London Stroke Care Tony Rudd London Stroke Clinical Director
The Case for Changing Stroke Care Above Target London Stroke Units Sentinel Audit Comparison 2004 and 2006 Below Target Target 91 90 89 88 88 86 84 83 90 80 80 77 76 76 75 72 71 71 71 70 70 68 68 66 65 65 62 61 60 London Stroke 55 51 49 Providers against 45 Sentinel Audit 12 key indicators 2006 25 25 24 21 21 19 19 Change in London Stroke Providers 14 12 12 against Sentinel Audit 12 key 9 9 8 indicators 6 6 5 2006 vs 2004 4 4 scores 2 1 0 -1 -3 -3 -4 -4 -5 -7 -9 -12
Decision to reorganise care National Stroke Strategy National Stroke Audit Darzi review of medical care in London Lobbying from London Stroke community Ruth Carnall and SHA choosing stroke and major trauma Clear case for change Good evidence as to what should be done A clinical community wanting to see change
The scale of the problem of stroke in London • Second biggest killer and most common cause of disability • Population >8 million • 11,500 strokes a year in London – 2,000 deaths
Process for implementing change Agreement from all London PCTs and formation of JCPCT to support the process and to invest additional £20m/annum Project board with representation from commissioners, clinicians, managers, patients, voluntary groups Agreement that additional funding paid as enhanced tariff if quality standards met Split care into hyperacute, acute, transient ischaemic attack and community care
Process for implementing change Setting the standards based on evidence Development of range of models – consultation with professionals Bidding process requiring close collaboration between managers and clinicians from each provider External review of applications
London Stroke Strategy Centralise hyperacute (hyperacute stroke units HASU) care into 8 units situated to provide easy access to the whole population (no more than 30 minutes by ambulance) All acute stroke patients admitted to HASU. This is not just a thrombolysis service Further 20 stroke units for on going rehabilitation Improve community care and longer term rehabilitation Neurovascular services for patients with TIA
30-minute blue light ambulance travel time from the hyper-acute stroke units The green area shows the areas that are within 30 minutes travel time (under ambulance blue light conditions) of a proposed HASU
London SHA Stroke Strategy London Clinical Director and Stroke and cardiac networks working to support units needing to improve quality Development of local leaders Clinical Advisory Group Educational programmes developed (>400 additional nurses and 100 therapists recruited to work in stroke) Regular inspections to ensure quality of care maintained Obligation to submit continuous audit
Where are we now? All units open All achieved high level standards Subject to regular inspection and requirement to submit data Close collaboration between stroke units and HASUs
Processes of Care Thrombolysis rates 16% 14% 14% 12% 12% 10% 10% 8% 6% 4% 2% 3.5% 0% Feb-July 2009 Aim Feb-July 2010 Jan-March 2011
Processes of Care Average length of stay 20 18 16 14 12 10 8 6 4 2 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 2009/10 2010/11
Department of Applied Health Research Department of Applied Health Research Doing improvement science: a study of major system reconfiguration in England Naomi Fulop Professor of Health Care Organisation and Management IS London Launch, 26 th June 2012
Department of Applied Health Research A study of the effectiveness, acceptability & processes of implementation of two models of stroke care o London o Prof Naomi Fulop, Prof Tony Rudd, Prof Charles Wolfe, Dr Christopher McKevitt, Prof Steve Morris, Mr Nanik Pursani, Dr Angus Ramsay o Manchester o Dr Pippa Tyrrell, Prof Ruth Boaden 1 st September 2011 – 31 st August 2014 NIHR Health Services & Delivery Research Programme
Department of Applied Health Research
Department of Applied Health Research Conceptual framework o Our conceptual framework combines o Traditional approach: ‘what works, and at what cost ?’ o With ‘how?’ and ‘why’? o ‘Diffusion of innovations’ ( Greenhalgh, 2004): how the nature of the innovation, the approach to implementation, and context interact o ‘Social matrix’ (Webster, 2007): how the nature of relationships between key stakeholders influences implementation
Department of Applied Health Research What works and at what cost? o ‘Before’ v ‘after’ and comparison between 2 models o Processes: e.g. national & local audits covering provision of care (e.g. SINAP and SLSR) o Outcomes: e.g. mortality, QALYs gained o Costs: e.g. staffing, treatments, length of stay, implementation costs o Model changes in terms of short term (1 st 3 months after stroke) and longer (1 year)
Department of Applied Health Research Previous evaluation of new London stroke model • Compared costs & outcomes ‘before’ (July 2007 -July 2008) vs. ‘after’ (July 2010 -June 2011) introduction of new London stroke model • Calculated costs and benefits at 90 days using data from a range of sources (SINAP, LMDS, SLSR, audit data) • Headline results: – Increases in ambulance times (emergency call to arrival at hospital): ‘before’ 50 minutes, ‘after’ 62 minutes – 12% fewer deaths at 90 days after vs. before (adjusted for national trends outside London)
Department of Applied Health Research London Stroke Survival vs Rest of England Hazard ratio for survival in London 0.72 95%CI 0.67-0.77 p<0.001 19
Department of Applied Health Research Previous evaluation of new London stroke model Headline results (cont.) – Lower costs per patient at 90 days: ‘before’ £14,117, ‘after’ £13,306 • New model: reduced mortality & represents good value for money ( Morris et al, 2011) • But: – Limited follow- up in ‘After’ period – Did not include costs of setting up the new model e.g. NHS and public consultations • These limitations will be addressed in current study
Department of Applied Health Research Evaluating the process of implementation Qualitative analysis of: • key processes & factors influencing the implementation and sustainability ( e.g. role of contextual factors, governance, consultation) • views of impact/experience Through use of: • stakeholder interviews (e.g. ‘winners’ & ‘losers’) x2 • interviews with patients/carers • documentary analysis • observations of meetings
Department of Applied Health Research Emerging findings: a taster Approach to process of reconfiguration differed e.g. how resistance was managed Greater Manchester: “the minute it felt like unanimity was being compromised on that clinical discussion on the 24 versus the 4 hour pathway, I think we were always going to be minded then to tilt towards holding unanimity and taking what might be a small step, but still the right step.” (Commissioner) London: “Stroke was their [clinician representatives’] life , and they wanted to get the best for stroke […] but actually what got it through was being straight with them, trying to explain it to them, but in the end holding the line.” (Commissioner and Project Board Member)
Department of Applied Health Research Feedback/outputs Formative evaluation • Regular feedback to local services/commissioners e.g. through stroke networks, to enable learning • Lay versions for patients & the public • Feedback to wider NHS – lessons for reconfigurations of stroke services and other service reconfigurations • Usual academic dissemination routes: peer reviewed journals, conferences
Department of Applied Health Research Challenges in doing improvement science • Partnerships between NHS and academic researchers – different drivers, different expectations Some issues arising: • timing of findings • process for dealing with uncomfortable findings • need to be flexible to respond to e.g. organisational turbulence
Department of Applied Health Research Department of Applied Health Research Win-win partnerships for improvement science
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