MEETING OF THE GOVERNING BODY IN PUBLIC

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1 MEETING OF THE GOVERNING BODY IN PUBLIC 4 th February 2016 Title: Transforming Stroke Services Programme - Next steps to improving stroke services Agenda Item: 15 From: Alison Lathwell, Acting Director Strategy and Redesign Purpose of Paper: To provide the Governing Body with an update on the Bedfordshire, Luton, Hertfordshire and Milton Keynes (BHMK) Stroke Review. To set out the recommendations from the review and proposed hyper acute stroke unit (HASU) configuration. To describe the impact of the proposal for BCCG To present the options for post HASU acute stroke services. Detail key Issues for the Governing Body to note: The proposed HASU reconfiguration will require a change to existing patient flows for Bedford locality. There are a number of gaps in service provision, Governing Body is asked to note the plans to address these gaps Changes to HASU pathway presents a number of options for post-hasu care. It is proposed that the options form part of the Healthcare Review consultation programme. What risks may there be around this topic/what risks have been considered and mitigating action put in place: The HASU reconfiguration proposal spans a number of CCGs. There is a risk that individual CCG timelines for implementation could result in a lack of alignment to delivery of the stroke review recommendations. All partner CCGs are signed up to jointly manage this work to minimise the risk of misalliance in local commissioning plans. Actions required by the Governing Body: Governing Body is asked to (a) note the update on stroke review and to (b) consider the options proposed to consult on (c) approve proposal to include options in the wider Healthcare Review consultation. Conflicts of Interest: 1

2 Executive Summary: A stroke is a medical emergency. To prevent disability or brain damage, patients must get to a hospital quickly to begin treatment. Acute stroke therapies try to stop a stroke while it is happening by quickly dissolving the blood clot or by stopping the bleeding, this is known as thrombolysis. These services are typically delivered in an acute setting known as Hyper acute Stroke Unit or HASU. Post-stroke rehabilitation helps individuals overcome disabilities that result from stroke damage. Hyper acute services provide expert specialist clinical assessment, rapid imaging and the ability to deliver thrombolysis 24/7, usually for no longer than 72 hours after admission. At least 600 stroke patient admissions per year are required to provide sufficient patient volumes to make hyper acute stroke service clinically sustainable, to maintain expertise and to ensure good clinical outcomes. Acute stroke care immediately follows the hyper acute phase, usually after the first 72 hours after admission. Acute stroke care services provide continuing specialist day and night care with access to physiological monitoring and urgent imaging as required. In-hospital rehabilitation should begin immediately after a person has a stroke and continue for as long as required. There are currently four stroke units providing HASU beds Watford, Lister, L&D and Bedford. Bedford provides a thrombolysis service for its catchment area 9am-5pm five days a week and is the smallest of all the units. All the other Trusts provide the service 24/7. A stroke review undertaken across Midlands and East in 2012 and 2014, both reviews concluded that the number of HASUs across the network should be reduced from four to three units (1) Watford (2) Lister and (3) Luton & Dunstable (L&D) for clinical sustainability. It is planned that by April 2017 HASU units covering the BHMK network will be reconfigured in line with the stroke review recommendations. The planning of how the stroke review recommendations will be delivered will be managed jointly by the relevant CCGs, the Strategic Clinical Network and NHS England. BCCG is the only CCG within the BHMK network with a change to current activity flows. The changes will affect the stroke activity currently at Bedford Hospital only. Please note current Bedfordshire activity at L&D and Lister will be unaffected by this change. As part of the HASU reconfiguration the CCG will need to develop models for acute stroke care. Governing Body is asked to note the update on stroke review and to consider the options that will form part of the wider Healthcare Review consultation. 2

3 Introduction This paper will provide the Governing Body with an update from the Stroke Review including the recommended configuration for Hyper-Acute Stroke Unit (HASU). The paper will also provide Governing Body with specific considerations for commission post-hasu care. Bedfordshire and Luton, Hertfordshire and Milton Keynes Stroke Review Nationally, the Beds, Herts and Milton Keynes (BHMK) network (made up of provider trusts and commissioners) has been identified as outliers in stroke provision. BCCG has been challenged by NHS England to urgently improve stroke services as a result of the network having the poorest performance against national stroke quality standards in the country. Stroke services in Bedfordshire are fragmented and key elements of an integrated stroke pathway have not been commissioned. There are currently four stroke units providing HASU beds Watford, Lister, L&D and Bedford. Bedford provides a thrombolysis service for its catchment area 9am-5pm five days a week and is the smallest of all the units. All the other Trusts provide the service 24/7. The initial stroke review undertaken across Midlands and East in 2012 concluded that the number of HASUs across the network should be reduced from four to three units (1) Watford (2) Lister and (3) Luton & Dunstable (L&D) for clinical sustainability. A second review was undertaken in 2014 by the Stroke and Cardiovascular Strategic Clinical Network Review of Stroke Provision for CCG s in Hertfordshire, Bedfordshire and Milton Keynes. This review supported the findings of the original stroke review in terms of recommended configuration of units. Bedfordshire patients currently have access to Hyper Acute Beds at L&D, Bedford and Lister Hospital. A service specification was developed across the East of England with the intention of improving quality and performance of stroke units. It was developed based on the latest clinical evidence and requires designated HASUs to provide the following: Units should have a minimum of 600 strokes a year Seen by the stroke team within 30 minutes Scan within 1 hour 24/7 thrombolysis in-house or use of telemedicine to provide thrombolysis service Ability to admit to HASU within 4 hours after arrival at A&E Daily ward rounds including weekends Appropriate nurse staffing levels Access to fully monitored beds for the first 24 hours Access to therapy 7 days a week Access to daily one stop TIA clinics for high risk patients Proposed HASU Configuration It is planned that by April 2017 HASU units covering the BHMK network will be reconfigured in line with the stroke review recommendations. 3

4 The planning of how the stroke review recommendations will be delivered will be managed jointly by the relevant CCGs, the Strategic Clinical Network and NHS England. BCCG is the only CCG within the BHMK network with a change to current activity flows. The changes will affect the stroke activity currently at Bedford Hospital only. Please note current Bedfordshire activity at L&D and Lister will be unaffected by this change. Of the approximate 450 strokes per year in Bedfordshire, in 14/15 there were 243 strokes treated at Bedford Hospital. Based on this data the stroke network have calculated that the Bedford Hospital activity flows would shift to L&D and Lister. This would increase activity at these two trusts under the proposed new model. The L&D will see the biggest increase to patient activity. Trust SCN region No of strokes 14/15 Activity shift new model Total strokes new model Bedford EoE E&NHerts EoE L&D EoE WHerts EoE 547 = 547 Milton Keynes TV The diagram below outlines the location of all stroke units including the proposed HASUs for consideration 4

5 A detailed review of the stroke pathway has identified a number of gaps in service provision. Small activity levels across local providers smaller units cannot deliver stroke service specification Fragile services workforce gaps in medical, nursing and therapy staff groups Quality needs to improve significantly CQC review and quarterly Stroke Audits concluded BCCG to be one of the poorest performing CCGs in the country Poor stroke rehabilitation services no commissioned Stroke Early Supported Discharge and little access to inpatient community rehabilitation. In 2016/7 we will address the inequalities in stroke care provision to improve patient outcomes, service performance, quality and patient experience. To achieve this we will: Commission Hyper Acute Stroke service in accordance with East of England Stroke Network service specification Redesign community services to provide improved rehabilitation both in an inpatient and home setting (including ESD) Pilot 6 month reviews as a preventative measure to contribute to reducing unnecessary hospital readmissions As part of the HASU reconfiguration the CCG will need to develop models for acute stroke care. The developing options are: Option Impact Considerations 1 Direct all suspected stroke patients to designated HASU. Patients remain for up to 10 days with majority discharged home. 2 Direct all suspected strokes to designated HASU. Patients stay for 72 hours and then repatriated to Bedford Hospital for onward rehabilitation Based on current average LOS (13 days) this model will not significantly alter current practice. Bedford will no longer provide HASU services assessment, imaging and thrombolysis but will continue to provide acute stroke care and in-hospital rehabilitation Designated HASUs will need to ensure they have capacity. Need to determine what additional community provision will be required Patient choice for those patients living closer to Lister or L&D Clinical opinion that transfer from one hospital to another may not be advisable for this vulnerable group of patients 3 Direct all suspected strokes to designated HASU. Stay for 72 hours then discharge to We do not currently have community service capacity but will ensure that the requirements are Will require community beds for inpatient rehabilitation, stroke early supported 5

6 Community Stroke Rehabilitation. fed into any future community model. discharge which provides rehab at home Please note neighbouring CCGs are exploring similar options. The reconfiguration and options have been shared with the CCG Executive where there was support for this programme of work and a recommendation to include the options within the Healthcare Review. Recommendation Governing Body is asked to note the update on stroke review and to approve that the three options are taken to public consultation as part of the wider Healthcare Review consultation. 6