Tom Penman Sue Perkins Head of Stroke Services

Tower Hamlets Community Health Services

Commissioning Manager for Long Term Conditions

NHS Tower Hamlets

Every PCT should commission a community rehabilitation service for stroke patients delivered by staff with stroke specialist skills Service configuration should be locally determined and the service must meet all of the performance standards

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Tower Hamlets demographics …

Deprived Overcrowded Diverse Young Growing population High unemployment 20% families live on less than £15,000 ▪ ▪ ▪ ▪

And our health our needs assessment tells us …

Low life expectancy Health inequalities (male life expectancy vs national average) High burden of cardiovascular disease Health inequalities within the borough ▪

But …

Ranked 1st nationally for economic growth

Health Needs Assessment – Stroke in North East London ▪ Approx 2,000 residents on GP stroke registers ▪ Absolute number of deaths from stroke low compared to London (young population)..but..

▪ Deaths in under 75s (“preventable”) from Stroke third highest in London ▪ Death rates in under 65s fourth highest in London ▪ Highest hospital admission rates for Stroke in London

Parts of the jigsaw in place in 2008

Agreed, mapped Stroke pathway Service development & innovation driven by staff • Staff working across acute and community pathway • Inpatient community rehabilitation ward • Multi-disciplinary Community Stroke Team (CST) established Stroke a priority area - Commissioning Strategic Plan

Missing pieces

1. Capacity of CST and inpatient rehabilitation 2. Accountability for stroke pathway 3. Clear service specification for community rehab team and structured Performance Monitoring process 4. Ongoing patient and public involvement 5. Clear link to prevention

Post discharge 12 week input Team Manager 0.5 WTE Occupational Therapist B7 Occupational Therapist B6 Bengali Therapy Link Worker Clinical Psychologist 0.6 WTE Physiotherapist B7 Physiotherapist B6 Speech & Language B7 part-time Therapy Assistant B3

Consultant Junior Dr FY2 Registrar

Nursing (not all stroke specialist) Psychology & Dietician

Speech and Language Therapy Occupational Therapy Physiotherapy Some staff shared across Acute Stroke Unit, or across Older People’s Ward, or all Community Intermediate Care & Rehab services

Further pathway review

From patient perspective & against Stroke Strategy Stakeholder involvement Staff interviews, ward observations, discovery interviews, Local Authority engagement To develop a “vision” for the service

Skill mix review

Identified need for more specialist nursing staff & nursing clinical leadership role

JSNA

To add to PHAST data re. admissions, expected prevalence, current inequalities

Investment and redesign needed

Early Supported Discharge Pathway available to stroke survivors without an acute admission Post 12 week follow up Specialist vocational rehab service

POST

Head of Stroke Services accountability Clinical Nurse Specialist Patient Facilitator & Family Support Worker ESD team Physio, OT, Speech & Language, RSW, Dietitian Vocational Rehabilitation

RATIONALE

Management accountability for stroke pathway, service development, strategic leadership Clinical leadership across acute, inpatient rehabilitation and community Champion stroke survivor, family, carer voice Guide through pathway Non clinician point of contact Appropriate frequency & intensity of rehab 7 day a week service Health and social care interventions ESD to target 20% of admissions Support for people to remain in, or return to work or meaningful occupation

Quality & Outcomes • Maximum time a patient waited for 1 st clinical contact • % of clients with goals / care plans agreed Patient / User Experience • % appointments cancelled by the service • % seen within 30 mins of appointment time Performance & Activity • # of referrals and discharges • # of clinical and non-clinical contacts Staffing • % of vacancies Statutory compliance • % of staff up to date with safeguarding children and adults training Service Specific criteria • Use of London Stroke Strategy measures • # patients being case managed

Agreed patient pathway Performance Management process Governance structure Link to Prevention Clear Service Specification

From prevention, through acute, out to community, ongoing care Performance Dashboards, quarterly reviews for CST and inpatients HfL performance monitoring link Important for multidisciplinary teams working across a number of settings Role of CHD Nurse Specialists and Vascular Strategic Board Department of Health new contract template

How to commission for a pathway rather than for a care setting How to capture data for performance monitoring The role of Local Authority commissioner and LA Stroke funding Where does community rehab start and stop e.g. in-reach How to engage primary care in what we develop How to “share” savings in social care package costs

Where does community rehab start and stop e.g. in-reach How to capture data for performance monitoring The role of Local Authority and / or third sector providers Who manages new posts across disciplines e.g. Rehab Support Workers How to engage primary care and the role of GPs in rehab Can we combine uni disciplinary budgets for a multidisciplinary service How does the service work with more general reablement teams

Additional resources sometimes distract from bigger issues Transitions can be improved (acute to community and community to long term support) without investment Stroke Networks have information about best practice Important to engage GPs – 12 month follow up Be clear what you want to commission (service specification) Meaningful PPI is difficult in short timescales and needs to be embedded in whole process Establish an explicit performance management process