Aneurin Bevan University Health Board

Aneurin Bevan University Health Board Together for Health Stroke Delivery Plan Update July 2015 1

Version History Version Date issued Amendment History Owner s Name V0_1 (First Draft) 23.04.15 ML V0_2 12.05.15 Amendments by AS ML V0_3 Submitted to ABUHB Executive AS Team V1_1 29.06.15 Further work on Hypertension; Atrial Fibrillation; Patient Reported Outcomes Measures as requested by Executive Team. Table of contents added ML/AS V1_2 04.06.15 V1_3 30.07.15 Primary Care input on Hypertension and Atrial Fibrillation updated wiuth input from NCN Leads. Submission date updated.forwarded to AS for finalisation and sign-off AWMS section updated. AS revisions. FINAL AS AS 2

Contents Introduction and Background... 4 Health Board Priorities... 5 The Current Stroke Service at ABUHB... 7 Hyper-acute Stroke Care... 7 Acute Stroke Care... 8 Stroke Rehabilitation... 8 Community Neuro-rehabilitation Service... 8 Ongoing Assessment and Care... 9 Life after Stroke... 9 Stroke Bundle Compliance... 9 Stroke Care Performance Indicators... 10 Our Vision for ABUHB Stroke Services... 11 We believe in:... 11 Outline of the Planned Service Change... 12 Progress on Themes for Action Specified by Welsh Government in the Stroke Delivery Plan for 2014-15... 14 Strategic Key Actions... 14 Preventing Stroke... 14 Detecting Stroke Quickly... 19 Delivering Fast Effective Care... 20 Supporting Life after Stroke... 21 Improving Information for People... 21 Improving Clinical and Service Planning Information... 22 Targeting Research... 22 Next Steps in Re-designing ABUHB Stroke Services... 23 Benefits of Service Re-design... 24 Outcome Measures for Stroke... 26 Significant Risks and Issues in Re-designing Stroke Services... 29 Conclusion... 30 3

Introduction and Background Stroke is a preventable and treatable disease. It is the leading cause of adult disability in Wales, and the third most common cause of death, after cancer and heart disease. Over the past two decades a growing body of evidence has overturned the traditional perception that stroke is simply a consequence of ageing that inevitably results in death or severe disability. It is a devastating condition that changes lives and can have a huge effect on people and their families. Every year there are approximately 152,000 strokes in the UK - one stroke every five minutes. Most people affected are over 65, but anyone can have a stroke. The Aneurin Bevan University Health Board (ABUHB) Stroke Delivery Plan was first published in 2013 in response to the Welsh Government s Together for Health Stroke Delivery Plan: a Delivery Plan for the NHS and its Partners (Welsh Government, 2012) Aimed at building on progress already made across Wales, the Welsh Government plan articulates long-term aims for promoting and protecting the health of people in Wales, and for planning and delivering high quality stroke services. Providing a framework for action by Local Health Boards and NHS Trusts working with their partners, the Stroke Delivery Plan sets out expectations of all stakeholders for tackling stroke in people of all ages, wherever they live in Wales, and whatever their circumstances, focussing on: Expected population outcomes Expected outcomes for treatment and support to return to health and independence How success will be measured and expectations on levels of performance Themes for action by the NHS together with its partners This update focusses on the Welsh Government priorities for 2015-16 and summarises progress with our local response to the Welsh Government plan. The ABUHB response details actions required to maintain and improve stroke services. In line with its delivery plan, the Health Board is committed to participation in the Sentinel Stroke National Audit Project (SSNAP) which bases its requirements on the Royal College of Physicians (RCP) National Clinical Guidelines for Stroke fourth edition (Royal College of Physicians, 2012) and NICE Guidelines and Quality Standards for Stroke (NICE, 2010). 4

ABUHB has made good progress in recent years in improving stroke services to meet national standards, however, achieving the standards consistently has become increasingly challenging as the resources available for stroke care are spread too thinly across Gwent and South Powys. Figure 1 outlines the current configuration of ABUHB stroke services. Figure 1: Current Configuration of ABHUB Stroke Services Specific areas where it has been difficult to achieve the required standards are admission to a stroke ward and specialist therapy assessments. The target for direct admission to a stroke ward has reduced from 12 hours to 4 hours. Currently, therapists do not only care for stroke patients and expertise is diluted across multiple sites with limited opportunity to improve specialist skills and resource. Health Board Priorities The Health Board s priority areas for stroke improvement are defined within the following themes for action: Preventing stroke Detecting stroke quickly Delivering fast, effective care Supporting life after stroke Improving information Targeting research 5

Early in 2013, the ABUHB embarked on an ambitious journey to transform its stroke services in the interim period before realisation of its Clinical Futures strategy and the opening of a new Specialist Critical Care Centre (SCCC), currently scheduled for completion in 2019 subject to full business case approval by Welsh Government. Changing stroke services across an integrated Health Board is a complex process due to the range of patient groups, divisions, services and partner organisations involved. A range of options was scoped and appraised, leading to a decision by the Health Board in May 2014 to establish a transformational change programme to deliver the chosen option. The Stroke Services Re-design Programme (SSRP) was established in June 2014 to take forward an improved model of care enabling ABUHB to achieve its aim of best in class stroke services. Central to the transformation is the need to consistently achieve high-quality stroke services and a high level of performance against Welsh Government Tier 1 Targets as measured from data provided to SSNAP. A business case was developed to provide the core justification, specifying the expected benefits, resources and timescales to deliver the changes. The business case was approved by the Health Board on 21 st April 2015 and also supported by the Aneurin Bevan Community Health Council (ABCHC). The SSRP fully aligns with the Welsh Government priorities for stroke care in 2015-16: Identification of individuals with atrial fibrillation Reconfiguration of stroke services in Wales including the development of hyper-acute services Community rehabilitation The SSRP aims to deliver new capability through: Centralization of one hyper-acute stroke unit (HASU) at the Royal Gwent Hospital (RGH) as an interim until the SCCC is opened in 2019 Sub-acute stroke care at RGH, Nevill Hall Hospital (NHH) and Ysbyty Ystrad Fawr (YYF) Inpatient stroke rehabilitation at St. Woolos Hospital (SWH), NHH and YYF 6

A Community Neuro-rehabilitation Service (CNRS) to facilitate early supported discharge (ESD) for stroke survivors Anticipated benefits of the re-design include: Faster and more equitable access to definitive stroke care Improved outcomes for stroke patients Improved performance against national targets and clinical standards Increased rehabilitation in the home Reduced residual disability Reduced residential care and long term dependency Increased patient and carer experience and satisfaction Reduced hospital length of stay Reduced hospital beds required The Current Stroke Service at ABUHB Hyper-acute Stroke Care Current routes of emergency admission for patients from Gwent and South Powys with a suspected stroke diagnosis are the Emergency Departments (ED) and Medical Admissions Units (MAU) at RGH and NHH. Patients with suspected stroke may be admitted through several routes: Emergency ambulance Urgent referral from primary care Self-presentation at EDs or the Local Emergency Centre at Ysbyty Ystrad Fawr (YYF) Patients are also admitted to neighbouring Health Board hospitals such as Prince Charles Hospital (PCH) in Merthyr Tydfil and University Hospital of Wales (UHW), Cardiff before repatriation to ABUHB for rehabilitation. One of the key aspects of hyper-acute stroke care is a need for timely delivery of thrombolysis treatment where clinically indicated. The thrombolysis service at NHH only operates within normal working hours. Outside normal working hours, the Welsh Ambulance Services NHS Trust 7

(WAST) takes all suspected strokes to the nearest appropriate centre which may be PCH or UHW. However; most Gwent patients are admitted to RGH during the out of hours period from 17:00 to 09:00. Patients can currently experience significant delays in assessment and treatment with thrombolysis where indicated for embolic stroke, as well as delays in admission to a stroke ward. Acute Stroke Care Care during the acute (sometimes known as sub-acute ) phase of stroke care is currently provided in RGH and NHH. The level of acuity for these patients is usually higher in the acute phase than the rehabilitation phase as they may require intensive monitoring following thrombolysis treatment or because of the acute complications of stroke which may include difficulties with airway, breathing and circulation as well as neurological deficits that require higher levels of nursing care. Therapy assessments and treatment are also started in the acute phase; although currently there is limited capacity for specialist therapy input and no capability for seven day working across therapy services (limited six-day support is available in Physiotherapy). Stroke Rehabilitation Rehabilitation following a stroke is currently at any one of 9 sites across the Health Board area which includes the acute admission sites and local hospitals. This dilutes the specialist expertise available to provide the required levels of daily input for stroke rehabilitation. Frequently, wards where stroke survivors are cared for are mixed acute medical or Care of the Elderly (COTE) wards where care may be fragmented and difficult to provide consistently for all patients following a stroke. Due to the spread of sites patient flow is also compromised, with multiple transfers between wards, consequent need for re-assessment by therapy staff, and delays in discharging patients home or to a more appropriate setting once their stroke rehabilitation has been completed. Community Neuro-rehabilitation Service A Welsh Government priority for 2015-16 is for Health Boards to introduce community rehabilitation for stroke patients. Until recently, there was no such service for stroke survivors at ABUHB. In 2014 the Health Board was successful in securing funding for a pilot Community Neuro-rehabilitation Service (CNRS) from the Intermediate Care Fund (ICF). The CNRS started in October 2014 and has shown good results in its evaluation, with t30% of patients with a stroke transferred 8

home earlier from the acute phase than they would have otherwise been discharged. The Health Board is committed to the continuation of the service as part of the new stroke pathway. Ongoing Assessment and Care Following their period of stroke rehabilitation some patients who will not benefit from further stroke rehabilitation have more complex needs and require an extended period of general rehabilitation; a care package in the community; or palliative care. Delays in promptly locating these patients in an appropriate setting for their care needs often affect patient flows and contribute to bed-blocking, often with extended lengths of hospital stay. Life after Stroke The configuration of stroke services does not currently provide optimum outcomes for stroke survivors or enable them to benefit fully from the care bundles provided through the Life after Stroke Programme. Pilot implementation of CNRS has enabled the links with these services to be improved and facilitated better integration of Health Board services with the Life after Stroke Programme. Stroke Bundle Compliance Performance against the stroke Tier 1 targets and shadow stroke bundles deteriorated in 2013-14 from a high-point in previous years where ABUHB demonstrated a leading level of performance in Wales. NHS Wales Delivery Unit intervention was initiated to improve compliance and due to the improvements made the intervention was stepped down in December 2014. Figure 2 shows current compliance against the Welsh Government Tier 1 targets for stroke. 9

Figure 2: Tier 1 Target Compliance Improved performance from August 2014 was due to the actions taken to ring-fence acute stroke beds, and a strong daily operational focus on the stroke pathway. More recently, data that is currently being validated appears to indicate a dip in Bundle 2 performance due to difficulties in maintaining performance in the current configuration of services. Stroke Care Performance Indicators Figure 3 shows the Health Board s Performance against more stringent Shadow Bundles expected to be adopted soon as the new Stroke Care Performance Indicators. Our performance, despite being aligned with the Wales average, is currently well short of the 95% target, particularly for the 4 hour, 12 hour and 24 hour bundles. Service re-design is necessary to enable the Health Board to reach, and consistently maintain the expected performance levels. 10

Figure 3: Stroke Draft Shadow Bundle (Stroke Care Performance Indicators) Compliance Our Vision for ABUHB Stroke Services The future for ABUHB stroke services is high-qual ity stroke care equalling best-in-class and aspiring to World class standards, provided equitably and for all patients We believe in: Minimising the risk of stroke Providing the best quality of care and support so that patients get better and return to independent living as quickly as possible Our local Stroke Delivery Plan reflects the principles set out in the Government National Stroke Delivery Plan which aims to: Welsh Prevent stroke Detect stroke quickly Deliver fast, effective, treatment and care Support life after a stroke Improve information Target research Our task is to help people minimise the risk of having a stroke; and when stroke does occur, to provide the best quality care and support to maximise survival and return to independence as quickly as possible. Significant improvements have been made to stroke care in ABUHB and acrosss Wales in recent years by providing specialist, timely interventions 11

that helped to save lives and reduce the impact of stroke for many people. The public also recognise increasingly that stroke is a medical emergency and people seek help more quickly. In order to build on our progress we need to use valuable specialist resources differently to keep pace with the increasingly challenging care standards identified by the RCP. Outline of the Planned Service Change To fulfil the vision for our population, a transformational programme of change is needed across the whole stroke pathway, from prevention to long-term care, centred on the agreed model for stroke services shown below in Figure 4. Figure 4: Future ABUHB Stroke Services Model KEY Prevention Acute/Hyper-acute Stroke Prevention Management of Transient Ischaemic Attack (TIA) Rehabilitation Pre-hospital Stroke Care Life after stroke Care setting Hyper-acute Stroke Care (= 3 days) HOME HOSPITAL Early Supported Discharge Acute Stroke Care & Early Rehabilitation 3-7 days Community Resource Teams Community Rehabilitation (Frailty/Community/Neuro) Rehabilitation +/- Complex Discharge 7 days 6 weeks Life After Stroke This vision for our stroke services is consistent with the Health Board s overarching strategic direction inherent in the Clinical Futures model of care and Best in Class services. Achieving the vision entails examination of current service configurations and the culture of care across the whole organisation, with a focus on the organisational transition needed to fully align stroke services as a pathfinder within Clinical Futures. 12

Initially, the priority was to ensure a safe and sustainable stroke service within the available resources that are currently spread thinly across a wide area and multiple sites, leading to inefficiencies and inability to consistently achieve and maintain the required standards. Condensing the service into fewer sites will provide opportunities for a safer, more equitable and higher quality service for all patients. Following a detailed options appraisal and wide staff and public consultation, the Health Board agreed the future proposed model for stroke services in May 2014 shown below: Figure 5: Proposed Stroke Services Configuration 13

Progress on Themes for Action Specified by Welsh Government in the Stroke Delivery Plan for 2014-15 Strategic Key Actions This local Stroke Delivery Plan reflects activity undertaken in each of the key areas as specified below. The plan is updated annually and monitored throughout the year by the Stroke Board and its workstreams. The Health Board reports formally to Welsh Government on the Delivery Plan according to the agreed reporting schedule. The Health Board is updated regularly on service performance and achievement of the Tier 1 targets for stroke. Steps are being taken to regularly publish progress on the Health Board internet and intranet sites; updating patients, public and staff on progress with implementing the Delivery Plan and the SSRP. Local Delivery Plans and updates are available at: Aneurin Bevan University Health Board Local Delivery Plans. Preventing Stroke Smoking Cessation Smoking cessation was included as a Tier 1 target in the NHS Delivery Framework 2013/14. The target aims to ensure that at least 5% of smokers make a quit attempt via smoking cessation services, with at least a 40% validated quit rate at 4 weeks. An assessment was undertaken to determine whether capacity from Stop Smoking Wales was sufficient in terms of their ability to cope with increased demand. In January 2014, having identified a significant shortfall, the ABUHB Board approved a business case to expand the range of smoking cessation services available to patients by providing smoking cessation services in Community Pharmacy and Hospital settings, leading to additional Health Board investment in 2014/15 and a consequent increase in the number of community pharmacies offering smoking cessation services. The Smoke Free Support Service was recently launched at RGH and NHH. Two Smoking Cessation Counsellors are available for inpatients and staff, with provision for out-patients requiring rapid access to smoking cessation support. Currently managed through the Respiratory Directorate, the service is being rolled out into Cardiology. Plans are also being developed to extend the service to stroke wards and the Medical Assessment Unit. The hospital service will be fully integrated with Community Pharmacy 14

enhanced services to ensure seamless support for patients following discharge from hospital. There has been a substantial improvement in referral and uptake to Stop Smoking Wales in the last year. In February 2015, ABUHB were the top performing Health Board in Wales in relation to the number of Stop Smoking Wales clients that became treated smokers. In the last quarter 975 clients contacted the service and 448 became treated smokers. There was also an improvement in the 4-week Carbon Monoxide (CO) validated quit rates (see Table 1). This is a substantial improvement across all these indicators, when compared to the same period last year. Table 1: Stop Smoking Wales - Performance against the Tier 1 Target Performance Indicator Number of clients contacting the service Number of clients that became treated smokers 4-week CO validated quit rate (%) Jan-Mar 2015 Jan-Mar 2014 975 462 448 233 42 29 The most recent Tier 1 target report to Welsh Government for Quarter 3 showed that a total of 712 patients had received treatment through Stop Smoking Wales. Based on provisional Quarter 4 data a total of 1,160 patients were treated by Stop Smoking Wales during 2014/15 which represents 1.1 per cent of the smoking population. This is an improvement in performance compared to last year and the overall position has improved further this year as a result of Board investment in smoking cessation services in Community Pharmacy and Hospital settings. Adult Weight Management Service The Adult Weight Management Service was launched across Gwent in April 2014. An analysis of the first year of outcome data is currently underway. Childhood Obesity ABUHB are in the final stages of drafting a partnership Childhood Obesity Strategy and Action Plan along with a family-based childhood weight management service (Level 2 and 3) business case. Both developments have now been agreed with a range of relevant operational partners across the public service sectors. These proposals will be discussed at ABUHB Executive in May before going back through the Public Health and 15

Partnerships Board Committee in June, and then through partner Local Authority formal approval mechanisms. Alcohol Misuse In 2012, the Health Board became a Responsible Authority under the Licensing Act 2003. As a Responsible Authority, the Health Board can make representations to influence a Licensing Authority s policy (Local Authorities act as the Licensing Authority). A Responsible Authority can also make representations against granting a licence or request a review of a licence for individual premises. The Health Board has delegated responsibility for its Responsible Authority functions to the Executive Director of Public Health. The Aneurin Bevan Gwent Public Health Team is working with the other Responsible Authorities in Gwent to develop the Health Board s role as an active Responsible Authority. A multi-agency group has developed a data sharing process for the sharing and coordination of data, within the framework of an agreed Information Sharing Protocol. The data will be used to provide evidence to local authority Licensing Committees when considering licensing applications or licence reviews. On 14th April of this year, ABUHB, at the request of another Responsible Authority made its first representation as part of a licence review by Newport City Council s Licensing Committee. The Health Board provided evidence of the harm alcohol causes to the health of young people in support of evidence presented by other Responsible Authorities that a newsagent in Newport had been making under age sales to children in Newport, some who were as young as eleven. The Licensing Committee revoked the newsagent s license to sell alcohol removing a significant source of supply of alcohol to children in the Newport area. Health Inequalities Reducing premature mortality from Stroke through the Living Well, Living Longer Programme In 2014/15, the ABUHB Living Well Living Longer Programme (LWLL) was funded to begin addressing the legacy of the inverse care law. The key focus of the programme is on reducing premature mortality from cardiovascular disease in deprived areas, particularly targeting men and women between the ages of 40 and 64. In the initial phase, the programme will focus on systematic and population scale implementation of proven interventions through engagement with primary care and its wider networks. The programme 16

will primarily target the five Neighbourhood Care Networks with the highest level of deprivation, commencing in Blaenau Gwent West. This programme aims to address the impact of the inverse care law by embedding a sustainable, primary system for identifying people at risk of cardiovascular disease through population based risk assessment and systematically delivering evidence based interventions in primary care at a scale that will achieve a percentage change in population outcome. The intention is to deliver a population scale programme of health checks to identify people at risk of CVD. These health checks are being provided by Health Care Support Workers in community settings with supervision from Registered Nurses. Each eligible individual is offered a 30-40 minute session, in accessible, local community venues. The health check involves simple questions about age, ethnicity, lifestyle and family history. It includes near patient testing of cholesterol as well as a blood pressure measurement and pulse check. Height, weight and waist measurements are also taken to assess the individual s risk of diabetes and those at high risk of diabetes will have an additional non-venous blood test, to assess whether they are likely to have diabetes. Supported by customised software the individual is provided with information on their risk of developing CVD over the next ten years and their current heart age. Individuals at high risk can receive further support from a Health Trainer for up to six months. Direct referrals are also made to Stop Smoking Wales, National Exercise Referral Scheme, Adult Weight Management, Gwent Drug and Alcohol Service, and the Expert Patient Programme. Results from the health checks are coded and electronically transmitted directly into the GP clinical system. This enable practices to follow up patients for further clinical management in a timely and efficient way. Participating GP practices are provided with direct and indirect support, including direct payment through a Local Enhanced Service, and support from Cardiff University through Clinical Academic Fellows scheme. The Board has allocated funding to the programme and has also received Welsh Government funding through the Improving Primary and Community Care Central Fund. The LWLL Programme was officially launched by the Deputy Minister for Health, Vaughan Gething, AM, on 12 th January 2015. Since the Ministerial launch, clinics have started in Tredegar. Over the last three months the Health Board has been working with Tredegar Health Centre and Glan Yr Avon surgery to validate existing 17

disease registers and identify eligible patients. To date, a total of 654 patients have attended for their Health Check in the Tredegar area. Identification and management of hypertension and atrial fibrillation in deprived areas Hypertension Screening Hypertension is recognised as an important risk factor for Cardiovascular disease (CVD). There is a significant burden of CVD in some of the more deprived areas of ABUHB and much of this is disease is undetected. The Living Well Living Longer Programme has been established to address this and is aimed at improving identification and management of hypertension in deprived populations with high rates of premature mortality from CVD in people under the age of 75 years. The improvement will be achieved through a targeted programme of CVD risk assessment involving Neighbourhood Care Networks (NCNs) that have a high proportion of patients living in deprived areas. Patients with a blood pressure of 140/90 mmhg, or above, are referred back to their GP practice for further assessment and diagnosis. In line with recent clinical guidance from the National Institute for Health and Care Excellence (NICE) the programme supplied GP practices with ambulatory blood pressure monitors to confirm a diagnosis of hypertension. There is no national screening programme for hypertension. However, campaigns to detect hypertension in various ABUHB localities are often run by 3 rd sector organisations, including the Stroke Association. Hypertension Management General Practitioners are encouraged to manage Hypertension according to NICE Guidance and the guidance is reflected in the General Medical Services (GMS) Quality and Outcomes Framework (QOF), which specifies indicators for management of hypertension: http://bma.org.uk/workingfor-change/negotiating-for-the-profession/bma-general-practitionerscommittee/general-practice-contract/contract-agreement-wales/walesqof-changes Screening for Atrial Fibrillation During 2013-14, nine general practices in ABUHB were involved in a collaborative project that demonstrated increased activity with regards to screening for Atrial Fibrillation (AF). This activity continued beyond the end of the project, however the project work was not rolled out accross ABUHB following a decision by the National Screening committee in 2014 not to recommend formal screening for AF. 18

Management of Atrial Fibrillation The National Instiute for Health and Care Excellence (NICE) published its guidance on AF in June 2014 with major changes were recommending that a different risk scoring tool called CHADS2-VASC should be used instead of CHADS2 and that aspirin should not be considered at all for stroke prevention in AF. The GMS QOF was changed in September 2014 to reflect these changes and GPs in ABUHB were encouraged to review all pateints with AF who were taking aspirin as stroke prophylaxis. The QOF for 2015-2016 now reflects NICE Guidance and ABUHB General Practitioners will be working to this guidance. Education sessions are being run in ABUHB GP CPD events to refresh GPs knowledge regarding these changes. Anticoagulation is a critical aspect of stroke prevention in AF and it has been recognised both nationally and locally that care could be improved. As a result anticoagulation services in ABUHB are currently being reviewed. The South Wales Cardiac Network is working on a management pathway in an attempt to streamline the management of AF across South Wales. This pathway has input from primary and secondary care clinicians from ABUHB. Population screening for Atrial Fibrillation is no longer recommended by the National Screening Committee, however the blood pressure measuring devices used in LWLL programme are recommended by NICE for opportunistically detecting atrial fibrillation during diagnosis and monitoring of hypertension. Use of this device will increase the number of people with atrial fibrillation diagnosed. If the device suggests that someone has atrial fibrillation, they will be referred to their GP practice for ECG for confirmation of the diagnosis. The results of CVD risk assessment are Read Coded and electronically transmitted back to the GP clinical system to ensure that patients with suspected hypertension and atrial fibrillation receive appropriate and timely follow up. The Primary Care & Networks Division has introduced a Local Enhanced Service to enable GP practices in deprived areas to cope with the surge in work associated with the management of patients identified with hypertension or atrial fibrillation. Detecting Stroke Quickly The Health Board works closely with the Stroke Association to engage our population on stroke issues. The Stroke Association carried out a national 19

awareness campaign during February 2015 to raise awareness of the symptoms of stroke, the F.A.S.T. test, and the need for prompt action to initiate emergency care. ABUHB is also working in partnership with WAST to ensure that stroke is diagnosed rapidly and treatment is delivered quickly and effectively. WAST and ABUHB have worked in partnership to re-define the stroke clinical pathway to ensure that the re-designed service is based on the need to detect stroke quickly in support of fast and effective care. This includes patients suffering a stroke whilst in hospital as well as those affected in the community. Whilst collaborative audit of individual delays in the detection to early treatment pathway has yet to be developed and put into place, the Health Board participates fully in the SSNAP audit and carries out its own clinical audits to inform better care. Through the SSRP, a specialist stroke team is to be introduced into the Emergency Department to improve the speed of treatment for patients with stroke and also to appropriately manage those patients with symptoms that mimic stroke such as Transient Ischaemic Attack (TIA) and those admitted with stroke-like symptoms, but then diagnosed with other conditions. This development is designed to significantly speed up diagnosis and treatment in each of these groups from the cohort of suspected stroke patients 7 days a week during peak admission times and ensure that the Health Board is moving towards achieving the anticipated new Shadow Stroke Bundles (Stroke Care Performance Indicators). The expected new stroke bundles specify stringent targets for stroke care in the first 4 hours which include specific targets for door-to-needle time; pre- and post-thrombolysis NIHSS Score; direct admission to a stroke unit and swallow screening, as well as brain imaging within 12 hours. ABUHB is committed to attaining these standards and the SSRP provides the delivery mechanism for achieving them. Delivering Fast Effective Care The SSRP is fundamental to achieving the outcomes specified in the Together for Health Stroke Delivery Plan and progress with moving to a single hyper-acute stroke unit (HASU) for ABUHB is outlined in the preceding chapters on Stroke Services Re-design. The move to a single HASU for ABUHB at RGH is scheduled to take place by October 2015 along with the simultaneous re-configuration of sub-acute and rehabilitation stroke services and is aimed at full compliance with the acute stroke bundles along the renewed pathway of care for stroke. 20

Significant work was undertaken to scope and test elements of the new service model to ensure that it is fit-for-purpose including ring-fencing of stroke beds and a pilot ASHICE scheme pre-alerting the specialist stroke team to the imminent admission of a suspected stroke patient. Telemedicine with home connections for stroke consultants is facilitating equitable access to stroke care and radiology services have been realigned to the need to achieve brain imaging within 12 hours. Supporting Life after Stroke Community Neuro-rehabilitation is a Welsh Government priority for 2015-16 and a CNRS was piloted at ABUHB during 2014-15 providing rehabilitation for stroke survivors in their own homes. The pilot scheme aimed to provide early supported discharge for 30% of confirmed stroke patients with mild to moderate stroke and also to develop into a service for patients with Acute Brain Injury and long-term neurological conditions. The clinical team included Physiotherapy, Occupational Therapy, Speech & Language Therapy, Dietetics, Clinical Psychology, Clinical Nurse Specialist and Medical input supported by Health Care Support Workers and administrative support. During October 2014 to March 2015 the CNRS provided early supported discharge to 96 patients, achieving 30% of the ABUHB confirmed stroke patients over the 5 month period of the project. 56 patients were discharged from the CNRS having completed the pathway ESD was initiated on average on day 3 post stroke event An average reduction in length of stay of 4 days was achieved The Health Board has agreed to continue with the CNRS as part of the redesigned stroke pathway. This is a positive development which ensures that stroke survivors receive short, patient focussed, intensive rehabilitation centred on patient and carer involvement and improved outcomes for service users. Discharge is co-ordinated through the multidisciplinary team and integrated with local frailty services, primary care services and Life after Stroke services provided by the Stroke Association. Improving Information for People ABUHB has designated a Communications and Engagement lead for the Stroke Services Re-design Programme and a number of developments have taken place to support improved information for people during the communication and engagement carried out for the programme, including 21

setting up of a stroke engagement group with representatives from stroke survivors, their carers, and the Third Sector. The group has assisted the SSRP in developing information for stroke survivors, their carers and the public as part of the process of re-design and is planning the development of a new stroke web-site. The SSRP is working with the ABUHB Communications Team on behalf of the Stroke Board through third sector organisations including the Stroke Association to provide regular and easy to understand information to stroke survivors and carers including written information and online resources. Avenues for engaging through other remote technologies are being explored such as Webex meetings and social media. Information needs for patients are identified and recorded by Stroke Clinical Nurse Specialists on admission and on discharge at specific sites. Carers clinics are also open daily for relatives to discuss concerns for patients/carers receiving rehabilitation. Improving Clinical and Service Planning Information Identifying robust information on admissions for the process of Stroke Services Re-design was challenging in some areas, particularly the ability to identify robust information to inform service changes. To have confidence in the data supporting the business case, triangulation of existing Health Board data with manually collected data, and data provided by WAST was necessary. ABUHB recently purchased a product called e-forms which electronically captures data at various stages of workflow from the Clinical Workstation (CWS) and will substantially improve the ability to identify the presenting condition for suspected stroke patients entering the hospital system. Mathematical modelling techniques have supplemented more traditional modelling methods for analysis and have strongly contributed to the feasibility assessment in service planning for SSRP, particularly in identifying areas of risk along proposed new pathways for suspected stroke. Targeting Research A Health Board stroke lead was identified and a Stroke Research Group (SRG) convened. This group is meeting regularly in alignment with Health Board Research and Development governance processes and is submitting through these processes for approvals. 22

A new trial called RESTART (Restart or Stop Antithrombotics Randomised Trial) has opened at two of the Health Board s hospitals testing whether a policy of starting antiplatelet drugs results in a beneficial net reduction of all serious vascular events and is actively recruiting participants. The group has also requested approval for another international trial called HEADPOST (Head Position in Stroke) is designed to resolve uncertainty and provide reliable evidence over the optimum head position in the acute phase of stroke and intracerebral haemorrhage. Capacity for protected research time is currently limited due to spread of staff resources across multiple sites. The stroke services re-design will concentrate stroke care into fewer sites and the potential for protected research time will be explored through SSRP as the service is reconfigured. Opportunities for increased participation in academic training schemes will also be explored through SRG participation in SSRP and specified in the SRG objectives. Several stroke team members are actively involved in the Older People & Ageing Research & Development Network (OPAN) Cymru and there is an evolving process of involvement in regional, national and international research with a broad focus from the SRG. Next Steps in Re-designing ABUHB Stroke Services Following the Health Board s approval to proceed with implementing the Stroke Services Re-design Programme a timetable has been set to achieve the required changes by October 2015 following a period of staff consultation and management of change process for those affected by the changes. The following table represents the first step change in a phased approach to achieving the full vision of Clinical Futures for stroke services where patients will receive a full 7 day service at the required standard. 23

Table 2: Phase 1 Implementation of Stroke Services Re-design Complete Programme Identification Continued stakeholder engagement: Staff; Public; Local Authorities; CHC; neighbouring Health Boards April 2015 October 2015 Complete Programme Definition Implementation and evaluation of CNRS pilot Business case to Executive Team for review Business Case to Health Board Planning & Strategic Change Committee for approval to proceed October 2014 June 2015 11 th April 2015 21 st April 2015 Formal consultation with CHC 23rd April 2015 Staff consultation (Timescale dependent on specific change proposals) Communication and Engagement Public; Partner Organisations; Neighbouring Health Boards Implementation Integrate CNRS as specialist arm of Community Resource Teams Implement first phase of Community bed plan Implement centralised HASU at RGH Reconfigure stroke acute and rehabilitation units May 2015 September 2015 April 2015 October 2015 September October 2015 Benefits Realisation October 2015 October 2016 Benefits of Service Re-design The anticipated benefits of the SSRP are shown in Table 3 and are aligned with achievement of the overall Health Board objectives demonstrated through detailed outcome measures. Whilst some benefits will be realised immediately through service re-design, other benefits will take longer to realise, particularly the further benefits that could arise from analysis of the results of patient reported outcomes measures. 24

Table 3: Anticipated benefits Benefit Improved Thrombolysis Performance Improved Hyperacute Stroke Care Performance Baseline Performance at December 2014 (where available) 60% eligible patients thrombolysed 0% thrombolysed patients with door to needle time 30 mins 0% thrombolysed patients with door to needle time 45 mins 100% thrombolysed patients with pre and post thrombolysis NIHSS score (RGH only) 26% achievement of 4 hour bundle = access to stroke ward in 4 hours plus swallow screen within 4 hours 79% patients brain imaging reported within 12 hours of attendance 57% achievement of 24 hour bundle = assessed by stroke consultant plus stroke nurse plus one of PT, OT SLT 91% achievement of 72 hour bundle = assessed by PT, OT and SLT within 72 hours plus formal swallow assessment within 72 hours Outcome Measure 100% eligible patients thrombolysed 50% thrombolysed patients with door to needle time 30 mins 90% thrombolysed patients with door to needle time 45 mins 100% thrombolysed patients with pre and post thrombolysis NIHSS score 95% within 4 hours of attendance 95% patients receiving a swallow screen within 4 hours of attendance 95% patients brain imaging reported within 12 hours of attendance 95% patients assessed by stroke specialist consultant within 24 hours 95% patients assessed by a nurse trained in stroke management within 24 hours 95% patients assessed by one of PT, OT or SLT within 24 hours 95% patients assessed by PT within 72 hours 95% patients assessed by OT within 72 hours 95% patients assessed by SLT within 72 hours Anticipated Date of Achievement October 2015 December 2015 December 2015 October 2015 December 2015 December 2015 April 2015 October 2015 October 2015 December 2015 December 2015 December 2015 December 2015 25

Increased rehabilitation in home environment (care closer to home) Reduced length of hospital stay 30% patients discharged early through ESD 2013-14 average acute LoS = 12.6 days 2014-15 Q3 average acute LoS = 8.7 days (ESD initiated) 95% patients receive formal swallow assessment within 72 hours 30% patients discharged early through ESD Average acute stroke LoS reduced to 7 days December 2015 August 2015 December 2015 Reduced beds required for stroke Reduced readmission rates Improved outcomes for stroke patients, including reduced residual disability, reduced dependence on social care, Increased patient/ carer satisfaction Improved patient safety 2013-14 average provider super-spell LoS = 27.8 days 2014-15 Q3 average provider super-spell LoS = 21.2 (ESD initiated) Average provider super-spell LOS reduced to 20 days 83 beds used for stroke Beds used by stroke patients reduced to 73 Baseline not currently available Readmission rates reduced to: (To be developed) Patient reported outcome measures (PROMs) to be developed Patient reported experience measures (PREMs) to be developed ICHOM Outcome Measures Standard Set for Stroke Barthel Index Modified Ranking Scores PROMs/PREMs to be developed Patient safety measures to be developed October 2015 October 2015 October 2015 October 2015 December 2015 Outcome Measures for Stroke Measuring and reporting meaningful outcomes for stroke matters because in terms of absolute numbers, the burden of stroke continues to increase and a focus on mortality can obscure large differences in patients regaining function following a stroke as illustrated in Fig. 6: 26

Figure 6: Importance of Measuring and Reporting Meaningful Outcomes The International Consortium for Health Outcomes Measurement (ICHOM) Data Collection Reference Guide [Version 2.0] (2015) specifies a standard data set for stroke which includes case-mix variables such as demographic factors; stroke type and severity; vascular and systemic; treatment/caree related variables as well as treatmentt and survival variables, and outcomes measures including patient reported measures of disease control and health status. The standard set enables benchmarking against national and international standards (although there are differences in timing requirements). Standardisation and transparency of outcome measurement can drive healthh carer improvement, with universal development and reporting of outcomes at a medical condition level seen as a high priority in improving the performance of health care systems and will enable comparison acrosss healthcare systems using outcomes that matter to patients. Figure 7 describes the standard set of outcome measures for stroke specified by ICHOM which is accompanied by a standardised demographic and clinical data set. 27

Figure 7: ICHOM Standard Set of Outcomes Measures for Stroke 28

The following timeline illustrates when ICHOM Standard Set variables should be collected. There is no requirement in the UK to review patients at 90 days after their stroke and patients are currently followed up at 6 months post-event at ABUHB. Figure 8: Timeline for ICHOM Outcomes Measurement Initiating these outcomes measures would be a significant undertaking that requires Health Board and consultant support including exploration of opportunities to align follow-up after stroke with the ICHOM timeline, however aligning outcome measurement with Stroke Services Re-design would present a clear opportunity to demonstrate the effectiveness benefits of a re-designed service and provide a launch pad for further development of outcomes measures towards implementation of the Clinical Futures strategy. Significant Risks and Issues in Re-designing Stroke Services Re-designing the stroke service inevitably involves risks and issues that need to be managed and mitigated both in planning and throughout the implementation process. The most significant risks and issues associated with the SSRP have been assessed to be the: Impact on acute hospital non-stroke beds Impact on community beds Impact on the front door at RGH Impact on WAST and hospital transport 29

Impact on staff, including consultation and recruitment Financial implications Whilst challenging, it is believed that the risks and issues have been mitigated as far as possible, or a plan developed to manage them, and this detail is described in the programme business case. Significantly, steps are needed to appropriately manage patients who are subsequently diagnosed as not having a stroke, ensuring that patient flows and standards of care are not compromised in a centralised stroke service. Conclusion In developing the ABUHB Stroke Delivery Plan, the Health Board has recognised the need to reconfigure services in order to deliver high quality consistent care for stroke patients. To achieve this, the Health Board has embarked upon a challenging programme of re-design, which encompasses the whole pathway from prevention to life after stroke. Successful implementation of the re-design programme will enable our stroke services to consistently meet the SSNAP clinical standards and Welsh Government Tier 1 targets for stroke care. ABUHB has made significant progress with its Stroke Services Re-design Programme, with a planned implementation date of October 2015 to realise the new stroke pathway. 30

Action Plan (Updated July 2015) Strategic Key Actions Objectives Actions Expected Outcome Risks to Delivery Timescale Lead Update as at April 2015 Review current stroke services and use the outcome to inform an updated local delivery plan to reflect activity under each of the themes for action Review current stroke services against the expectations set out for 2016 Update Local Stroke Delivery Plan Revised Local Delivery Plan Timescales Comprehensive engagement April 2013 ABUHB Stroke Board Achieved and updated through Stroke Board processes and workstream leads Report formal progress against the delivery plans and NHS Performance Measures to Health Board and Welsh Government Develop Progress Report Template Review current stroke services against the expectations set out for 2016 Progress report to Health Board Progress report to Welsh Government Annually from Sept 2013 Strategic Stroke Lead Achieved and updated through Stroke Board processes and workstream leads Populate report annually Report progress against local delivery plan via own website Agree key measures to be published Develop web based publication format Progress against delivery plan milestones reported to patients, public and stakeholders Timescale for first publication Risks associated with Quarterly From Sept 2013 Strategic Stroke Lead Performance Management team Communications Team Local Delivery Plan published at the following link: Aneurin Bevan University Health Board Local Delivery Plans A stroke specific website is being developed through the SSRP to communicate proposed changes Review and update delivery plans and milestones Review and update Stroke Delivery Plan, including milestones Updated Stroke Delivery Plan Alignment of Delivery Plan schedules with Health Board processes and timescales for redesign At least annually ABUHB Stroke Board Updated through Stroke Board processes and Workstream leads 31