Aneurin Bevan University Health Board Services Redesign Programme 1 Introduction This report aims to update the Health Board on progress with the Services Redesign Programme of work which commenced in January 2013. It sets out the agreed clinical model of care for stroke and a preferred inpatient configuration model designed to deliver effective stroke care in the interim between now and completion of the Specialist Critical Care Centre. The Board is asked to:- Note progress with the delivery of the ABUHB Delivery Plan Note the work undertaken to scope and appraise options for inpatient service re-design Approve the recommended option for the interim reconfiguration of in-patient stroke services ahead of the opening of the Specialist Critical Care Centre (SCCC) Financial Assessment and link to Financial Recovery Plan Risk Assessment Annual Operating Framework Standards for Health Services Wales A financial appraisal has been undertaken of staffing costs and a reduction in designated bed needs identified against the preferred model. Risk assessments will be undertaken as appropriate to each aspect of delivery. NHS Wales Delivery Framework - Tier 1 Target for elements of the pathway. Together for Health Delivery Plan 2013/16. Standards 1, 2, 3, 8, 11, 12, 14, 20, 25 National Institute for Health and Care Excellence (2008) Clinical Guideline CG68 - Diagnosis and initial management of Acute stroke and transient ischaemic attack (TIA) National Institute for Health and Care Excellence (2010) Quality Standard QS2 Equality Impact Assessment Royal College of Physicians (2012) National Clinical Guidelines for Fourth Edition Undertaken as relevant for each area. 1
2. STRATEGIC CONTEXT Aneurin Bevan University Health Board In December 2012, Welsh Government specified its vision and delivery plan for the population of Wales, and what this means for stroke services. The publications: Together for Health Delivery Plan: Our Vision and Together for Health Delivery Plan: a Delivery Plan for the NHS and its Partners outline this vision and actions required to achieve it by 2016. Aimed at building on progress already made across Wales, the Welsh Governments 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 national 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. The Health Board responded to the Welsh Government plan with its own Delivery Plan, approved by the Board in May 2013, which details the actions required to improve and maintain stroke services. 3. BACKGROUND AND RATIONALE FOR CHANGE is the leading cause of adult disability in Wales and the third most common cause of death, after cancer and heart disease. Approximately 900 new strokes are admitted every year in ABUHB with a further 700 patients presenting with Transient Ischemic Attacks (TIA) or other symptoms that mimic a stroke. Over the past two decades a growing body of evidence has overturned the traditional perception that stroke is simply a consequence of aging that inevitably results in death or severe disability. is now recognised as both a preventable and, where it does occur, a treatable condition. A stroke is however a devastating event that changes lives and can have a huge effect on victims and their families. Aneurin Bevan Health Board has made good progress in recent years in improving stroke services to meet national clinical standards and government targets. However, consistently achieving them has become increasingly challenging as new and higher standards are set and the available resources are spread too thinly across Gwent. Intelligent Targets for acute stroke care, using a Care Bundle approach, were introduced in 2007 as part of the Tier 1 performance framework for NHS Wales, with compliance now monitored through the Annual Quality Framework. The use of Care Bundles improves the reliability of clinical 2
care and, for acute stroke, are set out in four time sensitive groups of interventions. Fig.1 Intelligent Targets Acute Bundles 1 3 hrs 2 24 Hours 3 3 days 4 7 days INTELLIGENT TARGETS - ACUTE STROKE BUNDLES rapid diagnosis using a recognised tool eg ROSIER diagnosis confirmed by experiences clinician directly admitted to co-located beds (Acute Unit) manual handling assessment swallow screen nutritional screen CT scan ( unless thrombolysis potential requiring immediate scan ) prescription of regular aspirin if clinically appropriate reviewed by a Consultant mobilised where clinically appropriate physiological monitoring for first 72 hours physiotherapy assessment OT assessment full screening/appropriate assessment of residual impairments MDT goals set information shared with patients/carers in the appropriate format estimated discharge dates discussed with patients/carers The Health Board improved its performance from a baseline of zero compliance with the Acute Bundles in 2008-9 to achieving 100% compliance with three of the four bundles in 2010 to 2012. While major improvements were also made with Bundle 2, the first 24 hours, the 95% compliance target has not been consistently achieved. During 2013 compliance with all four acute bundles dropped due to a number of factors including staffing shortfalls, systems pressures and some peaks in numbers of strokes presenting. The Health Board has consequently been subject to interventional support from the NHS Wales Delivery Unit since February 2014. Performance against the bundles has improved but remains challenging to maintain consistently. The stroke teams are also now required to aim to achieve compliance with the more exacting standards set out in the Sentinel National Audit Programme (SSNAP). Developed by the Intercollegiate Working Party for hosted by the Royal College of Physicians, the SSNAP was introduced in Wales in July 2013 as the new professional standards and associated auditing process for stroke care. SSNAP encompasses the whole stroke pathway from acute onset to long term care. The acute component of these more exacting standards can also be set out in a bundle format as shown below. 3
Fig.2 Sentinel National Audit Acute Bundles SENTINEL STROKE NATIONAL AUDIT PROGRAMME (SSNAP) ACUTE STANDARDS 1 1 hour arrive to hospital with paramedics 2 3 hrs 3 4 hours rapid diagnosis using a recognised tool eg ROSIER diagnosis confirmed by experiences clinician admitted to Acute Unit manual handling assessment swallow screen nutritional screening 4 12 hrs CT scan ( unless Thrombolysis potential requiring immediate scan ) reviewed by one stroke nurse 5 24 hours 6 72 hour 7 5 days 8 7 days reviewed by one member of the rehab team reviewed by a Consultant mobilised where clinically appropriate reviewed by a Specialist Nurse physiotherapy assessment speech and language assessment OT assessment MDT goals set full screening/appropriate assessment of residual impairments information shared with patients/carers in the appropriate format estimated discharge dates discussed with patients/carers While significant improvements have been made to stroke care in ABUHB and across Wales in recent years the stroke leads recognised in 2012 that in order to deliver sustainable high quality care for stroke patients both revised evidence based clinical model and revised service configuration would be required. The actions needed to achieve these aims have since been set out in the ABUHB Delivery Plan. Our vision is to help people minimise the risk of having a stroke and, where stroke does occur, to provide the best quality care and support to maximise survival and return to independence as quickly as possible. Our local Delivery Plan, which reflects the principles set out in the Welsh Governments National Delivery Plan, aims to: Prevent stroke Detect stroke quickly Deliver fast, effective, treatment and care Support life after a stroke Improve information Target research 4
4. STROKE SERVICE REDESIGN Aneurin Bevan University Health Board A service redesign programme commenced in January 2013 with its aims focussed on achievement of compliance with the new standards set out in the SSNAP and the Welsh Governments National Delivery Plan. Reporting to the Health Board Executive Team, the ABUHB Board has engaged clinical teams in hospitals and community, patients, the Association, Local Authorities and neighbouring Health Boards in the identification and appraisal of options to re-design our stroke services. 4.1 A New Clinical Model for Services The stroke clinical community together with its partners has explored and agreed a revised Clinical Model for Services. Based on the best available evidence and the guidance in the National Delivery Plan the key features of the new model set out in in our delivery Plan are: An increased focus on prevention One centre of excellence for hyper-acute care, acute care, and early Community based Early Supported Discharge services Fewer inpatient stroke units providing specialist Ongoing general, complex care planning and palliative care in a local hospital or home setting as appropriate Multi-agency support for life after stroke and secondary prevention Fig.3 A New Clinical Model for Services Prevention Management of Transient Ischaemic Attack (TIA) Pre-hospital Care Hyper-acute Care (= 3 days) HOME HOSPITAL Early Supported Discharge Acute Care & Early Rehabilitation 3-7 days Community Resource Teams Community Rehabilitation (Frailty/Community/Neuro) Rehabilitation +/- Complex Discharge 7 days 6 weeks Life After 5
Many of the changes needed to deliver the new pathway are being worked up or delivered through a number of actions including, for example:- the prevention work set out in our Public Health Strategic Framework which includes national and local initiatives that aim to tackle lifestyle risks the identification and actively management of clinical risk factors in primary care the provision of TIA assessment services seven days a week timely access to carotid artery surgery where indicated detailed review and refinement of the thrombolysis pathway to minimise door to needle time the provision of an out of hour thrombolysis service in the Royal Gwent for all appropriate stroke victims closer working arrangements between the acute stroke units and community hospital units 4.2 A New Organisational Configuration for Services The current in-patient configuration model for stroke service does not lend itself to the delivery of a consistent efficient and effective service. Patients who have suffered an acute stroke are currently admitted to either Nevill Hall or the Royal Gwent Hospitals from where they are either discharged with or transferred to one of a further seven in patient units. This spread of stroke resources presents a significant challenge to consistently meeting the required standards of clinical care. Fig.4 Current configuration of Service Royal Gwent Hospital Hyper-acute and Acute Care (24hr thrombolysis) Nevill Hall Hospital Hyper-acute and Acute Care (thrombolysis 9am-5pm) St. Woolos Hospital County Hospital Chepstow Hospital Ysbyty Ystrad Fawr ELGH Acute stroke care Ysbyty Aneurin Bevan Redwood Hospital Monnow Vale Limited community-based health and social care services Development of Community Resource Teams Limited Early Supported Discharge Services Primary Care management of risk factors for primary and secondary prevention Association Communication Support and Keep in Touch Service Survivors Groups 6
The Redesign Programme has explored a number of options for the reconfiguration of the in patient components of the pathway. The identified options have been informed by available data on stroke incidence, best clinical practice and demographic and travel time information provided by Public Health Wales Observatory. A final four options consisting of one hyper-acute admitting unit supported by one, two or three in-patient units was then subject to further analysis and appraisal using the same criteria of quality; safety; access; sustainability; and strategic fit used for the South Wales Programme, together with alignment to the ABUHB Clinical Futures Strategy. The debates and ongoing dialogue with stakeholders aimed to arrive at an option that sought to balance clinical, structural and strategic priorities with the planning process now at a point where a recommendation can be made on the preferred interim organisational model for the delivery of our stroke services, ahead of the opening of the SCCC. In order to fully deliver the new Clinical Model of Care it is therefore proposed that the number of in-patient stroke facilities in ABUHB is reduced and that community services continue to be developed to enable people to return home earlier. 4.3 One hyper-acute stroke unit Moving to the Clinical Futures model of one hyper-acute unit will concentrate our expert acute stroke staff in a centre of excellence able to deliver consistent high quality care in the most efficient way for patients 24 hours a day. The preferred site for delivery of hyper acute specialist care, before the SCCC is built, is the existing stroke unit in the Royal Gwent Hospital for the following reasons: Larger centre of population Availability of neurologist support and access to regional neurology rota Radiology resilience (2 x CT scanners) Availability and suitability of facilities, in particular with respect to space and appropriateness for and mitigation of the cost of capital alterations Alignment with the broader re-configuration plans for Aneurin Bevan University Health Board services (Clinical Futures) Strategic fit with regional planning and assumptions about patient flow 4.3 Specialist Rehabilitation Units Approximately 17% of stroke patients will require an extended period of in-patient stroke. The clinical view is that these patients should be transferred to a specialist stroke unit, rather than continue their in the acute hospital. Wherever possible patients should then be discharged home with support from the Community Neuro- (Early Supported Discharge) service. 7
Others will be transferred to a local hospital for ongoing care, complex discharge planning or palliative/end of life care. It is proposed that ABUHB reduce the number of in-patient sites to three at Nevill Hall Hospital, Ysbyty Ystrad Fawr and St Woolos Hospital. 4.4 Early Supported Discharge Evidence from early supported discharge trials suggest that up to 41% of stroke patients could achieve greater functional independence from returning home early with appropriate support. The ABUHB stroke pathway includes the introduction of community-based Neuro teams to pull appropriate stroke patients home from the stroke unit and to provide intensive within the person s home or in their locality. The HB, in partnership with our five Local Authory partners, has been successful in securing funding from the Welsh Governments Intermediate Care Fund to develop this aspect of the stroke pathway during 2014/15. Fig.5 Proposed configuration of Service Nevill Hall Hospital ELGH 4-7 days Acute Care Up to 6weeks Rehabilitation Development of Early Supported Discharge Royal Gwent Hospital Hyper-acute Unit 0-3 Days Newport patients 4-7 Days (Acute Care) St. Woolos Hospital 6weeks Rehabilitation Ysbyty Ystrad Fawr ELGH 4-7 days Acute Care Up to 6weeks Rehabilitation Community Resource Teams Primary Care management of risk factors for primary and secondary prevention Association Communication Support and Keep in Touch Service Survivors Groups Acute Care Life After The Health Board has already agreed the move to a single hyper-acute admitting site ahead of the opening of the SCCC and has been updated on progress on the whole pathway redesign through Board Briefings. The Aneurin Bevan Community Health Council (CHC) has also been kept appraised of progress and will consider this report at it May Planning Committee. 8
It is anticipated that the CHC will advise that the proposed organisational structure is aligned to the Clinical Futures strategy and, while it will be a major service change, will not require formal public consultation. A programme of public engagement will however be required. 5. COMMUNICATION AND ENGAGEMENT The proposed model for stroke services was developed by the multidisciplinary Board, through a series of clinical workshops during 2013 and early and ongoing dialogue with Local Authorities, the Community Health Council, patients, advocacy groups, partner organisations and staff. The Health Board has previously carried out consultation on the Clinical Futures programme and this Services Re-design Programme is aligned with the Clinical Futures principles. A period of consultation with staff will be necessary, along with further engagement with patients, the public and stakeholders on the significant service re -configuration changes proposed. A detailed communications strategy is nearing completion and will be supported by the Community Health Council. 6. REPORTING ARRANGEMENTS The proposed Services Re-design Programme will report to the Health Board via the Clinical Futures Board and the ABUHB Executive Team. 7. BENEFITS REALISATION The draft set of outcomes associated the Improvement Programme are listed below and will be developed further to include metrics and timeframes in a Benefits Map:- Fewer people will have a stroke More people receiving a higher quality care following a stroke Faster treatment for people suffering a stroke Fewer people will die as a consequence of stroke Fewer people will have residual disability from stroke More people returning home more quickly following a stroke Fewer beds days used for stroke care Reduced length of hospital stay for stroke patients Less continuing health care costs for patients with complex needs following a stroke Fewer sites deliver stroke care Reduced estates costs to deliver stroke care 9
8. TIMETABLE Aneurin Bevan University Health Board Key Actions Timescale Establish Improvement Programme February 2013 Board Development Session Hyper Acute Unit Clinical Workshop 1 ABUHB Delivery Plan approved and published ABUHB CHC Engagement Meeting Clinical Workshop 2 Clinical Workshop 3 ABUHB CHC Engagement Meeting LA Heads of Adult Services Engagement Powys Executive Team Engagement Delivery Plan - Annual Report to WG Board Development Session Clinical pathway and operational structures progress LA Scrutiny Committee Engagement CHC Engagement Meeting Public Board - Organisational Reconfiguration CHC Planning Committee Establish Reconfiguration Programme Establish Community Neuro- service Final flow modelling of stroke pathway Final Workforce and Financial Plan Confirm Benefits Realisation data set Public and stakeholder engagement Staff consultation Reconfigure beds February April May May June July July August August September January 2014 Feb - May April May May June June - Aug June July June July June - Aug June - Aug July - Sept Oct - Dec 10
9. CONCLUSION Aneurin Bevan University Health Board ABUHB Services must be re-designed to consistently achieve national standards and guidelines for stroke care. A newly defined clinical pathway is being implemented but, in order to achieve full compliance with national standards, the configuration of the hospital based components of the pathway need to undergo significant change. The preferred interim option for the hospital configuration of stroke services, ahead of the opening of the SCCC, is to centralise the emergency service for stroke at the Royal Gwent Hospital with three units at St Woolos Hospital, Ysbyty Ystrad Fawr and Nevill Hall Hospital. These hospital based services will be supported by improved preventative measures and community services for people who have suffered a stroke. The proposed reconfiguration aligns to the Health Board s Clinical Futures strategy with a specialist centre supported by a necklace of local general hospitals and enhanced community services. 10. RECOMMENDATIONS The Board is asked to:- Note progress with the delivery of the ABUHB Delivery Plan Note the work undertaken to scope and appraise options for inpatient service re-design Approve the recommended option for the interim reconfiguration of in-patient stroke services ahead of the opening of the SCCC Report Sponsored by: Report Prepared by: Jan Smith Executive Director of Therapies and Health Science; ABUHB Executive Lead Martin Lane Senior Planning Project Manager; ABUHB Services Re-design Programme Manager (Designate) Date : 28 th May 2014 Sam Crane ABUHB Services Management Lead 11