Commissioning for Quality Stroke Services by pptfiles


									                 Stroke Services in South Birmingham
                         The Patient Journey


The PCT is concerned with ensuring that the services it commissions for its
population are of the highest possible quality. To support this aim the Board
needs to be aware of existing services both in terms of quantity and quality.
Where multiple service providers are involved in the delivery of services, these
are best provided on a care pathway basis, so that service users can move
seamlessly from one provider to another. It is often at the transitions where
problems occur, and the patient’s journey is fraught with risks. The role of the
PCT is to smooth the path for patients and their carers.

This paper will give an overview of the current care pathway available for patients
with stroke in South Birmingham. It will identify positive elements of the service,
and areas where improvements are needed in order to meet National Targets for
Stroke. Recommendations for future developments are included.

Background – Stroke Illness

Stroke is the single biggest cause of disability in the UK, and the third most
common cause of death. Each year, 110,000 people in England and Wales have
a stroke. The impact on health and social services resources is significant (DOH
2001). In South Birmingham, the incidence of stroke was 3.1 per 1000 for the
year 2004/5. Stroke becomes more prevalent in older people, therefore the
incidence of stroke in South Birmingham is likely to rise in proportion to the
increasing age of the population.

The needs of people with stroke span the entire health and social care economy,
from prevention treatments and advice, to acute medical emergency, complex
rehabilitation needs and long term disability.
Although stroke can affect a broad spectrum of people, there are certain factors
associated with a higher risk of stroke incidence. These are:

      High blood pressure
      Diabetes
      High cholesterol in the blood
      Smoking
      Being overweight
      Atrial fibrillation
      Having heart disease

Health care providers must therefore be committed to addressing the health and
social factors that increase the risk of stroke.

National Standards for Stroke Care

There are national publications that set standards and guidelines for stroke
services to follow. The National Service Framework for Older People (NSF)
Standard 5 for Stroke specifies the local requirements for stroke services.
Milestones for PCT’s include establishing stroke specialist services, GPs to have
a register of patients with stroke, and local protocols for the management of TIA
and stroke follow up to be in place (appendix 1).

National targets for stroke are focussed on reducing the risks associated with
stroke, in particular smoking, and enabling people with stroke to live in their own
homes (DOH 2004) (appendix 2).

The National Clinical Guidelines for Stroke 2004 specify best evidence for
prevention, investigation, treatment and long term management of stroke illness
and are a comprehensive guide on which to base services. They specify that
there is “overwhelming evidence” for treatment by a specialist stroke team (RCP

The National Sentinel Audit for Stroke is undertaken on a two yearly cycle, and
compares local services to twelve key indicators for stroke care taken directly
from the National Clinical Guidelines.

The Current Stroke Care Pathway

Stroke services in South Birmingham are unique in having an established
relationship between the acute trust and the PCT. The positive elements of the
service are:

      Key members of staff work in cross trust roles; a consultant geriatrician, a
       newly appointed consultant physiotherapist in stroke services, and a
       Specialist Stroke Nurse. These posts allow early assessment,
       identification and referral of patients requiring in patient rehabilitation, and
       facilitate the seamless journey through stroke services, from acute
       admission to long term follow up. These posts, and the increase of stroke
       beds to 12 in the acute trust and 24 in the PCT, have facilitated a more
       efficient and timely transfer of patients into rehabilitation beds at Moseley
       Hall Hospital. The throughput of patients is limited somewhat by the issue
       of PCT patients not being eligible for social services reimbursement.

      There are established links between the PCT stroke services and
       Rehabilitation Consultants, enabling early assessment of younger patients
       with complex stroke illness, and access to treatments including BTX
       injections, assessment for driving, and return to work. Access to
       rehabilitation services for younger patients remains difficult.

      Relationships with the Stroke Association in the voluntary sector are
       strong, and patients access a Family Support Worker for advice
       throughout the stroke journey. However, this service is funded for a
       particular catchment area, therefore does not serve all patients. There are
       close links with other organisations such as Crossroads and the Carer
       Support Initiative.

      Access to specialist rehabilitation and therapy following discharge from
       hospital is usually timely and tailored to individual needs. Stroke specialist
       rehabilitation has an important role in secondary prevention. There are
       several sources of rehabilitation including Assessment and Treatment
       Service at Moseley Hall Hospital, community therapy, intermediate care,
       Acute Neuro Rehab Outreach Team and Moorgreen. The PCT supports a
       “Strokability” Extend exercise class in a Local Authority Sports Centre,
       giving patients with stroke access to long-term exercise and social

      Long-term follow clinics are well established at Moseley Hall Hospital,
       using a specialist GP and Nurse-led model. Patients and carers are
       offered an holistic assessment at 3, 6, and 12 months post discharge from
       hospital. Issues of secondary prevention, rehabilitation and general
       support are addressed. There is potential to develop the long-term support
       and secondary prevention roles of the clinics further, exploring the links
       with primary care and avoiding duplication of service provision.

      A patient and carer focus group is a new addition to the stroke services in
       the PCT and has the potential to increase the scope of user involvement in
       the development and evaluation of stroke services.

      South Birmingham PCT was recently the subject of a HASCAS review of
       stroke services, which provided an opportunity to evaluate services. The
       immediate feedback indicated the positive effects of having cross trust
       posts working to facilitate the patient journey, and identified strong
       teamwork as a positive element.

      It is anticipated that a new post for Acute Stroke Consultant will be
       established in the near future. This will have the aim of ensuring best
       practice occurs in the first few hours after stroke, and will work closely
       alongside primary care and ambulance services in stroke care.

Figures 1 and 2 give an overview of the patient journey through stroke services,
and demonstrate the scope of services provided.

     Figure 1 - TIA Service

                                    TIA clinics,
              A&E                      UHB                       GP
             referral              TIA Pathway                 referral
                                    Access to:

Secondary      Neurosurgeon        Investigations:    Admission       Triage for
prevention      and Medical           CT scan,        to hospital      surgery
  advice         Consultant            Carotid         if needed
                assessment            doppler

     This new Transient Ischaemic Attack (TIA) service has recently been introduced
     at Selly Oak Hospital. This enables patients presenting to primary or secondary
     care with TIA to access investigations and assessments within the recommended
     7 day timescale (RCP 2004).

 Figure 2 - Stroke Services

                                 Acute stroke
               A&E               service, UHB               GP
              referral            Stroke Care             referral

           Exit:                    Access to:
          Home,                Acute assessment,
        residential              investigations,
        or nursing               treatment and
          home                management, referral
                                  to stroke unit

                                                         Written information
  Access to
                                                       12 acute, 24 rehab beds
  GP follow
                                   stroke unit           Follow care pathway,
                                      UHB             assessment, investigations
                                                        and treatment continue
    Home,                                             Stroke Association Family
 residential or                                            Support Worker
    nursing                          Rehab
     home                            Stroke           Access to rehab consultant
                                    Unit PCT

                                                           MDT approach

   Stroke Follow Up              Ongoing
clinics 3,6,12 months          rehabilitation                Goal setting
 Holistic assessment
                                                         Discharge planning

    Patient and                        Strokability
    carer focus                       Extend class

Strategic Health Authority Visits 2005 – Chief Executive’s comments

In March 2005, the Chief Executive of the Strategic Health Authority (StHA)
undertook a series of visits to stroke services across Birmingham and the Black
Country, with the aim of evaluating the current provision of stroke services.
Following the visits by the Chief Executive, the StHA hosted a regional Stroke
Conference in order to feedback the key findings to health care professionals
providing and delivering stroke services. Discussion about stroke services was
facilitated on the day with the aim of producing priorities to address in order to
improve stroke services.
The Chief Executive incorporated the findings from the visits and discussions at
the conference into specific action points and recommendations of relevance to
the PCT provider arm. These were communicated in a letter from the StHA to the
Chief Executive of the PCT. The general findings, relevant to services across the
region, are:

      The stroke service that works in best practice is one which is a seamless
      The Single Assessment Process needs to be a much greater part of the
       patient assessment
      A crucial part of the assessment is the Ambulance Service yet only Dudley
       could show how this was being utilised.
      The use of a stroke register with local data and information can support
       the pathway, facilitate audits and develop the stroke service, yet only
       Wolverhampton New Cross was able to demonstrate this.
      There are a number of steps to the admission of stroke patients into
       hospital, which could be simplified. For example a patient's journey can
       include a GP visit, A&E, MAU, and a medical ward all prior to a stroke unit
       admission. It is possible for the ambulance service to admit straight to a
       stroke unit.
      Investment in community support as an integral part of the stroke care
       pathway and patient's rehabilitation. As such more engagement with
       carers and the voluntary sector is also required.
      There are capacity issues with CT scans and diagnostics. While there are
       clearly demands on the service there is also evidence of creativity across
       the patch to maximise use of the service including dedicated slots and
       new ways of working including ensuring scanners are used at weekends.
      The stroke care system clearly works better with a dedicated full time
       stroke coordinator with medical leadership driving the team.
      Social care was often poorly coordinated for the discharge of stroke
      Having a stroke care pathway is not enough. Training, education,
       development and how the multi-disciplinary team is brought into it needs
       more consideration with the patient always at the centre.

Further to these general comments, there were issues raised that have specific

relevance to stroke services in South Birmingham. These were derived both from
the visit, and from discussions at the conference:

Issues for Stroke Services in South Birmingham

The recommendations for stroke services in South Birmingham arising from the
StHA visits are:

      There are issues regarding eligibility for reimbursement at Moseley Hall
       Hospital. Patients requiring access to social care in the community to live
       at home, or care home placements, are not given the same priority as
       those patients occupying acute hospital beds. As a consequence, there
       are long delays in discharge from the Stroke Unit at Moseley Hall Hospital.
       As well as causing distress to patients and their families, the above
       discharge related problems have a significant effect on staff morale.

      There are some gaps in the current care pathway, for example access to
       rehabilitation services for younger patients with stroke remains difficult.

      The service does not have a “specialist outreach team”. There are
       opportunities for the PCT to evaluate the follow up needs of patients with
       stroke, and investigate the relationships between the current stroke clinics
       and other community services, in particular for black and ethnic minorities.

      There is a need to develop and enhance the relationship between the PCT
       commissioners and the acute trust to develop the strategic stroke service.

      The development of a stroke register linked with the acute service is

Suggested further developments

In order to meet national targets, there are areas of service development of
relevance to the PCT. In the light of national standards, comments from the Chief
Executive of the SHA, and current knowledge of the service, the following
recommendations can be made:

      Reimbursement

The issue of reimbursement for the PCT has an impact on transfer of patients
through the service. Patients may inappropriately stay in an acute bed, either
because of lack of availability in the PCT due to a backlog of patients, or because
it can be detrimental to move patients to the PCT knowing they will experience a
long wait for social services care. This issue must be addressed if the care
pathway is to work efficiently.

      Gaps in the Care Pathway

There are gaps in the current stroke pathway, for example relationships with
ambulance services, single point of entry to a stroke unit, access to diagnostic
assessment, medical leadership, and coordination of the service. A lack of
continuity of care is highlighted at discharge. South Birmingham PCT needs to
address these in the light of the needs of the local population, ensuring user
views are considered in the design of services.

      Stroke Outreach

The overall aim of an outreach team should be to provide stroke specific support
and rehabilitation for patients for who do not need to receive their care in a
hospital setting. There are three key elements:

   1. Preventing unnecessary admission in patients known to have stroke.
   2. Facilitating early supported discharge from hospital.
   3. Supporting primary care in the provision of primary and secondary
      prevention measures for stroke.

Stroke Outreach should complement existing generic rehabilitation teams,
supporting them with expert advice and knowledge in order that care can be
provided by the team that best meets the individual patient need. Roles and
responsibilities need to be clearly defined, in order to prevent duplication of care.

      Primary and Secondary Care Interface

There is a need to strengthen relationships between primary and secondary
stroke services, in order to achieve the targets set nationally regarding stroke
prevention and reduction in mortality from stroke. Joint protocols should be
established to clarify aspects of the stroke pathway where practices currently
differ or services are poor; ambulance services and single point of entry to
hospital via A&E, comprehensive TIA services, acute care, rehabilitation, and
long term follow up. Provision of long term follow up for stroke needs to be
reviewed in the light of the Quality and Outcomes framework (QOF), and
identification of current and future services for long term monitoring of patients
with stroke. Routes for access to assessment, investigations and specialist
rehabilitation need to be established for the group of patients who do not wish to
attend secondary care at acute stroke onset.

      Stroke Database

The stroke service in South Birmingham currently lacks a comprehensive record
of patients accessing stroke services. Ideally the database should span the
interface between primary and secondary care, and be integrated into the QOF
registers for stroke in GP practices.


This paper has outlined the current care pathway and services for people with
stroke in South Birmingham. It indicates the recent appraisal of services by the
StHA, and highlights areas for development. It illustrates the need for
commissioners and providers to continue to work together alongside service
users to develop stroke services. Stroke services should continue to strive to
develop care pathways that optimise patient experience and outcomes, and
reflect the needs of the local population.


DOH (2001) National Service Framework for Older People, Standard 5 Stroke,

DOH (2004) National Standards Local Action. Health and social care standards
and planning framework 2005/6 – 2007/8,

Intercollegiate Stroke Working Party (2004) National Clinical Guidelines for
Stroke 2nd edition, Royal College of Physicians, London,

Appendix I - National Service Framework for Older People, Stroke Milestones.


 April 2002              Every general hospital which carers for people with
                         stoke will have plans to introduce a specialised stroke
                         service as described in the stroke service model from

 April 2003              Every hospital which carers for older people with stoke
                         will have established clinical audit systems to ensure
                         delivery of the Royal College of Physicians clinical
                         guidelines for stroke care.

 April 2004              PCTs will have ensured that:

                                every general practice, using protocols agreed
                               with local specialist services, can identify and treat
                               patients identified as being at risk of a factors
                                every general practice is using a protocol agreed
                               with local specialist services for the rapid referral
                               and management of those with transient
                               ischaemic attack (TIA)
                                every general practice can identify people who
                               have had a stroke and are treating them
                               according to protocols agreed with local specialist
                                every general practice has established clinical
                               audit systems for stroke.

                         100% of all general hospitals which care for people with
                         stroke to have a specialised stroke service as described
                         in the stroke service model.

Appendix II - National Targets (Health and Social Care Standards and Planning
Framework, DOH 2004)

Timescale    Target
2010         Decrease mortality from heart disease, stroke and related illness to
             40% in under 75s, and a 40% reduction in inequality gap between
             5th of areas with worst health and deprivation indicators
             Achieve by managing hypertension, cholesterol, diabetes and
             decreasing smoking, in primary care setting
2010         Decrease in adult smoking from 26% in 2002 to 21% or less by
2008         Of those patients requiring support to live increase to 34% those
             living at home as opposed to in residential care
2007/8       Increase by 1% per year those living at home


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