Final report

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MODELLING SERVICE INNOVATION IN STROKE CARE
FINAL REPORT
Core research team, Imperial College:
Dr Benita Cox; Prof. James Barlow; Dr Christina Petsoulas; Dr Steffen Bayer
Advisory team:
Dr Stephen Morris (Brunel University); Dr Alasdair Honeyman (independent consultant)
Prepared for:
Department of Health, Information and Communication Research Initiative 2 (ICRI II)
October 2008
EXECUTIVE SUMMARY
The UK government published the National Stroke Strategy in December 2007. This
emphasises the urgent need to change all aspects of stroke care, from patient awareness
and prevention to long-term rehabilitation after stroke.
Our study contributes to a better understanding of the need to reconfigure healthcare
services for stroke and the challenges of supporting aspects of stroke care with telecare or
telemedicine solutions. It was funded as part of the Department of Health’s Information and
Communication Research Initiative II.
The research had four main objectives: to map out the care journey for stroke patients, to
identify components of the care journey which could potentially be improved, to identify
appropriate interventions (ICT or others) that might improve stroke care delivery in line with
new policy guidelines and thereby to support local care community with planning stroke
services.
The reconfiguration of stroke services requires choices to be made between a variety of
models, for example whether to provide regional specialist stroke centres for the acute
phase of stroke care or to provide district general hospitals with specialist 24/7 facilities for
treatment. Other potential configurations may be to connect district general hospitals via
telemedicine to specialist advice in stroke centres. For each configuration there are
associated advantages and disadvantages which are discussed in this report.
A major difficulty facing stroke care provision is the lack of service integration between the
many authorities, professionals and stakeholders involved in the process. In addition, there
are also difficulties experienced during both the acute phase of care as well as during the
period of rehabilitation. Some of the more salient of these may be summarised as follows:
Acute phase

capacity pressures

availability of CT scanning

inadequate out-of-hours cover,

lack of thrombolysis facilities,

bed pressures in stroke units,

inappropriately long lengths of stay.
2
Community care

lack of workforce availability,

limited facilities for long-term care,

paucity of appropriate facilities for Early Supported Discharge
At the interface between acute and community care, delays exist in seeing patients after
discharge.
In this project we used simulation modelling to map the flow of care in the acute and
community parts of the care pathway for stroke patients and built alternative models of care
provision.
In recent years emphasis has been placed on the importance of patient self-care and the
need to support independent living. The use of telemedicine has the potential to enhance
patient independence and contribute to better chronic disease management. Technologies
for the remote monitoring of an individual’s health condition (telecare) could also, in time,
become a mainstream part of community care delivery. In general, these technologies have
the potential to be used in all aspects of healthcare from prevention, to acute care, to care in
the community.
While there is knowledge of the impact of technological innovations on individual patient
outcomes, their wider systemic impact is little understood. Simulation modelling can help to
develop such an understanding and ensure that future services are appropriately designed
and targeted.
Through modelling our study captures the current process of stroke care delivery (in its
acute and community settings) and offers the potential for scenario building in an interactive
way. The modelling process highlights areas where sufficient data is not available as well as
neglected problem areas in the care system. We suggest that this type of modelling is
suitable for application to highly complex processes, such as stroke care, and can be used
successfully as a communication and decision making tool before committing real resources.
However, the use of modelling is made challenging by the paucity of robust data.
3
CONTENTS
1
Introduction: project background................................................................................................ 7
2
The policy context ........................................................................................................................ 9
3
2.1
Financial implications of stroke ......................................................................................... 9
2.2
The need for more efficient use of resources ................................................................. 9
2.3
Need for service re-configuration and improvement ................................................... 10
Literature review: services for stroke patients ....................................................................... 12
3.1
3.1.1
Integrated services ....................................................................................................... 12
3.1.2
Stroke units.................................................................................................................... 13
3.1.3
Weekend cover ............................................................................................................. 14
3.1.4
Early supported discharge (ESD) .............................................................................. 14
3.1.5
Post-stroke rehabilitation ............................................................................................. 15
3.2
Diagnostics and treatments ............................................................................................. 16
3.2.1
CT scanning .................................................................................................................. 16
3.2.2
Thrombolysis ................................................................................................................. 17
3.2.3
TIA and secondary prevention.................................................................................... 17
3.3
4
Organisational structures and services ......................................................................... 12
The use of telecare, telemedicine and telerehabilitation ............................................ 18
3.3.1
Telestroke ...................................................................................................................... 18
3.3.2
Telerehabilitation .......................................................................................................... 19
3.3.3
The potential benefits of telestroke – and the evidence ......................................... 19
Case study: local stroke services ............................................................................................ 21
4.1
Background ........................................................................................................................ 21
4.2
Current stroke care process – hospital .......................................................................... 21
4.3
Current stroke care process – community .................................................................... 22
4.4
Identified problems and potential improvements ......................................................... 23
4
4.4.1
Stroke unit capacity ...................................................................................................... 23
4.4.2
Scanning and other tests............................................................................................. 23
4.4.3
Thrombolysis ................................................................................................................. 24
4.4.4
Transient ischaemic attack (TIA)................................................................................ 24
4.4.5
Length of stay................................................................................................................ 25
4.4.6
Early supported discharge (ESD) .............................................................................. 25
4.4.7
Rehabilitation................................................................................................................. 25
4.5
5
6
Data analysis of local stroke services ............................................................................ 26
Modelling .................................................................................................................................... 30
5.1
The planning challenge in healthcare ............................................................................ 30
5.2
Modelling in healthcare planning .................................................................................... 31
5.3
The prototype stroke care model.................................................................................... 33
5.3.1
Introduction .................................................................................................................... 33
5.3.2
Implementation ............................................................................................................. 34
5.3.3
Features of the prototype ............................................................................................ 35
5.3.4
Parameters and data ................................................................................................... 37
5.3.5
Experiments with the prototype .................................................................................. 38
Discussion ................................................................................................................................... 43
6.1
The need for service integration ..................................................................................... 44
6.2
Regional reorganisation of stroke services ................................................................... 45
7
Conclusions and recommendations ................................................................................... 48
8
References .................................................................................................................................. 50
Appendix 1: Methods ......................................................................................................................... 59
Appendix 2: Dissemination ............................................................................................................... 61
5
Figures
Figure 1: Length of stay haemorrhage patients ............................................................................. 27
Figure 2: Length of stay infarction patients .................................................................................... 27
Figure 3: Hospital admissions by type ............................................................................................ 28
Figure 4: Waiting time between discharge and therapy start ...................................................... 28
Figure 5: Care costs for patients receiving community rehabilitation ......................................... 29
Figure 6: Model overview .................................................................................................................. 35
Figure 13: Regional reorganisation of stroke services ................................................................. 46
6
1 Introduction: project background
The improved management of chronic disease is a central policy aim of the UK government.
The vision is one in which services are situated close to the patient and patients are
supported in self-care. Technological advances have the potential to facilitate the delivery of
this vision. Exploring the potential of telemedicine and telecare in the management of
chronic disease is the general theme of the Department of Health’s Information and
Communication Research initiative II under which this research was funded.
This project is concerned with stroke. Stroke is the third leading cause of death (after cancer
and heart disease) and the single largest cause of long-term severe disability in the UK and
other economically advanced countries. In recent years there has been a widespread
recognition of the need for improvements in the provision of stroke services (Markus 2007;
Schwamm et al. 2005; Saposnik, 2007; Rodgers, et al. 2003; Norrving and Adams 2006;
Langhorne 2006; Darzi, 2007). Radical changes are needed throughout the stroke pathway,
i.e. from prevention to acute care to care in the community with wide scale service reconfiguration. Planning wide scale service re-configuration is complex and requires
numerous factors and alternatives to be balanced.
One approach to this problem is to use modelling. Modelling can facilitate planning complex
processes such as stroke care and can be used successfully as a communication and
decision making tool before committing real resources. This project considers the use of
modelling to assess the likely impact of changes to care practices and services on the
outcomes of stroke care.
The research had four main objectives:
1.
To map out the care journey for stroke patients in order to gain a detailed
understanding of the whole patient pathway as well as the organisations and professionals
involved in stroke care.
2.
To identify components in the care journey that could potentially be improved. The
stroke patient pathway is a complex one which involves the close collaboration between
many organisations across primary, acute and social care. Fragmented services can mean
unnecessary long delays and bottlenecks with harmful effects both for patients and for the
organisations involved. Identifying the reasons for delays is a key step towards improving
stoke care services.
7
3.
To use modelling to identify appropriate interventions that might improve stroke care
delivery in line with new policy guidelines.
4.
To support the local care community in planning stroke services. Planning and re-
structuring complex, multi-agency services requires the close collaboration between different
stakeholders. Modelling can facilitate discussion around issues such as preferred priorities
and cost-effectiveness, and lead to better decision-making.
We adopted a case study research design and used a combination of methods for the
research: semi-structured interviews, observation, literature scanning, policy documentation
analysis, modelling (Appendix 1).
8
2 The policy context
The financial burden of stroke care has been widely recognised creating an awareness of
the need for a more efficient use of resources. Inefficiencies in resource use as well as
dissatisfaction with care outcomes and care processes have triggered calls for a reconfiguration and improvement of services.
2.1 Financial implications of stroke
As a leading cause of the need for inpatient hospital stay, long-term rehabilitation and care in
the community, stroke represents a huge financial burden on NHS resources. According to
one estimate this is as high as 4-6% of the total NHS expenditure (Saka, et al., 2005). The
national average length of stay in hospital for stroke patients is 28 days, so a large
proportion of NHS spending on stroke is for hospital inpatient stay. According to a recent
National Audit Office report, £2.8 billion represent direct care costs, £2.4 billion are informal
care costs (e.g. home care by families) and £1.8 billion are wider economic costs. The same
source reports that on average 20% of nursing home residents are there as a result of
stroke, with total annual care costs of approximately £680 million (NAO, 2005).
2.2 The need for more efficient use of resources
There is wide variation in the quality of stroke care provision between the UK and other
economically advanced European countries, with the UK consistently achieving poor
outcomes. Markus (2007) found that spending on stroke services in the UK is as high or
higher than in other European countries which achieve better outcomes. According to the
National Director for Heart Disease and Stroke, spending on the NHS has increased
significantly, and currently the UK’s average spending on healthcare costs, as a percentage
of GDP and per capita, including the percentage spent on stroke services, is double the
European average.
Despite this increase in spending, the stroke mortality rates in the UK have remained
relatively high and the use of effective treatments, such as thrombolysis, is making slow
progress (Boyle, 2007). Grieve et al. (2001) note that high cost stroke care in London is
accompanied by high levels of post stroke mortality and dependence. Together, these
findings suggest that the organisation of stroke care delivery, rather than levels of funding, is
an important factor contributing to poor outcomes. The key question is thus how existing
resources may be deployed in a more cost-effective way (Grieve et al. 2001). According to
the estimates of the NAO report, better organisation of stroke services could result in £20m
annual savings, 550 fewer deaths and 1700 fewer cases of disability. (NAO, 2005)
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2.3 Need for service re-configuration and improvement
The need for improving stroke services has been recognised in the National Service
Framework for Older People (DH, 2001), which stated that every general hospital should
introduce a specialist stroke service by 2004. However, a national survey conducted by the
British Association of Stroke Physicians found that many hospitals lacked a number of
factors required by the NSF (Rodgers et al. 2003). The The findings are summarised in the
box.
British Association of Stroke Physicians survey

Only half of the acute stroke units admitted patients within 24 hours. (Rodgers et al.
2003).

The number of beds available on acute stroke and stroke rehabilitation units did not
reflect the total number of stroke inpatients, and a large number of these units (53% and
79% respectively) had admission criteria.1 The impact of limited bed availability in stroke
units means that not all patients have access to dedicated stroke services throughout the
entire duration of their stay in hospital. The authors also found that stroke unit therapy
staffing levels in UK hospitals were often lower than the staffing levels present in
randomised controlled trials. In order to provide the early and intensive rehabilitation
required by the NSF, therapy staffing levels would have to be increased (Rodgers et al.
2003).

The need to restructure stroke services in the UK is urgent. In other countries, for
example, stroke care is an integral part of neurology. In the UK it tends to fall between
neurology and general geriatric medicine (Markus 2007).

Greater emphasis should be placed in the UK on improving the acute phase of stroke
care. This would not only significantly improve patient outcomes but would also be costeffective by reducing the length of stay in hospitals and by resulting in less long-term
disability (Markus 2007).

The vast majority of the cost incurred in in-hospital stay in the UK is for nursing and
overheads rather than investigations and medical care (Markus 2007).

Patient awareness and recognition of stroke symptoms needs to be improved with
immediate ambulance assessment and transfer to specialist stroke centres. (Markus
2007).

While in many European countries CT or MRI scanning is performed on admission to A
& E departments, many UK hospitals struggle to provide it within 24 hours (Markus
2007).

There is inadequate access to stroke specialists for administering thrombolysis where
suitable. According to Markus (2007), while 20-30% of eligible patients are given
1
According to the 2004 National Sentinel Stroke Audit, 67% of hospitals nationally applied selection
criteria for their stroke units.
10
thrombolysis in Australia2, North America and Europe, only 1% of patients receive the
therapy in the UK.

A severe shortage of specialists trained in the management of acute stroke care exists.
(Markus 2007).

Despite the evidence for the benefits of organised stroke units, only 62% of patients in
the UK were treated in such a unit at any time during their stay and only 54% spent more
than half of their stay in such specialised units (Royal College of Physicians, Sentinel
Audit, 2006)
These issues suggest that new strategies and possibly a substantial reconfiguration of
services are required in the UK. The recently published National Stroke Strategy (DH, 2007)
makes the following major recommendations:

improve awareness of the symptoms and urgency of stroke among NHS staff and the
public,

educate the public about stroke risk factors and provide advice on lifestyle and treatment
options,

improve the management of minor strokes or transient ischaemic attacks (TIAs) (e.g.
through expert assessment, MRI within 24 hours, follow up care),

radically change existing services of acute (e.g. 24/7 access to clinical assessment, rapid
imaging and the ability to deliver intravenous thrombolysis, prompt access to high quality
stroke unit, stroke networks, regional stroke centres) and post-acute stroke care
provision (e.g. early supported discharge, rehabilitation as long as needed),

provide adequate specialist therapy and support in the community,

provide active end-of-life care,

deliver patient care through stroke skilled workforce.
Implementing these recommendations will require careful planning and close collaboration of
those involved in the provision of stroke care e.g. decision makers, professionals as well as
patients and carers.
2
An Australian government research paper, however, claims that thrombolysis is not widespread in
either Australia or New Zealand and in the US, at least until 2005, the rate was only between 2% and
4% (Wojner-Alexandrov and Malkoff, 2006).
11
3 Literature review: services for stroke patients
The purpose of the review was to identify published research and trials on stroke care and
the main issues concerning the optimal organisation of stroke care services. The literature
may be broadly classified into two domains: organisational structures and services, and
diagnostic treatments. The literature on the role of telecare, telemedicine and
telerehabilitation in stroke services is also reviewed.
3.1 Organisational structures and services
3.1.1 Integrated services
Stroke is a complex condition which requires a systemic integration of services e.g. primary
care, ambulance services, acute treatment and rehabilitation, post-acute rehabilitation and
often long-term health and care support in the community. For this reason, it presents a
significant challenge to existing generally fragmented health and social care services, not
only in the UK but in other advanced countries (e.g. the US, Canada).
There is a need for integrated planning and delivery of stroke services (Plochg and Klazinga
2002). A recent OECD report comparing the treatment, costs and outcomes of stroke
services in seventeen European countries concludes that there are benefits from taking an
holistic systemic approach to managing stroke, including prevention, acute care and
rehabilitation and, second, that stroke units appear to have the potential to deliver real
benefits, which are not currently fully realised (Moon et al. 2003).
The recent National Stroke Strategy (DH, 2007b) and the American Stroke Association’s
Task Force on the Development of Stroke Systems (Schwamm et al. 2005) both recommend
the implementation of ‘stroke systems’ or ‘stroke networks’. As well as raising public
awareness of the symptoms of stroke and providing information for appropriate action, such
systems help to ensure that patients are brought to ‘hyper-acute’, fully-equipped hospitals for
the acute phase of stroke. They also enable a smooth transition from hyper-acute to subacute care and then from inpatient to outpatient care and rehabilitation in the community.
Stroke networks include all healthcare organisations involved in the provision of services. .
In order to work effectively, stroke networks require appropriate communication links and
transportation protocols which can be facilitated by advances in ICT (see section 3.3. on
telecare and telemedicine). Despite long standing scientific proof of the effectiveness of
organised stroke care, stroke systems have been slow to implement (Norrving 2005;
12
Norrving and Adams 2006). To move from the current fragmented approach to integrated
stroke systems is a complex task. Radical service re-configuration needs time, resources
and careful planning with input from all relevant stakeholders.
Resource limitations or delays in reaching agreement between stakeholders may mean that
adopting an incremental instead of comprehensive service reconfiguration approach is more
realistic. It may be necessary, for example, to start by improving the acute aspect of stroke
care before moving on to rehabilitation in the community. Simulation modelling can be
useful during the planning stage of complex service re-configuration (see ‘Modelling’ section
below).
3.1.2 Stroke units
Dedicated specialist stroke units, typically including a co-ordinated multidisciplinary team
operating within a discrete ward, can be either acute only, rehabilitation only or a
combination of the two (comprehensive). A number of studies show that patients treated in
stroke units rather than in general medical wards benefit in terms of survival, regained
independence and return home (Stroke Unit Trialists’ Collaboration 2001; Evans, Perez et al.
2001). Studies that have extended the follow-up for five or ten years have found that the
benefits are sustained for patients treated in stroke units (Jorgensen et al. 1999).
There is wide variation in practice which makes it difficult to give a precise definition of
‘stroke units’. This means there is some uncertainty about which components of stroke units
contribute to better outcomes. A review of trials (Langhorne and Pollock 2002) suggests that
the characteristics that make stroke units effective appear to be: early comprehensive
assessment of medical problems and complications (e.g. medical history and diagnostic
examinations), early and active management of physiological abnormalities (including early
mobilisation of patients), skilled nursing care, early setting of rehabilitation goals and early
planning to discharge. Effective stroke units require a core multidisciplinary team of medical,
nursing and therapy staff (physiotherapy, occupational therapy and speech and language
therapy).
Despite the problems in measuring the impact of stroke units, a number of studies have
pointed to their effectiveness. A study in Norway, for example, shows that stroke units
provide better treatment in terms of reducing death and disability, with beneficial long-term
effects on survival, disability and quality of life. In Norway, where most acute hospitals have
dedicated stroke units, the recommended model is a non-intensive combined unit able to
focus simultaneously both on acute care and rehabilitation. This has been well evaluated in
randomised trials and has achieved some of the best results regarding acute stroke care
(Indredavik 2003).
13
Evans et al. (2001) argue that beneficial practices such as thrombolysis, physiological
homoeostasis, early prescription of aspirin, anticoagulation and early mobilisation are likely
to contribute significantly to reducing mortality and dependence, and that such interventions
are more common in stroke units than in non-specialist settings. Diagnostic investigations,
such as CT scans and carotid duplex studies, are also undertaken earlier in stroke units than
in general wards. In addition, aggressively managed supportive care to assist neurological
recovery and which is applicable to most stroke patients can be provided in stroke units.
Another study (Kalra et al. 2000; 2005) compared stroke units, stroke teams and care in the
patient’s home, and found that stroke units were more effective than a specialist stroke team
or specialist domiciliary care in reducing mortality, institutionalisation and dependence after
stroke. The authors found little support for either specialist domiciliary services for acute
stroke or for stroke management in general medical wards, even with specialist team input.
The stroke unit intervention was less costly per patient day alive and more effective than the
stroke team intervention. The stroke unit was found to be a more cost-effective intervention
than either stroke team or home care (Kalra et al. 2000; 2005). Another study concludes
that, compared to stroke teams or domiciliary care, stroke units are more expensive, but they
have better quality outcomes. (Patel et al. 2004).
In general, the value of stroke units is now widely recognised. According to one expert,
‘although recommendations and guidelines on stroke care may differ in details, they all point
towards stroke unit care and speed. Cost may be an argument against such units, but the
benefits are substantial’ (Hacke 2000).
3.1.3 Weekend cover
Studies show that reduced weekend and holiday cover has a negative impact on stroke
outcomes. Hasegawa et al. (2005) and Saposnik (2007) investigated the effects on stroke
outcomes of low-volume care resulting from weekends and holidays, when staffing levels are
lower and without rehabilitative services. Weekday admission was found to be an
independent negative predictor of case fatality and a positive predictor of favourable
outcome at discharge from acute stroke units. In patients with rehabilitative therapy, a
reduction in the weekday ratio was also associated with unfavourable outcome, probably
due to a reduction in multidisciplinary care.
3.1.4 Early supported discharge (ESD)
The national length of stay in NHS hospitals is in general a lot higher than in the US (Ham et
al. 2003), and the biggest differences are for stroke and hip fracture. Although this study has
been criticised (Mallet 2004), the authors argue lessons can be learnt about the scope for
14
reducing hospital lengths of stay for stroke by providing care in alternative, non-acute
settings
Plans for introducing alternative arrangements for the provision of therapy for stroke patients
have recently been the focus of health policy in the UK, for example through ‘early supported
discharge’ (ESD) for patients following a mild or moderately severe stroke. ESD is a system
of care which aims to provide earlier discharge with rehabilitation and support in a home
setting, as opposed to conventional hospital based rehabilitation. ESD is typically provided
by a specialist multi-disciplinary team including medical, nursing and therapy staff as well as
social work input.
A number of studies have found that ESD can be beneficial both in terms of cost
effectiveness and care outcomes (Larsen et al. 2006). A review by Anderson, et al. (2005)
showed that the greatest economic benefits have been seen in trials involving a co-ordinated
multi-disciplinary ESD team3 and in patients with mild-moderate disability. These benefits
arise from reductions in length of hospital stay, long-term dependency and admission to
institutional care (Anderson et al. 2005). This review also found that patients receiving ESD
services were more likely to be independent and living at home six months after stroke than
those who received conventional care. Thorsen et al. (2005) show that the good outcomes
experienced by patients receiving ESD were still present five years later
Fjaertoft et al. (2005) found that ESD is most cost-effective for patients with a moderate
stroke and concludes that acute stroke unit care combined with an ESD programme may
reduce the length of institutional stay without increasing the costs of outpatient rehabilitation
compared with traditional stroke care Langhorne (2006) also found that ESD reduces
hospital length of stay and long-term dependence, mostly for patients with less severe
strokes. This review points out, however, that more research is required to define the
essential characteristics of ESD services, as well as to determine cost-effectiveness for
different patient and service groups (Langhorne 2006).
3.1.5 Post-stroke rehabilitation
The problems most frequently mentioned by stroke survivors and their carers are the social
and emotional consequences of stroke and, second, service deficiencies. There is little
clarity about the structure of a comprehensive primary care service providing long-term
support to stroke patients and their carers (Murray et al. 2003). Co-ordination between
3
Comprising medical, nursing, physiotherapy, occupational therapy, and speech and language
therapy staff.
15
health and social care service providers, in relation to the provision of community
rehabilitation, can also be lacking (McKevitt et al. 2004).
Stroke care units are seen as the appropriate setting for the acute phase of stroke. However,
whether an acute hospital setting is the most appropriate environment for post-acute stroke
rehabilitation has been questioned (Von Koch 1998). Much of the literature has concentrated
on the appropriate length of time for rehabilitation to be provided and whether the optimal
setting is within the hospital or elsewhere.
According to the European Stroke Initiative, rehabilitation should begin as soon as patients
are clinically stable and during the acute phase should not last longer than 6-12 weeks. After
this time, it should be administered for as long as improvement in function is observed
(Hacke 2003).
It has been argued that rehabilitation should, whenever possible, take place in the patient’s
home (Wade 2003). However other studies suggest that whilst rehabilitation in a stroke-unit
care can be valuable for stroke patients in hospital, the effectiveness of outpatient care is
less certain (Legg et al. 2004). Research suggests that therapy-based rehabilitation
services for stroke patients living at home is beneficial in terms of maintaining independent
living.
3.2 Diagnostics and treatments
3.2.1 CT scanning
CT scanning is essential in diagnosing different types of stroke (e.g. infarction, haemorrhage
and stroke mimics) and in determining the appropriate clinical management decisions.
Limitations to immediate CT scanning may be due to lack of availability in scanners or a
shortage of radiologists and radiographers. Wardlaw et al. (2004) argue that as CT scanning
is an expensive and limited resource, determining its cost-effectiveness is important. The
authors used modelling techniques to estimate the expected benefits and costs associated
with different CT scanning policies. They recommend a policy of scanning all patients
immediately. Costs are offset by savings in the length of inpatient stay. Because of the
overall cost-effectiveness of immediate CT scanning, the cost of installing CT scanners (or
training more radiologists) would quickly be recouped in reduced costs of stroke to health
services.
16
3.2.2 Thrombolysis
In some countries, the intravenous injection of clot-busting drugs such as t-PA (thrombolysis)
in the treatment of stroke was given approval more than a decade ago (e.g. in the US in
1995). Although the availability of thrombolysis has revolutionised the treatment of stroke
patients, its use is still limited. While in some countries thrombolysis is used widely (e.g. US,
Germany), others (e.g. UK, Australia, New Zealand) have been slower in adopting the
treatment (ANZHSN, 2006). This slow uptake may partly be due to the fact that it is only
suitable for a relatively small proportion of patients within a short time window from the onset
of stroke and because it requires careful co-ordination of services and 24/7 availability of
medical expertise (including prompt CT scanning).
Alternative models for offering thrombolysis (e.g. ‘hub and spoke’ systems in which hospitals
form a network with one specialist centre offering support and advice via the use of
telemedicine) may be more cost-effective. In the light of these challenges, the costeffectiveness of introducing thrombolysis to every single general hospital has not yet been
proven. A 2003 review of thrombolysis trials suggests that the procedure can have promising
outcomes but its widespread use in routine clinical practice is not supported (Wardlaw et al,
2003). Khaja and Grotta 2007argue that since only a small percentage of acute ischaemic
stroke patients meet the criteria for thrombolysis, alternative acute treatment strategies
should also be in place.
3.2.3 TIA and secondary prevention
Effective management of mini-strokes or Transient Ischaemic Attacks (TIAs) is important for
stroke care planning as these are warning signs for the onset of a major stroke in 15-20% of
cases (Rothwell et al. 2006). These authors argue that the emphasis should be placed on
identifying, including through brain imaging (CT and MRI), and treating the patients most
likely at risk of a recurrence. Blight et al. (2000) suggest that compared to conventional
practice of seeing the patient first, ordering of tests and then reviewing them, a single
consultation dedicated Cerebrovascular Disease (CVD) clinic is cost effective in the
outpatient management of minor stroke or TIA incidents. Educating the public to recognise
the symptoms of TIA is also essential (Rothwell, Buchan et al. 2006).
Urgent treatment of TIAs and minor strokes can result in effective secondary prevention and
even if secondary prevention is ineffective, urgent admission to hospital can still have
beneficial effects for high risk patients because of the potential for rapid thrombolysis in the
event of an early recurrent stroke. Prompt surgery for suitable patients may also justify
urgent hospital admission in high risk patients (Rothwell et al. 2006).
17
3.3 The use of telecare, telemedicine and telerehabilitation4
3.3.1 Telestroke
There is a substantial literature on the use of ICT to support and enhance stroke care
services 5. Applications broadly fall into the following categories: remote consultation
between health professionals (called ‘telemedicine’ in this report), remote reading of scans
(‘teleradiology’) and remote provision of rehabilitation support, for example through video
links (‘telerehabilitation’).
A ‘hub and spoke’ model is the most frequent type of telestroke system. In this model remote
hospitals communicate with a centre of expertise. The data may be captured in a variety of
formats (incl. for example video) and transmitted in real time to the hub (Cho et al. 2007).
The patient’s clinical information and scans are then examined by a specialist. The decision
as to whether or not to administer thrombolysis is jointly taken by the specialist and local
physicians. Neurologists, neurosurgeons, nurses, programme administrators and technicians
are part of the network. Existing telestroke networks are typically spread over distances of
160 to 400 kilometers (Deshpande et al, 2008).
In the past ten years a number of pilot stroke networks supported by telemedicine have been
established, notably the Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) in
Bavaria (Audebert, et al. 2006) and similar networks in the US (Wang, et al. 2003; Wang,
2003; Wang, et al. 2000; Hess et al. 2005).
TEMPiS involves two specialised acute stroke centres which provide 24/7 consultation to
twelve local hospitals via a two-way video conference system and CT/MRI image transfer
with a high-speed data transmission. Each local hospital has specialised stroke wards with
qualified stroke teams. The aim of the network is to administer thrombolysis to patients in
rural areas at their local hospital within the 3 hour window.
The Remote Evaluation in Acute Ischemic Stroke (REACH) programme in rural Georgia in
the USA provides community rural hospitals with access to specialist neurologists who can
4
This section is partly based on research carried out by Erik Yves Landriault for his MSc research
report on ‘Towards the Development of a Stroke System of Care. Implementation of a Regional
Telestroke Programme in Malaysia.’ Imperial College Business School, September 2008.
5
Susman 1997; Levine and Gorman 1999; Shafqat et al. 1999; Gagliano et al. 2000; LaMonte et al.
2003; Gourlay et al. 2000; Dawson et al. 2001; Scheideman-Miller et al. 2001; Silverman 2001;
Brennan et al. 2002; Piron et al. 2002; Richardson-Nassif et al. 2002; Tran et al. 2002; Johnston and
Worrall 2003; Wang 2003; Wiborg and Widder 2003; Audebert et al. 2004; Buurke et al. 2004; Choi et
al. 2004; Lai et al. 2004; Piron et al. 2004; Schwamm et al. 2004; Waite et al. 2004; Levine and
McConnochie 2007; Schwab et al. 2007.
18
remotely assess patients, read CT scans and potentially guide non-stroke rural hospital
physicians in administering thrombolysis.
3.3.2 Telerehabilitation
There is growing interest in the use of virtual reality within stroke rehabilitation, driven partly
by concerns that clinicians are not often able to provide adequate rehabilitative environments
(O'Brien, 2008; Rizzo et al, 2004, Rizzo and Kim, 2005). Authors argue that such systems
might provide performance feedback and support the learning process underlying
rehabilitation.
Virtual environments have been developed for a variety of rehabilitation purposes, including
interventions for assisting with activities of daily living, way-finding in urban environments,
wheelchair training and public transport navigation. Some feasibility trials have focused on
post-stroke, home-based intervention. Lewis-Brooks (2004) describes a system whereby
patients’ limb movements and body posture are tracked and converted into pleasant,
abstract images and a melody to heighten activity, function and motivation. Should this
approach prove beneficial, it is possible to envisage it also contributing to remote monitoring
of at risk patients via a more conventional telecare system. The technology has also been
used to train therapists in remote areas (Iwatsuki et al, 2004).
Various reviews of the research literature have been published (e.g. Crosbie et al, 2007;
Henderson et al, 2007). O’Brien (2008).
3.3.3 The potential benefits of telestroke – and the evidence
Telestroke allows remote access to clinical advice. Many studies have recognized that
telemedicine is very well suited to the evaluation of acute stroke, since most symptoms can
be assessed through audio and visual information. Telestroke enables immediate remote
access to an expert stroke diagnosis, the avoidance of costly air-transport of stroke victims,
expert supervision of patients receiving thrombolysis, as well as specialist advice on
secondary prevention and risk management. Telestroke improves the uptake of evidencebased medicine/ (Bahouth, 2003; Deshpande et al, 2008; Gorman and Levine, 1999;
Audebert et al, 2006).
The evidence base, however, remains inconclusive. The Canadian Agency for Drugs and
Technologies in Health, which has undertaken the only systematic review of telestroke
studies, found that the literature is contains many low quality observational studies.
However, it also concluded that most studies suggested that telestroke is consistently
associated with enhanced process of care, with improvements in health outcomes, including
19
reduced mortality and morbidity at six months post-stroke (Deshpande et al, 2008) (see box
for examples).
Improvements in stroke consultation and door-to-needle times, and a decrease in transfers
of patients, imply cost-savings through reduced morbidity or avoidance of expensive care,
the resource implications of telestroke remain unclear (Deshpande et al, 2008). This is due
to a lack of data on how much it costs to implement or manage a telestroke system in
mainstream use.
Compared to telemedicine, there are few studies reporting on home telecare or
telerehabilitation specifically for stroke patients. A systematic review of home telecare
applications found 8666 studies (early 2007), of which 98 met the inclusion criteria (Barlow
et al. 2007). None of these focused on stroke patients.
Results from the TEMPiS project show that adverse outcome of thrombolysis after remote
consultation are comparable to those reported in the National Institute of Neurological Disorders and
Stroke trials, and that the service is cost-efficient. The network made thrombolysis far more widely
available without diminishing the quality of care received by the patients. (Audebert et al, 2007).
Numerous studies have analyzed the reliability of face-to-face stroke consultation in person versus a
live video link (e.g. Chang et al, 1999; Gaul et al, 2003; Al-Khoury et al, 2005; Chacon et al, 2008).
Remote examination of acute stroke patients is generally reliable according to these studies. For
example, in a study of 153 telestroke patients in all but four cases both the local physician and remote
neurologist were satisfied that the neurologist had contributed with relevant advice to enhance stroke
management (Wiborg, 2003). These findings are consistent with research from the Massachusetts
General Hospital where all physicians involved felt that telestroke improved care and 96% of
physicians approved of the quality of telestroke (Hirschberg et al 2004).
The REACH programme highlighted problems in administering thrombolysis via a telemedicine
network, notably the lack of facilities and expertise in community hospitals to manage stroke patients
appropriately throughout their stay and deal with complications. Many patients may therefore need to
be transferred to a tertiary stoke centre after remote thrombolysis, raising the question of why they
should not be transferred directly there (Crome and Bahr 2003). Since studies have shown benefits in
rural settings of transporting stroke patients by helicopter to specialist centres, this may represent a
better solution than telemedicine in certain circumstances. In the future, pre-hospital thrombolysis
might become a further option. Recent innovations in mobile ultrasound imaging equipment may
potentially support the administration of thrombolysis even before the patient arrives in hospital.
20
4 Case study: local stroke services
4.1 Background
Our case study involved a district general hospital in London and the primary care trust and
social services areas within which it was located. In order to explore the potential impact of
the changes and innovations discussed in the previous section, we considered how local
stroke care services were currently provided and where potential improvements could be
made. We then explored the possible impact of selected improvements using simulation
modelling (see section 5).
4.2 Current stroke care process – hospital
There is no formal stroke pathway in the acute trust, but our interviews suggested that the
following processes are in place:

Patients present to A&E and if appropriate are referred to the stroke team (normally the
stroke coordinator).

If patients need specialist treatment that is not offered at the hospital, they are sent to the
nearest trust offering such treatment. (Like the majority of acute trusts in the country, the
trust does not offer specialist stroke treatments e.g. thrombolysis.)

The patient is admitted to the stroke unit providing there is bed availability. At weekends
the unit relies on the hospital’s site managers to put stroke patients into the stroke unit if
there is a bed available.

If there is no stroke unit availability, the patient is admitted to the Acute Medical Unit
(AMU). Patients can stay in the AMU for a maximum of three days.

If after three days there is still no bed available in the stroke unit, patients are transferred
to other hospital wards. When a bed becomes available in the stroke unit, the most
acute patient is admitted. For most patients the wait is 2-3 days, although outlying stroke
patients in other wards can wait up to seven days to be transferred.

Any outliers (i.e. patients in other wards) are visited only by the stroke co-ordinator and
the therapists. The stroke consultants do not visit patients in other wards. However, at
the time of the fieldwork this practice was about to change and consultants intend to visit
all stroke patients in the hospital in the future.

When patients first come into the stroke unit, the stroke coordinator makes sure that they
are seen as soon as possible by a physiotherapist, an occupational therapist, a speech
21
and language therapist, and the dietician if necessary. The stroke coordinator also
makes sure that CT scans, blood tests and any other necessary tests are ordered, and
that patients are given aspirin or anything else prescribed by the stroke clinician.

A scan is ordered from the radiology department. 95% of patients have the scan within a
24h period.

Therapy starts on the day of admission if patients are fit, or as early as possible. There is
no weekend cover for therapy. While in hospital, patients receive 45 minutes of
physiotherapy per day for five days per week. They are seen by an occupational
therapist within the first three days of arrival and then daily according to their needs.

Patients continue to receive rehabilitation6 until either they stop achieving the goals set
for them or until they have achieved them and are no longer making any progress. If
there is still potential for progress, when they are discharged from hospital the
community therapy team takes over.
4.3 Current stroke care process – community
At discharge from hospital, if there is a need for further rehabilitation, patients are referred to
the community’s intensive rehabilitation team7. Community based care is provided by a
combined social and healthcare team. Relations between the acute trust, the PCT and social
services were described by interviewees as good. A senior therapist from the community
stroke team is the link between the acute trust and the PCT and attends the weekly multidisciplinary team meetings in the acute hospital. In this way, the community team is kept
informed about the progress of the hospital’s stroke patients, especially those about to be
discharged home so that an appropriate care package can be put in place.
6
The hospital stroke rehabilitation team comprises four physiotherapists (One Senior grade 1 (parttime i.e. two days a week), two Senior grade 2 full-time, and one Junior full-time), who cover the
stroke unit and any other neurological patients in the hospital. But this is likely to change. There are
two occupational therapists (One Band 7 and one Band 6) and a Band 5 therapist who rotates
between different teams, e.g. medical, surgical, orthopaedic, old people and stroke care. There are
also a full-time dietician, Band 7, and a speech and language therapist. In the acute trust, there are
two multi-disciplinary team meetings every week, each led by one of the two stroke consultants in the
unit, in which therapists and the consultants discuss patient progress.
7
The community stroke rehabilitation team consists of three physiotherapists (one Senior grade 2 fulltime and two part-time Band 7). There are two occupational therapists (one full-time Band 7 and one
half-time Band 6). There is also one speech and language therapist and three assistants (two full-time
and one part-time).
22
At the time of the research, interviewees perceived the local wait for community rehabilitation
to be on average two weeks, but were aware that the figures were volatile because of
service restructuring. Our subsequent analysis of PCT data showed waits to be frequently
substantially longer than two weeks. With the introduction of early supported discharge, the
PCT planned to bring this down to two days.
There is no separate neuro-rehabilitation unit in the community. Patients discharged from
hospital either go to their own home (where they receive rehabilitation from the community
therapy team) or to a care/residential home. Patients requiring neuro-rehabilitation are
referred to one of three units outside the borough. Patients who go into care or nursing
homes are seen by the community rehabilitation team depending on their needs and
potential for improvement. Patients with psychological or cognitive needs are also referred
outside the trust (to either NHS or private hospital).
4.4 Identified problems and potential improvements
4.4.1 Stroke unit capacity
There was agreement amongst the interviewees that that appropriate acute stroke
management for the majority of patients will reduce long term disability, leading to major cost
savings. Limited bed capacity in the hospital’s stroke unit due to beds not being ring-fenced
for stroke patients was perceived to be a serious problem. Stroke patients admitted to other
wards maybe under the care of non-stroke consultants. Research shows that specialised
stroke units have better results (see section 3.1.2). The lack of a psychologist in the stroke
unit (a Royal College of Physicians guideline) was another issue mentioned at interviews.
‘Our consultants are stroke specialists. And one consultant in the medical ward has stroke
experience. But patients may on admission be put under a medical consultant without stroke
experience. So it’s a matter of luck’. (Acute trust interviewee).
4.4.2 Scanning and other tests
There is emergency cover for CT scanning 24/7, with radiographers or radiologists on call on
evenings and weekends. However, scanning for stroke patients is not regarded as a routine
emergency and it is likely to be performed out-of-hours only in special circumstances. There
is one CT scanner in the acute trust which is very old and very slow, although there are
plans to replace it. Currently scanning and other tests can take 2-3 weeks. The aim is to
reduce this to one week although the local stroke strategy recognises the need for CT
scanning ideally within three hours or a maximum of 24 hours.
23
‘I know last year we had lots of incidents of the scan being broken. And it would be broken
for a whole week. I remember sending patients to another hospital for scanning’. (Acute trust
interviewee).
4.4.3 Thrombolysis
The trust does not offer thrombolysis to stroke patients, but the possibility of offering it was
discussed in the local stroke strategy meetings. Interviewees were in favour of thrombolysis
and discussions were underway about how to plan a cost-effective service and supporting
infrastructure. This includes establishing a co-ordinated regional approach to identify a
specialist site to be ‘on take’ for stroke, and significantly improved scanning availability.
‘We don’t have thrombolysis here yet, and that’s something we are going to look towards but
because we are a smaller district hospital, I don’t think we are going to get that within the
next 3 years possibly. If we have that, we are going to need more equipment, monitoring
etc.’ (Acute trust interviewee).
‘Yes, the clinicians are very keen on having a thrombolysis clinic but all this needs money
and investment and knowledge about whether they are viable or not’. (Community
interviewee)
‘A lot of emphasis is placed on thrombolysis but even if all patients presented at the hospital
immediately after the stroke, only about 1/3 or less of them would be suitable for
thrombolysis’. (Acute trust interviewee)
4.4.4 Transient ischaemic attack (TIA)
Improvements could be made to the care of patients who have suffered a minor stroke or
TIA. These patients often fall through the net because either the wait to see a consultant is
too long, or they are sent back home without treatment. One solution would be TIA clinics
and more generally improved prevention of stroke via better information about the dangers
of stroke, and better management of patients at risk or who have suffered a TIA.
‘If GPs decide to refer patients e.g. to a cardiologist, of course they would have to wait until
they get an appointment, whatever the waiting time is, it could be three months. And this is
why we think that maybe we should have a TIA clinic, specifically for TIA patients so that we
can manage them as quickly as possible’. (Community interviewee)
24
4.4.5 Length of stay
In 2005, the local average length of stay (ALOS) for cerebral infarction was well above the
national average (32 days compared to 25). The ALOS for all stroke patients was 27.1
against the national average of 23.6 days. For patients discharged to long term care
(10.7%), the ALOS was 70 days.
Length of stay in hospital is partly related to the provision of appropriate facilities and
rehabilitation for stroke patients in the community, for which there is currently an average
wait of two weeks. Delays in providing equipment or making home alterations can also
increase the length of stay in the acute trust. One interviewee cited an example when it took
about 4-5 weeks to move a patient’s furniture downstairs so they could return home.
Improvements and changes to the discharge and rehabilitation process could be made
locally.
4.4.6 Early supported discharge (ESD)
An initial ESD pilot was not successful because the selection criteria8 made it hard to identify
suitable patients. However, the acute trust and the PCT are trying to develop an ESD service
for suitable patients. The local stroke strategy aims to

Enhance the hospital’s stroke multi-disciplinary team by developing a stroke therapy
team managed by a lead clinician.

Enhance the community therapy team in order to support ESD (aiming for a two day wait
from hospital discharge) and enable continuation of treatment to be needs led.

Explore need for a Community Matron service for patients with complex needs.

Provide training and development for the intermediate care at home team.

Appoint a Stroke Association Family Support Worker to focus on the transition into
community.
4.4.7 Rehabilitation
Evidence suggests that in the post-acute phase the rehabilitation should be provided by
teams specialised in stroke care in a non-hospital environment, either the patient’s home or
a community rehabilitation centre. Our interviewees agreed.
‘We have intermediate beds but maybe we need a mini hospital out there, not as a hospital
but a community place where people can go even in the interim, maybe they need further
8
The criteria were that patients needed a Barthel score of 9 or 10, were living in the local area and
had no major cognitive problems.
25
rehab but they don’t need to stay in the acute hospital. Something for when they are not
quite ready to go home, or when you have these big delays’. (Acute trust interviewee).
At the moment there is no such centre in the area, and the community rehabilitation
intensive therapy team treat all neurological conditions. According to the local stroke
strategy, the reason for not having specialist rehabilitation stroke team is the low number of
patients and available resources.
The local strategy suggests that the preferred long term aim would be to transfer the
rehabilitation element of stroke recovery from the hospital into a separate unit in the
community offering specialised rehabilitation for stroke patients. This would make it easier to
provide ESD. Such a step would involve major reorganisation of services with implication for
staff posts, and impact on finances.
The strategy also identifies other opportunities for improving long term support and
rehabilitation in the community such as:

Appointing a Stroke Association Family Support Worker and development of stroke
clubs/support groups, aphasia groups and services by working with existing voluntary
sector organisations.

Working with local agencies to create more specific exercise opportunities for stroke
patients and developing transport options for attending existing opportunities.
4.5 Data analysis of local stroke services
The local hospital we studied improved from a difficult situation over time. Hospital episode
statistics data shows that lengths of stay reduced by about 20% from 2002/3 to 2005/6
(figures 1 and 2). It is notable that over the same period of time the share of admissions
classified as suffering from a non-specified type of stroke halved from over 40% to less than
20% (figure 3). This indicates improvements in the diagnosis of patients.
26
Figure 1: Length of stay haemorrhage patients
Figure 2: Length of stay infarction patients
27
Figure 3: Hospital admissions by type
At the interface between the hospital and the community long waiting times for rehabilitation
were observed (figure 4). This indicates that the implementation of early supported
discharge as an intervention to shorten length of hospital stays will require adequate
resourcing and careful management.
Figure 4: Waiting time between discharge and therapy start
28
For patients who receive rehabilitation services in the community, we compared estimates of
hospital costs with rehabilitation costs. Estimates for hospital beds are based on the number
of bed days in hospital for each patient and the average national bed day cost for stroke
patients derived from the National Schedule of Reference Costs - NHS Trusts (Department
of Health, 2006). Rehabilitation costs are based on the number of rehabilitation hours
received for each of the patients and an hourly cost estimate which was derived using the
PSSRU Units Costs of Health and Social Care (PSSRU, 2006). Clearly, these costs are not
representative for all stroke patients. Patients with minor stroke not requiring rehabilitation
are likely to have shorter hospital stays. Patients who die in hospital or those severely
disabled and requiring long-term care will also differ in average length of hospital stays. The
comparison of costs for stroke patients in hospital and in the community (figure 5) shows that
rehabilitation cost are relatively small if compared to the hospital costs.
Figure 5: Care costs for patients receiving community rehabilitation
29
5 Modelling
5.1 The planning challenge in healthcare
While service innovations have often been judged desirable or positively evaluated in trials,
their translation into mainstream practice is often difficult. Innovations whose implementation
affects many actors across the health and social care system and which require significant
changes in several organisations have often proved particularly challenging. Organisational,
cultural and funding barriers within the care system, as well as the lack of shared knowledge
about the potential impact or benefits of these innovations, make whole systems thinking
difficult.
Evidence-based care models, consistent with well-established guidelines, are important for
widespread acceptance and mainstream adoption of innovation in service delivery.
Gathering evidence for the impact of innovations on care organisations or a local care
economy is frequently challenging, though pilot projects may provide evidence of the impact
of an innovation on the individual and clinical level. However, the wider effect of its
mainstream use is often difficult to judge, especially when substantial organisational
changes, such as alterations in working practices, are required.
Planning new services – perhaps on the basis of new opportunities opened up by
technological innovation – requires the differing needs of stakeholders to be understood and
addressed. Delivering effective care services to patients frequently requires the coordination
of the activities of several providers: GPs, other primary care services including
rehabilitation, acute hospitals and potentially social care providers might all need to come
together to meet the needs of an individual patient. Planning such services is difficult.
Communication and the coordination of the flow of resources between many stakeholders
across organisational boundaries needs to be managed.
The modernisation of stroke care exemplifies the challenges of whole systems planning in
an evolving care system, where the locus of care is shifting out of secondary care, new
private sector providers are becoming available and organisational relationships are
changing.
In health planning, rational decision-making may be highly desirable but experience shows
that fixed, rigid decision-making processes often do not work because the context changes
quickly. New policies are introduced and new targets mean attention needs to be focused
elsewhere. Local decision-makers change frequently and new stakeholders have to be
brought on board. Local political needs, complex and sometimes perverse financial
30
incentives, differing values between professional groups from different parts of the system
(such as social services and acute care) can lead to open or hidden conflicts and
misunderstandings. In arriving at decisions, not only is the factual accuracy of the
assumptions and the rationality of the decision important, but also the decision process.
Processes which give some degree of structure and rationality, by highlighting uncertainties,
encouraging stakeholder dialogue, supporting and documenting the decision, are therefore
desirable.
5.2 Modelling in healthcare planning
In order to understand the effect of implementing a service delivery innovation, modelling
approaches are often appropriate. Modelling has the potential to support both local and
national or regional planning of service delivery. Since the 1960s, many different
approaches, including spreadsheets and simulation models, have been used in healthcare
planning. Over recent decades the amount of work in the area has increased substantially
(Brailsford, 2008; Pitt et al., 2008). More powerful computers, more accessible software and
growing capabilities in the computer graphics and animation area, have helped to spread the
use of simulation modelling. While many models have been developed for planning
purposes in health care, successful and sustainable use of modelling remains a concern
(Brailsford, 2005; Pitt et al. 2008).
Modelling in health care planning often occurs in situations where understanding has to be
created across organisational and professional boundaries. This makes it necessary to take
into account a larger scale of system than that which individual stakeholders are located in.
‘Whole systems thinking’ often needs to consider the consequences of decisions for social,
primary and acute care as well as different providers and funders. However, creating crossdisciplinary understanding in healthcare settings is difficult (Ferlie et al, 2005). Simulation
modelling can be used as a tool to facilitate whole systems planning by helping to explore
the consequences of decisions across the system (including unintended consequences,
bottlenecks and delays, distribution of costs and benefits). In addition modelling can support
and facilitate communication between diverse stakeholders by creating a shared
representation of the whole system.
Models can also be used to make predictions about outcomes in the real world and allow
experimentation with different courses of action in a safe, quick and cheap way. However, as
has been shown in the case of engineering (Dodgson et al., 2007), simulation modelling can
also help to shape the conversation between stakeholders in problem solving and foster
collaboration. In the modelling literature a tension between using modelling for representing
31
reality and for negotiating mutual understanfing has been identified (Zagonel, 2002). In
health care applications these different roles of modelling are visible and vary with the
purpose, the accessibility of the model and the modelling process as well as the type of
modelling approach and the preferences of those involved in the modelling process. The role
a simulation model can have in a decision process in health care is constrained by the
degree to which the model and its results are accessible to stakeholders such as clinicians
and managers. The visual representation of the model and its results are likely to be of a
major influence on the accessibility of the model to a non-specialist audience.
Simulation modelling can be used to experiment with different options and assess the
consequences of different choices on the behaviour of the system. Options which can be
assessed include the availability of alternative treatments, capacities (e.g. number of beds,
available scanning slots or therapy hours), rules for allocating treatment and resources to
patients. Aspects of the system behaviour which could be of interest include costs, waiting
times or care outcomes (e.g. independence, disability or death).
However, the insights at the system level will depend on the understanding and availability of
data on the relationships in the system – without this, insights may be rather limited and
possibly misleading. Simulation modelling supports sensitivity analyses which can help deal
with the uncertainty in available data that characterises much of health and social care
research. It allows investigation of ‘what if’ scenarios for mainstream implementation of a
new service or intervention (e.g. what if more training was available or more resources
provided during the rehabilitation phase; what if the demand for services increases?). Not
only do models allow the creation of a range of projections to illustrate possible impacts of
innovation implementation, from worst-case to best-case scenarios, but they also allow
comparison of different implementation paths.
There are also benefits from the model development process itself, where participants are
able to use the framework to gain a better understanding of implementation issues in the
context of the larger system. Simulation modelling therefore offers opportunities for
contributing to the implementation of complex innovation in health and social care. This is
especially useful when a static comparison of different approaches of care delivery – for
example through traditional cost-benefit studies exploring the effect of implemented changes
against the current system – is unable to fully capture the effects of a gradual change
towards a new approach.
Among the major approaches to simulation modelling in healthcare system dynamics and
discrete event simulation are particularly prominent, other approaches include Monte Carlo
simulation and agent-based modelling.
32
In system dynamics flows in the system as opposed to individual patients are modelled. This
approach is therefore best suited to problems where the relevant behaviour of the system is
less influenced by what happens to the individual patient and more by influences on an
aggregated level. In particular, the effect of feedback and delays within the whole system
can be particularly well represented and studied (Wolstenholme 1993). Indeed, system
dynamics can be argued to be the origin of the emphasis on whole systems in health care
planning (Wolstenholme, 2005). System dynamics models are often used to analyse
strategic questions, often in a quick and intuitive way. System dynamics can be used to
study the whole systems effect of an innovation as it is implemented and becomes effective
over time. It is ideal in cases where a static comparison of different models of care delivery is
not enough and the time dimension has to be taken into account (Bayer et al 2004) and also
when several types of intervention are to be evaluated together (Homer et al 2003; Hirsch et
al, 2004).
Discrete event simulation has a more disaggregated focus than system dynamics and is
more suited for detailed, operational models. Applications of this modelling approach
typically emphasise the journey of individuals through the care system. In discrete event
models emphasis is often placed on the effects of random variations (e.g. of arrivals of new
patients, treatment durations etc.). Such stochastic effects are less often considered in
system dynamics models. Often discrete event simulation models are used for decision
making about care operations, as opposed to strategy and policy. This type of simulation has
been used for many different healthcare applications including the organisation of specific
clinics such as a vascular-surgery (Dodds, 2005) or emergency department activity
(Connelly and Bair, 2004), care service innovation such as intermediate care (Kotiadis,
2004) or the evaluation of screening programmes (Davies et al., 2002; Brailsford et al.
2006). While system dynamics models favour a visualization of systemic relationships such
as feedback loops, discrete event simulation lends itself to a visualisation of the journey of
individuals.
5.3 The prototype stroke care model
5.3.1 Introduction
In order to develop the prototype stroke caremodel9 we have chosen to use a discrete
event simulation approach. This was chosen over system dynamics because though our
engagement with the partners in our case study it became clear that at any point the care
9
The model can be inspected at http://www.imperial.ac.uk/business/dynamic/sbayer/stroke.html
33
provided for a small number of patients had the potential to significantly impact on the
system as a whole. For example,a patient admitted to the hospital as an emergency typically
might be the only patient that day, the further journey in the hospital of that patient would
depend on the availability of a bed in the stroke unit and/or the ability to scan that patient
within an appropriate period of time. It is therefore important whether a single bed is
available at a specific point in time – averages of occupancy over a period of time are not
enough for understanding the process. Discrete event simulation allows us to follow the
journey of single patients, while system dynamics typically works on a more aggregated
level. In this example, it is important for the strategic understanding of the problem to take
that individual and their journey into account. For other health and social strategy
discussions this might not be the case and a more aggregated treatment, including through
system dynamics modelling, could be more appropriate for supporting strategic or policy
decision making.
5.3.2 Implementation
Our model was developed using the simulation package Anylogic10. This general purpose
simulation the software package allows the building of models in different application
domains and permits following different modelling paradigms including discrete event
simulation.
It should be emphasised that the model is a prototype which needs to be adjusted to the
specific circumstances in a locality11. The assumptions made in the model are appropriate
for demonstrating the model’s features. However, it would be misleading to use this
prototype for planning services without adapting it to the local circumstances. The insights of
local stakeholders in particular those of managers and professionals from the acute, primary,
secondary and voluntary sector need to be drawn together (through workshops and in
interviews) and their buy-in is required for successful implementation. A model developed in
collaboration with local stakeholders could then be used by commissioners to plan and
implement stroke services.
While the prototype does not predict precise service utilization due to the randomness of
service demand and of outcomes for individual patients, it will help to make more informed
decisions about the structure of the service and capacities. An adaptation of the model to a
specific locality could then contain the particular features of the local services, including the
10
The package has been developed by XJ Technologies (http://www.xjtek.com/) and is distributed in the UK by
Saker Solutions (http://www.sakersolutions.com/).
11
We are currently investigating the possibility to take this work forward in a locality and develop a tailored
model which is based on local needs and validated to local data.
34
relationship to the wider regional setting as appropriate. Additional detail could include the
separation of a hyperacute stroke unit (for the first 72 hours of treatment), inclusion of
several institutions of a specific type (e.g. acute hospitals, rehabilitation centres, care
homes), the distinction of several types of rehabilitation services, detailed consideration of
issues around the transport of patients to A&E, TIA services or a more explicit consideration
of workforce capacity and financial issues.
5.3.3 Features of the prototype
The prototype (see figure 6) encompasses the main features of the journey of patients from
the moment of the stroke occurrence. It includes treatment in the hospital as well as
rehabilitation in the community and is a simplified representation of an acute hospital, the
community rehabilitation service and care home provision. Depending on the policy option
under discussion, other details of the system or additional elements could be included. A
balance has to be found between the level of detail required to support decision making and
implementation in a specific case and simplicity to facilitate understanding. An overly
complex model is less likely to achieve buy-in and understanding by decision makers and
other stakeholders, and might require too much effort to collect the underlying data.
Figure 6: Model overview
35
The prototype distinguishes different types of strokes (infarction and haemorrhage).
Incidents with either of the two diagnoses are distinguished in the animation using different
colours (blue for infarction and red for haemorrhage).
Stroke patients arrive at the hospital after a certain delay (this represents the time taken for
the ambulance to be alerted and the patient to be transported to the hospital). Once admitted
to hospital, stroke patients are put on a waiting list for scanning. Depending on scanner
availability, they are scanned as soon as possible (differentiating scenarios with or without
scanning outside standard working hours and accounting for the likelihood of scanners not
being available is possible). For each patient the delay from stroke incident to hospital
admission and scanning is recorded.
The prototype allows us to experiment with the introduction of thrombolysis. In a scenario
where thrombolysis is available, the following rule is applied: if a stroke patient with an
infarction is scanned within the appropriate time window of three hours, thrombolysis is
administered. In the prototype animation patients which have undergone thrombolysis are
distinguished by a different colour (yellow).
After the initial period in A&E, stroke patients are placed in the stroke unit if a bed is
available. If a stroke unit bed is not available, the patient is placed on a different ward as an
outlier and then transferred to the stroke unit as soon as a bed there becomes available.
Beds in the stroke unit can be used for non-stroke patients if pressures dictate. The
capacities of the stroke unit can be changed. The prototype also allows us to experiment
with ring-fencing the stroke unit (to prevent the assignment of patients without stroke to
those beds). Death rates, length of stays and outcomes (high vs. low level of disability on
discharge) are treated probabilistically. They also vary for patients who have been
thrombolysed or have spent more time in the stroke unit.
Depending on the level of disability at the end of their hospital stay, patients are (with a
certain probability) discharged to care homes or their own home with or without rehabilitation
in the community. The waiting period for rehabilitation at home depends on the therapy
capacity in the community. For different scenarios, it is possible to change the number of
therapists who can deliver rehabilitation in the community.
The prototype shows for each moment in time how many patients are in various parts of the
hospital (A&E, stroke unit, outliers in other wards) and in various locations after discharge
36
(care home, living in the community, in the community receiving rehabilitation services).
Outputs are produced showing performance indicators such as length of stays, percentage
of patients having been scanned within 3 and 24 hours, percentage of patients having spent
more than half their stay on the stroke unit. These indicators have been chosen to reflect the
current concerns of policy and research in stroke care.
5.3.4 Parameters and data
The data we used was extracted from existing records (community rehabilitation records) as
well as local and national statistics (hospital episode statistics). We had local data for all
those who received rehabilitation in the community provided by the PCT. We made the
assumption that the gap between this number and those discharged from the hospital to
their usual place of residence was made up of people not receiving rehabilitation. We
assumed a Poisson process for the stroke incidences. Parameters (see table 1) describing
the shortening of length of stays and the reduction of disability due to stroke unit treatment,
early supported discharge and thrombolysis were based on the medical literature. Other
parameter choices are based on data from the case study as well as some estimates. Better
data both within and outside the acute setting would be desirable and would improve the
reliability of the model and the granularity of our results.
Table 1: Model parameters
Parameter
Value
Sources
Share of stroke patients having infarction
0.83
Rosamond et al, 1999
Reduction of LOS due to stroke unit
(days)
Standard hospital death probability
4
Stroke Unit Trialists’ Collaboration, 2007
0.32
Standard length of stay on general ward
27
Share of several disabled stroke patients
after standard treatment
Share of not-severely disabled going to
care home
Share of severely disabled stroke patients
going to care home
0.24
Health Episode Statistics (2004/5) adjusted
for stroke unit coverage and stroke unit effect
Health Episode Statistics adjusted for stroke
unit coverage and stroke unit effect
Candelise et al., 2007
0.15
estimate
0.75
Probability of community rehabilitation
0.56
calculated from other parameters and
discharge destinations found in Health
Episode Statistics
estimate based on case study data
Effect of stroke unit (fraction of severe
disability compared with general ward)
Effect of stroke unit on death rate
0.79
Candelise et al., 2007
0.69
Candelise et al., 2007
37
Reduction of LOS due to ESD (days)
8
Early Supported Discharge Trialists, 2005
Death probability after thrombolysis
0.18
Wardlaw et al. 2003
Effect on share severely disabled after
thrombolysis
LOS thrombolysis patients
0.82
calculated based on Cochrane 3h
thrombolysis
Fagan et al, 1998
Weekly therapy slots per therapist
18
Duration of community rehabilitation
42
days
2
Average weekly sessions per client
11
calculated based on assumptions in Personal
Social Services Research Unit (2006) taking
into account annual leave and sickness etc.
local data from case study
local data from case study
5.3.5 Experiments with the prototype
The prototype allows comparative scenarios for the implementation of different service
modification both in hospital and the community. The policy choices which can be simulated
include:

Availability of thrombolysis

Out of hours scanning and vailability of 24h coverage for the interpretation of brain
scans (e.g. through teleradiology)

Changed capacity of stroke unit

Ring-fencing of stroke unit to prevent inappropriate admissions

Telecare to prevent admissions to care homes

Changed size of community rehabilitation team

Telerehabilitation to increase community rehabilitation capacity
In addition other parameters reflecting the consequences of some more indirect or complex
measures such as shorter travelling times to hospital (e.g. due to changes in the ambulance
service) or reduced waiting times for care home admissions can also be adjusted.
During a run the model shows an animation of the flow of patients through the care system
(figure 7). The prototype output includes statistics on activities which give rise to costs (e.g.
bed days in stroke unit, general ward and the care home, scans performed and
thrombolysis administered, community rehabilitation sessions provided, number of patients
receiving telecare), as well as capacities whose provision incurs costs (stroke unit beds,
therapists employed in the community). Based on averages of this activity and capacity data
38
over a large number of runs it is possible to arrive at estimates of the costs arising for the
acute and the community sector under the different scenarios.
Figure 7: Animation of patient flows
5.3.5.1 Base case
In the base case thrombolysis is not available. There are capacity pressures on the (nonringfenced) stroke unit and on community care. (see table 2) Figure 8 shows the modelling
output from the base case scenario.
Table 2: Base case parameters
Parameter
Value
Comments
Average yearly stroke cases
365
Delay between stroke and presentation
at hospital
2h
Stroke unit capacity
22
ESD coverage
0
share of patients receiving early supported
discharge support
Average inappropriate admissions to
stroke unit
0.25
dependent on bed management practices
Length of stay of patients without stroke
in stroke unit
4
dependent on bed management practices
Start working hours - scanning
8
End working hours - scanning
17
Probability of scanner availability during
working hours
0.8
dependent on competing demands,
prioritisation and equipment breakdowns
Percentage diverted by telecare
0.1
scenario depends on type of telecare package
dependent on geography and ambulance
service
39
Waiting for care home
7 days
Number of therapists available
5
Effect of telerehabilitation on rehab
capacity
0.1
dependent on discharge practices and local
care home place availability
dependent on technology used
Figure 8: Base case scenario
5.3.5.2 Improved acute care scenario
In the literature, treatment in a stroke unit has been identified as being preferable to
treatment in a general ward both in terms of outcomes and the length of stay. The prototype
takes these effects for the individual patient into account. In order to allow more patients to
stay in the stroke unit for most of their time in hospital two measures can be undertaken:
increasing the capacity of the stroke unit and preventing inappropriate admissions of patients
without stroke to stroke beds. However, the prototype model of the stroke care system
captures only a small part of the total care system. An intervention like ring-fencing the
stroke unit such that patients without a stroke are not admitted would have consequences
elsewhere in the hospital which are not covered in our model. Such consequences might
include the impact on A&E waiting times if non-stroke patients can not admitted to the stroke
ward if no other bed is available.
40
In this scenario we introduce thrombolysis and increase the size of the stroke unit by 20%
compared to the base case and prevent inappropriate admissions to the stroke unit (see
figure 9). The remaining parameters are chosen like in the base case.
Figure 9: Improved acute care scenario
5.3.5.3 Telestroke scenario
Three areas where telemedicine can be used in the system have been identified in:
teleradiology to ensure permanent availability of expert guidance for the interpretation of
brain scans even if no radiologist or other expert is available locally, telerehabilitation for
some aspects of community rehabilitation work and telecare to support people after a stroke
in the community. The model allows the effects of these innovations on the stroke care
system to be studied. Clearly, there exists considerable uncertainty around these
interventions. This constrains the possibility of predicting precise effects and makes an
approach which involves stakeholders in exploring the possibilities through experimentation
potentially more useful. This is particularly so for the case of telerehabilitation for which only
very limited experience has been reported in the literature.
41
Teleradiology is captured in the prototype as a possible way of achieving a 24h scan
interpretation capability; this could of course be also achieved by having staff available
locally. Telecare is included in as far as it allows diverting some of the patients destined for a
care home to the community. Telerehabilitation is conceptualized here as a way of improving
the number of patients which can be seen by a given number of therapists (within a given
number of time slots) since some face-to-face sessions with patients can be replaced by
remote interaction.
The telestroke scenario (see figure 10) illustrates the possibilities: we assume 24h scanning
interpretation is covered by teleradiology, 20% of clients are diverted from a care home by
telecare support in the community and that the rehabilitation capacity is increased by 10%.
In this scenario we also assume that thrombolysis is available. The remaining parameters
are chosen like in the base case
Figure 10: Telehealth scenario
42
6 Discussion
A large number of stakeholders have to come together to enable service integration. Some
improvements can be made directly in the District General Hospitals (e.g. in relation to rapid
diagnosis, the acute treatment available, the intensity of rehabilitation or the use of stroke
units), while others require the collaboration of acute service providers with the health and
social care services in the community. Early supported discharge requires that appropriate
services are available in the community and that the interface between acute provision and
community provision is carefully managed. Similarly, stroke prevention by identification of
high risk groups (in particular those that have suffered a transient ischaemic attack) is likely
to involve collaboration between stroke consultants in the acute trust and primary care
providers (see figure 11).
Figure 11: The need for service integration
The provision of specialist acute or rehabilitation services (under some services models this
will include thrombolysis) in regional specialist centres will require a wider reorganisation of
stroke services. Close coordination with ambulance services is required to shorten the time
from the incidence of stroke to provision of treatment in the appropriate acute facility.
43
6.1 The need for service integration
Different innovations in stroke care will vary in the extent to which they require integration
into the wider care system, with variation not only with regard to their integration
requirements but also as to how narrow or specific the innovation is in relation to the
conditions it is applicable to. The success of innovation implementation will also depend on
availability of resources, the alignment (and attention) of stakeholders, the appropriate
redesign of pathways as well as the supporting infrastructure (see figure 12).
Figure 12: Types of stroke innovations
Like other changes to stroke services, telecare and telemedicine interventions have to take
these factors into account. Telemedicine (e.g. teleradiology to support remote thrombolysis)
still needs appropriate systems around it in the district general hospital (e.g. urgent access to
CT scanning, dedicated stroke care units, weekend cover) and cannot therefore just be
“dropped in” as an easy solution in order to achieve better services. Care has to be taken to
get the basics right before introducing telemedicine. The requirements for embedding ICT44
based technologies in the support of rehabilitation (e.g. speech and language therapy or the
monitoring of exercises therapy via video link) into a wider service are likely to be
comparatively less challenging.
Telecare for frail elderly people as a more generic intervention will also be a valuable aid to
support independent living for those who have suffered a stroke: stroke patients with mild or
moderate disability can benefit from the same systems of telecare for the elderly. Clearly,
patients with severe disability need more hands-on support and telecare can at most been
an add-on to a more comprehensive package of care.
6.2 Regional reorganisation of stroke services
When taking this work forward in an applied setting thought needs to be given to how
embedded local services are in the regional setting. Our prototype model illustrates the use
of this approach by outlining the case of a simple care system comprising one hospital and
the community sector. Currently, there are several potential models for the regional
organisation of stroke services under discussion (see figure 12). While the current model
generally provides treatment and rehabilitation in the district general hospital nearest to
where the stroke occurred, alternative service models coordinate and concentrate services
on a regional basis. If the patient is taken to the nearest hospital travelling times are short
resulting in faster treatment. However, the quality of care received will vary with services
available at the particular hospital at that time which will depend on factors such as the
specialist and equipment available, bed availability in the stroke unit, or the extent of out of
hours service.
45
Figure 13: Regional reorganisation of stroke services
An alternative service model would be to take patients to a specialist centre for the acute
phase of stroke, after which sub-acute treatment and rehabilitation would be given in the
local district general hospital. This model would help to improve equitable access to
specialised care (including thrombolysis). However, because the time window for
thrombolysis treatment is very short, the increased travelling times for acute admissions
might become an issue especially if distances to the next specialised centre are large or
traffic is congested.
A second alternative service configuration would be to provide all acute services in a
specialist neurological centre while rehabilitation would be provided at home or - depending
on disability and need - in a specialist rehabilitation centre. Again travelling times for acute
admissions might be a problem with this configuration.
A third alternative would be to provide acute treatment in the nearest district general hospital
(like in the currently predominant model), but to provide back-up to district general hospitals
via a telemedicine link to the specialist neurological centre. In this way procedures such as
thrombolysis can be delivered locally drawing on expert advice. Issues to consider include
the 24h cover which will still be required in the district general hospital as well as the needs
of patient requiring specialist care which can not be delivered in the district general hospital
even with telemedicine back-up.
46
The model of the regional organisation of stroke care will need to be considered when
applying the modelling approach to planning stroke services in a particular location. These
considerations go, however, beyond what we considered to be the scope of this project.
47
7 Conclusions and recommendations
The UK government recognises the need for attention to be given to stroke care. The
National Stroke Strategy (December 2007) emphasises the urgent need to change many
aspects of stroke care, from patient awareness and prevention to appropriate acute phase
treatment and to long-term rehabilitation and care in the community. The Strategy also
places emphasis on the need for integration of services and close collaboration of all those
involved in the delivery of care.
Major technological and scientific advances in the last 20 years offer the potential for lifesaving interventions in stroke patients. However, significant challenges still exist which
prevent the practical implementation of such advances. It is necessary to first identify these
challenges and secondly to re-organise stroke services in a way which takes full advantage
of recent scientific developments. Our study has contributed to a better understanding of
some of these barriers and the challenges facing stroke service restructuring or the
introduction of telemedicine and telecare solutions.
We used a case study research design, focusing on one particular locality in London. We
examined the literature on technology and service delivery innovations for stroke care,
conducted interviews with key local stakeholders and experts in the field and collected and
analysed primary data from the community.
We captured through simulation modelling the current stroke pathway (in its acute and
community settings) and built scenarios of changes in the pathway and their potential impact
on outcomes (clinical and costs). This type of modelling is suitable for application to highly
complex processes, such as stroke care, and can be used successfully as a communication
and decision making tool before committing real resources. We selected stroke care as an
example of chronic disease management because, as a leading cause of adult long-term
disability, stroke poses a huge demand on health and social care resources.
The key insights from this study can be summarized as follows:

Stroke is a complex disease which needs widespread service integration. Within the
current fragmented services, achieving such integration poses a significant challenge
for service planners. It involves examining various alternatives and assessing their
likely impact before deciding to commit real resources.
48

The potential benefits of introducing telemedicine and telecare in assisting the
delivery of stroke care have been a subject of widespread research and debate.
During the course of this research we have come to the conclusion that if telecare is
to be used to its maximum advantage in supporting patient care, it cannot be just
‘dropped in’ as an easy solution on existing highly fragmented services. The success
of introducing innovations in healthcare depends on the availability of resources,
stakeholder agreement, careful pathway design, and appropriate supporting
infrastructures. Introducing technological innovations such as telemedicine/care in
stroke care primarily requires the creation of a relatively stable service configuration.

Modelling can help to determine what such a configuration might look like. However,
the development of a model in itself raises a number of interesting and challenging
issues. To develop a robust model necessitates the collection of appropriate data
and information on which to ground the model. It was our experience that the
collection of this information was problematic. Frequently the requisite information
was unavailable or not available in an appropriate format.

The exercise of model development in itself highlights problem areas and issues of
paucity of data. Highlighting such areas has a value in its own right and is of
relevance to health care professionals, policy makers and commissioners.

Modelling helps to map out the care journey (thereby helping to develop a shared
understanding of different stakeholders) and to compare alternatives before
committing real resources. Modelling can in this way both support stakeholder
communication and decision making.
Acknowledgements
We are grateful to the Department of Health for their support in funding this research. We
also acknowledge the contribution of EPSRC for funding James Barlow and part of Steffen
Bayer’s time via the Health and Care Infrastructure Research and Innovation Centre
(HaCIRIC). We thank Erik Yves Landriault for use of material on telestroke from his MSc
dissertation. Finally, we wish to thank our advisory board and all the participants at the case
study site.
Favourable ethical opinion obtained from the local research ethics committee (reference
number 06/Q0707/70) on October 31st, 2006.
49
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Appendix 1: Methods
Interviews
We conducted 12 in-depth interviews with relevant local stakeholders gathering detailed
information about the way stroke care is organised in the locality, any existing areas causing
delays and bottlenecks and ideas about possible solutions. In addition, through a number of
face-to-face interviews and attendance in conferences, we gathered expert information (e.g.
stroke consultants, health economists, policy representatives) about the current organisation
of stroke services in the country and ideas about possible alternative models.
Observation
We attended a weekly stroke multidisciplinary team meeting at the hospital site in which
progress of patients was discussed. Informal conversations with the stroke co-ordinator
about various aspects of current stroke care provision in the trust and relations between the
trust and other relevant organisations e.g. PCT and Social Services.
Documentary analysis
In order to make the research and possible recommendations relevant to policy decision
making, we became familiar with existing policy documents available in the public domain:
1. National Service Framework for Older People (DH, 2001).
2. National Clinical Guidelines for Stroke (2nd ed., 2004). Intercollegiate Stroke Working
Party, Royal College of Physicians.
3. The National Service Framework for Long-term Conditions (DH, 2005)
4. Reducing Brain Damage. Faster Access to Better Stroke Care. (National Audit Office,
November 2005).
5. National Sentinel Stroke Audit 2004. (Royal College of Physicians, 2005).
6. Economic burden of Stroke in England, (King’s College London, 2005).
7. Mending Hearts and Brains. Clinical Care for Change. Report by Professor Roger
Boyle, National Director for Heart Disease and Stroke. (DH, 2006a).
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8. ASSET 2 – Action on Stroke Services: an Evaluation Toolkit for Commissioners (DH,
2006b).
9. A New Ambition for Stroke. A consultation on a national strategy (DH, 2007a)
10. National Sentinel Stroke Audit 2006. (Royal College of Physicians, 2007).
11. National Stroke Strategy, (DH, 2007b).
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Appendix 2: Dissemination
Following the publication of the National Stroke Strategy we have described some of our
findings in a press release. We also presented to or discussed our research with Roger
Boyle (National Director for Heart Disease &Stroke), Mike Burrows (Chief Executive Salford
PCT), Patricia Leahy (Director of Public Private Partnerships, NAO), Tom Allen (MIT), Stan
Finkelstein (MIT and Harvard Medical School), National Advisory Council for Stroke
(Scotland), NW London Cardiac and Stroke Network, Kensington and Chelsea PCT, NHS
Tayside, and Pfizer.We presented our research in the clinical governance meeting for stroke
at the acute hospital in our case study locality.
We have ongoing discussion with Kensington and Chelsea PCT with a view of using
modelling for supporting their implementation of the new stroke strategy for London.
Engagement with them would allow us access to the data required to take our modelling
work beyond the prototype stage. A further presentation at Brighton & Sussex University
Hospitals NHS Trust is also planned.
We are also exploring taking the work further in the Boston area with colleagues at MIT,
Harvard Business School, and Harvard Partners.
We are in the process of preparing a paper (“Towards the facilitation of stroke care planning
using simulation modelling “) to be submitted to an academic journal.
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