Appendix Wiv Kent and Medway Stroke Review Dartford and Gravesham NHS Trust Deliverability Panel 1
Contents • Background and context • Overview of the options • How we will deliver the capacity • How we will implement the model Please note - the following are indicated throughout the presentation against the relevant icons: ! Identified risks (also provided in Appendix A) Examples of our track record Quotes from relevant stakeholders 2
Background and context Stoke services across the region have been challenged, particularly as the review has been ongoing • Dartford and Gravesham performance The performance of stroke services across the Kent and 2013/14 2014/15 2015/16 2016/17 2017/18 Medway region have been inconsistent, leading to this review Scanning key indicators • As most Trusts in the region, Dartford and DGT 42.7% 51.4% 50.3% 53.0% 49.7% Percentage of patients scanned within 1 hour Gravesham has of clock start 41.9% 44.1% 47.5% 51.3% 52.6% National faced challenges, particularly during Stroke Unit key indicators the review DGT 33.1% 59.2% 41.2% 30.1% 27.1% Percentage of patients directly admitted to a stroke unit within 4 hours of clock start National 58.0% 56.8% 58.3% 57.4% 57.2% DGT 79.7% 88.7% 84.0% 67.2% 66.3% Percentage of patients who spent at least 90% of their stay on stroke unit National 83.0% 81.9% 83.5% 83.8% 76.2% “ Joint assessment at the front door by the stroke Thrombolysis key indicators team and A&E colleagues is Percentage of eligible patients (according to DGT 91.7% 95.2% 82.6% 92.3% 100.0% vital to ensure that patients the RCP guideline minimum threshold) given are triaged to receive the National 74.3% 80.7% 84.9% 86.9% 87.8% thrombolysis right treatment, first time. ” DGT 30.3% 45.2% 42.1% 76.0% 59.8% Dr. Tom Clark, Clinical Percentage of patients who were Director, PRUH thrombolysed within 1 hour of clock start National 53.2% 56.1% 58.5% 62.3% 63.7% 3
Background and context Dartford and Gravesham has a clear action plan, a track record of delivering improvements Example elements of the Dartford and Track record of delivering improvements Gravesham action plan: • Track record: creating a ring-fenced bed Support for SSNAP data collection • Results of introduction of ONE ring fenced bed in April 2018 to ensure the prompt Improvement in % thrombolysed transfer to the acute stroke unit. : Our direct admissions (total) has improved from all within 60 minutes time low of 28% in Feb 2018 to 78% (April- July 2018) • Executive approval for ring fenced bed Track record: driving up thrombolysis • Collaborative working with site An improvement project with a focused approach analysing door to needle SSNAP team, rehabilitation sites to ensure data to increase the percentage of patients thrombolysed (where thrombolysis is good patient flow indicated) within 1 hour (golden hour); this project has been successful and • Stroke specific discharge summary sustained (evidenced in an increase in the percentage of patients thrombolysed • Monthly stroke data within 1 hour from 30% in 2013/14 to 64% in 2-17/18) Track record: an experienced team Key risk: Payment of best practice tariff would still Clinical lead for stroke: DGT’s dedicated and driven service lead is an experienced result in stroke being a loss- stroke consultant who has developed the DGT stroke service and led on DGT’s making service for the Trust. service improvements, examples of which are outlined above Both London and Head of Nursing: DGT’s HoN was a stroke CNS and then a lead stroke nurse, ! Manchester have providing clinical leadership and service development across Kent and Medway. She implemented top-up rates was a member of the expert clinical review group at the request of the South East for providers and we would Clinical Senate in 2016, and was previously member of the CRG for the K&M stroke wish to explore this further review. across Kent and Medway General Manager: The DGT GM has previously supported delivery of two network with our CCG commissioners. stroke service solutions, one in Cambridge/ Peterborough and another in West Essex. 4
Background and context Wider context to the provision of stroke services across Kent and Medway • Efficient patient flow across the system will be of paramount importance; this requires successful work with partner organisations, including rehabilitation service providers • Dartford and Gravesham commit to working with CCGs, Trusts and other partners across the region to ensure: – Rehabilitation pathways and services are consistent across Kent and Medway – All Kent and Medway HASU/ASU staff have the same competencies and training – Patients from Bexley also follow the same standardised pathways, with efficient routes out to rehabilitation services – Standardisation is clinician-led across the region Key risk: The stroke service consultation does not include rehabilitation services; this poses a risk to patient flow from future HASU/ASUs. This needs to include the pathways into neuro rehab and nursing home beds. A ! lack of collaboration with the following partners would lead to difficulties in patient flow from DGT’s HASU/ASU and/ or ED: Bexley CCG, Virgin Healthcare, non-HASU/ASU DGHs Track record of collaboration: Vanguard with Guy’s and St Thomas’: Through their Vanguard, Dartford and Gravesham and Guy’s and St Thomas’ effectively collaborated in three clinical programmes in paediatric services, cardiology and vascular services. Over 1,100 patient appointments were held at DGT rather than GSTT over the 18 month period of the programmes, improving the experience of these patients by providing care closer to home and saving money within the local economy. The clinical programmes also supported the upskilling of DGT staff, and there is qualitative evidence that this has improved recruitment and retention 5
Overview of the options There are three options under consultation in which Dartford and Gravesham has a HASU/ASU Under options Current Bed increase HASU beds Total beds ASU beds number of strokes Mimics Number of TIAs beds at DVH Options Option A : Darent Valley Hospital Options A and B are Medway Maritime 27 882 88 220 10 27 37 +10 comparable in scale Hospital for DVH; deliverability William Harvey Hospital is considered broadly Option B : equal Darent Valley Hospital Maidstone General 27 807 81 202 10 24 34 +7 Hospital William Harvey Hospital Option E is considerably Option E : larger for DVH; Darent Valley Hospital 27 1,174 117 293 14 36 50 +23 deliverability challenges Tunbridge Wells Hospital William Harvey Hospital scale up for this option 6
Capacity The deliverability of the HASU/ASU will be dependent on ensuring capacity in a number of areas Capacity constraint High-level view Page ref. The capacity of DVH has been modelled under Medical beds Capacity in medical beds across the organisation options A, B and E; in all cases sufficient capacity 8 can be achieved. Please note that Please note that the implementation plans are provided on pages 16-20. interdependencies are further details on p. 21 The existing capacity constraint within the A&E department will be eased through the co - location Capacity within A&E, resus and ITU The increase in stroke service activity under of UTC services and other improvement work with 9 options A, B and E will increase activity in A&E ambulatory pathways. Additional resus capacity is planned, and ITU is expected to be able to absorb and resus, and may impact ITU. any small activity increase. Radiology capacity Existing on-site machines have sufficient capacity The HASU/ASU will require radiology capacity 10 for all A&E, in-patient and future stroke patients. for urgent patients. Radiology clinical workforce remains a key risk for Workforce all units across the region. Mitigations (workforce A gap analysis has been completed to indicate the increase in workforce required under each engagement, planning) have been completed, 11-15 model. Leadership and project management although greater mitigation will be possible once resource is also considered. the option decision is taken. 7
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