Healthcare for London. 3. Background information

Transcription

1 Healthcare for London Acute Stroke Services Designation 3. Background information October 2008

2 Acute Stroke Services Designation Background information This paper provides background information relevant to the designation of acute stroke services across London including: 1. An overview of the Healthcare for London (HfL) programme 2. An overview of stroke incidence in London 3. An overview of the HfL Stroke Project 4. An overview of the Acute Stroke Project. 5. Engagement process and service delivery options 6. Implementation 1. Overview of the Healthcare for London programme In autumn 2006, NHS London commissioned Lord Ara Darzi to undertake a review of London s health services and develop a vision to meet Londoner s health needs over the next five to ten years. This resulted in the publication of the report Healthcare for London: A Framework for Action in July Amongst other findings, this report identified significant deficiencies in the treatment and care of stroke and presented overwhelming evidence that stroke should be dealt with by specialised centres. The London Commissioning Group (LCG) consisting of representatives from Primary Care Trusts (PCTs), NHS London, the Mayor s Office, local government, a Clinical Advisory Group and a Patient and Public Advisory Group has taken responsibility for leading on the delivery of the vision outlined in A Framework for Action. The LCG is accountable to all London PCT Boards and NHS London. A public consultation was conducted between November 2007 and March 2008 on the models of care and delivery proposed in A Framework for Action and a Joint Committee of PCTs (JCPCT) was established to consider the outcome of the consultation. Sixty-seven per cent of respondents to the public consultation supported proposals to create more specialised centres for the treatment of acute stroke. A full analysis of consultation responses can be found at the HfL website ( On the 12 June 2008 the JCPCT took decisions and agreed their recommendations following PCT Boards consideration of the responses to Consulting the Capital. The decisions included: The JCPCT agrees to the proposal to develop some hospitals to provide more specialised care to treat the urgent care needs of patients suffering a stroke (about seven hospitals in London providing 24/7 urgent care, with others providing urgent care during the day). The number and location of these hospitals should be subject to a further consultation by PCTs. The complete set of JCPCT decisions and recommendations can be found at the HfL website ( During the consultation phase the focus of the HfL programme was on supporting delivery of the Healthcare for London: Consulting the Capital consultation and the initial projects commissioned by the LCG that would allow progress to be made as quickly as possible following the outcome of consultation. 1

3 The focus of the HfL programme post-consultation will be on implementation of the JCPCTs recommendations and this will be driven forward by effective commissioning on both a local and pan- London basis. 2. Overview of stroke incidence in London. The Stroke Project has set out a number of objectives in its goal to achieve a step change in the quality of stroke care in London. A key theme is the creation of a stroke care system that ensures every Londoner receives the same high quality of care. This commitment to reduce inequality has some specific implications for the configuration and location of specialist stroke services in the capital. This section will outline the background to the configuration issues and provide supporting information about ensuring that the health needs of stroke patients are met through the configuration of specialist stroke services. 2.1 Incidence and potential coverage subject to travel time The map below (map 1) indicates that the periphery of London has a greater incidence of stroke, based on age profile and data extrapolated from the South London Stroke Register. The map depicts the number of strokes predicted within electoral wards for 2008, the redder the ward appears, the greater number of strokes predicted to occur. The main associations are with ageing and to lesser extent ethnicity and deprivation. Stroke Prevalence Source: LSE Prediction Model Highest Prevalence High Prevalence Moderate Prevalence Low er Prevalence The more intense the red the greater number of strokes predicted to occur in population of the area. Does not predict where the Stroke will happen, only the place of residence of the predicted stroke victims Map 1 - Incidence of stroke in London Figure 1, below, shows the key elements of travel time that have been modelled. To achieve optimal outcomes, the Clinical Panel and Project Board's view is that stroke patients must be able to access HASU care within 2 hours and thrombolysis (if appropriate) within 3 hours. This timeframe includes the time from the initial call, ambulance journey to the site through the paramedic assessment and then the delivery of the patient to A&E must be taken account of. To ensure that this target is met anyone having a stroke in London must be within 30 minutes of a HASU service. Each potential provider therefore will have a theoretical catchment area for the provision of access to hyper-acute stroke services within 2 hours. 2

4 Call to Arrival at Patient Onsite Assess Delivery to A&E Total Journey Time (Gold Standard < 2 Hours) Figure 1 - Gold standard travel time An example of a theoretical catchment area for an individual hospital site is shown on map 2 below. The red area shows the area for which a travel time of 30 minutes could be met, pink shows where the 2 hour limit could be met, and black where neither is achieved. London Regions within Travel Time Theoretical Catchment Areas of Current Providers 1 and 2 Satisfied Only 1 Satisfied Neither Satisfied Performance Standards 1 1a) - % of patients admitted to A&E within 2 hours of onset of symptoms via ambulance service Service Specifications 2 Travel Times Evidence of numbers of patients travelling more than 30 minutes to HASU Map 2 - Theoretical catchment area for hyper-acute stroke service providers It is expected that there will be a limited number of HASU specialist stroke units in London. This modelling (map 3 below) shows that some outer London areas have only two potential hospital sites that can ensure travel time within 30 minutes, whereas Inner London has up to 14 hospital sites that could cover the population within 30 minutes. 3

5 Theoretical Catchments Area Overlap for current Stroke Providers 12 to 14 Providers Overlapping 10 to 12 Providers Overlapping 8 to 10 Providers Overlapping 6 to 8 Providers Overlapping 4 to 6 Providers Overlapping 2 to 4 Providers Overlapping The more intense the red the greater number of providers available to provide service to the area. There is always at least two providers available to any give area. Map 3 - Availability of potential stroke service providers The implications of this are that the outer London areas that have a higher incidence of stroke will require specialist services (HASUs) to be developed so as to meet the equality of access goal. In this process, proposals that support the development of some outer London hospital sites to become specialist Stroke centres will be required. Due to the high potential overlap of service provision in the centre, not all Inner London will be required to provide HASU services. To support the development of services which meet the needs of Londoners, Trusts will be expected to work with Stroke Networks and other Trusts to develop proposals that take into account the need to have a limited number of central London HASUs. Providers with limited experience of providing specialist stroke services will be encouraged to develop proposals with Trusts with greater experience to provide coverage in the areas that have limited access, even if these take some time to implement. Given the scale of provision of HASUs it will be expected that Trusts work with local Trusts within a Stroke Network but also with other Trusts in other Stroke Networks so as to develop integrated plans for developing HASUs. 3. Overview of the HfL Stroke Project In November 2007 the LCG identified stroke care as one of the clinical areas where work should begin as a priority as part of the HfL programme and be informed by the outcome of the public consultation. The HfL Stroke Project was commissioned to explore options for improving how stroke care could be improved in London. The overarching objective of the project is to design and, informed by the outcome of the designation process and consultation, implement an inclusive stroke care service that assures the optimal care of all patients at all stages of the patient journey. The project is looking at the complete pathway, from prevention to long-term care and rehabilitation, looking at it both from the provider and commissioner point of view. Three preliminary strategies have been developed to address prevention, acute care, rehabilitation and community care, which will be put to public consultation in January 2009 and are discussed below. The planned new pathway for stroke care within London outlined below, has been approved by the HfL Stroke Project Board and the project s Clinical Expert Panel and gives an overview of the pathway and descriptions of each stage of the pathway. This designation process will be designating providers of services in the acute part of the pathway only. 4

6 Figure 2 below illustrates the proposed overall pathway for stroke. Figure 2 - Stroke pathway The London Stroke Networks will be supporting the implementation of the rehabilitation and prevention strands, and will be monitoring implementation and compliance of acute stroke services in line with the performance standards outlined in the Preliminary Acute Stroke Strategy, and laid out in the designation criteria. For more information around the role of stroke networks, see Appendix 24 to the strategy, available at: 4. Overview of the Acute Stroke Project In this section we provide an overview of the plans for the acute part of the pathway that have been approved by the HfL Stroke Project Board and the LCG and reflect the recommendations made in the National Stroke Strategy. The acute stroke service comprises three key service lots defined as follows: hyper-acute stroke units (HASU) provide the immediate response to a stroke, where the patient is stabilised and receives primary intervention, and where length of stay is typically no longer than 72 hours. stroke units (SU) provide multi-therapy rehabilitation and ongoing medical supervision following a patient s hyper-acute stabilisation, where length of stay varies and will last until the patient is well enough for discharge from an acute inpatient setting. stroke centre is a combined HASU / SU, all HASUs are expected to also have an SU. transient ischaemic attack (TIA) services provide rapid diagnostic assessment and access to a specialist within 24 hours for high risk patients following a TIA, and within seven days for low risk. The acute stroke service will commence for the service user when initial contact is made with the emergency services and emergency vehicles are dispatched. It is proposed that there will be a pan- London triage system, facilitating transport to the nearest, most appropriate hyper-acute stroke unit (HASU). The configuration of service providers selected across the whole of Greater London following consultation will aim, amongst other things, to ensure optimum coverage in terms of travel times whilst also ensuring acute stroke care centres experience sufficient throughput to maintain specialist stroke skills. 5

7 It is hoped that the proposed new service will be introduced from October 2009, with a step-change in the quality of service being delivered from the outset and commitment to an implementation plan to deliver the full service within 18 months and monitoring of the achievement of key results during that time. Only designated hospital sites will be commissioned to provide hospital-based services. The acute stroke project is divided into a number of key delivery phases. Phase 1: Strategy Development The development of a pan-london stroke strategy including a service specification and performance standards for the end-to-end stroke pathway, informed by the outcome of consultation (November 2007 September 2008) Phase 2: Engagement and Designation (July 2008 December 2008) The engagement of commissioners, service providers and other key stakeholders to discuss the options for delivery of acute stroke care, and the preparation for and running of a designation process to determine the possible providers who are able to deliver the required level of care. Phase 3: Public Consultation (January 2009 April 2009). Following the bid evaluation and configuration evaluation processes, a short list of possible configurations will be agreed by the JCPCT and issued for public consultation. Phase 4: Designation Decision and Configuration Implementation (from July 2009) The JCPCT will take a final decision on configuration at their meeting in July Implementation of the configuration of stroke services and optimal care pathways will be informed by the outcome of consultation on the configurations for service delivery and occur from October The project is currently completing Phase 1 and is moving towards Phase 2. The Stroke Strategy will be issued in early October. The governance arrangements for the project are provided in Appendix A. 5. Engagement process and service delivery options The Preliminary Acute Stroke Strategy outlined 3 options for implementing the model outlined in A Framework for Action. Engagement with a wide range of stakeholders over the summer period has indicated that the step change in services required is unlikely to be achieved under option 1, and potential providers have indicated that option 3 would prove problematic to implement. Option 2 provides the step change required and will be easier to implement as it is less demanding in terms of capacity for potential HASU providers. We will seek to designate HASUs of no fewer than 10 beds (although larger bed size units are considered to be better), ensuring that everyone in London is within acceptable travel times. The table below (figure 3) gives an indication of the approximate (rounded up to whole beds) number of beds required per network. Columns 1 and 3 refer to beds required for London PCT patients. Columns 2 and 4 refer to beds required by non-london PCT patients and tourists. Please note that beds required in a particular network would not necessarily be serviced by a provider in that network. Providers will overlap networks considerably, therefore a network will not necessarily be expected to service the beds within its boundaries. 6

8 HASU Ldn HASU Non-Ldn SU Ldn SU Non-Ldn North West North Central North East South East South West Total Figure 3 - Approximate bed requirement by network 6. Implementation Following the JCPCT decision in July 2009 there will be a short period of mobilisation before the designated providers will begin to deliver services from the go live date (in October 2009). Providers will have a period of up to 18 months after the go live date to complete their implementation plans to deliver against the full designation criteria. That 18-month period will be broken down into a number of step changes which they will need to fulfil (see figure 4). Each designation criteria is given an implementation code which specifies the target timeframe in which the service should be delivered. DESIGNATION CRITERIA Diagram shows the minimum criteria which designated providers will be required to meet at each time point from go-live. These are identified as A, B, C, D in the service specification for HASU, SU and TIA services. C GOLD STANDARD STROKE SERVICES D C B B B A A A A Current activity (will vary between providers) Go-live Go-live + 6 months Go-live + 12 months Go-live + 18 months TIME Figure 4 - Staged implementation of designation criteria This staged implementation will require commissioners to implement transitional arrangements to ensure service provision continues to meet needs during the development of designated HASU, SU and TIA services with gradual decommissioning of services provided by non-designated providers (outlined in Document 10 Overview of commissioning and finance arrangements ). 7