support
Neuroscience
centre
Likely to
benefit from
interventions
Link to neighbouring
network
Transfer to acute stroke unit
after 48 -72 hours
Acute/Rehabilitation Unit Combined
Acute Stroke Unit
Early Supported Discharge Teams
Community Stroke Teams
Likely to
benefit from
specialist care
Stroke Rehabilitation Units
• In London stroke is:
– Second commonest cause of death
– The commonest cause of disability
• 11,000 people suffer a stroke each year
– One person every hour
– One in six die
Dr Chris Streather
Rachel Tyndall
Supporting the strategy
• Mandated for every PCT within the
Operating Framework
• ‘Tier 1’ priority
• Central finance over 3 years (£105 million)
– Training (£16 m)
– Raising awareness (£12 m)
– Developing innovative practice (£77 m)
• £32 m to the NHS
• £45 m to social care
Implementation agenda
• Money to SHAs (circa £2.4 million)
• Money to local authorities (circa £100k each
year for three years)
• Problem solving small grants fund
• Awareness campaign
– NHS staff and the public
• National Training Forum (30 doctor training
places)
• Communication plan
• Evaluation
• Development of the stroke networks and the
stroke improvement programme
The Quality Framework in “High Quality Care for All”
Bring
clarity
to
quality
Quality
Standards
NHS
Evidence
Measure
quality
Publish
quality
performance
•Metrics – local, •Quality
national,
international
•QOF indicator
development
•Clinical
dashboards
accounts
•NHS
Choices
•Internation
al measures
and NQB
report
•CQC role
Recognise
Raise
and reward
standards
quality
•CQUIN
•Multi-year
and best
practice
tariff work
•CEAs
•QOF
Safeguard
quality
Stay
ahead
•Clinical voice at •CQC role
every level inc
•Regulation
NQB
•SHA duty to
•SHAs – Medical primary care
Directors and
•NQB
CABs
funds and
prizes
extended to
•PCTs – WCC
clinical
engagement
•NICE fellowship
programme
innovate
•Innovation
•AHSCs
•HIECs
Vital Signs
• % stroke patients who spend 90% of their
time in hospital in a stroke unit
• % of high risk TIA patients who are treated
within 24 hours
Audit as a lever for change
• Sentinel Audit sets the standard
• Expansion to a ‘MINAP’ style process for
acute care planned
• Expansion for extension into primary and
community care under consideration
Total Organisational Score – 2006 & 2008 – Average Score for Trust/Hospital Stroke
Services by SHA (National Sentinel Audit of Stoke 2008, RCP London)
No. of ASUs with 5 ACs (All) Specialist Community/Dom Team
(All) Comm/Domm Team Staffed (All)
by specs
Site (All) Change Rating (All) Site ID (All) Valid 2006 Org Score Yes
100.0
90.0
Average Total Organisational Score
80.0
70.0
60.0
Data
Ave Org Score 2006
Ave Org Score 20082008
50.0
40.0
30.0
20.0
10.0
0.0
East
East of
London
Midlands England
North
East
North
West
South
Central
South
East
Coast
South
West
West
Midlands
Yorkshir
e&
Humber
Ave Org Score 2006
59.9
61.3
63.4
69.2
63.8
64.7
58.2
67.8
65.6
66.8
Ave Org Score 20082008
68.6
65.8
68.8
74.0
71.1
67.8
70.0
74.6
70.6
72.0
SHA
Life after stroke - Key facts
• At present only around half of individuals
who have experienced stroke receive the
rehabilitation to meet their needs in the
first six months after discharge from
hospital, falling to around one fifth in the
following six months
Life after stroke – Key facts
• Three- quarters of younger individuals want to
return to work
• One third of individuals develop depression
• One third of individuals experience
communication difficulties
• About one third of individuals will die of their
stroke – not immediately but within three
months
QM 10
High-quality specialist rehabilitation
• People who have had strokes access
high-quality rehabilitation and, with their
carer, receive support from stroke-skilled
services as soon as possible after they
have had a stroke, available in hospital,
immediately after transfer from hospital
and for as long as they need it.
Multi-faceted stroke rehabilitation
•
•
•
•
•
•
•
•
•
•
Mobility and movement
Communication
Everyday activities, dressing, washing, meal preparation
Depression and distress
Swallowing
Nutrition
Cognitive difficulties
Visual disturbances
Continence
Relationships and sex
QM11
End-of-life care
• People who are not likely to recover from
their stroke receive care at the end of their
lives which takes account of their needs
and choices, and is delivered by a
workforce with appropriate skills and
experience in all care settings
QM 12
Seamless transfer of care
• A workable, clear discharge plan that has
fully involved the individual (and their
family where appropriate) and responded
to the individual's particular circumstances
and aspirations is developed by health and
social care services, together with other
services such as transport and housing.
QM 13
Long-term care and support
• A range of services are in place and easily
accessible to support the individual longterm needs of individuals and their carers.
QM 14
Assessment and review
• People who had strokes and their carers, either
living at home or in care homes, are offered a
review from primary care services of their health
anc social care status and secondary prevention
needs, typically within six weeks of discharge
home or to a care home and again six months
after leaving hospital.
• This is followed by an annual health and social
care check, which facilitates a clear pathway
back to further specialist review, advice,
information, support and rehabilitation where
required
QMs 15 and 16
• Participation in community life
– People who have had a stroke, and their
carers, are enabled to live a full life in the
community
• Return to work
– People who have had a stroke, and their
carers, are enabled to participate in paid
supported and voluntary employment
Sentinel Audit 2008
100
90
80
Clinical psychology
Dietetics
OT
Physio
SLT
Pharmacy
Orthotics
Foot health
70
60
% 50
40
30
20
10
0
2002
2004
2006
2008
Team meetings
100
90
80
Senior doctor
Nursing
Clinical psychology
Dietetics
OT
Physio
SLT
Social work
70
60
% 50
40
30
20
10
0
2002
2004
2006
2008
Patient access to management
plan
100
90
80
70
60
80
73
62
66
% 50
40
30
20
10
0
2002
2004
2006
2008
Variable but improving access to informative literature on the wards
Knowledge gaps
• State of community-based services
– Availablility
– Quality
– Extent of partnership working between health
and social care
• Patient and carer experience beyond
hospital discharge
Conclusions
• Plenty still to do
• Plenty for everyone whatever the setting
• Challenges are considerable beyond the
acute phase