Comprehensive Review of Current Stroke Rehabilitation Services in South London

Transcription

1 Report Comprehensive Review of Current Stroke Rehabilitation Services in South London March 2009 South London Cardiac and Stroke Networks

2 Table of Contents Executive Summary... 5 Methodology...5 Performance levels...5 Impact of Community Rehabilitation Standards...5 Investment of time... 6 Location of service... 6 Use of time and type of staff... 6 Modelling framework... 6 Current staffing for Stroke rehabilitation... 6 How many staff are needed?... 7 Benefits offsetting cost... 7 Early Support Discharge Programmes (ESD)...7 Impact of Voluntary Sector Standards...7 Review of Operational and Strategic Plans...7 Key Gaps identified...8 Emotional and physiological support... 8 Staffing... 8 The existing Baseline...9 Recommendations...9 Report Terms of Reference Project Work Methodology Literature search Interviews Staff modelling and gap analysis Staffing assumptions...13 Table 1: Community Rehabilitation Numbers of patients to be treated...15 Table 2: ICD-10 codes for stroke Table 3: Gold Standard Maximum model...16 Table 4: Minimum Performance Table...17 Early Supported Discharge Issues and Strategies to handle staffing Recruitment Links with the independent and/or voluntary sectors Vocational rehabilitation Providers of complex external rehabilitation Table 5: Voluntary Sector Review of PCT Stroke Commissioning Plans Bexley Care Trust Bromley PCT Croydon PCT Greenwich Kingston PCT Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 2 of 99 Final Report

3 Lambeth PCT Lewisham PCT Richmond and Twickenham Southwark PCT Sutton and Merton Wandsworth Summary of strategic and operational plans Table 7: Additional staff required: Minimum Gap Analysis Good Practice Examples...36 Summary of gaps and priority areas...36 Table 8: Gap Table by PCT...38 Other issues...40 Information systems Discharge team meetings Adaptations Total package funding Recommendations...41 PCT Resource Tables Bexley SE London...43 Bromley SE London...46 Greenwich SE London...51 Lambeth SE London...55 Lewisham SE London...59 Southwark SE London...63 South East London PCT s and Local Authorities...67 Croydon SW London...69 Kingston upon Thames SW London...73 Richmond & Twickenham SW London...76 Sutton & Merton SW...79 Wandsworth SW London...82 South West London PCT s and Local Authorities...85 South London PCT s and Local Authorities...87 Bibliography Bexley...89 Bromley...89 Croydon...89 Greenwich...90 Kingston...90 Lambeth...90 Lewisham...91 Richmond and Twickenham...91 Sutton and Merton...92 Southwark...92 Wandsworth...92 Stroke Association...93 Different Strokes...93 Fairlee House Nursing Home...93 NICE...93 Healthcare London...93 Modernisation Initiative...94 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 3 of 99 Final Report

4 Government and other publications...94 Cardiac and Stroke Network...95 Hospital provider trusts...95 Evaluation of the methodology Modelling Framework...97 Process evaluation...99 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 4 of 99 Final Report

5 Executive Summary In January 2009, the South London Cardiac and Stroke Networks (SLCSNs) commissioned a comprehensive review of existing stroke rehabilitation services across both southeast and southwest London. This review will inform the Network and provide a baseline against which to measure performance as the Community Rehabilitation and Voluntary Sector Quality Marker standards arising from the Stroke Strategy for London 1 are implemented. The review covers Health and Local Authority services as well as the voluntary and independent sectors. Methodology The methodology comprised: literature review of national and international publications assessment of the individual staffing input required to achieve each of the 13 Community Rehabilitation and Voluntary sector markers assessment of the total staffing requirement arising from the discharge into the community of all patients admitted to hospital following diagnosis of a stroke or TIA structured interviews with clinical leads, PCT and LA staff, voluntary and independent sector providers review of PCT operating and strategic commissioning plans preparation of a gap analysis and identification of priority areas for redesign and development appraisal of improvement priorities and cost effectiveness. Performance levels Within the Healthcare for London (HfL) standards, two levels of performance are identified. We have called these: The Gold Standard: In this report, the Gold Standard means that all 10 Community Rehabilitation and all 3 Voluntary Sector quality markers are achieved in respect of all stroke/tia patients discharged from hospital The Green Standard: In this report, the Green Standard is the minimum performance standard in respect of each of the 13 standards set out in the Stroke Strategy for London to be achieved by October Generally, this is the achievement of the standards in respect of 70% of stroke patients discharged from hospital Impact of Community Rehabilitation Standards The Community Rehabilitation quality markers cover Early Supported Discharge (ESD), early assessment following hospital discharge, timely and ongoing face-to-face contact with therapists, goal setting, cognitive screening, care planning and support services. 1 Appendix I Performance Standards for Rehabilitation Page 55 Stroke Strategy for London Healthcare for London Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 5 of 99 Final Report

6 Investment of time For each quality marker, we assessed the number of staff minutes required to achieve the standard using either: a. the time identified within the standard itself- e.g. standard 7a - 3 hours and 45 minutes per week for each of the three therapies - OR b. where no timing is given our best judgement of the staff contact time and travel time involved to deliver the standard for each patient. Location of service We assumed that the Community Rehabilitation Service would be provided in the patient s own home rather than in a hospital or other clinic setting. This has a significant impact upon cost because staff will have to travel from their work base to the patient s home. Use of time and type of staff In the full report, we set out in detail the timings applied to each standard in respect of face to face contact time, office time and travel time as well as the number of occasions/weeks over which the service is provided. We have also set out the type of staff member required to provide each service. Modelling framework Using these data, we constructed a modelling framework in which to assess the overall staffing implications of meeting these standards at both the Gold and Green levels. We used financial costing data supplied to us to estimate the cost of employing the staff required to achieve these standards. Current staffing for Stroke rehabilitation Following interviews with staff in each PCT and review of caseload and other documents, we assessed the proportion of all staff time currently spent on the care of Stroke patients by Neurorehabilitation and ESD programme teams in each of the 11 PCT s. We applied this proportion of time to the existing Neuro-rehabilitation establishment in each PCT to estimate the number of Whole Time Equivalents (W.T.E.) currently providing stroke services. This proportion is about 31% across all PCT s with some local variation. Finally, we compared the existing numbers of staff providing stroke services to the numbers of staff required to achieve the Gold Standard and the Green Standard. This analysis shows that the existing Neuro-Rehabilitation and ESD staff provide the equivalent of of services in respect of Stroke patients. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 6 of 99 Final Report

7 How many staff are needed? To fully achieve the Gold Standard would require 253 and, for the Green Standard, 177. This means that there is a net shortfall in the numbers of staff required to achieve either standard of between 184 and 108 staff. The recurring cost of these staff is estimated to be between 9.07 million and 6.23 million respectively. Benefits offsetting cost Published cost benefit reviews 2, 3 demonstrate that between 9 and 10 acute episode of care bed days can be saved by early discharge to ESD programmes in the community. Assuming that these savings are, in practice realised and benefits transferred from the Acute to Community sector, we estimate that between 4.5 million and 3.5 million should be saved at the Gold and Green levels of performance. Early Support Discharge Programmes (ESD) Almost all cost benefits arise from the introduction of ESD programmes. Only 4 PCT s have ESD programmes in place. A further three have plans to introduce ESD programmes and the remaining 4 PCTs have no plans to introduce an ESD service. Typically, the ESD programmes available and/or planned are targeted at an annual caseload of 36 patients. We estimate that, 50% of all hospital discharge patients might appropriately be referred to an ESD 4. This means that, on average, each ESD would need to have an annual capacity of 131 patients. We consider that, unless the ESD programmes are expanded in both number and coverage to all PCT s, the potential to realise benefits will be significantly reduced. Impact of Voluntary Sector Standards We have assumed that, to fully achieve the Voluntary Sector standards, each PCT would need to have in place a Service Level Agreement (SLA) with at least one voluntary agency. These SLA s might cover either Family and Individual Support or Communication or both. All but two PCT s already have formal SLA s in place. The cost of these SLA s is typically less than 50K pa for a basic level of service. Review of Operational and Strategic Plans In respect of each PCT, we have obtained the published Strategic Commissioning Plan and, where possible, supporting financial plans, operational plans, annual plans and 2008/9 or 2009/10 strategic intentions. None of the plans identify a sufficient level of financial resource to fund the numbers of staff required to achieve the 10 Community Rehabilitation quality markers at either the Gold or Green standard to be met. In our view, four authorities are well on their way to achieving the quality markers, albeit they have yet to identify sufficient resources with which to meet all 13 standards. These are: Croydon, Lambeth, Southwark and Wandsworth. 2 What is Early Supported Discharge? (ESD), Modernisation Initiative 3 Stroke Strategy for London Healthcare for London 4 Discussion with clinical leads Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 7 of 99 Final Report

8 In each of these, we consider that there is evidence of good practice that should be built upon in the other PCT s. These good practice items include: Base a stroke consultant for at least one session per week at the community rehabilitation/intermediate care base. In Southwark, this leads to benefits for both patients and staff Implement detailed workload measurement studies to inform the design of local services. In Lambeth, these studies have provided comprehensive and detailed evidence of cost, benefit and manpower needs. These studies will provide evidence upon which to establish the effectiveness of new stroke services. Build on the skilled Neuro-rehabilitation teams within the PCT and use expert clinicians to drive forward new services Wandsworth. Use creative commissioning to obtain new services to exacting specifications from the independent and voluntary sectors. These sectors can fast track new developments, bringing a completely new service on stream in less than six months. Public sector capital and revenue constraints often mean that the same development would, if carried out in house, take several years to implement. Croydon has used this approach to obtain part of its intermediate care service. Key Gaps identified Emotional and physiological support The lack of appropriate levels of mental health support with which to support patients dealing with the major impact on body image arising from a stroke was raised in every interview. In many cases, the lack of this support might hinder the patient s ability to get the most benefit from other rehabilitative therapies and undermine their potential to return to work or a normal life. Staffing We have already talked about the shortfalls occurring in staffing numbers to achieve rehabilitation standards and realise benefits from shorter length of stay. A key issue, even if sufficient cash is available, is how sufficient numbers of Physical, Occupational and Speech and Language Therapy staff can be recruited within a very short time scale. We consider that PCT s will need creatively to focus on how appropriately skilled staff might be recruited and/or trained to carry out work with this cohort of stroke patients. PCT s may need to consider developing and using generic healthcare assistants with additional training who will work under the direction of expert paramedical therapists. Early discussions need to be held with colleges and other secondary educational establishments who might undertake this education. Commissioning teams need to explore new links with the Independent and Voluntary Sector. There are some 16,000 registered and accredited care beds in South London. Additionally, there is a substantial registered and accredited domiciliary care sector. Some PCT s already use creative links with these sectors to provide high quality care in externally accredited establishments. Because the sector operates without the lengthy internal planning and financing processes of the NHS, they typically can offer new bespoke stroke rehabilitation facilities close to the patient s own home or in the home in the case of domiciliary care providers more quickly than the NHS, at a similar or lower price and at the same quality standard. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 8 of 99 Final Report

9 The existing Baseline In the full report, we have set out on a PCT by PCT basis, a detailed baseline of existing services including: Population and prevalence data Number of stroke/tia patients and the hospital to which they were admitted Current total Neuro-rehab staffing and the proportion devoted to stroke care Staffing needs to meet the Gold Standard of performance The additional staffing resource, and cost, to meet the Gold Standard Information of current caseload and number of contacts From interviews with key staff their view of: o Key issues facing the service o Gaps in services o Future development plans of which they are aware o Interface issues with other services both within and without the public sector o Range and nature of current services provided to stroke clients. We have then summarised this information into SE London, SW London and South London as a whole. To all of those staff that participated in interviews and provided information to this review, we extend our thanks and appreciation. Recommendations 1. We recommend that ESD programmes are introduced in each PCT area and that these are designed and resourced to provide in full the 3 hours and 45 minutes contact time specified from each of the three paramedical professions to 50% of those patients discharged from hospital following a stroke/tia episode. 2. We recommend that each PCT have in place a formal SLA with a voluntary sector provider to supply either Family and Individual Support or Communication or both. 3. We recommend that Good Practice identified in certain PCT s should be considered by each PCT for local introduction: a. base a session of a stroke consultant in community settings b. introduce detailed workload measurement to inform service design c. build upon existing Neuro-rehabilitation teams using expert clinicians to drive forward new services d. use creative commissioning to obtain new services from other sectors and fast track new developments. 4. We recommend that PCT s consider alternative strategies to deal with the numbers of staff required including: a. Link with educational establishments to provide additional stroke specific training to generic healthcare assistants who would work under the direction of expert Physiotherapy, Occupational Therapy and Speech and Language therapy professions to deliver stroke rehabilitation services b. Commissioning from the Independent and Voluntary sectors new top quality rehabilitative services located near to the patient s home to be implemented within the next six months and externally quality assured 5. We recommend that each PCT consider how to support the emotional and mental health needs of Stroke/TIA patients as they cope with the changes in body image arising from the initial health incident. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 9 of 99 Final Report

10 6. We recommend that the SLCSNs take a lead performance monitoring role, reporting direct to HfL on progress toward implementation of the Green and Gold Standards and participating in discussions on resource transfer between Acute and Community Service providers arising from the introduction of ESD programmes in each PCT. 7. We recommend that the Strategic Commissioning Plans be updated to reflect the financial implications of implementing in full the Community Rehabilitation performance standards contained in the HfL London Stroke Strategy, Appendix I. 8. We recommend that the SLCSNs review on annual basis the baseline of data set out to the back of this report so that an up-to-date and comprehensive view of rehabilitative services is maintained. Set against this background, SLCSNs should monitor progress on: a. reducing hospital length of stay b. occupancy in the Hyper-Acute and Stroke Units c. outposting of Stroke/TIA patients into non-specialist beds d. stroke re-admission rates following discharge to community. The use of these two data sets should enable SLCSNs to assess and monitor the extent to which the community rehabilitative services are successful in preventing silting up of acute hospital beds and improving outcomes for individual patients. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 10 of 99 Final Report

11 Report Terms of Reference In December 2008, the South West and South East London Cardiac and Stroke Networks (SLCSNs) commissioned a comprehensive review of the current community based stroke rehabilitation services provided across the 11 PCT s and 12 Local Authorities in South London. The work was to be completed by the end of March 2009 and reported to the Network and onward to the Clinical Reference Groups for Stroke & CVD Boards. The report was required to set out: A comprehensive review of current community based rehabilitation service provision across the health, social care and voluntary sectors including a baseline of Early Supported Discharge (ESD) provision. Comprehensive review of the 2009/10 PCT stroke plans Benchmarking the level of local service provision against the National Stroke Strategy Rehabilitation Quality Markers and Healthcare for London Rehabilitation Performance Standards. This will look at issues such as access, waiting times, quality, location of provision and staffing levels. A gap analysis to identify priority areas for redesign and development. An appraisal of improvement priorities in terms of impact, cost effectiveness and the local and national policy context. Recommendations to support and inform the South London Networks rehabilitation workplans and PCT commissioning plans. Evaluation of the methodology and process through which the report was formulated. Project Work The project work was carried out by Robert Oreschnick, RN, B.Sc. Nursing (Honours). Bob has carried out a number of pieces of work in the UK, the Republic of Ireland, Africa and Europe in which an accurate baseline of current services was identified against which gauge the changes needed to deliver a new service. In particular, he has developed systems used to predict the level of staff required to ensure that each new service achieve high quality standards. Methodology Literature search An initial literature search was carried out covering strokes. These are listed in the Bibliography for this report. We reviewed: o o o o o o o o o National Service Frameworks National Stroke Strategy National Institute for Clinical Excellence (NICE) Modernisation Initiative SENTINEL reports BMA and other professional organisations and groups Voluntary association reports, e.g. Stroke Association Strategic Plan, Operational Plan, Commissioning Plan, Financial reports for each PCT, Local Authority and stroke documents from each NHS Trust offering a stroke service in South London Healthcare for London Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 11 of 99 Final Report

12 o o International documents concerning stroke, coding issues, treatment protocols and clinical pathways Other reports including those produced by or for SLCSNs. Interviews We carried out over 30 structured interviews covering key staff having responsibility for service delivery, planning, design and/or commissioning in the Statutory health and social care sectors, the voluntary and private sectors. Each interview was designed to elicit information about both the current services provided as well as a view on future service developments required to ensure that the Gold Standard of stroke service is consistently delivered across South London. The Gold Standard, for the purposes of this work, is defined as achieving in full for all relevant patients each of the 10 performance standards relating to community rehabilitation set out as quality markers within the National Stroke Strategy, Staff modelling and gap analysis We: developed a model of the numbers of staff required to deliver in full the Gold Standard Performance Standards for Community Rehabilitation and Voluntary Community Services as set out by Healthcare for London (HfL) an arising from the National Stroke Strategy set against this model the current numbers of staff, expressed as Whole Time Equivalent (), employed in the Neuro-rehabilitation and Early Supported Discharge (ESD) teams where these exist estimated the proportion of the total current workload arising from Stroke services provided from within Neuro-rehabilitation and ESD teams compared the numbers of staff currently employed to provide stroke services to the numbers of staff required to achieve the Gold Standard for stroke identified gaps arising between the numbers of staff available and those required we estimated the costs of correcting these gaps at 2008 pay levels We have not identified any other non-staff resources that might be required, i.e. location, equipment, estates of other non-staff costs. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 12 of 99 Final Report

13 Staffing assumptions We set out below the assumptions used to calculate staffing number required for all patients discharged from hospital following a stroke/tia to achieve the Gold Standard of Performance 5. Table 1: Community Rehabilitation Standard Standard Description Number 1a All patients are contacted by a member of the community rehabilitation team within 24 hours of discharge and assessed within 3 days of discharge Assumptions applied to calculate staffing Activity 1b Assessment visit Assessment visit Write up in office 2 Appropriate patients treatment programme started Staffing contained in standard 7 below. within 24 hours (ESD intensity level) or 7 days (non- 50% of clients are assumed to be ESD) of assessment appropriate for ESD 3 All patients visited at home by community nursing team within 24 hours, where agreed as part of care plan 4 All patients have outcome measures recorded within one week of admission to and one week of discharge from community therapy services 5 All patients will have a named key worker inreach/outreach within one week of admission to community therapy services 6 All patients have a set of short and long term goals agreed with them, their family/carers and the rehab team of which they receive a copy appropriately formatted for their individual needs within two weeks of admission to the community therapy service Minutes per occurrence Minutes travel time per occurrence Number of occurrences Type of staff Contact visit Therapy lead Assumed to be part of the staffing in standard 1 above 1 hour of office time at start and again at end of treatment span for all discharged patients Assumed to be part of the office time in assessment standard 1 Preparation of goals Meeting with family and client Copy of outcome to team office time Therapy lead Nil minutes Therapy Lead Physio Physio Physio 7a. Appropriate patients receive 3 hrs. 45 mins per week within the first 2 weeks (ESD of individual sessions of OT, PT & SLT (Weeks start when treatment starts) Assume 50% of hospital discharges are appropriate for ESD. Times apply individually to each profession x 3 staff 6 weeks 6 weeks 6 weeks Physio OT SALT 5 Appendix I Performance Standards for Rehabilitation Page 55 Stroke Strategy for London Healthcare for London Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 13 of 99 Final Report

14 Standard Number Standard Description 7b. Low-intensity patients receive 135 minutes per week for the first 4 weeks (non-esd & Post-ESD) of individual sessions of OT, PT and SLT. 8a. All patients receive cognitive/perceptual screening within one week of admission 8b. All patients requiring a full perceptual assessment receive this within one week if required Assumptions applied to calculate staffing Activity 100% of all hospital discharges receive treatment. Duration 4 weeks. All hospital-discharged patients receive a baseline assessment in their home. Assume 10% require a full perceptual assessment at a hospital or testing centre. 9 All patients in work receive vocational rehabilitation Assume that 20% of all patients discharged required vocational rehabilitation for five weeks at a rehab centre 10 Patients and facility who the team identify have a need for further assessment or intervention to meet adjustment, behavioural or psychological needs and who are seen within 2 weeks of referral by the team Assume 20% of all patients discharged require this service at a central location Minutes per occurrence Minutes travel time per occurrence Number of occurrences 90 x 3 staff Type of staff Physio OT SALT Therapy leader 60 Nil 1 Psychologist 60 Nil 5 OT 60 Nil 1 Psychologist The timing set out in each assumption is: c. the time identified in the standard itself- e.g. standard 7a 3 hours and 45 minutes per week for each of the three therapies - OR d. Where no timing is given our best judgement of the staff time and travel time involved to deliver the standard for each patient. e. Staffing standards for ESD are the same for hospital based rehabilitation and for rehabilitation in the community. f. Where standards say for appropriate staff groups, e.g. the ESD standard, we have calculated based upon a worst case scenario. In other words, we have assumed that all staff groups will be appropriate. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 14 of 99 Final Report

15 Numbers of patients to be treated We used the Hospital Episode Statistics 6 (HES) to determine, by PCT of origin, the number of admissions for stroke to each hospital in South London. We defined stroke as patients admitted to hospital with a primary diagnosis of ICD-10 code I60 to I69. 7 Table 2: ICD-10 codes for stroke I 60: I 61: I 62: I 63: I 64: I 65: I 66: I 67: I 68: I 69: Subarachnoid haemorrhage Intracerebral haemorrhage Other non-traumatic intracranial haemorrhage Cerebral infarction Stroke, not specified as haemorrhage or infarction Occlusion/stenosis precerebral arteries not resulting in cerebral infarct Occlusion/stenosis cerebral arteries not resulting in cerebral infarct Other cerebrovascular diseases Cerebrovascular disorders in diseases classified elsewhere Sequelae of cerebrovascular disease The National Stroke Strategy 8, 9 estimates that, of the stroke and TIA patients admitted to hospital, 30% die before discharge. Using these data, we calculated the numbers of patients expected to be discharged from hospital and who would require community based rehabilitation and social support. For planning purposes, we assumed the Gold Standard would be achieved for all patients discharged from hospital 10. We then calculated the numbers of staff required, by profession to manage all of the stroke & TIA patients discharged from hospital in 2006/7, the latest year for which HES data is available. 6 Hospital Episode Statistics 2006/7 the latest year available 7 International Classification of Diseases 10. The latest version of the international classification of diseases. 8 National Stroke Strategy, London: Department of Health, Stroke Strategy for London, : Healthcare for London, November Appendix I Performance Standards for Rehabilitation Page 55 Stroke Strategy for London Healthcare for London Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 15 of 99 Final Report

16 Table 3: Gold Standard Maximum model South London Cardiac and Stroke Networks Implementation of these standards would be expected to produce acute hospital bed day savings with a value of approximately 4.57 million per annum. 11 Number of staff required by borough to achieve 100 % of the Gold Standard Maximum model 11 Assuming that 50% of all patients discharged in 2006/7 from hospital following a stroke according to the Hospital Episode Statistics were able to enter an Early Supported Discharge programme and that this resulted in a reduction of 10 days in the length of stay in the acute hospital and that the average cost per hospital day was 323 (blended Southwark and Lambeth costs in 2007). Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 16 of 99 Final Report

17 South London Cardiac and Stroke Networks Table 4: Minimum Performance Table. 12 Implementation of these standards would be expected to produce acute hospital bed day savings with a value of approximately million per annum 12 Assuming that 35% of all patients discharged in 2006/7 from hospital following a stroke according to the Hospital Episode Statistics (the Interim October 2009 level of performance) were able to enter an Early Supported Discharge programme and that this resulted in a reduction of 10 days in the length of stay in the acute hospital and that the average cost per hospital day was 323 (blended Southwark and Lambeth costs in 2007). Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 17 of 99 Final Report

18 Early Supported Discharge The implementation of Early Supported Discharge teams has been shown to reduce acute hospital length of stay by between 9 and 10 days 13. Of the 11 PCT s, three currently have an ESD team in place and one offers an ESD type of service through their Neuro-rehabilitation team. The key financial saving which arises from achievement of the performance standards is the release of funds from the acute hospital sector with which to offset the costs of early supported discharge and active post-hospital rehabilitation. Teams currently exist in Lambeth, Southwark and Croydon. Richmond provides and ESD service from within the Neurorehabilitation team. There are no teams in Bromley, Bexley, Greenwich, Lewisham, Kingston, Sutton & Merton, Richmond and Twickenham and Wandsworth. Some of the PCT s without an ESD team have already submitted bids to develop a team. Issues and Strategies to handle staffing To implement in full or in part the performance standards for Community Rehabilitation will, we estimate, require a substantial increase in staffing levels amongst Physiotherapists, Occupational Therapists and Speech and Language Therapists. Based upon our analysis of the current workload related to stroke care and the staffing resource available, only about 27% of current Community Neuro-Rehabilitation time is spent providing services to stroke clients. In South London, there are approximately 215 staff working in Neuro-rehabilitation teams and in Early Supported Discharge. About 27% of their time is spent working with stroke clients, this means that the current level of staffing attributable to Stroke Rehabilitation and ESD is 55 whole time equivalents. To fully meet the Community Rehabilitation Performance standards, 252 are required. This means that there is a shortfall of some 198 staff to achieve these standards. The cost of employing these additional staff would be approximately 9.5 million per annum. Recruitment It is unlikely that this number of staff could immediately be recruited into the South London NHS. In each of the three main paramedical specialties, about 60 additional staff are required. Potentially, locally trained paramedical assistants could support professional staff. This would help to reduce the numbers of fully qualified staff initially to be recruited. Links with the independent and/or voluntary sectors In South London, there are some 16,000 registered beds in nursing and care homes as well as a number of domiciliary care providers. PCT s could commission some entirely new rehabilitation services from this sector to ease the burden upon the NHS. In SE London, we reviewed one of the Care Homes contracted with several PCTs to provide specialist Neuro-rehab support services. The home is the first UK care home to achieve in full the Gold Standard 14 of quality and has excellent external statutory inspection reports. In addition, Fairlee House has its own internal Physiotherapy, OT and SALT staff as well as contracted and visiting Medical Consultant in Rehabilitation, Sessional psychologist input and links with the Lane Fox unit for ventilated and persistent vegetative state clients. Fees were on the order of 320 per day depending upon the package of care required for the client. Facilities like this do or could offer a range of highly specialised services tailored to the requirements of the commissioners without the rather longer lead-in times which might be required 13 What is Early Supported Discharge? (ESD), Modernisation Initiative 14 Certificate of Hallmark Award: Framework in Homes Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 18 of 99 Final Report

19 for NHS facilities. In addition, the external regulation of these facilities offers to the purchasers of care a second tier of independent quality assurance. Vocational rehabilitation The Wolfson Neuro-rehabilitation unit at St. George s Hospital NHS Trust provides rehabilitation to patients who require intensive therapy following acquired neurological conditions resulting in physical or psychological disabilities. This includes patients who have had strokes, traumatic injuries to the brain or spine, anoxic brain damage, diseases or infections of the nervous system, and longterm conditions like multiple sclerosis. The Centre also provides pain management to those with chronic back pain. Services are provided on an inpatient or day patient basis. It also provides a range of assessment and diagnostic clinics and advises on the care of patients who are not accepted to the Centre. Inpatients are admitted for eight to 12 weeks and follow individually tailored programmes based on goals set by the patient and their family or carers, in collaboration with the treating team. Close liaison is maintained with families, carers and community services, including statutory and voluntary organisations, to help patients' progression from the inpatient setting to the home environment. Day patient and outpatient services include individual and group cognitive rehabilitation, pain management and vocational rehabilitation to get people back to work. Support groups for patients and families are also available. The Wolfson is the only NHS Neuro-rehabilitation centre in London and the southeast that has a vocational rehabilitation programme The three stage programme offered accepts about 50% of those clients referred and consists of: Phase I: Vocational assessment cognitive and vocational evaluation Phase II: Employment Rehabilitation 12 weeks, 1.5 days per week - 1,500 Phase III: Vocational support in the workplace for up to 72 hours - 3,000 Vocational rehabilitation is an essential contributor to people returning to an active career and reestablishing their self worth. PCT s need to consider how to commission vocational rehabilitation as, without ongoing support, these services are unlikely to be able to cope with the peaks and troughs of activity. By working together, several PCT s might commission vocational service at a baseline funding level. This would represent funding for a total agreed number of patients. However, each PCT would draw upon the services as required by their individual needs and then, on a, say, two year basis, adjust funding levels to reflect more accurately the number of patient sent from each PCT. This would allow a group of PCTs in the southwest commissioning this service to act as a group and share risks. A similar approach already exists in some areas for high cost secure mental health services. The Department of Work and Pensions is also a source to which clients who require vocational assistance can be referred. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 19 of 99 Final Report

20 Providers of complex external rehabilitation The Wolfson provides complex Neuro-rehab for certain cases arising both within the District and from outside. For clients admitted from St. George s Hospital NHS Trust, there is a seamless pathway with a typical waiting time of 1 to 2 days and, at the most, one week. Clients referred from outside St George s enter the pathway which includes an initial MDT assessment done at the Wolfson. The waiting time for these beds does wary but is typically 20 working days (4 weeks). The Wolfson has 32 beds. 12 of these are district stroke beds into which stroke patients at St Georges from Wandsworth, Sutton and Merton can be transferred with the appropriate MDT screen done at St Georges. The other 20 beds are tertiary into which any patient with a neurological condition can be referred.. Cost per bed day: 210 Average length of stay (days) 38 Average cost of rehabilitation package 7,638 Waiting time for entry 1 day in district, 5 weeks tertiary Wandsworth operates a complex rehabilitation service at Queen Mary s Hospital. Cost per bed day: 546 Average length of stay (days) 89 Average cost of rehabilitation package 48,594 Waiting time for entry (days) 16 PCT s may refer some of their most difficult rehabilitation cases to The Royal National Hospital for Neuro-disability in Putney. Cost per bed day: 500 Average length of stay (days) 315 Average cost of rehabilitation package 157,500 Waiting time for entry (days) 10 (after funding decision is reached) Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 20 of 99 Final Report

21 The standards that apply to the Voluntary sector 15 and our assumptions regarding these services are set out below: Table 5: Voluntary Sector Standard Standard Description Assumption Applied Number 1 All clients are contacted within 2 weeks of referral An SLA will be in place with an external body to achieve all three standards set out for the Voluntary Sector and that all clients discharged from hospital following a stroke/tia will be entitled to receive this service. 2 All locations with commissioned activity have a comprehensive set of standards and information about services offered Part of standard 1 3 Outcomes are recorded for every patient who has accessed voluntary services as part of their stroke care Part of standard 1 Table 6: Voluntary organisations currently provide services to the following South London boroughs: Borough/PCT Current status Family and Carer Support Hours per week Communication Support Hours per week Croydon Stroke Association SLA in place & further bid submitted 25 hours 25 hours Greenwich Stroke Association SLA in place 125 hours 45 hours Lewisham Stroke Association SLA in place 40 hours 35 hours Kingston Stroke Association SLA in place 30 hours Merton& Sutton Stroke Association SLA in place 21 hours Richmond and Twickenham Stroke Association SLA in place 17.5 hours Wandsworth Stroke Association SLA in place & further bid submitted 25 hours for Family & Carer Support Bromley White Gables and MindCare SLA s in place Day Care and Respite places Day Care and Respite places Bexley Different Strokes Voluntary support Drop in centre with carer support Lambeth Dazzle Volume unknown Southwark Stroke association SLA in place Volume unknown A typical baseline service of 35 hours will cost about 47,000 per annum. Voluntary sector organisations all noted the difficulties patients and their families encounter in signposting understanding what community services are available, where and how to get access to these. 15 Appendix I Performance Standards for Rehabilitation Page 56 Stroke Strategy for London Healthcare for London Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 21 of 99 Final Report

22 Review of PCT Stroke Commissioning Plans In a number of cases, PCT s and Local Authorities provided us with documents that are not available for wide circulation as they are still in draft form or are commercially sensitive. We have referenced these documents as a source of information but, as agreed, have not incorporated them into the compendium of documents. We have listed these as confidential in the report. Bexley Care Trust We reviewed the: Draft Adult Strategy Draft Older People s Strategy Contract for Community Therapy Services Adult Services Community Services Therapies Outcomes required Annual Report 2007/8 Strategic Commissioning Plan Stroke is identified as the number one priority for the Care Trust. The Strategic Commissioning Plan sets Stroke as the number 1 priority for the Care Trust and describes the development of the strategy: This clinically led process with informed patient engagement has led to the development of a comprehensive stroke strategy which both responds to the challenges of Healthcare for London and meets the needs of the local population and that has described the establishment of a vertically integrated virtual directorate which will involve clinicians from the community and acute settings in a way which means that patients will be better able to move between elements of the care pathway in an easy and effective way. This flexibility was described by patients as a priority in all healthcare settings, especially those associated with long term conditions. Significant work is being undertaken in the field of Stroke including the establishment of TIA clinics which are already having positive benefits. It is recognized that Stroke and other vascular conditions have a higher prevalence in Bexley compared to many other London Boroughs, in part this is due to the ageing population locally as well as higher rates of hypertension and other contributing factors. In addition to the work associated with stroke care there are also programmes of work including a community cardiology service which has recently been recognised for a national award, and will be further rolled out in the early years of this CSP. These clinically focussed activities are also supported by a developing focus on prevention and promotion which will be primarily delivered through primary care settings but will be developed in conjunction with patients and the public to ensure that the messages are appropriate and accessible for all communities within Bexley. In our view, the Plan and associated documents set out a plan focused on improving the services to stroke patients. However, details of the Early Supported Discharge programme and the method and funding for increases in therapy and community nurse staffing levels to achieve the standards for Community Rehabilitation are not clear 16. To achieve the Gold Standard, Bexley would need to invest about 792 K in staffing. 16 Appendix I Performance Standards for Rehabilitation Page 55 Stroke Strategy for London Healthcare for London Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 22 of 99 Final Report

23 Bromley PCT Bromley undertakes a wide variety of services for people who have suffered a stroke. We reviewed the: Table of services contracted by the PCT Acute Bed Utilisation and Capacity of Care nearer to Home in Bromley Draft November 2008 (Confidential) Bed Utilisation Review Survey Findings, Bromley PCT (Confidential) PCT Strategic Plan PCT Financial Strategy To 2012/13 Stroke and cardiovascular disease prevention are defined as key service priority areas in the Strategic Commissioning Plan. The plan notes that A selection process is underway for hyper acute stroke centres which will provide the initial acute intervention for stroke patients. Again Bromley Hospitals will form part of a clinical pathway that ensures that the acute part of the treatment takes place in an expert centre, recovery takes place more locally, and rehabilitation takes place as far as possible in the community. The strategy goes on under Goals 3 and 5 to suggest that the PCT needs to Improve outcomes, for example, by improving the care pathway for stroke, may help to prevent stroke occurring (faster access to TIA services), but also reduce disability and death (fast access to diagnostic services enabling faster intervention when appropriate, and improved rehabilitation services). In 2009/10, 210 K is set aside to implement the whole range of stroke related priorities with a further 269K in 2010/2011. Investment peaks over these two years and then declines to the end of the strategic term. We have been unable to identify whether this funding relates strictly to community services or to acute services. We estimate that about 1,356 million, additional staff, is required to meet in full the Gold Standard 14. The finances set out in the strategy are insufficient for Bromley to meet the standards set out by HfL. The recent Balance of Care study reviewed clinical coding. This study concluded that some stroke patients were not initially admitted to the Stroke unit. It also noted that some patients on the Stroke Unit at PRUH did not have a verified primary diagnosis of stroke - code I 60- I 69. There is no evidence of a detailed Stroke Implementation Plan in any of the documents reviewed. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 23 of 99 Final Report

24 Croydon PCT We have reviewed the following documents: Enhanced stroke specification Annual report 2006/7 Croydon PCT Strategic Commissioning Plan Croydon PCT response to Health Care London on Stroke 2008 The commissioning strategy sets on providing care closer to home, including stroke as: Goal 3 Care closer to home By 2013 we will have models of care and deliver services designed around the needs and preferences of local people, which provide services closer to home where possible and centralised where necessary based, on quality and expertise. Summary of the case for change Acute hospitals should be places where people go when it is necessary, not as a matter of routine. There, therefore needs to be a fundamental shift to provide care geographically closer to home where quality, safety and value allow whilst grouping services to ensure timely access to specialist expertise as necessary. Experience of remodelling pathways of care by improving access and expertise in primary and community care has allowed the removal of unnecessary steps and has improved patient satisfaction while delivering best practice and best value. The PCT is seeking to invest in 4.8 million in the initiative over the next 5 years. This investment covers all of the initiatives listed as Urgent Care within Goal 3 in the SCP. The Enhanced Stroke Strategy dated 2008 sets out the development of: The Community Stroke Team including two stroke association posts The Rapid Access Transient Ischemic Attach (TIA) Clinic Addition medical services/health care assistant within Mayday to support fast track services from A&E to the acute stroke unit and delivery of the TIA clinic The Integrated Community Intermediate Care Service Additional diagnostics services (CICS) will work in partnership with the Community Neuro- Rehabilitation Team (CNRT) to provide the Community Stroke Service. There will be no waits between different elements of the service to ensure smooth transition for patients along the pathway. Much of this pathway appears to have been implemented although some areas await the appointment of a new Stroke Rehabilitation Coordinator based at Mayday. The Annual report for 2007/2008 notes: A stroke service pilot scheme for people in Croydon and the other PCT areas in south west London started in January 2008, initially for three months. The pilot service aims to meet the Gold Standard for urgent stroke care, with these key components: Rapid admission to a stroke unit and then on to stroke rehabilitation Urgent access to 24-hour stroke diagnostic services for immediate CT scan and clot-busting treatment within three hours, if appropriate Rapid referral to a one-stop mini-stroke (transient ischemic attack or TIA) clinic Early support to discharge teams The five south west London PCTs commissioned St George s Hospital, Tooting, as the hub that provides access to specialist treatment 24 hours a day. The other hospital providers in Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 24 of 99 Final Report

25 the area Mayday, St Helier and Kingston provide spoke stroke services from 8.30am 4.30pm, Monday Friday. It means that at weekends and between 4.30pm and 8.30am any stroke patient who is attended by an ambulance in south west London will be taken to the stroke service at St George s Hospital, where there are specialists who can give appropriate treatments. The pilot scheme the first in any of the London areas has been designed to improve access and quality of services for patients. It is about getting people to the right hospital quickly so that everyone suspected of having a stroke will benefit from urgent care by a specialist team. We estimate that about a further 572 K and 9.63 staff are required to meet in full Community Rehabilitation Gold Standard Greenwich We reviewed the following documents: Contract: Greenwich Teaching Primary Care Trust and Stroke Association Service Specification: Family and Carer Support and Health Promotion Services, Greenwich PCT Service Specification: Communication Support Services, Greenwich PCT Business Case to support Early Supported Discharge in Greenwich: Stroke Services, Greenwich PCT Service Level Agreement: Bevan Unit, Greenwich PCT Commissioning Strategy 2007/8 to 2011/12: Greenwich PCT Annual Report Greenwich PCT 2007/8 The Commissioning strategy identifies the PCT s intent to improve Intermediate care as follows: Nurse run with input from the patient s own GP. Increased capacity is required to serve a rising elderly population and wider range of conditions to be treated outside hospital. More convalescent/ recuperative type care where rehabilitation may not be the key determining criteria for admission but where further nursing, therapy (non rehab) and social support and assessment is required to prevent too early admission to long term residential care. GPs, Community Matrons, Nurses, Social Care & Allied Health Professionals can admit patients to the beds for short term management, medical and Multi-disciplinary assessment or therapies including e.g. re-hydration, blood transfusions and antibiotics for exacerbations of long term conditions or prompt management of UTIs and cellulitis. The unit would provide Rehabilitation post stroke providing early hospital discharge in line with the Stroke Strategy for Greenwich and reflects the objectives in the clinical case for change in DH Mending Hearts & Brains Dec The PCT has developed a business case for the implementation in 2009/10 of an EDT and other services to support early discharge and rehabilitation in community as follows: Both Lambeth and Southwark PCT s have successful early supported discharge services in place. The model we propose is most closely aligned to that of Southwark. We wish to build on the success of the Intermediate Care at Home Team to encompass stroke rehabilitation. This team work with Support Staff (previously home care staff), training them in health and social care competencies. They work under the supervision of rapid response nurses and therapists delivering a rehabilitative model of support. Their interventions are 7 days a week gradually reducing input as people improve. In order to take on early supported discharge there is a need to: Increase numbers of Intermediate Care at Home support worker staff to ensure they are able to deliver care in response to individual need. Based on an estimate of 4 new clients per month on average, we would need an extra 60 hours. This allows up to 6 hours per day face-to-face contact time that can be allocated to clients according to need. Average contact times currently stand at one hour for the morning visit, and half an hour for lunch, tea and bedtime visits. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 25 of 99 Final Report

26 Train all Intermediate Care At Home staff to deliver stroke rehabilitation Senior therapists in the community rehab team and rapid response have met to consider the existing competencies of support worker staff and plan for appropriate high quality information and training in line with national stroke strategy recommendations that will allow non-specialist staff to deal more effectively with people who have had a stroke. Training will consist of an initial introductory day of training (a recognised course provided by the Stroke Association), followed by specific local training in each of the specialised areas (another full 3 days). Have access to a therapist for directing the rehabilitation The post will be a full time senior physiotherapist (band 6) and will be based at memorial hospital as part of the community rehabilitation team. The rationale for placing the therapist within the community rehabilitation team is for specialist clinical support, cover, supervision and training. The individual in this role will work across Rapid Response, Community Rehabilitation Service, and Intermediate Care At Home, and will act as a key communication link between the 3 teams. Have access to a care manager/assessment officer Currently there is a care manager placed with the Intermediate Care At Home Team on a temporary 6-month contract. This is under review and likely to be extended. In order to ensure delivery of the early supported discharge service we would need ongoing funding for 0.25 care manager/assessment officer for the duration of the service. Detailed staffing and funding proposals are included in the proposal. These do not, however, fully address the quality standards with respect to each of the three paramedical professions each delivering 3 hours and 45 minutes of face-to-face contacts within the ESD. The costings in the proposal allow for about 150K per annum whereas to fully meet the Gold Standard would cost some 520 K, additional staff. Kingston PCT We reviewed: Annual report 2007/8, Kingston PCT Strategic Commissioning Plan , Kingston PCT Objectives, Kingston PCT Admissions and Length of Stay for Stroke clients in 2007/8 and 2008/9 to month 10 In its section on World Class Commissioning, the Strategic Commissioning Plan does not rate Stroke as having a top-level priority. However, the report sets the following goals with regard to Stroke: Implement revised Transient Ischemic Attack (TIA) pathway providing rapid diagnostic assessment and access to a specialist within 24 hours for high risk patients and 7 days for low risk to be put in place across the sector. (H4L designation process will end in March 2009). Review evaluation of stroke service pilot and work with providers to adopt appropriate model of service Develop model of local stroke rehabilitation service. Establish local service. The commissioning strategy notes: Any permanent changes to patient pathways will need to go to full public consultation, and be considered by the relevant Borough Council Health Overview and Scrutiny Committees. No permanent service change can be made until the outcomes of Healthcare for London are finalised (Possibly not until Jun 2009). Our current direction for stroke services is considered to be based on the SWL strategic context as far as possible. Goals and objectives will be revalidated once the final HfL recommendations are published. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 26 of 99 Final Report

27 The prov ider unit at NHS Richmond provides the Neuro-rehabilitation for acquired neuological conditions in Kingston under an SLA. No ESD service is currently available. When we discussed this with a Kingston PCT representative, we were told that stroke is part of the overall CVD strategy. The Financial Strategy sets aside 410K in 2009/10, 559 K in 2010/11 and 648 K in 2011/12 for additional stroke services. We estimate that about 978 K pa would be required to fully meet the HfL Quality Standards. Lambeth PCT We reviewed: Annual Report: Lambeth PCT Five year commissioning strategy: Lambeth PCT Business plan : Lambeth PCT Establishing the current cost of stroke relating to rehabilitation & community care in PCT s; Healthcare for London proforma Community Therapy activity data: 2007/8 CONFIDENTIAL: Economic Model: Summary of outcomes. Eden McCallum Limited and Internal presentation CONFIDENTIAL: Economic Model to support Phase 3 of the Stroke Modernisation Project, Lambeth and Southwark, Eden McCallum Limited One year summary of Lambeth stroke patient discharges Costings: ESD services Lambeth Performance against community outcome standards Lambeth Rehabilitation service for Stroke Guidance for hospital staff Lambeth Stroke Services for Hospital Discharges Finance and Activity Report Model 1 Lambeth has been part of a substantial piece of work carried out through the Modernisation Initiative. It therefore has a significant volume of very detailed data upon which to plan and to evaluate its services for clients who have had a stroke. The annual report discusses the substantial improvements already made in respect of length of stay and waiting times for people with a stroke. The in-house evaluation of compliance with the community standards shows that the PCT is already close to achieving many of the standards. Those areas that appear to be weakest relate to goal setting, second stage cognitive assessment and vocational rehabilitation. In spite of the significant progress in Lambeth, substantial increases in stroke specific staff spending are needed to meet in full the Quality Standards. These would be circa staff at an estimated cost of 971 K per annum. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 27 of 99 Final Report

28 Lewisham PCT We have reviewed: Commissioning Strategy Plan: Lewisham PCT Report of Joint Strategic Needs Assessment and PCT Commissioning Strategy Plan engagement event held on 20th October 2008 Long term condition strategy: Lewisham PCT Operating plan 2008/9: Lewisham PCT Integrated Care Pilot Programme Stage One Application Lewisham PCT The Stroke Care Pathway in Lewisham: Review of Stroke Services Lewisham s Commissioning Strategy identifies stroke as one of the top 7 priorities to be addressed. The Review of Stroke Services in October 2008 identified the following gaps in service: Need for psychological support research evidence shows that up to one third of stroke patients and/or stroke families benefit from psychological input Need for local education regarding the Stroke unit Need for more proactive and dedicated social work support Multidisciplinary team meetings clear aims and objectives Patients already seen while in LINC keep their Speech and Language therapist not so physiotherapy or occupational therapy The physiotherapy team currently meet 56% of their targets for assessment following referral. Physiotherapy team report spending a good deal of their time to case managing patients, particularly seeking funding for equipment rather than on direct patient contact. Stroke patients referred directly to LATT for SALT, for help with communication must wait four or more weeks prior to being seen. Problems with recruitment locally currently 1.5 posts unfilled. Communication support group. Funded until recently by PCT. The PCT Operating Plan notes: Lewisham PCT have commissioned through an external consultant a project to identify strengths and weaknesses in our current stroke pathway, to set up appropriate data monitoring systems aligned with the Sentinel stroke audit and agreed criteria across London, and to formulate and progress an action plan for those areas which will predominantly remain single PCT issues such as rehabilitation and transfer into the community. This project began on January 20th and will report at the beginning of June. It will report specifically on areas of the national strategy post stroke e.g. the business case for specialist stroke rehabilitation outside hospital. In addition Lewisham PCT will be working with NHS London to plan and deliver areas to be agreed by the acceptance of the Lord Darzi report. This is likely to impact on improving early scanning and thrombolysis in a hyper acute setting in highly specialist units within London. The exact citing of these services will require APOH resolution of acute services. It has been agreed that the current Sector wide Cardiac Network will now expand its role to include Stroke thus meeting the needs of the National Stroke Strategy. Lewisham PCT has undertaken a bed usage audit including the stroke unit, and Intermediate care, which will identify appropriateness of placement of patients. Primary care Audit work in the last year has assessed anticoagulation for those with atrial fibrillation in 50 of 51 general practices. Trajectories have been set for increasing access to acute stroke beds to 72% by March 09, and improved access to scanning within 24 hrs and provision of services to support TIA to 50% by March 09. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 28 of 99 Final Report

29 The Stroke project will be using a technique called systems dynamics modelling to identify where bottlenecks and excess capacity exist in the patient pathway. The project will also be working to define key indicators and embed them in the system in order to give routine performance management, in line with the Sentinel audit, National Clinical Guidelines for Stroke, the London Commissioning intentions and the trajectories submitted to us. These have already been flagged for preparation with our hosting acute services as part of the SLA process. Quality monitoring through a quarterly review meeting have also been planned and agreed with UHL. Currently additional resources of have been allocated to undertake the initial project set up and moving forward towards a stroke network. The resultant Lewisham stroke strategy plan will continue to include actions needed to deliver on the Sentinel audit findings for Lewisham in 2006 (e.g. improving the proportion of time people spend on a stroke unit versus other areas of the trust; improvements in targets for brain imaging). These improvements have been mapped in the stroke trajectories submitted. Lewisham has submitted a bid under the Integrated Care Scheme but the result of this bid is not yet known. Currently, managers in the PCT acknowledge that the Trust is unlikely to achieve the 2010 Quality Standards from HfL and the Stroke Strategy. No detailed costings are available from the PCT for implementing their strategy and an unbundling exercise is currently taking place to clarify costs associated with Stroke care. Our review indicates that an additional 804 K will be required for staffing in Lewisham to achieve in full the Gold Standard. Richmond and Twickenham We reviewed: Commissioning plan 2007 Annual health check September 2008 Health Newsletter Service specification for Community Health Service Despite lower than national levels of prevalence of stroke in the local population, Stroke care is put as Initiative number 1 in the Strategic Commission Plan. There is currently no ESD. The plan indicates that the PCT expect to achieve the quality targets from 2010 onwards. The strategic commissioning plan sets out four broad objectives: To improve primary prevention such that there is a reduction in the annual incidence of strokes. To commission local TIA one-stop clinics and develop appropriate clinical pathways for referral and treatment. To work with commissioners and providers in both Southwest and Northwest London to develop acute stroke units to ensure access to diagnostics and, where appropriate, treatment within 3 hours of onset of symptoms. To work with local authority colleagues and local providers to improve the quality of discharge planning and rehabilitation in order to reduce lengths of stay in both acute and rehabilitative units. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 29 of 99 Final Report

30 The PCT intends to review and then commission stroke services in line with best practice as determined by A new ambition for Stroke (DoH 2007) and Mending Hearts and Minds (DoH 2006). Specifically: 1 Primary Prevention: a) We will develop a public education campaign highlighting the preventative measures that help reduce likelihood of strokes. b) We will review existing compliance with NICE guidelines as they relate to hypertension, atrial fibrillation and the prescribing of statins and QOF results around stroke risk factors such as Hypertension and diabetes. c) We will appoint a PEC nominated lead GP to implement the recommendations of the review in relation to both NICE guidelines and QOF results. 2. Emergency Care: a) We will work as part of the SWL CCI to develop 24/7 acute stroke services. In the first instance this will take the form of commissioning in-hours services from Kingston Hospital and out-of hours services from St. Georges Hospital, Tooting. b) We will work with non-swl providers, specifically the West Middlesex Hospital and the Hammersmith Hospital to develop 24/7 acute stroke services, as these account for 50% of our existing stroke activity. c) We will undertake an option appraisal of the viability of developing community-based TIA clinics at Teddington Memorial Hospital and Queen Mary s, Roehampton, including a review of usage of the existing TIA clinic provided at the West Middlesex Hospital. d) We will include the outcomes of the review in 2009/10 Commissioning Intentions e) We will work in conjunction with our two local acute providers: Kingston and West Middlesex Hospitals, and the PCT community services provider to develop and then commission early supported discharge teams. 3. Rehabilitation: a) We will establish a multi-disciplinary project group to review existing rehabilitation services, and ensure that local authority social services representatives are fully engaged in the review. b) We will work as part of the SWL CCI to ensure that the timescale for the implementation of proposed changes to acute services is aligned with the review and development of rehabilitation services. c) We will incorporate the recommendations of the review into PCT Commissioning Intentions for 2009/10. d) We will appoint a PEC nominated lead GP to chair the review group. Their plan costed the changes required at 2006/7 prices to be on the order of 210K. Our model indicates that the costs to achieve 100% Gold Standard would be about 425 K. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 30 of 99 Final Report

31 Southwark PCT We have reviewed: 2008/9 Operating Plan Annual report 2006/7 Commissioning Strategy Plan 2008 to 2013 Annual report 2007/8 Southwark integrated stroke pathway hospital discharges Southwark integrated stroke pathway service description Social care Savings arising from ESD Performance standard compliance community rehabilitation Proposal to enable ESD support in Southwark Changes to the structure of Neuro-Rehabilitation in Southwark Individual client costs Intermediate care unit details Getting the most out of life Services for Older People Southwark PCT and London Borough of Southwark Southwark participated extensively in the Modernisation Initiative work on Stroke, using nonrecurrent monies to develop ESD and community services. There is already a very high standard of service in the PCT with regards to stroke. There are proposals to extend this funding and to develop further community services so that the rehabilitation team based at Dulwich hospital can continue towards meeting in full the Gold Standard. There are excellent links with the Stroke Consultant from Kings who attends the site and holds a clinic there, as well as supporting the rehabilitation team. There are currently only 5 working with stroke and additional resources are required to meet to total set of standards. To meeting full the Gold standard, we estimate that additional staffing costs of some 654 K would have to be met on an ongoing basis. Sutton and Merton We reviewed: Specification for Community Neurological Rehabilitation Service - Sutton & Merton PCT Service Initiatives - Sutton & Merton PCT Operating Plan - Sutton & Merton PCT Commissioning Strategy - Sutton & Merton PCT Key stroke initiatives in Sutton and Merton are: Increase Allied Health Professionals in community rehabilitation Establish an ESD team Establish exercise prescription programme Establish counselling and disability management services Commission Vocational Rehabilitation to HfL standards Increase Allied Health Professionals in secondary care Establish Communication Support Groups Specialist Stroke training for all staff Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 31 of 99 Final Report

32 The strategic commissioning plan sets out, under Goal 1: The Stroke CCI focuses on two areas: Sector-wide common pathways developed for acute stroke & TIA that are linked to measurable outcomes in primary care and secondary care through the collaborative commissioning arrangements. Implement a sector-recommended model and framework for commissioning primary and secondary stroke prevention services & community rehabilitation according to good practice (diagnosis, recall, maintenance, crisis and end of life care services). The PCT is working through the SW London Collaborative Commissioning Initiative group to align these priorities across the sector. The commissioning plan, appendices and financial tables do not set out how these priorities are to be achieved. We estimate that the costs of meeting the Gold Standard will be about 1,293 K. Wandsworth We reviewed: SW London Neuro-Rehabilitation Review, Final Report , NHS London Healthcare for London: acute stroke and major trauma services in London, report to PCT Board Strategic commissioning intentions The Commissioning Intentions states: The Healthcare for London Stroke Project has been established to develop and deliver a pan-london Strategy for the stroke pathway. A fully integrated pathway from prevention to acute care followed by community discharge/care and rehabilitation with associated Performance standards are planned for completion by The model for acute care will be based on the development of Hyper-acute stroke units (HASUs), receiving patients suspected of having a stroke. Here patients will have rapid access to diagnostics and receive high dependency care for the first 72 hours. After this time patients will be transferred to a Stroke Unit (SU), which may be on the same or another site. Patients who have a Transient Ischaemic Attack (TIA) require specialist diagnosis and monitoring; centralised and decentralised care needs to be improved. The number and location of HASUs, SUs and TIA services will be determined following a designation and consultation process, to be completed spring This will allow for implementation to commence during 2009/10. The PCT will commission sufficient, appropriate intermediate care capacity in 2009/10 to support the development of the care pathway to prevent avoidable hospital admissions and to facilitate early discharge and rehabilitation where clinically appropriate. The PCT will commission intermediate care services in the expectation that services are increasingly joined up with associated health and social care services. During 2008/2009 The PCT hosted a SWL sector review of neurological rehabilitation services. The final report of the review was received and endorsed by SWL PCTs in Autumn During 2009/10, the PCT will commence implementation of the review recommendations and action plan. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 32 of 99 Final Report

33 The Operating Plan sets out: Stroke: driving up standards of care to reduce mortality and morbidity through implementation of the Stroke Strategy The PCT is progressing work towards its stroke priority for 2008/09. The PCT is currently working with all acute providers in South West London and the London Ambulance service and in particular with St George s Hospital in Tooting, as its lead commissioner, to pilot the service package and develop quality standards to deliver improvements in stroke services for the people of Wandsworth, as well as across the sector. A clear direction for the development of acute stroke and emergency management of TIA has been set for 2008/09 to improve people s outcomes and reduce the number of serious strokes, based on the national stroke strategy launched in December The PCT estimates 100 additional people to be seen St George s Hospital in 2008/09 as the 24-hour, seven-day week unit for the sector. A quality and performance framework has been agreed, including outcome and patient metrics for the pathway. The PCT will also be setting out plans in 2008/09 to improve care and support needed after stroke, looking at stroke-specialised rehabilitation within hospital, immediately after transfer to home or care home and for as long as it continues to be of benefit as well as end of life care, whether in the hospital or in the community. Further details are set out in the end of life care and intermediate care sections of this document. The PCT has in place a robust evaluation programme for the acute stroke pilot. This includes evaluating the service change from the patient and staff viewpoints The Neuro-Rehabilitation report, work for which was led by a member of Wandsworth PCT, sets out in some detail the current face of services in SW London and needs for the future. However, this report focuses on Neuro-rehabilitation as a whole, of which stroke represents about 23% of the workload. A proposal has been submitted internally to support the development of an ESD and a wider rehabilitation service costing a further 464K. We estimate, based on its current staffing and excluding the recent proposed developments, Wandsworth would need to spend an additional 702 K on stroke services alone to achieve in full the Gold Standard. Summary of strategic and operational plans As shown in the tables below, no PCT has set aside sufficient funds with which to achieve either the Gold Standard of performance or the minimum standard. This arises for the following reasons: 1) The London Stroke Strategy assumes that all stroke patients discharged from hospital will receive community rehabilitation designed to meet all standards. 17 2) The London Stroke Strategy, Community standard 7, requires the input of 3 hours and 45 minutes of face-to-face contact time from each of Occupational Therapy, Physical Therapy and Speech Therapy. This means an input of hours of face-to-face contact with each client in his or her own home. 3) Staff will need to travel to the patient s house. Travel time for 5 visits per week for each professional will be needed. We have estimated an allowance of 75 minutes per visit. 4) We have assumed that the ESD element will last for 6 weeks. 5) To achieve the ESD standard will require a total staffing input of 180 hours per patient discharged into the programme over a 6-week period. 17 Page 33 Stroke Strategy for London, Healthcare for London Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 33 of 99 Final Report

34 6) We have assumed that 50% of the patients discharged following a stroke would require ESD care, 1,444 patients. 7) In addition, standard 7 requires a further 135 minutes per week per profession for a further period of 4 weeks for ESD patients as well as for all non-esd patients. This standard will require the input of 54 man-hours for every stroke patient discharged from hospital a total of 2,887 patients. 8) The proposals developed by PCT s underestimate both the time required per patient but also the number of patients expected to enter into ESD s. We expect that, on average, each ESD will have to treat 131 patients per year. The current or planned - capacity of most ESD s is about 36. Therefore, to cope with the workload envisaged by Standard 7, a substantial increase in staffing and cash will be required in each of the 11 PCT s. The cost of this increase is, in large measure, compensated by savings arising from the introduction of effective ESD programmes reducing hospital length of stay and readmission rates 18. We do not consider that this staffing need has been fully addressed in any of the plans developed by the PCT s. Table 6: Additional staff required: Gold Standard Our modelling indicates that additional number of staff required to achieve the Gold Standard of performance on all Community Rehabilitation standards is: Pages 35, 36 and 41 Investment Case: Stroke Strategy for London Healthcare for London 19 Appendix I Performance Standards for Rehabilitation Page 55 Stroke Strategy for London Healthcare for London Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 34 of 99 Final Report

35 Table 7: Additional staff required: Minimum Our modelling indicates that additional number of staff required to achieve the Green Standard of performance on all Community Rehabilitation standards is: 22. Gap Analysis Based upon interviews in and our review of plans within each of the 11 PCT s, we consider that a number of gaps in service exist. These gaps will hinder achievement of the performance standards set out in the London Stroke Plan for both community rehabilitation and the voluntary sector. Only four of the 12 Local Authorities have participated in interviews concerning the services that they provide. Therefore, we have had to use documentary evidence published within Borough s to identify the services they provide. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 35 of 99 Final Report

36 Good Practice Examples Those PCT s that we consider to be furthest forward in their implementation of an effective community Stroke service are Croydon, Lambeth, Southwark and Wandsworth. In each of these, there is evidence of good practice that should be built upon in the other PCT areas. These good practice items include: Base a stroke consultant for at least one session per week at the community rehabilitation/intermediate care base. In Southwark, this leads to benefits for both patients and staff Implement detailed workload measurement studies to inform the design of local services. In Lambeth, these studies have provided comprehensive and detailed evidence of cost, benefit and manpower needs. These studies will provide evidence upon which to establish the effectiveness of new stroke services. Build on the skilled Neuro-rehabilitation teams within the PCT and use expert clinicians to drive forward new services Wandsworth. Use creative commissioning to obtain new services to exacting specifications from the independent and voluntary sectors. These sectors can fast track new developments, bringing a completely new service on stream in less than six months. Public sector capital and revenue constraints often mean that the same development would, if carried out in house, take several years to implement. Croydon has used this approach to obtain part of its intermediate care service. Summary of gaps and priority areas We have reviewed the gaps identified to determine where the South London Cardiac and Stroke Networks might best focus their effort to secure full delivery of the Community Rehabilitation and Voluntary Sector Standards. With the exception of two PCT areas, SLA s are already in place with Voluntary Sector organisations and should, if continued, ensure delivery of the three Voluntary sector standards. We consider that those PCT s without an existing contract should be encouraged to immediately establish an SLA with a voluntary sector organisation. Completion of this task should then be monitored by the SLCSNs. One gap area offers the greatest potential for benefit realisation: introduction of Early Supported Discharge (ESD) programmes in those PCT s without one and expansion of the programme in every other PCT. Based upon the costing studies carried out as part of the work by the Modernisation Initiative in Lambeth, it was demonstrated that ESD programmes reduce acute hospital length of stay by between 9 and 10 days on average. 20 Across the group of 1,450 patients identified as potential entrants into the ESD programmes this would save between 13,000 and 14,500 acute bed days per annum with a value of between 4.2 and 4.7 million. These monies could be used to offset, in part, the increased rehabilitation staffing levels required to deliver all 10 of the Community Rehabilitation standards. 20 What is Early Supported Discharge? (ESD), Modernisation Initiative Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 36 of 99 Final Report

37 The SLCSNs will need to devote a considerable amount of time and effort to: assist PCT s to find funding for the additional staffing resources develop efficient strategies with which to recruit the large numbers of staff required validate with Acute Hospital Trusts the bed-day savings generated secure the release of the benefits and transfers of funds to the PCT to fund the increases in staffing monitor the implementation of these new services and in particular to take action to ensure that performance standards are in practice achieved We consider that the workstream leader for SLCSNs needs a strong track record working across the public and private sector, Acute and Community services as well as ability to lead benefit realisation projects and workforce engineering. The development of these new Stroke specific ESD and Community Rehabilitation teams should also lead to a rapid reduction in waiting times and fully support the prevention work being undertaken elsewhere in SLCSNs project streams. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 37 of 99 Final Report

38 Table 8: Gap Table by PCT PCT/Area ESD Adequate staff for Community Rehab Bexley No - proposed No short 17, No weekend rehab services Bromley No - no formal plan No short 25, no stroke specific rehab Croydon Yes No short 23 but good private sector links, no W/E therapy Greenwich No bid in No short of 11 8 new intermediate beds in 2011 SLA with Voluntary sector Voluntary only + day centre Different strokes SLA White Gables & MindCare Yes - Stroke association Yes stroke association Detailed plans to deliver all standards Psychological support services Vocational Rehabilitation Waiting Times No No No referral 1 week new referrals No No No referral Can be extended due to lack of resources Plan not yet available Yes but inadequate funding No Wolfson Unit No involved in MDT Inadequate Limited service 2 weeks from referral for new referrals Unknown Wolfson Kingston No No short 20 Yes Stroke Association No No Referral to Lambeth Yes No short 20 No. Dazzle used locally Yes but No Referral Wolfson underfunded and Roehampton Lewisham No not planned No short 17. Bid submitted for Integrated Care Richmond & Twickenham No ESD but Neuro-rehab team provide support No short 10 to service own workload Southwark Yes capacity 71 No short 14. No dietician, issues with Pharmacy Sutton & No No short 22 Merton Daytime M-F service Wandsworth No due to start No short of 15 9/09 Yes Stroke Association Yes Stroke Association Yes Stroke Association Yes Stroke Association Yes Stroke Association No plan in place Yes but underfunded No Also lacking dietician Referral Location of services Patient s home Patient s home Patient s Home Patient s home Patient s Home 3 days Patient s home 12 week SALTs, Urgent swallowing 48 hours No Referral 1 2 week, 4 6 week wait for slow stream care Yes No - Funding terminated Referral No No To be commissioned Yes but underfunded None participate in MDT s Patient s home Patient s home, Rehab Unit, Day Care Centre Patient s Home 2 weeks Patient s Home Home & Gyms No Referral Up to 7 weeks due to lack of ESD Local Authority Involvement Integrated Care Trust - split services Joint commissioning appointment Said to be good no contact Limited No Yes but interface issues Good linking Some linking No links Variable links No Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 38 of 99 Final Report

39 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 39 of 99 Final Report

40 Other issues There are several issues, mentioned in each interview, which might impact on the successful implementation of the new London Stroke Strategy. Information systems Information systems in the NHS use one or more medical diagnostic codings systems (ICD 9 /10, HRG short or extended or Snomed for example) to classify and group patients. None of the Social Services systems allow for the use of a diagnosis or diagnostic code as they are all based upon social needs. The only method of tracking an individual within both systems is by the Surname and address. This is a notoriously unreliable process because of the potential for misspelling and incomplete data entry. It is virtually impossible for Social Services departments to extract the number of clients who have had a stroke or TIA to whom they provide a service. This data is simply not stored. One cannot the obtain a complete picture of the full care pathway for an individual from the point of referral to hospital by the GP until that person returns home and no longer requires a service. This means that full costs and the potential to achieve savings throughout the entire pathway cannot reliably be estimated. Discharge team meetings In each acute hospital, frequent discharge meetings monitor the progress of patients toward discharge. Representatives of both the community health services and the local authority attend these. Significant numbers of patients are admitted to hospitals outside of the Borough in which they live. This is likely to increase as patients are transported to the new designated Hyperacute units. The result would be that Social Workers and community rehabilitation representatives would have to attend several meetings in different hospitals to monitor progress on people from their own area. SLCSNs may be well placed to facilitate inter-authority working so that PCT/LA workers attend each discharge meeting from only one Borough/PCT. They would then disseminate the information on patient progress to their colleagues in each of the Borough s where the patients live. Adaptations Our local authority interviews indicated that home adaptations to make the stroke patient s house acceptable as a rehabilitative environment can often take some time to effect. In one authority, this was said to be because of the time to obtain a means testing assessment. Another authority indicated that their own and contracted works departments were unable to carry out works within the timescale required by the patients imminent discharge from hospital. In some cases, patients were referred into a long stay independent sector bed to await the completion of works on the house. Total package funding A number of interviewees expressed concern that the funding for patients within the Stroke pathway was fragmented between Acute Hospital Trusts, PCT s, Voluntary Sector and Local Authorities. This means that it is more difficult to effect resource changes between services because of the need to go though multiple management and Board structures before change can be implemented. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 40 of 99 Final Report

41 Recommendations South London Cardiac and Stroke Networks 1. We recommend that ESD programmes are introduced in each PCT area and that these are designed and resourced to provide in full the 3 hours and 45 minutes contact time specified from each of the three paramedical professions to 50% of those patients discharged from hospital following a stroke/tia episode. 2. We recommend that each PCT have in place a formal SLA with a voluntary sector provider to supply either Family and Individual Support or Communication or both. 3. We recommend that Good Practice identified in certain PCT s should be considered by each PCT for local introduction: a. base a session of a stroke consultant in community settings b. introduce detailed workload measurement to inform service design c. build upon existing Neuro-rehabilitation teams using expert clinicians to drive forward new services d. use creative commissioning to obtain new services from other sectors and fast track new developments. 4. We recommend that PCT s consider alternative strategies to deal with the numbers of staff required including: a. Link with educational establishments to provide additional stroke specific training to generic healthcare assistants who would work under the direction of expert Physiotherapy, Occupational Therapy and Speech and Language therapy professions to deliver stroke rehabilitation services b. Commissioning from the Independent and Voluntary sectors new top quality rehabilitative services located near to the patient s home to be implemented within the next six months and externally quality assured 5. We recommend that each PCT consider how to support the emotional and mental health needs of Stroke/TIA patients as they cope with the changes in body image arising from the initial health incident. 6. We recommend that the SLCSNs take a lead performance monitoring role, reporting direct to HfL on progress toward implementation of the Green and Gold Standards and participating in discussions on resource transfer between Acute and Community Service providers arising from the introduction of ESD programmes in each PCT. 7. We recommend that the Strategic Commissioning Plans be updated to reflect the financial implications of implementing in full the Community Rehabilitation performance standards contained in the HfL London Stroke Strategy, Appendix I. 8. We recommend that the SLCSNs review on annual basis the baseline of data set out to the back of this report so that an up-to-date and comprehensive view of rehabilitative services is maintained. Set against this background, SLCSNs should monitor progress on: a. reducing hospital length of stay b. occupancy in the Hyper-Acute and Stroke Units c. outposting of Stroke/TIA patients into non-specialist beds d. Stroke readmission rates following discharge to community. The use of these two data sets should enable SLCSNs to assess and monitor the extent to which the community rehabilitative services are successful in preventing silting up of acute hospital beds and improving outcomes for individual patients. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 41 of 99 Final Report

42 PCT Resource Tables The tables that follow are the baseline of current statistics, services, staffing resources, key local issues and service contracts for each of the 11 PCT s and 12 Local Authorities. The tables are grouped so that those PCT s in South East London are presented first followed by a summary for all of South East London. The arrangement for South West London is similar. Finally in this set, we have produced one master table for all of South London the area covered by the Networks. The staffing levels set out in these tables are those required to meet in full the Gold Standard full implementation of all performance standards set out in Appendix I to the London Stroke Strategy. To aid in finding data, we have colour coded each section of these tables: Key to colour coding Information on stroke/tia prevalence Information on the number of patients with a stroke admitted to each hospital Information on what happens to patients after discharge from hospital Information on current and future staffing needs Gold Performance Standard staffing and cost Green Performnce Standard staffing and cost Information arising from interviews on local issues in stroke care, how quality is assess, how performance is measured and future plans Gaps identified in the services required for stroke rehabilitation Information of the types of services provided in health, social care and voluntary sectors to clients who had suffered with a stroke Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 42 of 99 Final Report

43 Bexley SE London 2006 population over age ,000 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 22 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 2.31% 4, % Hospital where patients are admitted Dartford & Gravesend NHS Trust Guys and St Thomas NHS Foundation Trust Kings College Hospital NHS Trust Queen Elizabeth Hospital NHS Trust Queen Mary s Sidcup NHS Trust The Lewisham Hospital NHS Trust Total Number of strokes admitted by hospital What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital 24 40% of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Disposition of stroke patients entering hospital Unknown Discharged to long term care Thought to be high but no data available 13% of survivors will die within 1 year of discharge Office of National Statistics, based Sub national population projections 22 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 24 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 43 of 99 Final Report

44 Current number of stroke contacts (6 months data uprated to full year) 822 stroke contacts out of 6,540 total face to face contacts for the team Average of 90 contacts per FTE per month 13% of all contacts related to stroke, 25% of workload Average of about 3 visits per new patient Issues The rehab team notes patients admitted to Queen Mary s about 50% of strokes don t return to Trust for rehabilitation. There appears to be a number of clients referred to long term care rather than to Rehabilitation in the Trust Lack of a Neuro-geriatrician Trust re-organisation taking place 04/09 location and managerial attachment of the Rehab service is still uncertain potentially Oxley Trust SALT s are seconded from S S Social Services has a 7 year contact with external limited company Care Partnership Trust thought to be unbreakable 1/3 of all strokes go to Dartford, as it is only 4 miles from the edge of Bexley. Rehab post-discharge in Bexley Waiting time for new clients is one week All services are provided in client s own home Length of rehab is typically 4 5 months Capacity of the team limits the number of clients No price tariff exists Difficulty recruiting new staff and junior staff 85% of caseload is elderly 13 % of caseload and 25% of workload is related to stroke Typical length of treatment is 6 12 week. Older cases reviewed every six months Waiting time for re-referrals is 4 weeks Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 44 of 99 Final Report

45 Bexley How is quality assessed Early Supported Discharge Gaps Locally developed personalised outcome measures Monitoring and database waiting time Patient satisfaction surveys, records audits Currently no Early Supported Discharge service, ESD proposed but has not been implemented Shortage of staff to deliver the Gold Standard Lack of weekend rehabilitation services Split of the Physio, OT, SALT services between Social Services and the PCT Lack of mental health support for patients suffering a stroke Business case for Stroke is currently being developed Commissioning Strategic Plan comments about the need to develop better Stroke pathways. There is an allowance of 200K in 2009 and 270K for Stroke services Existing baseline of stroke services Provider Service Contract Volume Cost Comments Aphasia service Bexley Care Trust Day Care for aphasic clients Internal Unknown Unknown Staffed by 1 Band 4 SALT Community Rehabilitation Service Bexley Care Trust Physiotherapy and helper services only Internal Consists of Physiotherapists only Voluntary services Bexley Social Services through Care Partnership Trust No links established at an SLA level at present SALT and OT services Family & carer support or Communication Support Externalised and monitored by the Local Authority SALT and OT services Voluntary services provided by Different Strokes Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 45 of 99 Final Report

46 Bromley SE London 2006 population over age ,100 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 26 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 2.38% 5, % Hospital where patients are admitted Bromley Hospital NHS Trust Guys & St. Thomas s NHS Foundation Trust Kings College Hospital NHS Trust Mayday Healthcare NHS Trust Queen Mary s Sidcup NHS Trust St George s Hospital NHS Trust Lewisham Hospitals NHS Trust Total Number of strokes admitted by hospital 27 What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital % of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Disposition of stroke patients entering hospital Discharged without rehabilitation Unknown Discharged to long term care No data available 50 13% of survivors will die within 1 year of discharge 25 Office of National Statistics, based Sub national population projections 26 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 28 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 46 of 99 Final Report

47 Bromley Staffing Resources Current staffing for community rehabilitation all services Estimated existing workforce working with Stroke patients 30% Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Staff required to meet the Gold Standard Surplus (Shortfall of staff) Estimated cost of the team required, ,356 Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) Number of contacts currently provided Early Supported Discharge Team Issues Not recorded Not recorded No Early Supported Discharge team in place No plans to develop an Early Supported Discharge team No information on cost or duration of stroke packages of care is available Typical length of stay in the provider unit is 15 days for stroke A recent study, in which clinical coding was validated, showed that up to 1/3 of patients on the PRUH stroke unit did not have a primary admitting diagnosis of CVA/TIA and that 5 additional patients with an admitting diagnosis of stroke/tia were house on medical wards Acute providers are said to acknowledge the lack of capacity within current rehab services and therefore reluctant to refer more post-discharge clients to stroke care There is a strong stroke skill base amongst the community Physio and OT services. Similar depth of experience does not exist in respect of early supported discharge Lack of medical consultant support to the therapy team Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 47 of 99 Final Report

48 Bromley Other services available 2 stroke clubs linked to the Stroke Association Long term care according to the NAO about 33% of stroke patients will require long term care 133 in Bromley There is a seamless speech and language therapy service covering the acute stroke wards and community settings with patients offered 1:1 treatment in both their homes and community clinics. They are offered up to 5 terms at an appropriate specific stroke group targeted at their communication difficulties. Carers support groups are also run. The SLT team has a strong skill base in stroke with 1/3 of the client base suffering from stroke Balance of care study Performance management measures Quality assurance systems in No specific measures identified place Future plans Moving to separate the Provider and PCT arms into separate organisations further details not provided Identified gaps Shortage of staff to deliver the Gold Standard All core rehab services need to be built up Lack of medical consultant support to the team No SLA link to Stroke association as yet bid submitted to borough for Family and Carer Support services There is currently no stroke specific rehabilitation services and a lack of critical mass of staff with stroke specific skills and knowledge There is no formal annual follow-up for stroke patients. It is difficult to recruit to some therapy posts due to the lack of a specialist stroke community services. Existing baseline of stroke Provider Service Contract Volume Cost Comments services Current Day care Services Mindcare 3 day care centres Block D/C 215 places per 115,738 26% of all clients are Respite sitting April week, Weekend Stroke and cost is adjusted service Extra care sitting March 2010 respite 600 hours to reflect this service over 50 overnight sits per year, Extracare up to 60 hours per week White Gables Alzheimer s Society Specialised day care for people with dementia Block contract Monday to Friday services Block contract for Sunday Service 27 places 15 places 18,102 22% of service relates to stroke and budget figure adjusted to reflect this ICARE day centre Specialist day centre for stroke survivors. There Block M-F service places per day; Monthly carers pop-in session; Twice monthly One Step Forward 16,407 Contract extended May 2008 to 31 March Therer is no SALT input to this service. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 48 of 99 Final Report

49 Bromley Provider Service Contract Volume Cost Comments Respite Care 29 Independent sector Older persons respite PDSI respite Spot contract Spot contract 47,119 2,693 Budget based on 24% use by stroke patient PDS based on 15% stroke use Shaw Healthcare Residential care Block contract 15 respite beds of which 8 are dementia and 7 are PD Domiciliary care Mindcare Domiciliary Care Spot Target 300 hours weekly Long term residential care Shaw Homes Residential Care Block 171 LT LB Bromley Beds used out of 227 beds available Various Residential Care Spot 84 beds used Providers (DE category) Short term nursing care Long term nursing home care Various providers (OP/P categories) Care with Nursing Physical Disability Mission care 49,194 DE actual occupancy 63% Costs are apportion based on 10% of PD respite beds and 24% of Dementia Elderly beds 17,935 PD at 64% occupancy 74,787 26% of referrals for stroke apportions on 300 care hours at 1844 per hour 1,095,339 ( per week x beds) Stroke Association statistic of 25% of stroke patients require long term placement Residential Care Spot 285 beds used 1,686,650 25% of annual OP residential budget Nursing and Rehab care Long term nursing care Spot 39 beds used 252,569 Cost adjusted to reflect that stroke relates to 15% of placements Block Spot 60 beds 31 beds used out of 1044 beds available 455, ,767 Stroke association figure of 25% stroke in NH care 29 CSCI codes for care homes are: DE People with Dementia; PD Physical disability; TI Terminally Ill; OP Older person over age 65; SI sensory impairment; LD learning disability; MD Mental Disorder not including learning disability or dementia Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 49 of 99 Final Report

50 Bromley Provider Service Contract Volume Cost Comments Homes with PD and DE in borough Long term care Block for 8 beds Spot 252 beds of 997 beds available 65,705 2,054,172 Costs attributed 25% to stroke and figures adjusted to reflect this Total of all care services 6,203,119 For stroke only Voluntary Stroke association Stroke Club 2 stroke clubs are available in the community. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 50 of 99 Final Report

51 Greenwich SE London 2006 population over age ,400 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 31 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 2.06% 3, % Hospital where patients are admitted University College London Hospitals NHS Foundation Trust Kings College Hospital NHS Trust Queen Elizabeth Hospital NHS Trust Queen Mary s Sidcup NHS Trust The Lewisham Hospital NHS Trust Total Number of strokes admitted by hospital What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital 33 40% of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care 13% of survivors will die within 1 year of discharge Disposition of stroke patients entering hospital Unknown No data available Office of National Statistics, based Sub national population projections 31 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 33 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 51 of 99 Final Report

52 Greenwich Staffing Resources Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Current staffing for community rehabilitation all services except for the Manager and specialist OT posts all time is dedicated to the stroke services Clinical Specialist band 8a, 0.5 Band 7, 1.0 Band 6, 0.5 Band 5, 2.0 assistant band clinical Specialist Band 8a 1.0 Band 7, 1.0 Band Band 8c Team Leader 1.0 Dietician band 7 9 Estimated existing workforce working with Stroke patients Staff required to meet the Gold Standard Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 52 of 99 Final Report Surplus (Shortfall of staff) Total staffing costs for Stroke Rehabilitation services to meet the Gold Standard (, 000) Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) Early Supported Discharge Team Issues stroke referrals per annum. Predominately domiciliary MDT: Physiotherapy, Occupational Therapy, Speech and Language therapy and dietetics. NO ESD team at present. Full business case submitted to the Board No local provision of external functional electrical stimulation equipment for clients (provided by Salisbury NHS Trust, SE sector Specialist commissioning decision). Compass specific communication assessment for use of communication aids in SALT. Access to orthotics is via GP referral to QEH Access to Botox is only via GP (prescribing budget issue) Limited service focus on vocational/work focused Rehabilitative therapy CBT and Psychology focus Waiting times 2 weeks from referral Pathway in QEH could be improved. Patients with stroke may go under care of non-stroke specialist rather than under stroke specialist.

53 Greenwich Issues (Continued) Other services available Performance management measures Quality assurance systems in place Future plans Gaps Community Rehabilitation team attend MDT meeting at QEH for Friday morning ward round and this assists clinical focus in the QEH on securing early discharge of patients who have suffered a stroke to the CRS. Level of some GP s expertise and awareness of effective stroke management is generally not consistent with achievement of the best clinical and patient centred outcomes for stroke patients. Lack of adherence to any single care pathway between service delivery agencies. No common service pathway computer database. Lack of a common process e.g. Social Services use Framework I, Community Health services use RIO. Red tape e.g. splint requests must go through GP (common source of delay) then to Orthotics. Community health service splinting clinic would allow OT s to do splinting. Similar delays (and route through GP) to access Healthwise service. In stroke beds are coming on stream for community rehabilitation at Eltham Community Hospital ESD service bid submitted Speech and Language therapy provision is being addressed internally Service conformity with the National Stroke Strategy Quality markers SF36 Quality of life client questionnaire Goal Attainment Scale (GAS) Canadian Occupational Performance Measure (COPM) clinical outcome performance measures Assessment of Motor and Process Status (AMPS) clinical outcome performance measures Business case presented for ESD Staffing shortfall of Commissioning plans set the goal of achieving and 40% reduction in cardiac and stroke disease in people over 75 by 2010 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 53 of 99 Final Report

54 Existing baseline of stroke services Provider Service Contract Volume Cost Comments PCT Provider arm Community 6,000 per of PCT Rehabilitation Services package Greenwich Independent sector Bevan Intermediate Care Unit Ash Green House Time Court Intermediate care beds Intermediate care beds Intermediate care beds Internal commission: 35 hr of PT, 35 hr of OT 18 hr of SALT and 10 hr of dietetics 188 patient programmes per year 8 patient episodes per annum Physiotherapy, Occ. Therapy, SALT, Dietetics Voluntary sector Continuing care Independent sector Stroke association Sandpit nursing Home Charlton nursing Home Brook House Nursing Home Ash Tree Nursing Home Time Court Nursing Home Ash Green Nursing Home Gallions View Nursing Home Communication and Family & Carer support Complex stroke 6 patients per diagnosis annum Day centre Spot contracts Day care and OT Ongoing care to people less than 64 years old Older persons care Older persons care Older persons care Older persons care Spot Contract Spot Contract Spot Contract Spot Contract Spot Contract Older persons care Spot Contract Focus on spasticity and positioning care Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 54 of 99 Final Report

55 Lambeth SE London 2006 population over age ,100 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 35 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 1.57 % 3, % Hospital where patients are admitted St. George s Healthcare Trust Guys and St Thomas NHS Foundation Trust Kings College Hospital NHS Trust Mayday Healthcare NHS Trust University College London Hospital NHS Trust The Lewisham Hospital NHS Trust Total Number of strokes admitted by hospital What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital 37 40% of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care 13% of survivors will die within 1 year of discharge Disposition of stroke patients entering hospital Unknown No data available Office of National Statistics, based Sub national population projections 35 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 37 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 55 of 99 Final Report

56 Lambeth Staffing Resources Existing Community rehabilitation staffing. 20 % of the total workload relates to stroke Estimated existing workforce working with Stroke patients Staff required to meet the Gold Standard Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Surplus (Shortfall of staff) Estimated additional cost of the team: (,000) Staff required to meet the Green Standard , Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) Current number of stroke contacts 36 new active rehab clients 36 new entrants to the ESD programme 150 patients referred direct from community Estimated costs of the early supported discharge team Current estimates Estimated direct costs of rehabilitation per patient = Estimated ESD staff costs per patient 5, Stroke rehab clients represent only 5 6 % of the total patients but consume over 20% of the total resources Typically about 6 patients per month are discharged requiring therapy this matches the number which are expected to have good rehabilitation potential discharged from hospital 36 new clients came into active rehabilitation, 36 entered the ESD programme and a further 150 came into rehabilitation and SALT services via a community referral Expected to receive 30% of clients come out of hospital in 3 days 33% go to rehabilitation 30% go to long term rehabilitation, 15% go to care homes Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 56 of 99 Final Report

57 Lambeth Early Supported Discharge Team Issues LA Other services available 30% of clients discharged into ESD services LA has no ESD services but is looking to provide these Poor quality housing services in the Borough delay client returning home. It can take weeks or months to obtain adaptations to the patients house Use long term care beds to provide a place whilst house is made ready LA looking to establish contract with external provider to do adaptations No stroke specific staff working in the community No re-enabling for home care this is being addressed at the moment Interface issues between Health and SS hospitals seem to have no concept of community care Unable to recruit OT s Support for carers FAST not ethnically sensitive Getting information to a very ethnically diverse population Not a problem to get people long term residential care Tertiary rehab centres in Roehampton and Wolfson but there is a wait to get patients in Patients automatically referred but some clients assessments doesn t support them going there Performance management measures Quality assurance systems in place Future plans Identified gaps Significant amounts of data are collected, analysed and presented back to the Board to monitor performance Humana Initiatives has done an external evaluation of services Internal self assessment reviews Patient outcomes Length of stay, waiting list reduction, increase in satisfaction APO being created from April 2009 Reassessment of its value in 2 years Increase/improve specialist Neuro psychology access and provision Increase capacity for specialist reviews by medical and nurse Integrate social care provision within the rehab pathway Develop clarity of provision, pathways for vocational rehabilitation Shortage of staff to deliver the Gold Standard Lack of psychiatric support Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 57 of 99 Final Report

58 Lambeth Provider Service Contract Volume Cost Comments Existing baseline of stroke services LA Lambeth Resource Centre LA Rehab UK Support for rehabilitation including return to work LA DWP Every Pound Counts LA Stroke association Little presence at the moment LA No dedicated staff Direct link into PCT to provide services for physical disabilities LA Typical package of rehab from the LA is currently 6 weeks long. Main supplier to the LA Neighbourhood fund to improve return to work PCT PCT OPCT DAZZLE is local initiative Intermediate care beds but minimal use for Stroke Community Rehab Team including ESD services Block contact 4 beds 1400 bed days, 24 patients, average LOS of 8.5 weeks Block contact 222 patients, 4358 face to face contacts, 4133 visits, 9166 total contacts including nonface to face K overheads of 235K 750K K overheads Loading of 33% overheads CCC, Pulcross Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 58 of 99 Final Report

59 Lewisham SE London 2006 population over age ,100 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 39 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 1.79% 3, % Hospital where patients are admitted Bromley Hospitals NHS Trust Guys and St Thomas NHS Foundation Trust Kings College Hospital NHS Trust Queen Elizabeth Hospital NHS Trust Queen Mary s Sidcup NHS Trust The Lewisham Hospital NHS Trust Total Number of strokes admitted by hospital What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital 41 40% of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care Disposition of stroke patients entering hospital Unknown No data available 13% of survivors will die within 1 year of discharge Office of National Statistics, based Sub national population projections 39 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 41 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 59 of 99 Final Report

60 Lewisham Staffing Resources Existing Community rehabilitation staffing. 20 % of the total workload relates to stroke Estimated existing workforce working with Stroke patients Staff required to meet the Gold Standard Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Surplus (Shortfall of staff) Estimated additional cost of the team (, 000) Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) Current number of stroke contacts Early Supported Discharge Team Issues Estimated that 150 new OT referrals took place LA estimate that the typical care package costs between in residential care There is a review at 6 weeks post discharge ESD is not available and not planned. Funding of 191K across all of Neuro-Rehab but that funding has now been cut Waiting time post hospital discharge is 12 weeks before SALTs available urgent swallowing within 48 hours, urgent communications 4 weeks Physio referral with rehabilitation potential seen within 4 weeks, little rehab potential up to 12 weeks Stroke = 39% of discharges Stated to be way off the Gold Standard No services specification No quality measures in place PCT estimates that the new Hyperacute admissions will cost about 500K per annum Longer than expected length of stay (but unable to specify) Major adaptations are difficult and can take 4 6 weeks for the initial means test by the LA. Work can then take another 12 weeks. The need to shorten these times has been identified. Other Total Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 60 of 99 Final Report

61 Lewisham Other services available Performance management measures Quality assurance systems in place Strategic plans Future plans Identified gaps Only slow stream provision is in Nursing Homes None No service specification Stroke association support rehabilitation but there is a lack of continuity in services, except for SALT GAS External review No service specification to measure quality against Stated that they are a long way off the Gold Standard but had not yet formulated plans to address this. Lewisham PCT is committed to working with partner agencies to implement the 11 quality requirements set out in the NSF. Bid in place to Integrated Care for Integrated Care pilot Programme Shortage of staff to deliver the Gold Standard Poor quality of data especially the HA/SS link Lack of dietician support Lack of Psychological support to clients and family Need for more proactive and dedicated social work support MDT meetings focused on aims and objectives Increased need of prevention required Social and re-enablement model need real community option Lacking a whole system s approach to services No satisfaction surveys Commissioning plan indicates that Lewisham does not expect to reach the performance targets by 2010 expected gap to be about 40% Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 61 of 99 Final Report

62 Lewisham Existing baseline of stroke services Intermediate care Stroke care Hospital Stroke Unit REHAB Provider Service Contract Volume Cost Comments University Hospital Lewisham University Hospital Lewisham University Hospital Lewisham Intermediate Care & home based rehabilitation for clients likely to benefit from short term rehab and need at least 2 services OT, PT, SALT Neuro-Rehab beds 3 beds in a 22 bed unit 2.2 beds in 24 bed Neurorehab unit Six week transition predischarge Usually stay for 6 weeks 1201 bed days, 29 patients, 5700 face to face contacts of 3100 completed visits Provider Service Contract Volume Cost/Comments Stroke beds 20 beds allocated for stroke led by two patients consultant physicians 1 in stroke and 1 in elderly Adult Therapies Service Intermediate care Ivy House PCT commissioned Non-stroke specific service but 45% workload relates to stroke Block Bed based care 15 beds HEN team Local community care support Slow stream rehabilitation Independent sector Based on panels, about 36% of the 240 cases pa relates to stroke hence about 80 stroke placements in long-term care No ESD No dedicated Psychological of Dietetic Support Multi-disciplinary team including PT, SALT and OT Adaptation assessments made within 48 hours, plans including specialist equipment complete within 28 days No dedicated stroke service in the borough Communication support group Voluntary Closed Funding cut Voluntary services Voluntary Information, advice, signposting Referral by self or family to meet others who have had stroke within 6-9 months Visits to persons home and weekly drop-in session Attends MDT meeting at UHL Bereavement support Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 62 of 99 Final Report

63 Southwark SE London 2006 population over age ,300 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 43 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 2.33% 5, % Hospital where patients are admitted University College London Hospitals NHS Foundation Trust Guys and St Thomas NHS Foundation Trust Kings College Hospital NHS Trust Queen Elizabeth Hospital NHS Trust Queen Mary s Sidcup NHS Trust The Lewisham Hospital NHS Trust Total Number of strokes admitted by hospital What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital 45 40% of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care Disposition of stroke patients entering hospital Unknown No data available 13% of survivors will die within 1 year of discharge Office of National Statistics, based Sub national population projections 43 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 45 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 63 of 99 Final Report

64 Southwark Staffing Resources Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Current staffing NEURO and Stroke Pathway 20% of workload is stroke 10 RSW s contacted from private sector. Rehab assistant held post. 1.0 band Band Band band band band 6 SALT band wte frozen RSW manager with therapy background 1.0 SW<65 s (withdrawn - funding cut), 2.0 SW - care taper & funding adj, Tech. Inst. Band Estimated existing workforce working with Stroke patients Staff required to meet the Gold Standard Surplus/(Shortfall) to required staff Additional cost of implementing Gold Standard ($,000) Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) There is a proposal to make a number of changes in structure as follows: ESD Stroke pathway (Ex. LTC Neuro Pathway) Administrator 10 RSW Band Band 6 1 Band 7 1 band 6 1 RSW Band 3 or 4 1 Band 6 manager Band Social work 7 post not yet agreed Current number of stroke contacts 55 other hospital discharges provided with rehabilitation at an average cost of 3,202. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 64 of 99 Final Report

65 Southwark Early Supported Discharge Team Issues Good practice initiative Performance management measures Quality assurance systems in place Future plans Identified gaps In year 1, expected to treat 33 patients at a cost of 6,100 each total 201.3K and save an average of 10 bed days per person. Actually treated 71 patients at 2,641 per person and cost of 111K saving 212K acute cost and 9 bed days per person. The team, including the Southwark Social Worker, meets daily in both Kings and GTT acute starting with the day on which each client is admitted. A single point of contact attends to all referrals, care and discharge. Length of stay is up to 26 weeks and there is no formal cut-off date. The statistics on LOS are NOT based on mode and may, therefore, over-estimate the average LOS and treatment intensity. Detailed study indicates that saving arise in Social Care Costs for clients going through ESD due to the lower service intensity required after discharge from health. A table is available quantifying these savings between August 2007 and October Current round of funding cuts are putting elements of the service at risk Consultant from Kings holds surgery at Dulwich 1 day per week. He is also on call from problems with clients there or in the community They believe they would attain 100 percent Average cost of a 3 time daily package of care is per week. With shopping, housework and laundry it increases to per week. Detailed stroke rehabilitation specification and cost model Traffic light system for merged standards relating to community care rehabilitation standards 9,10,3 are red, 1, 2, 5 are green, and 4, 6, 7, 8 are yellow. Goal Attainment Score (GAS) Service user evaluation Benchmarking against HfL Concerned performance may reduce due to a 10% funding cut The hospital site is to be developed as a PFI scheme but this is thought to be on hold Dulwich is a central source within which to base services LA base is well removed from the centres of population Shortage of staff to deliver the Gold Standard leads to no capacity to engage No dietician at all in Southwark Pharmacy is a problem people sent home with a bag of new drugs with no training and support. District nurse is called but takes at least one week to see the patient at home. The District Nursing service is not controlled as part of the rehab service Lack of psychology service Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 65 of 99 Final Report

66 Existing baseline of stroke services PCT Voluntary Dulwich Hospital Stroke Association Provider Service Contract Volume Cost Comments Intermediate care unit 12 beds Provides care for up to six weeks to enable patients to return to the community with a higher level of independence Communication Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 66 of 99 Final Report

67 South East London PCT s and Local Authorities 2006 population over age ,241,700 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 47 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 2.07% 25,737 2, % Hospital where patients are admitted Bromley Hospital NHS Trust Dartford and Gravesham NHS Trust Guy s and Thomas s NHS Foundation Trust Kings College Hospital NHS Trust Mayday Healthcare NHS Trust Queen Elizabeth Hospital NHS Trust Queen Mary s Sidcup NHS Trust Number of strokes admitted by hospital Number of strokes admitted by hospital What happens to these patients? St. George s Healthcare NHS Trust The Lewisham Hospital NHS Foundation Trust Univ. College London Hosp. NHS Foundation Trust ,409 Of the people 40% of survivors 30% of clients 17% of Discharged Discharged 13% of admitted to a have good will have a survivors will without to long term survivors will hospital following a rehabilitation communication have poor rehabilitati care die within 1 stroke, 30% will die potential difficulty rehabilitation on year of in Hospital 49 potential discharge Total Disposition of stroke patients entering hospital Unknown No data available Office of National Statistics, based Sub national population projections 47 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 49 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 67 of 99 Final Report

68 SE London Staffing Resources Existing Community rehabilitation staffing. Only about 20% of Community Rehabilitation workload is stroke related Estimated existing workforce working with Stroke patients Staff required to meet the Gold Standard Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Surplus (Shortfall of staff) Estimated additional cost of the team (, 000) Staff required to meet the Green Standard , Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) ,380 Current estimates Average Community Rehabilitation cost per patient: ( 3,443) Identified gaps Nin Bexley, Bromley, Greenwich, Lewisham Shortage of staff to deliver the Gold Standard , Million Lack of psychological support Shortfall in dietician support in some Lewisham and Southwark No voluntary sector SLA in Bexley and Lambeth No detailed plan for meeting Stroke performance standards re. Community in Bexley, Bromley, Lewisham Plans to meet Stroke performance standards re. Community Rehab underfunded in Greenwich & Lambeth Vocational rehab weak in all PCT s Some extended waiting times Links with Local Authorities variablealth and Social Care IT system not connected and SS does not accept diagnosis or Diagnostic Code Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 68 of 99 Final Report

69 Croydon SW London 2006 population over age ,800 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 51 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 1.96 % 5, % Hospital where patients are admitted Bromley Hospitals NHS Trust Epsom and St. Hellier University Hospitals NHS Trust Kings College Hospital NHS Trust Mayday Healthcare NHS Trust St. George s Healthcare NHS Trust Surrey and Sussex Healthcare NHS Trust Total Number of strokes admitted by hospital 52 What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital % of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care 13% of survivors will die within 1 year of discharge Disposition of stroke patients entering hospital Unknown No data available Office of National Statistics, based Sub national population projections 51 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 53 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 69 of 99 Final Report

70 Croydon Staffing Resources Current staffing Neuro rehab team + staff from CICS Numbers of current staff working solely on stroke = 32% Staff required to meet the Gold Standard Rehabilitation carer 2.0 generic workers funded by SS, 1.0 Care Manager In addition to numbers from CICS CICS Physiotherapist 1.5 band 6, 0.5 band from CICS Occupational Therapist 1.0 Band 7, 0.5 band 6, 1.0 unknown grade from CICS Speech and Language Therapist 0.5 Band 7, 1.0 unknown grade +0.5 from CCS Therapy Leader 1.0 care manager (joint appoinment with Mayday) +1.3 from CICS Other 0.8 Psychologist, 0.3 Band 7 Dietician, 0.5 Psychologist assistant Total Surplus (Shortfall of staff) Estimated additional cost of the team required (, 000) Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) Number of proposed stroke contacts Caseload 120 receiving up to 6 weeks community care and rehab Caseload of 250 people receiving ongoing therapy, nursing and review for up to 14 weeks Early Supported Discharge Team Stroke association will manage 200 referrals per Services to support early discahrge are provided by the Community Intermediate Care Services (CICS) team Average length of treatment is 9.2 weeks No weekend therapy if patients don t have an acute problem Issues Current stroke register appears to underestimate actual incidence of stroke by between 30% and 50% Staff recruitment is an issue at Mayday Little support for carers Some stroke clients are said by the PCT not always to go immediately to a Stroke ward bed at Mayday Other services available New stroke coordinator appointed at Mayday but will not come into post until March 2009 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 70 of 99 Final Report

71 Performance management measures Croydon Performance management continued Quality assurance systems in place Future plans Yes not specified Moving toward a monthly SLA evaluation meeting with their own providers Detailed performance standards set out in the Service Specification Monitoring that no excess bed days occur within secondary care (65 excess days in 2005/6) for HRG s A22 and A23 stroke tariffs. Length of stay will not exceed 62 days for A22 and 30 days for A23. CICS will manage a minimum additional 100 stroke patient referrals per annum CICS will deliver a minimum additional 3,550 face to face contacts for stroke patient CNRT will manage an additional 200 stroke patient referrals per annum CNRT will deliver an additional 2000 face to face contacts for stroke patients per annum The family and carer support office and communication support worker will receive 200 referrals per annum and provide 240 face to face contacts and 160 telephone contacts each per annum Monthly joint meeting between health and social services develops a joint strategic plan Partnership group meets bi-monthly Yes not specified Substantial Enhanced Stroke Service Specification dated August 2008 in place and provides comprehensive indicators of how the services will move forward to achieve in full the community standards. Identified gaps Existing baseline of stroke services Slow stream rehabilitation Shortage of staff to deliver the Gold Standard bid for additional funding has been submitted Lack of support for carers Qualified nursing staff numbers in Mayday both for those with and those without specific stroke qualifications. Lack of mental health support for patients Pilot started in January 2008 to move the PCT towards the gold standard Still awaiting Commissioning Strategy Provider Service Contract Volume Cost Comments Lennard Road Community Centres Hill House Fairlee House Nursing Home NHS Nursing Home CSCI registered rehab. beds Slower stream high level rehabilitation Up to 20 beds in total between these homes Croham Place Nursing Home Vocational rehabilitation Wolfson Unit Vocational and other rehabilitation for people with good potential Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 71 of 99 Final Report Stroke Coordinator controls discharge into care homes 2 beds Not known Nursing Home managed by CICS. To provide high-level rehabilitation. Up to 20 beds About Purchasing is largely flexible to 2,000 per allow for winter pressures week Only for clients with good potential

72 Croydon Provider Service Contract Volume Cost Comments Putney Neuro-rehabilitation centre Putney Neurorehab centre Very complex rehabilitation Proceeded by placement in a longterm nursing home bed until a place is available. Community Intermediate Care Team and Neuro-rehabilitation team Joint team in respect of stroke Funding fro 1 wte care manager Local Authority POPS bus Blood pressure and glucose screening. Health Visitor from the older persons team is on the bus [email protected] Croydon Neighbourhood Care Association Voluntary Stroke Association 1.0 coordinator Link for voluntary sector providers Croydon Older People s Network Networking and timetable of visits to car parks, shopping centres, and mosques, targeting people who would not normally self refer or seek help. Finding a lot of high BP. Capacity 250 clients per annum 31,000 [email protected] [email protected] Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 72 of 99 Final Report

73 Kingston upon Thames SW London 2006 population over age ,800 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 55 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 1.85% 2, % Hospital where patients are admitted Epsom and St. Helier University Hospital NHS Trust St. George s Healthcare NHS Trust Kingston Hospital NHS Trust Kingston PCT Hammersmith Hospitals NHS Trust The Lewisham Hospital NHS Trust Total Number of strokes admitted by hospital What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital 57 40% of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care 13% of survivors will die within 1 year of discharge Disposition of stroke patients entering hospital Unknown No data available Office of National Statistics, based Sub national population projections 55 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 57 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 73 of 99 Final Report

74 Kingston upon Thames Staffing Resources Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Current staffing All therapy services are provided from Richmond & Twickenham PCT Therefore no staff are shown in this table Numbers of current staff working solely on stroke number 0.00 Staff required to meet the Gold Standard Surplus (Shortfall of staff) Estimated additional cost of the team (, 000) Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) Current number of stroke contacts all Neuro-rehab including Richmond Early Supported Discharge Team Issues Other services available Performance management measures ,368 contacts across 16 of the new Neuro-rehab (34% new strokes went on strokes 1,600. Of the 429 to require long patients, 115 were new term care strokes. There is no ESD team serving the PCT or borough The community Neuro-rehabilitation team is managed and provided from outside the Borough therefore current contact data is collected at borough level. The only data available was that there were 37 admissions in 2007/8 and to month /9 42 admissions. Length of stay was 41 days in 2007/8 and 39 days in 2008/90 No data provided No data provided Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 74 of 99 Final Report

75 Kingston upon Thames Quality assurance systems in place Future plans No data provided The Strategic Commissioning Plan sets out the following year 1 objectives and comments: Stroke Implement revised Transient Ischemic Attack (TIA) pathway providing rapid diagnostic assessment and access to a specialist within 24 hours for high-risk patients and 7 days for low risk to be put in place across the sector. (H4L designation process will end in March 2009). Review evaluation of stroke service pilot and work with providers to adopt appropriate model of service Develop model of local stroke rehabilitation service. Establish local service. Any permanent changes to patient pathways will need to go to full public consultation, and be considered by the relevant Borough Council Health Overview and Scrutiny Committees. No permanent service change can be made until the outcomes of Healthcare for London are finalised (Possibly not until June 2009). Our current direction for stroke services is considered to be based on the SWL strategic context as far as possible. Goals and objectives will be revalidated once the final HFL recommendations are published. Identified gaps Shortage of staff to deliver the Gold Standard Provider Service Contract Volume Cost Comments Existing baseline of stroke services PCT Tolworth Hospital Intermediate care Gym Richmond Rehabilitation Gym Unit Richmond PCT services Communication Group for aphasic patients Exercise Group Carers Group PCT provider contact 37 admissions and 41 day average length of stay 6 stroke rehabilitation beds. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 75 of 99 Final Report

76 Richmond & Twickenham SW London 2006 population over age ,700 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 59 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 1.95% 2, % Hospital where patients are admitted Kings College Hospital NHS Trust St. George s Healthcare NHS Trust Richmond and Twickenham PCT Chelsea and Westminster NHS Foundation Trust Hammersmith Hospitals NHS Trust Wandsworth PCT West Middlesex University Hospital NHS Trust Total Number of strokes admitted by hospital 60 What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital % of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care Disposition of stroke patients entering hospital Unknown No data available 13% of survivors will die within 1 year of discharge Office of National Statistics, based Sub national population projections 59 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 61 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 76 of 99 Final Report

77 Richmond upon Thames Staffing Resources Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Current staffing All therapy services are provided from the establishment to Kingston upon Thames 2.18 Band 7 Senior Physio 2.47 Senior OT band 6 & SALT Physio band 8b % clinical 0.4 Dietician, 1.80 Administrator, 0.5 Therapy asst, 0.82 A&C band Numbers of current staff working solely on stroke = 32% of total staff number Staff required to meet the Gold Standard Surplus (Shortfall of staff) Estimated additional cost of the team required (, 000) Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) Current number of stroke contacts inclusive of services provided to Kingston Early Supported Discharge Team 4,368 contacts across Neuro-rehab (34% new strokes 1,600. Of the 429 patients, 115 were new strokes.) 16 of the new strokes went on to require long term care The team is rolled up into the general numbers for staff in Neuro-rehabilitation Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 77 of 99 Final Report

78 Richmond and Twickenham Issues Performance management measures Quality assurance systems in place Identified gaps Existing baseline of stroke services Hospital based beds Waiting time is 1 2 weeks for urgent referrals and 4 weeks for routine needs to reduce to 48 hours No acute hospital within the PCT so clinicians are liaising with several hospitals Stroke specification not currently separate from the rehab team Stated to be a long way off the Gold Standard Provider arm of Million is floating off as an alliance with Hounslow. Poor data quality in trusts codification issues Question whether they operate a true stroke unit or a virtual one. General admissions go to West Middlesex from 22/2. 22 stroke beds dissipated by direct access to the wards. Kingston has a similar proposal signed off by London but it is not being implemented till October Goal setting Annual personal objectives\recording of patient satisfaction at discharge and 6 months Quarterly review meetings Monthly and quarterly data returns Goal Attainment Scale (GAS) Patient satisfaction surveys KSF outline and team objectives Outcome measures in treatment e.g. BICRO 39 quality of life scale Comparison against stroke guidelines Provider sits on the discharge meetings Shortage of staff to deliver the Gold Standard Pathways not clear light on therapeutic input with no single point of access. Greater potential to use Telemedicine Neuro-psychology Speech and Language therapy Specialist stroke nurse Capacity issues Waiting times to slow stream care 4 5 weeks Provider Service Contract Volume Cost Comments Teddington Memorial Hospital Beds for rehab and step-down Cottage Hospital Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 78 of 99 Final Report 50 beds nonspecific Anything goes into these beds and there is no direct control for stroke Voluntary Stroke Association Communications SLA Not Known 20K Communications support to clients Self Help Groups, Richmond Nero Pathway Self Help, vocalisation of concerns Very vocal self help group

79 Sutton & Merton SW 2006 population over age ,100 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 63 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 1.93% 5, % Hospital where patients are admitted Guy s & St. Thomas NHS Foundation Trust Epsom and St. Hellier University Hospitals NHS Trust Kings College Hospital NHS Trust Mayday Healthcare NHS Trust St. George s Healthcare NHS Trust Total Number of strokes admitted by hospital What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital 65 40% of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care Disposition of stroke patients entering hospital Unknown No data available 13% of survivors will die within 1 year of discharge Office of National Statistics, based Sub national population projections 63 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 65 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 79 of 99 Final Report

80 Sutton & Merton Staffing Resources Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Current staffing (Merton LA) Stroke = 16% of workload. S&MPCT Teams (40% of Community Neuro-team relatesd to workload for stroke and includes EDT Consultant and Psychologist Current staffing devoted to stroke assuming stroke = 16% or 40% of of workload Staff required to meet the Gold Standard Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 80 of 99 Final Report Surplus (Shortfall of staff) Estimated additional cost of the team required (, 000) Staff required to meet the Green Standard , Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) ,138 Current number of stroke contacts 264 patients based on March 2008 data pro-rata Current services Monday to Friday + links to Intermediate Care Team and Night Nursing Service. Early Supported Discharge Team Expected length of treatment in 2006/7 was 12.5 weeks, 17.5 weeks in 2007/8. Neuro-rehab report says no ESD team in place. Information received fropm Susan McNab of S&MPCT indicates that a ESD team does exist with 3. Staffing in the table above includes both Merton LA and S&MPCT teams. Issues Initial information from the stroke needs assessment indicates that work will need to be carried out to improve the care pathway for people affected by stroke Lack of links between LA and stroke units Lack of talking therapies Professional lead Quality assurance systems in place Review of packages of care Merton Outcome focused reassessment of care plans to asses extent to which targets are met

81 Future plans Sutton & Merton Identified gaps Stroke initiatives Increase allied to health professionals in community rehabilitation Establish an ESD team Establish an exercise prescription programme Establish counselling and disability management services Commission Vocational Rehabilitation to HfL standards Increase allied Health Professionals in secondary care Establish communication support groups Specialist stroke training for all staff Shortage of staff to deliver the Gold Standard Stroke needs assessment is completing a service mapping which is intended to identify any gaps in provision by the end of March 2009 Existing baseline of stroke services Provider Service Contract Volume Comments Community Neurological Therapy Team (CNNT) Sutton and Merton PCT Assessment, intervention, rehabilitation, and patient education for patients who have had a stroke or who have a neurological disorder. 264 per annum of which 41% will be for stroke, 108 patients Long term care Care Homes (unspecified) Intermediate care Ludlow Lodge Local Authority (Sutton) Day Hospital Cheam Priory Centre Sutton Centre for Independent Livings and Learning SMASH Sutton and Merton Aphasia Support Local Authority (Merton) Canterbury Road, Merton Various long stay care homes LA Merton Intermediate care Woodland Nursing Home Approved provider list and brokerage Physical improvement Epson St. Helier Gym Intermediate care rehabilitation Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 81 of 99 Final Report 12 bed Block Contract Joint funding PCT and LA From their detailed specification

82 Wandsworth SW London 2006 population over age ,900 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 67 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data Hospital where patients are admitted 1.47% 3, % Chelsea and Westminster Hospital NHS Trust Epson & St Helier Univ. Hospitals NHS Trust Guy s & St. Thomas NHS Foundation Trust Hammersmith Hospital NHS Trust Kingston Hospitals NHS Trust St. George s Hospital NHS Trust Wandsworth PCT Total Number of strokes admitted by hospital 68 What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital % of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Disposition of stroke patients entering hospital Discharged without rehabilitatio n Unknown Discharged to long term care 13% of survivors will die within 1 year of discharge No data available Office of National Statistics, based Sub national population projections 67 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 69 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 82 of 99 Final Report

83 Wandsworth Staffing Resources Total current Neuro-rehabilitation staffing Current staffing devoted to stroke 28% Staff required to meet the Gold Standard Rehabilitation carer Neuro-rehab assistant ESD+A154 6 Physiotherapist Band 8a , Band , Band , DS 1.0 = 5.6 Occupational Therapist 1.6 Band 7, 1.9 Band 6, 1 ESD = total 3.6 Speech and Language Therapist 0.6 Band 8a, 0.6 Band 7, 1.60 Band 6, 1.0 ESD = total 3.8 Therapy Leader Clinical team leader 8a 0.5, Clinical Specialist ESD 1.0 = total 1.5 Other Total Mental Health Nurse Band , Consultant Psychiatrist 0.4, Clinical Neuro-Psychologist Band 8a -1.0, Complex case manager band , Admin band 3 1.0, Higher grade admin 1.0, Higher grade complex case manager (ESD) 0.5 = total Surplus (Shortfall of staff) Estimated additional cost of the team required (, 000) Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) Bid already submitted in PCT for additional staffing Neuro-rehab only Neuro-rehab assistant 3.0 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 83 of 99 Final Report Clinical Team Leader 8a 0.5 Mental Health Nurse Band , Consultant Psychiatrist 0.4 Clinical Neuro-Psychologist Band 8a - 1.0, Complex case manager band , Admin band Cost: proposed team Neuro-rehab (, 000) ,324 Proposed cost of ESD team Neuro-rehab (, ) Proposed total new costs Neuro-rehab (, , ) Current number of stroke contacts patients per year 19.90

84 Wandsworth Early Supported Discharge Team No ESD at present one is due to start by September 2009 Issues Other services available Future plans Identified gaps Existing baseline of stroke services Community Rehabilitation Team No referral coordinator needs to be at level 8a No ESD Due to start by September 2009 Politics Little is referred to Social Services as they already have a home care policy When the ESD comes back on stream, it needs to be more responsive and move patients on as quickly as possible. Lead person should be based at St George s and attend the MDN s and audit. Approximately 3 people per month could use the ESD for 4 6 weeks each. About 11,000 per ESD discharge but saves 9 hospital bed days for each patient. Need increased continuing care funding. Currently there are 5 packages at 100% funding. As much as a 7 week waiting time occurs because there is no ESD St John s Therapy Centre Atheldine Gym Queen Marys Considering establishing SLA with Ted Poulter for exercise programme Virtual ward in 4 community areas Wandsworth, Roehampton, Tooting and Battersea focus on high risk patients to prevent them coming into hospital. Staffing resource would come from within the community rehabilitation team. Each area to have 1 GP responsible for the virtual ward. Expect to treat 100 patients in each. NOT stroke specific Shortage of staff to deliver the Gold Standard ESD addressed OT, Vocational and SALT staff being addressed Provider Service Contract Volume Cost Comments Wandsworth PCT Based at St Johns Centre in Battersea Community Neurorehabilitation Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 84 of 99 Final Report Low intensity 10 sessions Medium intensity 20 sessions + rehab High intensity = 30+ sessions Contract is for 24 hours 1,573 3,492 4,013 Voluntary Stroke Association Hearing Therapies In-Patient rehabilitation Queen Mary s Hospital Intermediate 14 standalone Neuro-rehabilitation beds with specialist staff Continuing Care 5 100% funding Most packages are at high end Need increased continuing care funding.

85 South West London PCT s and Local Authorities 2006 population over age ,084,300 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 71 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 1.83% 19,849 2, % Bromley Hospitals Hospital where patients are admitted NHS Trust Chelsea and Westminster Hospitals NHS Foundation Trust Epson and St. Helier University Hospital NHS Trust Guy s and St Thomas NHS Foundation Trust Hammersm ith Hospital NHS Trust Kings College Hospital NHS Trust Number of admissions Kingston Hospitals NHS Trust Kingston PCT (Tolworth hospital) Mayday Healthcare NHS Trust Richmond and Twickenham PCT Surrey and Sussex Healthcare NHS Trust Hospitals continued Number of admissions Hospitals continued Wandsworth PCT (Queen Mary s Roehampton) West Middlesex University Hospital NHS Trust St Georges Healthcare NHS Trust Total Number of admissions ,213 What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital 72 40% of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care Disposition of stroke patients entering hospital Unknown No data available 13% of survivors will die within 1 year of discharge Office of National Statistics, based Sub national population projections 71 Health Needs Assessment: Stroke in South West and South East London, Table National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 85 of 99 Final Report

86 SW London Staffing Resources Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Current staffing Current staffing devoted to stroke assuming stroke = 27% of workload Staff required to meet the Gold Standard Surplus (Shortfall of staff) Estimated additional cost of the team required to meet Gold Standard (, 000) 80 1,210 1, ,465 Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) ,412 Cost per patient of new services 3,443 Identified gaps Shortage of staff to deliver the Gold Standard No ESD in Kingston, Sutton & Merton, Richmond & Twickenham or Wandsworth. Plans in place for Wandsworth All PCT s have an SLA with Voluntary Sector to achieve the performance standard 7 weeks waiting at Wandsworth due to lack of ESD. Richmond & Twickenham long wait for slow stream rehab. Kingston no information on waiting times. All lack psychological support services Strategic plan for Croydon still awaiting approval. Plan for Kingston is part of the overall CVD plan so not possible to identify priorities Plan for Sutton & Merton - no adequate detail on future stroke developments Greenwich and Wandsworth have detailed plans but underfunded Weak links with Social Services are noted IT systems in Health and Social Services are not compatible as there is no diagnosis or Code in the SS system Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 86 of 99 Final Report

87 South London PCT s and Local Authorities 2006 population over age ,326,000 Total Stroke/TIA Population Prevalence of stroke in Borough as recorded on GP records 74 Total number of strokes and TIA s based on prevalence Strokes admitted to hospital Admissions as a percent of total numbers of stroke/tia on GP records Predicted vs. admitted prevalence data 1.96% 45,586 4, % Number of strokes admitted by hospital ,622 Total What happens to these patients? Of the people admitted to a hospital following a stroke, 30% will die in Hospital 76 40% of survivors have good rehabilitation potential 30% of clients will have a communication difficulty 17% of survivors will have poor rehabilitation potential Discharged without rehabilitation Discharged to long term care 13% of survivors will die within 1 year of discharge Disposition of stroke patients entering hospital 1,387 1, Unknown No data available Office of National Statistics, based Sub national population projections 74 Health Needs Assessment: Stroke in South West and South East London, Table Hospital Episode Statistics (HES) for 2006/7 for ICD codes I60 I69 76 National Stroke Strategy, London: Department of Health, 2007 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 87 of 99 Final Report

88 South London Staffing Resources Rehabilitation carer Physiotherapist Occupational Therapist Speech and Language Therapist Therapy Leader Other Total Current staffing Current staffing devoted to stroke assuming stroke = 23% of workload Staff required to meet the Gold Standard Surplus (Shortfall of staff) Estimated additional cost of the team required to meet Gold Standard (, 000) 229 2,464 2,658 2,670 1, ,562 Staff required to meet the Green Standard Surplus (Shortfall of staff) Estimated additional cost to meet Green Standard (,000) Staffing cost of new service per patient Potential Acute Bed savings arising from Early Supported Discharge Team -65 1,502 1,699 1,864 1, ,792 3,433 Annual man hours = per patient 4,500K Net annual new costs Community Rehabilitation (, 000) 5,062 K Identified gaps Shortage of staff to deliver the Gold Standard Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 88 of 99 Final Report

89 Bibliography Bexley Bexley Local Authority Care Trust: Bexley PCT Structured interview with Michelle Brett 2. Community rehabilitation team statistics for June to December Strategy Review: Community Rehabilitation and objectives 2009/ Service specification: Community Rehabilitation Team 5. Key Performance Indicators: Adult Services Community Rehabilitation 6. Community Rehabilitation Team Structure 7. Draft adults strategy, Bexley Care Trust 8. Draft Old People s strategy, Bexley Care Trust 9. Prevention strategy, Bexley Care Trust 10. Physical sensory Impairment Leaflet 11. Bexley Care Trust Annual Report Bexley Care Trust Strategic Commissioning Plan Bromley Bromley Local Authority: Bromley PCT Structured interviews with Andrew Hardman, Rebecca Jarvis, Jayne Steadman 14. Table of contracted services by the PCT 15. Acute Bed Utilisation and Capacity of Care nearer to Home in Bromley Draft November 2008 (Confidential) 16. Bed Utilisation Review Survey Findings, Bromley PCT (Confidential) 17. PCT Strategic Plan PCT Financial Strategy To 2012/13 Croydon Croydon Local Authority: Croydon PCT Structured Interview Clare Godfrey 20. Enhanced stroke specification 21. Strategic Commissioning Plan 22. Financial Strategy Croydon LA Fees and Charges to clients 2007/ Annual Report 2006/7 Croydon LA 25. Budget for 2008/9 Adult Services Croydon LA 26. Annual report 2006/7 Croydon PCT 27. Croydon PCT response to Health Care London on Stroke 2008 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 89 of 99 Final Report

90 Greenwich Greenwich Local Authority: Greenwich PCT Structured interview with Jill Bell, Saadi El-Behiesi, Anthony Davis 29. Contract: Greenwich Teaching Primary Care Trust and Stroke Association 30. Service Specification: Family and Carer Support and Health Promotion Services, Greenwich PCT 31. Service Specification: Communication Support Services, Greenwich PCT 32. Business Case to support Early Supported Discharge in Greenwich: Stroke Services, Greenwich PCT 33. Service Level Agreement: Bevan Unit, Greenwich PCT 34. Greenwich Local Authority: Charging Information for People receiving services from Home (Nonresidential Care) Greenwich Local Authority: Charging Information for People receiving services from Home (Residential Care) Commissioning Strategy 2007/8 to 2011/12: Greenwich PCT 37. Annual Report Greenwich PCT 2007/8 Kingston Kingston Local Authority: Kingston PCT s from Julia Gosden 39. Admissions and Length of stay for stroke clients in 2007/8 and 2008/9 to month Quality in Community Care Services A Strategic Framework , Royal Borough of Kingston 41. Divisional aims and objectives 2007/8; Royal Borough of Kingston 42. Charging for Home Care; Royal Borough of Kingston 43. Framework for commissioning Community care Services, Royal Borough of Kingston 44. Care services directory 2007, Royal Borough of Kingston 45. Annual report 2007/8, Kingston PCT 46. Strategic Commission Plan , Kingston PCT 47. Objectives, Kingston PCT Lambeth Lambeth Local Authority: Lambeth PCT Structure interviews: Cathy Ingham, Alexandra McTeare; Liz Clegg 49. Establishing the current cost of stroke relating to rehabilitation & community care in PCT s; Healthcare for London proforma 50. Community Therapy activity data: 2007/8 51. CONFIDENTIAL: Economic Model: Summary of outcomes. Eden McCallum and Internal 52. CONFIDENTIAL: Economic Model to support Phase 3 of the Stroke Modernisation Project, Lambeth and Southwark, Eden McCallum Limited 53. One year summary of Lambeth stroke patient discharges 54. Costings: ESD services Lambeth Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 90 of 99 Final Report

91 55. Performance against community outcome standards 56. Lambeth Rehabilitation service for Stroke Guidance for hospital staff 57. Lambeth stroke Services for Hospital Discharges Finance and Activity Report Model Eligibility criteria for community care services: Lambeth Local Authority 59. Annual Report: Lambeth PCT 60. Five year commissioning strategy: Lambeth PCT 61. Business plan : Lambeth PCT Lewisham Lewisham Local Authority: Lewisham PCT Structured interviews: Mark Lowe, Lewisham LA; Ruth Sheridan, Head Independent Rehabilitation Service & Intermediate Care Services 63. Structured interviews: Dr Steve Smith Clinical Advisor, Mariccio Lomba Lewisham PCT 64. Integrated Care Pilot Programme Stage One Application Lewisham PCT 65. The Stroke Care Pathway in Lewisham: Review of Stroke Services 66. Corporate Strategy : Lewisham Local Authority 67. Extract from website: OT services in Lewisham: Lewisham Local Authority 68. Annual report 2007/8: Lewisham Local Authority 69. Corporate Plan : Lewisham Local Authority 70. Annual charging policy: Lewisham Local Authority 71. Commissioning Strategy Plan: Lewisham PCT 72. Report of Joint Strategic Needs Assessment and PCT Commissioning Strategy Plan engagement event held on 20th October Long term condition strategy: Lewisham PCT 74. Operating plan 2008/9: Lewisham PCT Richmond and Twickenham London Borough of Richmond upon Thames: Richmond and Twickenham PCT Structured interview with Neil Roberts 76. Service specification fro Community Health Service 77. Annual report 2008/8 London Borough of Richmond on Thames 78. Community Plan 2007 to 2017 London Borough of Richmond on Thames 79. Statement of accounts 2007/8 London Borough of Richmond on Thames 80. Budget considerations 2008/9 London Borough of Richmond on Thames 81. Commissioning plan 2007 Richmond and Twickenham PCT 82. Annual health check Richmond and Twickenham PCT 83. September 2008 Health Newsletter Richmond and Twickenham PCT Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 91 of 99 Final Report

92 Sutton and Merton London Borough of Sutton: London Borough of Merton: Sutton and Merton PCT Structured interview with Jon Palmer, Chanelle Ali, Annette Bunka, Jenny Rees 85. Specification for Community Neurological Rehabilitation Service - Sutton and Merton PCT 86. Service Initiatives - Sutton and Merton PCT 87. Operating Plan - Sutton and Merton PCT 88. Commissioning Strategy - Sutton and Merton PCT Southwark London Borough of Southwark: Southwark PCT Structured interviews with Heather Campbell & Alison Ewens 90. Southwark integrated stroke pathway hospital discharges 91. Southwark integrated stroke pathway service description 92. Social care Savings arising from ESD 93. Performance standard compliance community rehabilitation 94. Proposal to enable ESD support in Southwark 95. Changes to the structure of Neuro-Rehabilitation in Southwark 96. Individual client costs 97. Intermediate care unit details Southwark PCT 98. Independence and wellbeing for Life London borough of Southwark /9 Operating Plan Southwark PCT 100. Annual report 2006/7 Southwark PCT 101. Commissioning Strategy Plan 2008 to 2013 Southwark PCT 102. Annual report 2007/8 Southwark PCT 103. Getting the most out of life Services for Older People Southwark PCT and London Borough of Southwark Wandsworth Local authority website: PCT website: SW London Neuro-Rehabilitation Review, Final Report , NHS London 105. LA Website Improving Social Care 106. Voluntary Sector Survey, Corporate resources overview and scrutiny committee - 19th November Healthcare for London: acute stroke and major trauma services in London, report to PCT Board 108. Interviews with Rachel Sibson and Katie Walsh 109. Wandsworth PCT Strategic Intentions 2009/10 Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 92 of 99 Final Report

93 Stroke Association Website: Interview with Sue Hampton 111. Stroke association Support Services Quality Framework June List of Bids to provide services 113. List of current services provided in London 114. Pro-forma communication support proposal 115. Core Costings for Family and Carer Support services and Communications Services Different Strokes 116. Structured interview with Jeffie Won, Regional Coordinator 117. Support for younger stroke survivors (handout) Fairlee House Nursing Home 118. Certificate of Hallmark Award: Framework in Homes 119. Investors in People Review Report CSCI reports of unannounced inspection September Main brochure 122. Structured interview of the registered manager NICE 123. Stroke Audit Report final version 124. CG68 TIA Algorithm 125. CG68 Stroke Algorithm 126. CG68: Costing Report 127. CG68: Costing template 128. CG68: NICE Guidelines 129. CG68: Stroke Slide set in PowerPoint 130. Stroke Audit Support Final Version Healthcare London 131. Rehabilitation and community care stroke strategy 132. Stroke Incidence 133. Acute Stroke Strategy and all Appendices 134. Essential Stroke Audit Detailed Consultation results of Acute Stroke Strategy 136. JCPCT various minutes Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 93 of 99 Final Report

94 Modernisation Initiative 137. What is ESD, Working paper from Modernisation Initiative 138. Goal attainment Scoring system 139. Good Practice Guide Practitioners Toolkit 140. Closure Project Summary Assessments 141. Closure Project Summary Lambeth ESD 142. Closure Project Summary - Southwark ISP 143. Patient Handbook 144. Prevent a stroke today refer your TIA 145. Producing a Stroke information toolkit 146. Closure Project Summary Stroke skill and development 147. Closure Project Summary Stroke peer support 148. Closure Project Summary user involvement 149. Psychology CD 150. Stroke competency Database Unqualified 151. Stroke competency database qualified 152. Stroke Long term project support 153. Stroke pathway final 154. Development of a peer support network for people living with stroke 155. TIA GP Referral Toolkit 156. TNA Instructions for template Government and other publications 157. National Stroke Strategy Department of Health 158. Minutes of inaugural meeting of the Parliamentary Group on Stroke 159. Department of Health Demonstrating How Stroke Care Works - LAC (DH) (2008) National Guidance for Stroke 161. Stroke guidelines version Stroke strategy public affairs briefing 163. Community Health Partnerships\03 Operations\1.0 Communications\02 CHP Website\Community Hospitals\care pathways\bristol\004 Appendix 4.vi Stroke Pathway (part 1 of 3) onset to 72hrs.doc 164. Community Health Partnerships\03 Operations\1.0 Communications\02 CHP Website\Community Hospitals\care pathways\bristol\004 Appendix 4.vii Stroke Pathway (Part 2 of 3) -72hrs to Discharge.doc 165. Calgary Health Region Alberta Provincial Stroke Strategy Implementation report 166. Alberta Provincial Stroke Strategy Stroke Blueprint 167. Alberta Stroke Pathway 168. Australian Stroke Care Pathway 169. Calgary Stroke Pathway 170. Lambeth and Southwark Stroke pathway 171. Northumberland Community Stroke Pathway 172. Gloucester Stroke Pathway 173. Integrated Stroke care Pathway, Amanda Adams 174. Grampian Stroke Pathway 175. Minutes: Toronto Stroke Council 176. Western Isles Stroke Pathway 177. Worcester Stroke Pathway Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 94 of 99 Final Report

95 178. Interactive population data updated to 2006: Office of National Statistics, Full set 179. CSCI Statistics and registration of all care providers in South London 180. Improving Commissioning Services Guidance to providers 181. Table of staffing standards by profession covering all Stroke involved healthcare professions Cardiac and Stroke Network 182. PHAST Project Report: Health Needs Assessment: Stroke in South West and Southeast London, January Structure Interview with Geoff Cloud and Gill Clackie 184. CONFIDENTIAL Draft Stroke Rehabilitation Strategy 185. PHAST Project Report: Health Needs Assessment: Stroke in North East London Hospital provider trusts 186. Barts and London NHS Trust Annual Report July Barts and London NHS Trust Pathfinder summary report 188. Guys and St Thomas s Trust annual report 189. Kingston Hospitals NHS Trust Annual Report 190. Kingston Hospitals NHS Trust Business Plan 191. Kingston Hospitals NHS Trust Annual Review 192. Mayday Hospital NHS Trust Annual Report 193. Mayday Hospital NHS Trust Corporate Objectives 194. Mayday Hospital NHS Trust Service Improvement Plan 195. Mayday Hospital NHS Trust Executive performance report 9/ Mayday Hospital NHS Trust September 2008 dashboard report 197. Queen Elizabeth Hospital NHS Trust Greenwich Annual Report 198. Princess Royal Hospital Bromley Annual Report 199. Queen Mary s Hospital Roehampton Web site downloaded Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 95 of 99 Final Report

96 Evaluation of the methodology At the end of this process, we have considered the methodology used and the process that we followed in carrying out this work. The staff development methodology is well tested in the United Kingdom as well as in a number of other countries. The key risk area in this methodology is the assignment of discrete times to each element of service and the potential that different activities overlap. This normally occurs in clinical situations where staff routinely undertakes more than one task at the same time e.g. preparing the equipment to carry out a clinical procedure whilst discussing the care of another patient with a staff member, giving them a verbal report. In this situation, we consider that there is very little likelihood of task overlap between travel, face-toface contact, and office reporting which are the three elements for which timings were set. Therefore, we consider that the timing method is robust. However, different clinical staff may consider that the number of minutes assigned to each talk is too high or too small. We built our staff-modelling tool as an Excel spreadsheet. Each, any group or all of the variables can be changed and the results will be predicted accurately. The variables in the spreadsheet are as follows: Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 96 of 99 Final Report

97 Modelling Framework South London Cardiac and Stroke Networks Input variables Output results Group modifiers Number of patients admitted to hospital Percentage of hospitalised patients who die prior to discharge Number of patients who will be discharged from hospital and require care in the community setting Local death rate statistics National death rate statistics For each standard, The percentage of all patients discharged from hospital that will require the service described in this standards (0-100%) The number of minutes required for each face to face contact (No limits set) The number of occasions per week during which this face to face contact will be required (no limit set) The number of weeks over which this service will continue to be provided (no limit set) The grade of staff by RSW, Physio, OT, SALT, Psychiatrist, Psychologist,, Team or Therapy Leader, Other who will provide the service this is as express as a % where 100 percent means that the total number of minutes is given by 1 professional group. No limits are set so that: 200% would mean that 2 people are always required to provide that service for whatever reason e.g. say risk of injury 100% of each of three groups of staff would mean that each of, say, PT, OT and SALT were required to provide the service for example ESD services provision. A staff input could be split equally or unequally across two type of staff say and RSW and a team leader by enter 50% in each of two boxes As above but number of minutes of travel time required per return journey to the clients house all same input variables apply As above but number of minutes of office preparation time required all same input variables apply The total number of input minutes of face to face contact required to achieve in full the standard The total number of face to face contacts by type of staff required for all relevant patients over the course of one year The total number of minutes of travel for all patients for this standard is calculated as above The total number of minutes of office time for all patients for this standard is calculated as above Green Standard or Gold standard of performance Green standard or gold standard of performance Green standard or gold standard of Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 97 of 99 Final Report

98 Input variables Output results Group modifiers performance Cost variables are: Weighted staff cost for each group of staff per None Base cost per per type of staff minute of services Overhead contribution percent applicable to staff Other contribution percent applicable to staff Other amounts to be added with respect to staff Performance variables: Percent of patients to which this standard applies at the Gold Standard Level Percent of patients to which this standard applies at the Minimum Standard Level Percent of patients estimated to be appropriate for this type of care or service Compound weightings applied to the numbers of patients being discharged from hospital Gold or Green Standard Staffing general Number of house per All of these variables are applied on a standard or sub-standard basis within a relatively simple Excel model that has no protected fields. It can be used live to model the impact of changes in any one or any group of variables. Numbers of staff required by staff group and by borough/pct across South London. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 98 of 99 Final Report

99 Process evaluation The time allocated to complete this work was a total of three months commencing January 2009 and with the final report to be presented on 31 March The key stage that imposed some delays was the Interviews. In the run-up to the new budget year, it is always difficult to arrange appointments for a 90-minute session at relatively short notice especially at the post-christmas stage in the planning and commissioning process. It proved particularly difficult to obtain interviews in Local Authority Social Services Departments, partly because they do not record information on diagnosis. Therefore, they were unable to recognise the numbers of clients with stroke who were returning to their communities. Ideally, it would have been helpful to have a period between submission of the report and its adoption in which to revalidate with interviewees that we have properly interpreted their comments. Comprehensive Review of Current Stroke Rehabilitation Services in South London Page 99 of 99 Final Report