Tom Penman
Head of Stroke Services
Tower Hamlets Community Health Services
Sue Perkins
Commissioning Manager for Long
Term Conditions
NHS Tower Hamlets
Every PCT should commission a community
rehabilitation service for stroke patients
delivered by staff with stroke specialist skills
Service configuration should be locally
determined and the service must meet all of the
performance standards
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Tower Hamlets demographics …
Deprived
Overcrowded
Diverse
Young
Growing population
High unemployment
20% families live on less than £15,000
And our health our needs assessment tells us …
▪ Low life expectancy
▪ Health inequalities (male life expectancy vs national
average)
▪ High burden of cardiovascular disease
▪ Health inequalities within the borough
But …
▪ Ranked 1st nationally for economic growth
Health Needs Assessment – Stroke in
North East London
▪ Approx 2,000 residents on GP stroke registers
▪ Absolute number of deaths from stroke low compared
to London (young population)..but..
▪ Deaths in under 75s (“preventable”) from Stroke third
highest in London
▪ Death rates in under 65s fourth highest in London
▪ Highest hospital admission rates for Stroke in London
Parts of the jigsaw in place in 2008
Agreed, mapped Stroke pathway
Service development & innovation driven by staff
• Staff working across acute and community pathway
• Inpatient community rehabilitation ward
• Multi-disciplinary Community Stroke Team (CST) established
Stroke a priority area - Commissioning Strategic Plan
Missing pieces
1. Capacity of CST and inpatient rehabilitation
2. Accountability for stroke pathway
3. Clear service specification for community rehab team
and structured Performance Monitoring process
4. Ongoing patient and public involvement
5. Clear link to prevention
Post discharge 12 week input
Team Manager
0.5 WTE
Bengali Therapy
Link Worker
Occupational
Therapist B7
Occupational
Therapist B6
Physiotherapist
B7
Physiotherapist
B6
Clinical
Psychologist 0.6
WTE
Speech &
Language B7
part-time
Therapy
Assistant B3
Consultant
Junior Dr FY2 Registrar
Nursing (not all stroke
specialist)
Speech and
Language
Therapy
Occupational
Therapy
Psychology
& Dietician
Physiotherapy
Some staff shared across Acute Stroke Unit, or
across Older People’s Ward, or all Community
Intermediate Care & Rehab services
Further pathway review
From patient perspective & against Stroke Strategy
Stakeholder involvement Staff interviews, ward observations, discovery interviews,
Local Authority engagement
To develop a “vision” for the service
Skill mix review
Identified need for more specialist nursing staff & nursing
clinical leadership role
JSNA
To add to PHAST data re. admissions, expected prevalence,
current inequalities
Investment and redesign needed
Early Supported Discharge
Pathway available to stroke survivors without an acute admission
Post 12 week follow up
Specialist vocational rehab service
POST
RATIONALE
Head
of Stroke
Services, ClinicalManagement
Nurse
Head
of
Stroke
Services
accountability for stroke
Specialist – leadership and management
pathway, service development, strategic
accountability
leadership
Clinical Nurse Specialist
Clinical leadership across acute, inpatient
rehabilitation and community
Patient Facilitator &
Family Support Worker
Champion stroke survivor, family, carer voice
Guide through pathway
Non clinician point of contact
ESD team
Physio, OT, Speech &
Language, RSW, Dietitian
Appropriate frequency & intensity of rehab
7 day a week service
Health and social care interventions
ESD to target 20% of admissions
Vocational Rehabilitation
Support for people to remain in, or return to
work or meaningful occupation
Quality & Outcomes
Patient / User
Experience
Performance & Activity
Staffing
Statutory compliance
Service Specific criteria
• Maximum time a patient waited for 1st clinical contact
• % of clients with goals / care plans agreed
• % appointments cancelled by the service
• % seen within 30 mins of appointment time
• # of referrals and discharges
• # of clinical and non-clinical contacts
• % of vacancies
• % of staff up to date with safeguarding children and
adults training
• Use of London Stroke Strategy measures
• # patients being case managed
Agreed patient pathway
From prevention, through acute, out
to community, ongoing care
Performance
Management process
Performance Dashboards, quarterly
reviews for CST and inpatients
HfL performance monitoring link
Important for multidisciplinary teams
working across a number of settings
Role of CHD Nurse Specialists and
Vascular Strategic Board
Department of Health new contract
template
Governance structure
Link to Prevention
Clear Service
Specification
How to commission for
a pathway rather than
for a care setting
Where does community
rehab start and stop e.g.
in-reach
How to capture data for
performance monitoring
The role of Local
Authority commissioner
and LA Stroke funding
How to engage primary
care in what we develop
How to “share” savings
in social care package
costs
Where does community
rehab start and stop e.g.
in-reach
How to capture data for
performance monitoring
The role of Local
Authority and / or third
sector providers
Who manages new
posts across disciplines
e.g. Rehab Support
Workers
How to engage primary
care and the role of GPs
in rehab
Can we combine unidisciplinary budgets for
a multidisciplinary
service
How does the service
work with more general
reablement teams
Additional resources sometimes distract from bigger issues
Transitions can be improved (acute to community and
community to long term support) without investment
Stroke Networks have information about best practice
Important to engage GPs – 12 month follow up
Be clear what you want to commission (service specification)
Meaningful PPI is difficult in short timescales and needs to be
embedded in whole process
Establish an explicit performance management process
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Community rehabilitation best practice