LUTON STROKE PATHWAY REVIEW. DRAFT PAPER 4 th APRIL 2014

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1 LUTON STROKE PATHWAY REVIEW DRAFT PAPER 4 th APRIL 2014 Helen Miller Page 1

2 CONTENTS Ref Content Page 1 Background 3 2 National Priority 4 3 Local Context and Activity Review 5 4 Current Provision 6 a) Prevention 7 b) Acute Care 9 c) Early Supported Discharge 11 d) Longer Term Rehabilitation and Reablement 13 5 Options Analysis 14 6 Recommendations 15 Helen Miller Page 2

3 1. BACKGROUND A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue. The most common symptom of a stroke is sudden weakness or numbness of the face, arm or leg, most often on one side of the body. Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; fainting or unconsciousness. The effects of a stroke depend on which part of the brain is injured and how severely it is affected. A very severe stroke can cause sudden death (World Health Organisation 1 ). 85% of strokes are caused by a blockage (called ischaemic strokes).15% of strokes are caused by bleeding in the brain (called haemorrhagic strokes) A transient ischaemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours. Stroke is a preventable and treatable disease 2. Smoking doubles the risk of stroke. The more you smoke, the greater your risk. A person smoking 20 cigarettes a day has six times the risk of stroke compared to a nonsmoker. Higher salt intake is associated with a significantly greater incidence of stroke. An increase of 5g of salt a day is associated with a 23% increased risk of stroke. Being overweight increases your risk of ischaemic stroke. High blood pressure is the most important risk factor for stroke, contributing to about 50% of all strokes. People with diabetes are twice as likely to have a stroke compared to those without the condition. Atrial fibrillation (irregular heart beat) increases your risk of stroke by up to five times. High cholesterol is a contributory risk factor for stroke, having more of an effect on people who smoke or who are inactive. Reducing cholesterol levels with use of statins has been shown to reduce the risk of stroke by 21%. The evidence proves that stroke is not an inevitable consequence of aging. Improved recognition of high risk patient s, effective primary, secondary prevention strategies, better recognition of people at highest risk, and interventions that are effective soon after the onset of symptoms can lead to better outcomes. Understanding of the care processes that contribute to a better outcome has improved, and there is now good evidence to support interventions and care processes in stroke rehabilitation (NICE Guidance, 2008) 3. Luton CCG has established a multiagency Stroke Task and Finish Group. The purpose of this group is to review current Stroke services and develop a local, whole system strategy for stroke services in Helen Miller Page 3

4 alignment with national priorities, the development of Hyper Acute Stroke Units (HASU) and the requirement for Early Supported Discharge (ESD). The current Task and Finish Group have contributed to the development of this first draft paper. Dr Abdul Shakoor (Chair and Clinical Lead) Dr Paul Singer (LTC Clinical lead) Dr Fiona Sim (Planned Care Clinical Lead) Anne Adams (Head of Intermediate Care) Rebecca Chatterton (Stroke Association) Grahame Atkins (Headway Luton) Jean Forrest (Health Watch Luton patient Representative) Helen Miller (Strategic Implementation Manager for Long Term Conditions) Emma Dwyer (Strategic Implementation Manager for Planned Care) Paul Lindars (Strategic Implementation Manager for Primary Care) David Davies (Information and Pathway Analyst) A Group is being expanded to include LBC Adult social care, Public Health, BCCG and The L&D Hospital Foundation Trust. 2. NATIONAL PRIORITY Stroke services have been the subject of development and improvement since the publication of the National Stroke Strategy in 2009, and remain a priority within the Operating Framework for the NHS in England 2012/13 as part of the need to reduce premature mortality. Stroke killed more than 40,000 people in 2009 in England and over 12,000 in NHS Midlands and East. In addition, many people recovering from strokes are left with long term disability. It is a key component of Domain 1 and 2 of the NHS Outcomes Framework 4 and the Public Health and Adult Social Care Outcomes Frameworks for 2013/14 5. In 2012 Midlands and East Strategic Health Authority (SHA) undertook a major review of stroke provision which resulted in a core service specification against which commissioners and Clinical Networks were asked to configure services with some clear recommendations for improvement. This included: Consistency in the delivery of Primary Prevention and Long Term Care; Clarity about the definition of long-term care, which generally should not be premised on bed-based intermediate care. Developing clear plans for each element of the pathway to ensure consistency and coverage across the entire specification. Addressing the lack of psychology 4 Outcomes-Framework pdf 5 The Outcomes Framework for public health and adult social care are available respectively at: and _ pdf Helen Miller Page 4

5 Clear plans for Early Supported Discharge. That the system looks at the sustainability of their TIA services provided at L&D and Bedford. Reviewing the proposed configuration of the hyper acute stroke units (HASU) and Acute Stroke Units (ASU) across the region. To develop 7 day working along the Stroke pathway. There is now reported evidence that 7 day working makes a significant difference to outcomes. 3. LOCAL CONTEXT AND ACTIVITY REVIEW There are estimated to be over 37,000 people currently living in Luton with some form of long term condition. Luton has a higher than national average death rate for heart disease and stroke with a standardised rate of 80 per 1000 population compared to national average of 67 per 100,000 (Health Profile, 2012) On average there are 180 strokes a year in Luton. The public health needs of Luton, including demographics and high risk behaviours are reasons for this higher than national average prevalence rate. Luton s population includes 40.6% from Black and Minority Ethnic (BME) groups. These groups are up to six times more likely to develop Type 2 diabetes than the White European population, a high risk factor for Stroke. Projections indicate that type 2 diabetes will increase in prevalence by more than 70% by 2050, with increases of 30% for stroke over the same period. ACTIVITY REVIEW There were 515 patient admissions to the Luton and Dunstable Hospital between April 2011 and January 2014 (34 months), at a cost of 1,738,053. Of these: 63.7% had Primary Diagnosis: "I63-Cerebral Infarction" at a cost of 1,106, The highest peak in total activity (for all Stroke diagnosis codes included here) occurred in Feb-12 with 23 patients at cost of 74,963. Adversely, the lowest dip in activity was in Sep- 12 with 9 patients at cost of 25, % of patients were discharged to usual place of residence. 57.3% had Length of Stay (LOS) of 7 days or more, at cost of 1,040,805 split into: o 20.2% with LOS 7-13 days - with a cost of 384,406. o 10.9% with LOS days - with a cost of 212,950 o 26.2% with LOS 21 plus days with a cost of 443,449 Table 1: Hospital length of stays for Patient having a stroke under 7 days (April 2011 and January 2014). LOS 0 days 1 day 2-3 days 4-6 days 6 The national rate for cerebral infarction is 85% compared to Luton 63.7%. This requires further investigation Helen Miller Page 5

6 Total Number Percentage of Total Stays 4.3% 8.7% 13.2% 16.5% Table 1 indicates that potentially 26% of Luton patients may be eligible for discharge home within 3 days for Early Supported Discharge (ESD). With 182 strokes in total per year, this equates to approximately 47 patients per year eligible for ESD. (This does not include any patients from Bedfordshire who may be eligible). 73.2% were aged 65 or more with a cost of 1,277, % were White Ethnic background of which: o o o 56.5% = British White 6.6% = Irish White 2.7% = Other White In the published 2011 Census Ethnic populations, 81.8% of the 65yrs and over age group in Luton were recorded as being from White backgrounds. This supports the activity data in the MedeAnalytics extract; i.e. the 3/4 of diagnosed strokes which are in the 65+ age range, tend to also be predominantly made up of patients with white ethnic backgrounds. 7 Projections indicate that type 2 diabetes will increase in prevalence by more than 70% by 2050, with increases of 30% for stroke over the same period as the older Black and BME populations increase in Luton. 4. CURRENT PROVISION There is no commissioning of specialist community stroke rehabilitation services have evolved into their current configuration without strategic oversight. Staffing capacity and skills could be utilised more effectively especially through the integration of health and social care teams and better utilisation of the Stroke coordinator roles. The pattern of delivery suggests a fragmented stroke pathway, lacking joined-up working, but with pockets of good practice. This includes the new stroke pathway into Moorlands rehabilitation unit. Luton has proactively introduced innovative, best practice ideas such as GRASP AF(Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrillation) and the Action for Rehabilitation from Neurological Injury (ARNI) programme but these require embedding into a whole system strategy. The third sector and charities need to form part of the strategic solution. The acute sector is failing to meet national targets for Stroke. Evidence from best practice sites is that further improvements in clinical outcomes and performance can be made by adopting a whole systems approach. The main gaps in local community provision are: Census data source: Helen Miller Page 6

7 Whole pathway Coordination including Multidisciplinary working across acute, primary and community sector Early Supported Discharge and Intensive Specialist Rehabilitation in the Community 6 week and 6 Month Holistic Care Reviews Appropriate 7 day working a. PREVENTION A Healthier Future Improving Health and Wellbeing in Luton ( ) The Health and Wellbeing Strategy is designed to improve health and wellbeing and reduce health inequalities. This will happen through better integration of services and a planned move of resources towards prevention and early intervention away from avoidable treatment and care. The strategy recognises the risk factors for Stroke as identified through the Joint Strategic Needs Assessment 8. It aims to tackle the key lifestyle issues in Luton such as smoking, obesity, physical activity, alcohol and drugs as key priorities. GRASP-AF (Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrillation) A primary care Investment Scheme project 2014/15 Research has shown that the existence of atrial fibrillation (AF) an irregular heartbeat, is a major precursor to the occurrence of stroke, and treatment of this condition with anticoagulant therapy is highly effective in reducing stroke risk. The aim of the GRASP AF project is to identify patients currently on the practice clinical system who have some indication that they may have AF, and to ensure that they are receiving effective anticoagulation and medical intervention to reduce the risk of ischaemic stroke. Low reported prevalence of AF was identified as an issue in Luton Luton CCG worked in collaboration with the Cardiac quality improvement lead (Strategic Clinical Network) to become early adopters of the GRASP-AF (Primis) tool for 2013/ of 31 Luton Practices signed up to the project through the Primary Care Investment Scheme Following a first run of the tool baseline data for Luton prevalence increased from 0.9% to 1.1% demonstrating there was previously an unidentified group of high risk patients. As a benchmark the comparator across the Midlands and East Region for prevalence is 1.77% so it is possible Luton still has a cohort of AF patients still to be identified. The first GRASP AF audit across Luton highlighted that 40% of AF patients are on Warfarin, with 55% recorded as not on warfarin or having any documented contra-indication to an anticoagulant. The remaining 5% were either contraindicated or had declined an anticoagulant 8 pdf Helen Miller Page 7

8 The second audit/ upload of data is in progress and early reports suggests a further increase in the percentage of AF patients prescribed warfarin (or have a documented contraindication to an oral anticoagulant). A full report on the outcomes of the GRASP-AF tool from October 2013 to March 2014 will be available to share at the end of April / early May The outcomes of the report will be used to inform next steps in relation to management of AF and Stroke prevention in primary care. The GP Quality Outcome Framework (QOF) data in Table 2 describes the stroke indicators that GP practices are required to report on and performance against those indicators. Chart 1 below shows how these indicators for Luton compare against regional and national performance. Table 2 (Data for Stroke/TIA taken from for period ending 31 March 2013) Indicator Description Numerator Denominator Ratio STROKE 1 STROKE 13 STROKE 6 STROKE 7 STROKE 8 STROKE 12 STROKE Patient on Stroke/TIA Register The % of new patients with a stroke who have been referred on for further investigation Stroke/TIA and BP 150/90 Stroke/TIA and cholesterol check in last 15 months Stroke/TIA and cholesterol 5.0 or less The % patients with a stroke shown to be non-haemorrhagic, history of TIA who have a record that antiplatelet agent (aspirin, clopidogril, dipyridamole or a combination) or an anti-coagulant is being taken (unless a contraindication or side effect is recorded) Stroke/TIA given flu % % % % % % % Helen Miller Page 8

9 10 vaccine Chart 1 indicates that Luton is currently underperforming against the entire QOF stroke metrics compared to the rest of the region and national performance. Chart 1: Comparators for Stroke and TIA (%) STROKE 1 STROKE 13 STROKE 6STROKE 7STROKE 8 STROKE 12 STROKE 10 Luton CCG Hertfordshire & the south midlands area team Midlands and East of England Commissioning Region NHS England UK b. ACUTE CARE The National Stroke Strategy 2007 and NICE quality standards for Stroke June 2010 clearly set out the standards for acute stroke care. The Luton and Dunstable Hospital current service quality performance report (SQPR) indicates the following key performance indicators as shown in Table 3 below; Table 3: L&D Hospital Quality Performance Metrics for Stroke Services Summary Threshold Reporting Frequency Aug- 13 Sept- 13 Oct- 13 Nov- 13 Dec- 13 Jan- 14 Feb- 14 % of stroke patients spending at least 90% of their time on a stroke unit % of patients with a high risk TIA treated within 24 hours but not admitted % of patients admitted to the stoke unit within 4 hours of arrival 80% Monthly % Monthly % Monthly Helen Miller Page 9

10 % of patients admitted directly to an acute stroke unit within 4 hours of hospital arrival 90% Monthly A formal contract query was issued on the 18 th March regarding the underperformance against the stroke metrics and a remedial action plan is expected from the L&D Hospital Foundation Trust to assure Luton CCG that they are implementing changes that will ensure performance against national targets. The Sentinel Stroke National Audit Programme (SSNAP) dashboard report in Table 4 has also provided the following snap shot stroke performance data for Luton (Jan Sept 2013) Table 4: The SSNAP dashboard report for Luton Indicator National Luton CCG Rag Score Number of patients (January Sept 2013) Case ascertainment band % % % of people going 57.9% 51.1% direct to stroke unit within 4 hours Percentage of all stroke patients receiving thrombolysis 11.8% 18.9% Number of patients (July-Sept 2013) Case ascertainment band Percentage of applicable patients who are discharged with joint health and social care plan Percentage who spend 90% or more on their in-patient stroke unit Percentage of applicable patients receiving a 6 month follow up % 44 90% % 72.2% 83.8% 77.3% 13.4% Insufficient data Helen Miller Page 10

11 An acute stroke walkthrough review is planned for the 1 st May 2014 to obtain assurance that the Trust is meeting the standards laid out in the National Stroke Strategy and NICE quality standards or have a robust action plan to address within an acceptable timeframe. The walkthrough will review the data from admission to discharge to map the patient journey. The coding of the data will be analysed to ensure that it clearly reflects the activity undertaken in the Trust so a true picture of services can be reflected. Areas where further quality measures can identify and measure improvements will be discussed and an update of the current action plan provided by the Trust will be undertaken. A full report ensuring all quality measures are reviewed in acute care will be presented to the Stroke Task and Finish Group and identified actions monitored here reporting through the Long Term Conditions and Planned Care Strategic Implementation Groups. Where there are failures to meet these standards the commissioners will work with the Trust and the Commissioning Support Unit contracting team to progress an action plan and utilise the appropriate contractual levers. HYPERACUTE (HASU) and ACUTE STROKE UNITS (ASU) The option appraisal report on the location of HASU units across the regions was completed in February and has been circulated to all the CCG Chief Officers for review by their CCGs. The review group have been asked to address some outstanding questions prior to any decisions being taken. These include: To provide assurance on ambulance travel times with East of England Ambulance Service NHS Trust (EEAST), taking into consideration local road network difficulties To obtain Early Supported Discharge and plans from each of the 5 CCG s to ensure that they will have the capacity and resilience to meet the demand of the HASU s and achieve best practice against national standards. To agree the criteria for decision making for both HASU and ASU development. Current best practice indicates that they should be co-located. Affordability and tariff modelling Plans for formal consultation that aligns with the Milton Keynes and Bedford Hospital consultation timelines. Chief Officers of the five CCGs, will submitted to their boards the final options paper in April/May with a view to agreeing a way forward and commencing formal consultation. c. EARLY SUPPORTED DISCHARGE (ESD) An Early supported discharge service is a comprehensive stroke skilled multidisciplinary team who manage patients at their place of residence and who are able to provide rehabilitation of similar intensity to that of a stroke unit. ESD services have been shown by the Cochrane Reviews Helen Miller Page 11

12 (2005/2012) to reduce length of hospital stay and improve clinical outcomes for stroke survivors with mild to moderate disability. 9 The required standards are as follows: Standard 7 Patients with stroke are offered a minimum of 45 minutes of each active therapy that is required, for a minimum of 5 days per week, at a level that enables the patient to meet their rehabilitation goals for as long as they are continuing to benefit from the therapy and are able to tolerate it Standard 9 - All patients after stroke are screened within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment. Standard 10 All patients discharged from hospital who have residual stroke related problems are followed up within 72 hours by specialist stroke rehabilitation services for assessment and ongoing management The Specialist Stroke Rehabilitation Team requires the following recommended staff establishment for ESD stroke rehabilitation per 100 caseload 10 : Physiotherapist band7 0.8 Occupational Therapist band Speech and Language Therapist band Physician 0.1 Social Worker band Nurse band Co-ordinator - Band 4 1 Administrator - Band 3 1 Clinical Neurophysiologist band 8B 0.5 The national evidence indicates that up to 40% of stroke patients may be eligible for Early Supported discharge; however the data in Luton suggests that this may be significantly lower in Luton, at about 26% of patients, due to a range of factors including the number of frail elderly having strokes, complex comorbidities and poor housing preventing the necessary adaptation for successful rehabilitation. NICE guidance (CG 162) states that early supported discharge is only suitable for, people with stroke who are able to transfer from bed to chair independently or with assistance, provided a safe and secure environment can be provided. Currently Cambridge Community Services (CCS) provides a small generic Community Assessment and Rehabilitation Team (CART) for Luton patients. The service provides post-acute discharge and rehabilitation for longer term stroke survivors but the current team structure does not meet the standards and definition of an Early Supported Discharge (ESD) Team, as defined by the Accelerated Stroke Improvement (ASI) Metrics and by the following current strategies/guidance. The CART team provide support for patients discharged home and also a step down pathway into Stroke rehabilitation beds at Moorlands Nursing home. The CART team currently consists of the following whole time staff equivalents: 1 Service Manager 9 Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD DOI: / CD pub3 10 The Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Helen Miller Page 12

13 1 Parkinson s disease specialist nurse 5.5 Physiotherapist 2.4 Occupational Therapist Therapy Technician 2.28 admin The team supported 159 patients with stroke at home and in rehabilitation beds at Moorlands Nursing home. (April 13 March14) Falls Team 1WTE B7 physiotherapist the Falls co-ordinator 3.5WTE B4 Falls support workers Wider teams that could be incorporated into community stroke care include: Stroke coordinators 1.4 wte based within the hospital. (The role of the coordinators is currently under review) Reablement workers 75 whole time equivalent through Luton Borough Council (The role of the coordinators in relation to stroke care is to be clarified with LBC) Luton Headway, commissioned by Luton CCG, is currently supporting 80 Luton patients with a diagnosis of stroke. Action for Rehabilitation from Neurological Injury (ARNI) programme at Chaul End Lane Community Centre. ARNI has supported 72 stroke survivors since March 2012.The funding of 18K from LBC to cover transport and hire of the trainers has now been discontinued putting the service at risk. The service has evidenced positive patient improvement outcomes. The improvements shown have implications for reducing the amount of care that clients would require through health and social services The ARNI programme has seen a reduction in care packages, continence requirements, and falls. It is therefore able to demonstrate financial savings. d. LONGER TERM REHABILITATION AND REABLEMENT Currently Luton has a co-located health and social care rehabilitation and reablement teams based at Tomlinson Avenue. This also includes the falls team and Parkinson s disease specialist. However, there is limited joint working and the capacity and skills are not being used to full potential. A practical, best practice option for Luton is to fully integrate health and social care ESD services with social care enablement supporting some of the rehabilitation functions. The ESD service will also coordinate transfers of care and deliver all 6 month reviews. This would increase opportunity for the community ESD team to work closely and flexibly with other rehabilitation teams (eg neurological rehabilitation) in response to fluctuation in stroke and specialist rehabilitation activity. A seamless transition from rehabilitation to reablement and the use of third sector organisations, such as Headway would ensure that patients remain supported after the intense rehabilitation phase is completed. The Stroke Association Our Life after Stroke Services should be embedded in the long term support of Stroke survivors. Helen Miller Page 13

14 Currently Luton Borough Council funds the ARNI programme at Chaul End. This programme uses personal trainers to support patients with strokes and their carers become more independent. The aim is to take people from the stage where a therapist becomes unavailable or no longer required, to the stage where patients can achieve their personal goals for daily life and independence. This service needs to form part of any agreed strategic stroke pathway. 5. OPTIONS ANALYSIS Three options have been considered: Option 1: Do Nothing; which requires no financial investment. Evidence suggests that this option would increase the financial burden on health and social care services, and the wider economy due to increased dependency/disability; non-compliance with CQC Audit recommendations and NICE Quality Standards and inequity of service compared with neighbouring CCG s who are developing an ESD pathway. The Hyper Acute and Acute stroke units will not be sustainable without a robust Stroke ESD service in place. It is required to ensure timely patient flow through the acute sector and to prevent bed blockages at the point of discharge. Option 2: New Service Outreach Model from the Luton and Dunstable Hospital Benefits: Risks. The acute stroke medical team have seamless care for the patient. Identifies correct patients early & facilitates speedy discharge Robust medical management May facilitate quicker follow up response to provide medical interventions in the community May be too cautious assessing the level of ability that patients can be supported at home leading to longer hospital stay Patient dependency on acute staff may make transition to mainstream community services difficult and lead to poor patient experience Supporting the discharge home could be disjointed & limited without the knowledge and breadth of community teams supporting Presumably an L&D based ESD team would cover Luton, S Beds & Herts. There could be wasted time spent on travel even if the team was divided into locality specific groups. Activity numbers, patient flow & distribution may mean an increase in staff journey times. The potentially low numbers of patients eligible for Luton may make it financially unviable to set up a specific ESD team Option 3: Enhance Existing Community Rehabilitation and Reablement Services. This would look to review current capacity and skills across the whole system, including third sector and to develop an integrated, flexible model that fully utilises all of these skills. To develop a locally robust neurological team as part of the existing Community Assessment and Rehabilitation Team (CART) and provide, as part of this, the Early Supported Discharge service. This would also allow Luton to further integrate health & social care and to facilitate patients suffering from other neurological conditions and reintegrate into community life. Helen Miller Page 14

15 Benefits. Transfer of care happens early in the pathway (This relies upon good in reach of community staff in to the acute unit) The focus is clearly set for the patient and the whole pathway of being at home with as much function as possible. Earlier rehabilitation at home has been shown to increase the chance of survival from stroke and improve adverse outcomes (Langhorne et al 2005), Discharge home is planned and implemented by staff familiar with the whole range of issues that are encountered in the community and the infrastructure to solve problems as they arise. The ESD in reach team participate in the assessment & Multidisciplinary Team (MDT) within the hospital Strong links with other community teams who may need to be involved Seamless transfer at the end of the ESD intervention to other community services (whether therapy, nursing, 3 rd sector or Adult Social Care) Staff used to conducting holistic assessments (i.e. patient, condition, environment, social needs, family & carer needs) Evidence that this is an approach that is more beneficial for the patient Opportunity to develop robust ESD services in the community whilst procuring a new community and intermediate care providers. Risks. Possible slow access to acute medical advice should it be required once patient is at home (possible perceived loss of control of patient by the acute team) This could be rectified by strong team work & robust pathway At the moment provision of some parts of the MDT necessary for ESD (e.g. psychology & Speech and Language Therapy (SALT) are currently limited in the community and may be more easily supported by the acute unit. Currently, there is little confidence within the acute unit as to what is provided in the community and the quality of nursing and therapeutic interventions. This is a national problem which could be countered by rotation of staff along the pathway, MDT working and feedback regarding outcomes. 6. RECOMMENDATIONS The preferred option is currently Option 3. This proposal supports the development of an enhanced, holistic ESD service, including psychological support, to facilitate the discharge of eligible stroke patients from acute hospitals back into their place of residence within the community. This model would introduce a system-wide, fully integrated ESD service between all statutory and voluntary sector stroke services. The proposal is based on evidence from the Stroke Improvement Programme and aligns to Luton s ambition for an Helen Miller Page 15

16 integrated Stepped Model of Care for the frail elderly and those with long term conditions. It works with the local vision for enhancing primary care and the Integrated Care Hub. A single team with joint health and social care leadership coordination of community stroke rehabilitation and care, including management of a stroke register, ensuring follow-up of all patients a single point of access for stroke contact and coordination the short term delivery of intensive packages of care and rehabilitation Single assessment and care planning for service users and carers integrated competency based health and social care roles hybrid care and rehabilitation roles seamless rapid smooth transfers to the community including to home Short-term 7-day community rehabilitation, inclusive of any required care, each of the required therapies and psychological support for up to 6 weeks. education and training for longer-term professional and informal carers 6 month holistic health and social care reviews for all stroke patients and their carers The gold standard model would see a much more fluid continuity of care between the acute unit and the rehabilitation Services, working as a fully integrated service with full rotation of staff in order to improve skill levels and ensure robust clinical governance. There is a known deficit in the workforce in regards to the Midlands and East Stroke specification. Clear operational leadership covering the full pathway would alleviate some of the pressures in the workforce. This would help to reduce complacencies and clinical anxiety in moving patients quickly through the rehabilitation pathway, consequently making it more efficient in terms of patient outcomes and financially. In order for Stroke rehabilitation patients in Luton to have access to a quality service and the commissioners to be confident that it is efficient in terms of both workforce and cost, it is important that the service is run as a complete pathway and not as two separate services. This should be evident in any contractual arrangements. A key outcome to any model chosen is that the patient and care must experience the services as a single seamless pathway. Next Steps: A Multiagency Stroke Task and Finish Group has been established to progress the Luton Stroke Strategy. This is chaired by clinical lead Abdul Shakoor and is accountable to the Cardiovascular Local Implementation Group and the Long Term Conditions Strategic Implementation Group. The Group request that: The executive support this matrix approach to the service review. Helen Miller Page 16

17 The Contract Team robustly manage underperformance by the Luton and Dunstable Foundation Trust against contracted stroke metrics using the contractual levers and monitoring of remedial action plan provided. The executive approve option 3 and progress the integrated health and social care model through the Better Together Strategy. Helen Miller Page 17