Stroke rehabilitation in the community: commissioning for improvement

Stroke

NHSNHS Improvement

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Stroke rehabilitation in the community:commissioning for improvementAn information resource for providers andcommissioners of stroke rehabilitation andearly supported discharge services in thecommunity

Co-authors

David Broomhead, MCSP.SRPPhysiotherapy Service Manager, NorthLincolnshire and Goole NHS Foundation Trust

Pam Green, BSC (Hons) MSCPSpecialist Physiotherapist and AssistantDirector Contracting N.E. Essex

Jill Lockhart, MCSP. SRPNational Improvement Lead - Stroke, NHSImprovement

Tracy Walker, BAOT. MSc Stroke Lead and Clinical SpecialistOccupational Therapist Community StrokeService, Lancashire Care NHS FoundationTrust

Advice and support

Steve PrunerCommissioning Officer Adults, Health &Community Wellbeing, Essex County Council

Michael KaiserHealthcare Commissioning Consultant,NHS Improvement – Heart

Thank you

Thank you to all the early supporteddischarge (ESD), community stroke andneurology teams who shared informationabout their services with us, andthe cardiac and stroke networks, includingcommissioners, who answered our questionsand shared their knowledge with us.

Acknowledgements

Executive summary

Chapter 1: Setting the scene for stroke rehabilitation in the community • The current situation• Existing evidence and guidance to support rehabilitation in the community • Tariff progress for stroke • Commissioning for stroke rehabilitation - guidance

Chapter 2: Defining and developing a community service for stroke• Understanding what good looks like • Developing a good service - the process• What influences and shapes the selection of a local model for ESD• Models of delivery• Practical help in understanding your local services• Opportunities to realise economic benefits through community rehabilitation• Useful tools to help understand the local picture• Developing an integrated approach between health and social care

Chapter 3: Planning for improvement• Engaging stakeholders• Tools to support the process• Measuring for improvement• Effective leadership, management and workforce

Chapter 4: Examples of innovations in stroke rehabilitation• Improving access and uptake• Using telemedicine• Providing stroke services in rural areas • Capitalising on pathway redesign

Chapter 5: Commissioning stroke rehabilitation in the community • The practicalities • Unbundling the stroke tariff• The process for achieving unbundling of the stroke tariff• Achieving quality and value through procurement

Conclusion

References

Contents

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Executive summary

‘Achieving sustainableimprovement will also meantaking on the challenge ofservice change, to provideservices closer to patientswherever appropriate and toimprove integration betweenservices……real change can beachieved where managers andclinicians work together withcourage and skill where changeis needed in the interest ofpatients and taxpayers forexample to the organisation ofcare for long term conditions egthe configuration of strokeservices. As well as trulyclinically led commissioning anda robust and diverse providersector, service change requiresthe right environment at locallevel, an environment in whichpatients, the public andcommunities are highlyengaged.’1

The development of communityrehabilitation including earlysupported discharged (ESD) servicesfor stroke survivors provides both achallenge and an opportunity. Overthe last five years many goodcommunity rehabilitation services havebeen developed that can demonstratepositive impact on the experience andoutcomes for stroke survivors in theirlocality. Sustainable and effectiveservices put the patient at the heart ofthe service, and make year on yearimprovement in outcomes. They bringfinancial savings across the pathwayand for social care, and continue todevelop in line with the aspirations ofthe stroke strategy for meaningful lifeafter stroke and long term integrationby embedding their service withintheir local community.

Discussions around ESD offer localcommunities an opportunity toexamine and review their existingservices and the local pathway ofrehabilitation in the community for allstroke survivors. Where this is done inthe context of a whole integratedsystem, ESD can be a catalyst forchange and improvements in thecommunity for all stroke survivors.

Early supporteddischarge (ESD) can bethe impetus for changeto rehabilitation in thecommunity. Identifyingexisting local services,and joining up specialistand non-stroke specialistexpertise creates thefoundations of aneffective service.

• Community rehabilitation services should be organised around local patient need

• Community services should be commissioned for all stroke survivors notjust ESD to avoid inequity

• Considering the perspectives of all stakeholders can mean taking a flexible approach

• ESD requires a process of financial flow to follow the patient and clear budgetary movement to release and redirect revenue

• Identify quality community data and protect resources to sustain the process.


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1NHS Outcomes Framework 2012-13. Department of Health, 2011.


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‘It will be equally importantthat, as more decision making is taken locally to reflect theneeds of patients and theclinicians who support them,the NHS does more to integrateservice delivery, not only acrossprimary and secondary care but also with social careorganisations. Each sectorneeds to look at where it canwork better with partners,including voluntaryorganisations, so that servicesare organised around theinterests of patients and serviceusers rather than institutions.’1

‘Stroke rehabilitation in thecommunity - commissioning forimprovement’ provides keystakeholders with information tosupport them with the process ofdeveloping rehabilitation services forstroke survivors in the community. Itincludes examples of good practice,and information about service modelsimplemented in England. It exploresfactors which influence localcommissioning and identifies tools toassist with the process ofcommissioning and funding ofrehabilitation for stroke survivors inthe community. This is particularlyimportant at this time of majorchange within the NHS. A differentcommissioning landscape is emergingalong with a new outcomesframework and positioning of strokewithin long term conditions.

For stroke community services thismay mean starting off small and astep by step process. It requiresstakeholders to look at the wider poolof people who impact on the localstroke survivors’ environment, manyof whom are not exclusively strokeskilled, and how this can beaddressed. With education andtraining, support and time, the poolof stroke skilled people within acommunity across health, social care,the voluntary sector and local supportorganisations can be widened. Bybringing these people together withclinical communities, patients andcommissioners, cost effective andmeaningful rehabilitation in thecommunity can be delivered.

1NHS Outcomes Framework 2012-13. Department of Health, 2011.


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Chapter 1: Setting the scene for strokerehabilitation in the community

The current situation

Stroke rehabilitation works. Specialistcoordinated rehabilitation, startedearly after stroke and provided withsufficient intensity, reduces mortalityand long-term disability2. Whilstthere is robust evidence showing thebenefits of ESD services, and aconsensus3 to guide theimplementation of evidence basedESD service, there is currently a lack ofacademic literature that can be easilyused to guide service provision afterESD, or for stroke survivors for whomESD is not beneficial. This is beingaddressed by work carried out byCollaborative Leadership in AppliedHealth Research and CareNottinghamshire, Derbyshire andLincolnshire. (CLAHRC NDL) and NHSImprovement - Stroke and will bereported on in a separate publication.

Consequently the evolution ofrehabilitation services in thecommunity, including ESD is patchy,variable and inconsistent, reflectinglocal attempts to make it work;reconciling the evidence,recommendations and guidelines withlocal need and local financial context.

‘There is a wide variation in theavailability of rehabilitation andcommunity services. Some areas haveearly supported discharge services,responsive community strokerehabilitation teams and vocationalrehabilitation services. Other areashave no dedicated community strokeservice.’4

The Care Quality Commission (CQC,2011)5 reported across a number ofaspects of ESD and communityrehabilitation services and concluded:‘The overall picture is one ofinconsistency, waits between transferhome and commencing communityrehabilitation and lack of specialistaccess. They comment ‘thesedifferences suggest that clearerguidance is required on whatconstitutes ESD’.

The NHS Improvement - Stroke teamhas developed a clear understandingof the challenges and rationale behindthe local development of strokerehabilitation services, throughworking with clinical teams,commissioners, networks and serviceproviders. Services range fromeffectively embedded strokerehabilitation pathways demonstratinggood outcomes and value for money,to virtually non-existent access to evengeneric rehabilitation services. It isclear that the term ESD is oftenmisinterpreted; it is used instead of‘community rehabilitation’ with themistaken assumption that the termsare synonymous and some serviceshave adapted ‘early’ into earliest. Forclarity in this document communityrehabilitation refers to therehabilitation patients receive onleaving hospital and includesrehabilitation for patients bothappropriate for and not eligible forESD, pertaining to the commissioningprocess. The services have beendifferentiated where necessarythroughout the document.

‘Stroke costs

the country £7

billion, with £1.7

billion spent on

community

costs, which

includes

nursing home

care for stroke

survivors’

National Audit Office, 2010

2National Stroke Strategy, Department of Health, 2007.3A Consensus on Stroke; ESD, Fisher et al, Stroke AHA, 2011.4Stroke Rehabilitation Guide, Health Care for London, 2009.5Supporting life after stroke, Care Quality Commission, 2011.


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Existing evidence andguidance to supportrehabilitation in thecommunity

Early supported discharge There is research evidence supportingthe implementation of ESD servicesincluding work by Langhorne6,7 andthe ESD consensus work fromCLAHRC. The latter states that ESDteams should be stroke specific andmultidisciplinary, offering co-ordinatedand planned discharge from hospitaland continued rehabilitation whenpatients are settled at home. Theintervention is beneficial for a subsetof the patient population; those ofmild-to-moderate stroke severity.Strong links are required between theacute service and the ESD team, withboth hospital staff and ESD teammembers identifying patients. Tomeasure effectiveness, ESD teamsshould use standardised assessmentsto monitor stroke severity,dependency, activities of daily livingand satisfaction as well as the impactof the ESD service on length of stayand readmission rates.

Healthcare for London (HfL) guidancedescribes ESD as enabling a seamlesstransfer of care from hospital tohome. This gives stroke patients theopportunity to continue rehabilitation,while being supported in their ownsurroundings and with input from aspecialist stroke team.

They recommend an intensity of ESDand state, ‘for the time they wouldotherwise have been receivinginpatient rehabilitation (usually up totwo weeks), stroke survivors receive atleast five sessions per week ofoccupational therapy, physiotherapy,and speech and language therapy.While initial assessment of the strokesurvivor is carried out by qualifiedprofessionals, some care may bedelivered by therapy assistants underthe supervision of a qualifiedprofessional. Following this initialintensive period, the therapy regimethen reverts to the level of normalcommunity rehabilitation.’

The Royal College of Physicians8 (RCP)guidance around intensity states, ’ESDis designed to give eligible strokepatients rehabilitation in their ownhome at the same intensity asinpatient care.’

The National Stoke Strategy2 (2007)comments that, ‘the number ofpatients suitable for ESD will also varyaccording to eligibility criteria, but intrials an average of 41% of patientswere found to be suitable.’

‘The team went aboutachieving my aims andwhilst doing so made itfun for me and I lookedforward to their visits.They set about workingwith me and filling mewith confidence andenjoyment and I soonmade very quickprogress. While I know Ihad to put in a lot ofeffort, their kind friendlynature I would sayplayed a big part. Thegreatest pleasure andcredit I could give themwas my progress. Ifanyone wants to knowif the scheme worksthey only have to lookat my happy progress.’

Taken from a patient’s thank you letter

6Langhorne et al, 2005.7Langhorne et al, 2007. 8National Clinical Guidelines for Stroke, RCP, 2008.


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HfL states, ‘community rehabilitationshould be a simple, coherent servicethat is easy to navigate. This serviceshould have a single point of entry, nowaiting lists and be accessible to allstroke survivors. It should be designedaround the needs and goals of theindividual, so the stroke survivor isassessed by a specialist stroke multi-disciplinary team who will determinethe best use of the team’s resources.Community rehabilitation teamsshould also assist appropriate strokesurvivors to access vocationalrehabilitation.’

The NICE quality standards10 for strokeset specific measures for frequencyand intensity of rehabilitation andaccess times. They make no distinctionbetween ESD and non ESD services.

9Life after Stroke; commissioning guide. NHS Commissioning support for London, 2010.10NICE Quality Standards for Stroke. National Institute for Clinical Excellence, July 2010.

The National Stroke Strategy focusesfour quality markers, aroundrehabilitation in the community, QM10 rehabilitation; QM 12 seamlesstransfer of care; QM 15 participationin community life, and QM 16 returnto work.

b) Shaping of the pathway forcommissioning rehabilitation inthe communityThe National Stroke Strategycomments that some people maymove into care homes, but can stillbenefit from rehabilitation, dependingon individual needs. Depending onthe model of delivery adopted,commissioning for care homes may berelevant for community services thatinclude ESD and non ESDcomponents.

In its guidance on support forLondon, NHS Commissioningstates that, ‘all staff in nursinghomes, care homes and residentialhomes should be familiar with thecommon clinical features of strokeand the optimal management ofcommon impairments and activitylimitations. Although thispopulation has long gone withoutthe access to quality stroke andsocial care services that they needand deserve, local commissionersneed to organise services to ensurethat this population can alsoreceive the care they need’.

Early Supported Discharge

ESD team members attend weekly MDTon acute stroke and rehabilitation unit

Stroke survivoridentified by orreferred to ESD

Does strokesurvivor fit the

criteria?

YES

NORationaledocumented

Face to face contactmade with ward, strokesurvivor +/- family/carer

ESD team memberestablishes level ofrehabilitation needed

Rehabilitation

Weekly MDTmeetings

Stroke Association/TSSS attend MDT

All identifiedhome equipmentis in place

Patientdischargedhome

ESD makecontactwithin 24 hrs

Goals agreed byESD and strokesurvivor +/-family/carer within 1 week/named key workerassigned within1 week

Referral tospecialist servicesif required

Have all goalsbeen met or

potentialreached asagreed byESD/strokesurvivor +/-

family

YES

NO

All relevantinformationgiven to strokesurviovor/familyand relevantorganisations toinclude ongoinggoals/careplans

Onward referralsagreed by ESDand strokesurvivor/familyand made

Onward referralsaccepted andstart datesagreed ifapplicable

ESD dischargesonce all agreedsupport networks inplace andcontact name and detailsgiven

Rehabilitation in the communityThe National Stroke Strategy, NationalInstitute for Health and ClinicalExcellence (NICE) quality standards forstroke, RCP clinical guidelines and HfLinclude guidance around thecommissioning of rehabilitation in thecommunity, to assist withunderstanding the wholerehabilitation pathway. London hasadditional guidance, Life after Stroke;commissioning guide. NHSCommissioning support for London20109 which focuses on how servicesshould be configured to supportstroke survivors in the period of theirlives following their acuterehabilitation.

a) Pathway configuration and designThe RCP (2008) recommend wholepathway commissioning stating,‘commissioning organisations shouldensure that their commissioningportfolio encompasses the wholestroke pathway.’


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c) The use of specialist and non-specialist services The National Stroke Strategy states,’specialist teams may be moreimportant in the early stages ofrehabilitation, while generic teams canbe appropriate for the later stages.However, the configuration ofcommunity teams is less importantthan ensuring that these teams aremultidisciplinary and all staff have theright specialist skills to helprehabilitate people who have had astroke.’

HfL guidance indicates that, ‘everyprimary care trust (PCT) shouldcommission a communityrehabilitation service for strokepatients, delivered by staff withspecialist stroke skills. Serviceconfiguration should be locallydetermined. Every PCT shouldcommission an early supporteddischarge service for people whowould benefit. This service shouldinclude staff with specialist strokeskills and must meet all of theperformance standards.

d) The processHfL expresses how this can bedelivered:

• Where effective community rehabilitation teams are in place ESDservices should be offered. ESD services should have appropriate staffing levels to provide ESD for suitable patients

• Every PCT should ensure access to a specialist stroke community rehabilitation service before developing an ESD service

• An ESD service is an addition to effective community rehabilitation.

• An ESD service could be provided byan appropriately resourced community stroke rehabilitation team

• There may be benefits to having theESD team and community rehabilitation team in one location. If appropriate, this would allow for the sharing of resources, such as social workers, speech and language therapists, clinical psychologists; improved communication between professionals on the stroke pathway; and a more seamless transition of care for the client between services.


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Tariff progress for stroke

NHS Improvement continues to workwith the DH Payment by Results team(PbR) on ways to support the flow offunding into the rehabilitation part ofthe pathway.

Stroke is part of HRG4, (HealthResource Group) a group of tariffsthat can be unbundled ie making itpossible to separately report, cost andremunerate the different componentswithin a care pathway. Unbundlingprovides a mechanism for movingparts of a care pathway such asrehabilitation away from thetraditional hospital setting. They donot receive a separate tariff. It ischallenging for stroke because of thedifficulties identifying a specific pointat which acute care ceases andrehabilitation begins. In most casesthere is a degree of overlap.Unbundling is useful where it supportschanges to care pathways butexcessive unbundling carries risks,such as inadvertently creating a fee-for-service system where every serviceis commissioned and billed forseparately. More detail around localwork on unbundling is available inChapter 5.

‘Equality and Excellence: Liberatingthe NHS’ (DH 2010)11 also announcedplans to accelerate the developmentof currencies and tariffs forcommunity services. Communityservices have lacked some of thebuilding blocks such as national dataflows that allow the consistentcapture of a classification or currency,and this has impeded the move awayfrom block contracts.

‘Transforming community services:currency and pricing options forcommunity services’12 recognises thechallenges progressing this worknationally and helps the NHS to createnew local currencies and betterpricing.

PbR stroke guidance for 2012-13 is to carry forward existing guidancefrom 2011-12. This includes anaspiration for local unbundling, localnegotiations and processimprovements around managing tariff so that the flow of funds follows the patient from acute intothe rehabilitation parts of thepathway.

More information to understand thetariff process13 can be found at:www.dh.gov.uk/health/2012/02/confirmation-pbr-arrangementsand in relation to unbundling, atwww.improvement.nhs.uk/stroke/Stroketariff/Stroketariff1pathways/tabid/260/Default.aspx

11Equality and Excellence; Liberating the NHS. Department of Health, 2010.12Transforming community services: enabling new patterns of care. Department of Health, 2009. 13A simple guide to Payment by Results .Department of Health, 2011.


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Commissioning for strokerehabilitation - guidance

1. National Stroke Strategy2. NICE Quality Standards for

Stroke3. RCP National Clinical Guidelines

for Stroke4. Healthcare for London Stroke

Rehabilitation Guide; Supporting London commissioners to commission quality services 2010/11

5. Life after stroke; Commissioningguide. NHS Commissioning support for London

Commissioners may choose toestablish key performance indicatorsas part of a tendering processor toincentivise provider performancethrough the mechanism ofCommissioning for Quality andInnovation CQUIN paymentframework.

More details are available at:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance

An example of CQUIN to supportstroke rehabilitation can be foundhere: www.improvement.nhs.uk/stroke/ESD/ESDsupportingcommissioning/tabid/168/Default.aspx

Decisions on commissioning shouldalso take account of the costeffectiveness of the service, plus anyrelated costs, and include attention tostakeholder views, including the viewsof patients.

The RCP (2008) set the context,responsibilities and the challenge forcommissioners of stroke servicesstating, ‘rehabilitation services arebest delivered as close to the patient’sown environment as is compatiblewhile ensuring the patient’s care andwell-being, and taking into accountthe cost consequences of the patternof service delivery. Commissioners arekey in determining the overallorganisation of stroke rehabilitationservices, but must exercise this powertaking into account evidence andmaintenance of core services.’

Commissioning organisations mustcommission a service capable ofdelivering specialist rehabilitation athome in liaison with inpatient services,as recommended in the guidelines.

• Consider the overall organisation of services delivered to their population

• Specialist services in relation to the overall population need, rather thanspecifically in relation to stroke.


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Understanding what goodlooks like

Defining what a good service lookslike can be problematic as there aremany different models of communitystroke rehabilitation and ESD servicescurrently in place England with avariety of delivery methods, and arange of outcome metrics and datareporting.

Often the more established ESDservices were set up before the strokestrategy was published, but notbranded as such. They were createdon a foundation of good strategiclevel support, adopting pragmaticsolutions to local needs and usingexisting local resources available atthat time. They have been supportedto undergo evolutionary developmentto become today’s mature‘community stroke rehabilitationservices’ incorporating ESD.

They are not always badged as ESDservices, but incorporate its keyprinciples, together with strongleadership with clear vision, clarity ofpurpose and evidence for efficacy.They are well integrated with otherlocal providers e.g. social care, leisureservices, the voluntary sector andother community rehabilitationservices, facilitating effectivethroughput of patients. These holisticservices can also demonstrate throughtheir data, successful patientoutcomes. They have good staffretention, are flexible in the servicesthat they provide, have proven to besustainable over time and havecredibility within and outside of theirorganisations.

Portsmouth and Blackburncommunity stroke rehabilitationservices are examples of thisapproach. Their definition of earlyrelates to the earliest possibleopportunity for every patient.

More detail about these services canbe found at:www.improvement.nhs.uk/stroke/CommunityStrokeResource/CSRRehabilitationservicemodelsincludingESD/tabid/213/Default.aspx

However, this is not the caseeverywhere. In some areas, especiallymore rural and remote places, servicesare non-existent, or delivered bygeneric intermediate care teams oftenwith a strong admission avoidancefocus and limited stroke expertise.

‘Rehabilitation after stroke works’(National Stroke Strategy, 2007). It isacknowledged that patients whoaccess rehabilitation are more likely toexperience an improved quality of lifeand better functional outcomes;however translating this into thedelivery of a quality community strokeor ESD service in practice becomesmore complex where the provision ofthe rehabilitation service is shared orcrosses the pathway between primary,secondary care and social care.

Chapter 2: Defining and developing a community service for stroke

• A stroke focus and ability to provide timely transfer from hospital for all patients with a comprehensive range of rehabilitation and support

• Providing an intensity and frequency of meaningful intervention that is coordinated and reviewed

• Leadership, clear vision, clarity of purpose and evidence of efficacy

• Effective throughput of patients through integration with local providers’ social care, leisure services, the voluntary sector and other community rehabilitation services

• Good outcomes that are relevant for patients and offer value for money

• Demonstrable evidence of sustainability and credibility within and outside of their organisations.


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Developing a good service -the process

The process begins with defining andagreeing the desired purpose of astroke rehabilitation service within thecommunity and how this will bemeasured through key performancemeasures both clinical and service.This helps with understanding whatexisting local services provide, wherethe gaps are and what might need tobe done to build a service fromscratch or to improve or transformexisting community services to be fitfor supporting stroke survivors anddelivering ESD. In many instances thelocal discussions around how toimplement ESD have been the catalystfor change across the communityrehabilitation pathway for all strokepatients and have galvanised localcommunities into deliveringimprovement.

A business case should be developedin support of securing a properlycommissioned communityrehabilitation service, within whatever model is agreed locally.

An example of a business case can be found at:www.improvement.nhs.uk/stroke/Stroketariff/Stroketariff1pathways/tabid/260/Default.aspx

The purpose and aims of thecommunity rehabilitation for stroke,including ESD services should beinformed by attention to currentevidence, national policies andguidelines. It can be enriched bylearning about examples of goodpractice, and practical evidenceavailable from other sources, such asthe NHS Improvement communitystroke resource at:www.improvement.nhs.uk/stroke/CommunityStrokeResource/tabid/204/Default.aspx and the Department ofHealth publication ‘Transformingcommunity services (rehabilitation)12

enabling new patterns of provision’at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093196.pdf

A detailed service delivery model canbe planned and produced based on alocal service specification. This willvary depending on localdemographics, patient populationneeds and approach to specialistcommissioning. Engagement andcontribution from patients and carersis essential as part of the process ofbuilding the detail within the model. Itshould also include suitable metrics tocollect.

Partnership working with secondarycare stroke services and social care cansupport the design of a pathway andensure that the service model selectedis relevant and cost effective for all,and meets patient needs. Cardiac andstroke networks are often ideallyplaced to coordinate this process.

An example of a service specificationfor community rehabilitation,including ESD, can be found on theSouth London Cardiac and StrokeNetwork web site at:www.slcsn.nhs.uk/research.html

More examples can be found on theNHS Improvement website at:www.improvement.nhs.uk/stroke/ESD/ESDsupportingcommissioning/tabid/168/Default.aspx

11Transforming Community Services: Enabling new patterns of provision DH 2009


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What influences and shapesthe selection of a localmodel for ESD

There are a number of factors thataffect the selection of a model for ESDin addition to the evidence base andguidelines:

• Ability to align and contextualise theresearch and evidence to local need

• The local perspective and interpretation of ESD

• The local impact of shorter length ofstay in acute care and the demand for more rehabilitation at home

• The flavour of exiting community services - skills, content, remit and their potential for shaping to be able to deliver effective ESD

• Geography - urban, rural or remote• Funding and flow of money• Leadership within the community, presence/absence of a voice at strategic level

• Relationship between health and social care within stroke services.

When the local stakeholder grouphave agreed their local approach andthe plan for delivery, an action plancan then be devised forimplementation. It should align withthe local key performance indicators(KPIs), national indicators and fourdomains within the NHS OutcomesFramework (2011) and should includecontingency planning, review, andopportunity for remedial action. Localstakeholder groups should ideallyinclude the providers of communityrehabilitation and ESD services, localcommissioners and patient serviceusers and social care, workingtogether to agree local delivery.

Examples of KPIs can be found at.www.improvement.nhs.uk/stroke/ESD/ESDsupportingcommissioning/tabid/168/Default.aspx

KEEP

UNDERSTANDWhat you have already got and where

it is, benchmark existing services

AGREEWhere you want to be - which model

is best for your area?

PLANWhat do you need?

How will you get there?

PROGRESSTowards it, step by step

BRINGEveryone with you

Patient and carer feedback integral to the processMeasuring effect against aspirations

Collecting data and outcomes

it is, benchmark existing servicesWhat you have already got and where

it is, benchmark existing services you have already got and where

it is, benchmark existing servicesWhat you have already got and where

Where is best for your area?

e you want to be - which modelWhere you want to be - which model

How will you get there?What do you need?

owards it, step by stepTPROGRESS

owards it, step by stepT

Everyone with youBRING

Collecting data and outcomesMeasuring ef

Collecting data and outcomesfect against aspirationsMeasuring ef

arer feedback integral to the process

Collecting data and outcomesfect against aspirations

the process


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Models of delivery

A range of models is emerging acrossEngland to deliver the principles ofESD. This includes acute based,community based, and hybrid models,that broadly fall into one of fivecategories.

1. Stand-alone/acute outreach ESD only

2. ESD with community stroke/neurology team service

3. Integrated ESD within community stroke team service

4. Integrated ESD within community neurology team service

5. ESD hybrid

These are detailed in the followingtables and include cost per caseinformation, derived from the skillmix information and referral detail,provided by the teams who haveshared their service model details withNHS Improvement - Stroke. The postshave been costed at the midpoint ofthe Agenda for Change band in allcases inclusive of on costs (nationalinsurance, pension etc.). Non paycosts, travel expenses and fixed assetcosts have not been included in thecalculations as these have not alwaysbeen available, so the staffing costsact as a proxy for the cost of theservice. Where two teams share thepathway, such as models three andfour the costs should be addedtogether to give a pathway cost.

The costing model (see ‘Useful toolsto support the process, (Page 29) willallow commissioners and providers tocost services more accurately includingthe local costs where they are known.The costs of services used here areindicative and relate to theconfiguration and integration of theservices as a comparator to the fivegroups of services that have beennoted in the community and are realcommissioning solutions.


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Model 1Stand-alone ESD/outreach ESD from acute providers with follow onrehabilitation available from generic community services if required

There are relatively few of these compared with other models. This may reflectchallenges with funding additional discrete smaller services. They tend to bemore prevalent in denser populated urban cities and where there are large cityhospitals. There are examples of services that have started in this model beingadapted or merged into models three and four after a period of time.

Timeframe of rehabilitation • Usually six weeks - some teams provide two weeks, or the estimated time of acute rehabilitation, but in the patient’s home

Proportion of patients who fit criteria • Up to 40%

Number of pathways from acute provider to home• Two – ESD and non ESD

Stroke dependency level catered for• Mild to moderate dependency levels

Potential patient wait • Yes – to access the service, if the team does not contain a dedicated social worker there may be waits for care package/enablement

• Yes - potential waits between cessation of ESD and access to generic rehabilitation depending on capacity of generic services

Groups of stroke patients unable to access service • Complex/severe dependency cohorts of patients• Care home based patients• Community based patients who have not been admitted to acute care first (declined)

Additional support infrastructure that may be needed. • Follow on access to a community stroke/neuro/generic team for continued rehabilitation • Community stroke/neuro/generic team for patients who do not meet the criteria• Social care enablement/care packages: seven day patient support to enable early discharge and intensive daily rehabilitation

Re referral access • Normally one discrete episode of care post discharge without capacity to accept rereferral

Stroke skilled management for whole rehabilitation pathway • No - only for duration of service ( two to six weeks) with referral onto generic services

FACTORS FOR CONSIDERATION

COSTS

Cost per case range between £2,580 and £1,132


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Model 2ESD services with a pathway into a community stroke team or a community neurology services

Frequently created before the National Stroke Strategy, these community services are more mature and establishedservices, which have been shaped and developed further. They work alongside ESD teams, (out-reach or in-reach). Manyservices initially of this category have subsequently been developed into model three or four. Typically reasons for thisare insufficient cohort of patients to justify a separate ESD service, perceived expense of the ESD component and wherethe model was deemed to be creating a two tier service for stroke patients locally. The model offers all the componentsof model one with additional opportunities from specialist follow on rehabilitation.

Timeframe of rehabilitation • Typically six weeks ESD then referral on to the community stroke, or neurology team for continued rehabilitation of approximately three months

Proportion of patients. who fit the criteria • Up to 100% of rehabilitation patients

Number of pathways from acute to home• Two – ESD and non ESD

Stroke dependency level catered for • All dependency levels catered for, mild to complex severe

Potential patient wait • Yes – potentially to access the service, if the team does not contain a dedicated social worker there may be waits for care package/enablement to access either component from acute care

• Yes - potentially between ESD and follow on rehabilitation depending on the capacity of stroke and neurology community teams

Groups of stroke patients unable to access service • Usually all groups of patients can access rehabilitation via the ESD and non ESD pathways including ESD/Non ESD fromacute care, care home and community based locations

Additional support infrastructure that may be needed • Social care enablement/care packages providing seven day patient support to enable early discharge and intensive daily rehabilitation

Re referral access • Normally one discrete episode of care post discharge

Stroke skilled management for whole rehabilitation pathway• No - only for the length of the service (typically six weeks – three months). Further referral can be made onto generic services


COSTS

Cost per case range between £1,157 and £1,868.95


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Model 3ESD is delivered within an integrated community stroke team

Typically these services originated from an existing community stroke team that could demonstrate an ability to deliver ESDelements effectively, or where setting up a separate ESD service might compromise staffing of an existing performingcommunity service. It is more prevalent in urban/rural mix areas with district general hospitals, and in rural areas with higherstroke populations. It is one of the most comprehensive models including all the components of models one and two withadditional elements. Most of the teams in this model have re-enablement/health care, domiciliary support workers to supportwith delivery of seven day rehabilitation including multiple visits a day for up to six weeks.

Timeframe of rehabilitation • Typically goal directed approach, so available for as long as required (range three months to one year)

Proportion of patients who fit criteria • Up to 100%

Number of pathways from acute provider to home• One pathway for all patients, through a coordinated discharge/rehabilitation process led by the team

Stroke dependency level catered for• All dependency levels, from mild to complex severe

Potential patient wait • Usually no wait and immediate access to supported discharge/rehabilitation .Typically these services coordinate and lead the transfer from hospital to home

Groups of stroke patients unable to access service • All groups of patients can access timely rehabilitation including, ESD/non ESD from acute care, care homes, and community-based patients

Additional support infrastructure that may be needed• Social care enablement/Health domiciliary rehabilitation support staff: Seven day patient support to enable early discharge and intensive daily rehabilitation

Re referral access • Yes - usually these services accept re referral back into the service post discharge

Stroke skilled management for whole rehabilitation pathway • Multidisciplinary stroke skilled therapy for whole pathway, including staff from intermediate and social care

Additional components• Examples of managing patients in intermediate care beds• May offer review services• May offer specialist additional services e.g. FES, spasticity clinics


COSTS

Cost per case range between £1,336 and £2,502


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Model 4ESD delivered within an integrated community neurology service

These services have a wider remit to include neurological conditions therefore have experience and skills withmanagement of with very complex presentations. They tend to be more prevalent in rural, less urban areas, or wherethere are issues recruiting (specialist) staff or smaller stroke populations. Some of the services in this model have re-enablement/health care domiciliary support workers to support with seven day rehabilitation, multiple visits a day forup to six weeks. A comprehensive model offering all the components of models one, two and three and additionalelements.


COSTS

Cost per case £770

Timeframe of rehabilitation • Typically adopt a goal directed approach, so the services are available for as long as required (range three months to one year)

Proportion of patients who fit criteria • Up to 100% of patients

Number of pathways from acute provider to home• One pathway for all patients; coordinated discharge/rehabilitation via the team

Stroke dependency level catered for• All dependency levels of stroke patients mild – complex severe, and neurological patients

Potential patient wait • Usually no wait and immediate access to supported discharge/rehabilitation .Typically these services coordinate and lead the transfer from hospital to home

• Where the team does not include a dedicated social worker, there may be delays accessing service from acute care awaiting packages/enablement support

• There is an example of wait of up to three weeks for non ESD patients within this group

Groups of stroke patients unable to access service • All groups of patients can access the service including, ESD/non ESD from acute care, residential care and community based locations

Additional support infrastructure that may be needed• Social care enablement/Health domiciliary rehab support staff, or seven day patient support to enable early discharge and intensive daily rehabilitation

Re referral access • Yes- usually these services accept re referral back into the service post discharge

Stroke skilled management for whole rehabilitation pathway • Yes - multidisciplinary stroke skilled therapy for whole pathway

Other benefits• Examples of managing patients in intermediate care beds• May offer review services• May offer specialist additional services e.g. FES, spasticity clinics• Experience with complex case management


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Model 5Hybrid ESD – supporting more complex patients

This model is emerging from the evolution of established and successful ESD services. Irrespective of their starting model,these ESD services have develop into bigger community stroke teams by widening criteria, demonstrating the ability to safelymanage more complex patients and ensuring a comprehensive fit within the community pathway. In many circumstancesthese are community providers. They frequently operate through an in reach approach and typically offer input from fourtimes a day (ESD phase), seven days week, reducing to weekly visits by the time of exit.

Timeframe of rehabilitation • Usually time limited (range six weeks to 12 weeks)

Proportion of patients who fit criteria • Varies depending on individual criteria but usually there are higher percentages of patients than traditional ESD models, but lower than 100%

Number of pathways from acute provider to home• Two pathways, ESD and non ESD pathway

Stroke dependency level catered for• All dependency levels of stroke patients mild to complex severe

Potential patient wait • Yes, potentially a wait for the non ESD patients who do not fit the criteria• Yes, potentially a wait for follow on rehabilitation depending on the capacity of follow on rehabilitation teams in intermediate care services

Groups of stroke patients unable to access service • Patients who do not meet the criteria• Community-based patients who have not been admitted to acute care

Additional support infrastructure that may be needed• Social care enablement/health domiciliary rehabilitation support staff, to provide seven day patient visits to enable early discharge and intensive daily rehabilitation

• Follow on support from community stroke/neurology teams or generic rehabilitation teams

Re referral access • Normally one discrete episode of care post discharge

Stroke skilled management for whole rehabilitation pathway • Usually time limited for as long as the service is provided. This may cease on transfer into the community, depending on otherlocal services’ availability for example, community stroke/neurology or generic intermediate care services

Additional components• May include six month and one year review services


COSTS

Cost per case £5,162


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Working out how much ‘good’ costsThe evidence suggests ESD is costeffective, however establishing localcosts and benefits of widercommunity rehabilitation services ischallenging due to the variability ofthe intervention, the setting, and thehealth care professional delivering theinterventions. Additionally difficulty inestablishing the cost per patient andthe corresponding outcome isengendered through the use of blockcontracts for community services anda dearth of accurate measurement.Agreement and understanding of thecosts and the impact of the service arebest developed through discussioninvolving all key stakeholders whichwill in turn direct the focus on serviceobjectives.

Practical help with understanding your local services

There are many documents and resources to assist with the process ofidentifying what you need to know tounderstand your current services and help with any planned improvements.

• ESD Toolkitwww.improvement.nhs.uk/stroke/ESD/tabid/160/Default.aspx

• Community Stroke Resourcewww.improvement.nhs.uk/stroke/CommunityStrokeResource/tabid/204/Default.aspx

• Tariff Supportwww.improvement.nhs.uk/stroke/Unbundlingthestroketariff/tabid/259/Default.aspx

• DH Tariff Guidancewww.dh.gov.uk/health/2012/02/confirmation-pbr-arrangements

• Stroke Associationwww.stroke.org.uk/information/our_publications

• Different Strokes www.differentstrokes.co.uk

• Social Care for Strokewww.improvement.nhs.uk/stroke/SocialCareforStroke/tabid/89/Default.aspx

• Mind the Gap14

www.improvement.nhs.uk/stroke/Rehabilitation/tabid/285/Default.aspx

• Equality for all: Delivering safe care seven days a week, produced by NHS Improvement15

www.improvement.nhs.uk/SevenDayWorking/tabid/218/Default.aspx

• Psychological care after stroke, produced by NHS Improvement - Stroke16

www.improvement.nhs.uk/stroke/Psychologicalcareafterstroke/tabid/177/Default.aspx

• Care Quality Commission (CQC) reportwww.cqc.org.uk/public/reports-surveys-and-reviews/reviews-and-studies/services-people-who-have-had-stroke-and-their

• Delivering Quality, Innovation, Productivity, Prevention (QIPP)www.improvement.nhs.uk/qipp

• Measurement tools andpractical moduleshttp://system.improvement.nhs.uk/ImprovementSystem/Login.aspx?ReturnUrl=%2fImprovementsystem%2fdefault.aspx

14Mind the Gap: Ways to increase access to therapy and rehabilitation. NHS Improvement, 2011.15Equality for all: delivery of safe care seven days a week. NHS Improvement, 2012.16Psychological care after stroke: Improving stroke services for people with cognitive and mood disorders. NHS Improvement, 2011.


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Investment for future savingsFollowing the National Audit Officereview of stroke services in 201017,the House of Commons PublicAccounts Committee recognised thatESD could deliver better outcomesand save costs through bed closures,after initial investment to establish theservice. CLAHRC research reports thatESD reduces mean hospital length ofstay by about six days, however thetrials were done when averagehospital length of stay wasconsiderably longer. Translating theresearch into practice, the NHSCamden - stroke REDS team reducedthe average length of stay by ten daysfor 32% of people with new stroke inCamden in 2009. Five hundred andeighty acute and inpatient bed dayswere saved, leading to potentialsavings of £307,161 in acute bed daycosts. The Camden team estimatesavings of more than £200,000 or£83,000 per 100,000 population.Reducing hospital length of stayindicates only potential cost savings ifthe bed is subsequently used again.Closure of beds is needed to realiseactual cost savings.

Supporting people with stroke back towork through rehabilitation and jointworking with the Department ofWork and Pensions, vocationalrehabilitation schemes and employersis another opportunity to realisesavings for the wider health economyas well as the obvious personalbenefits to individuals and theirfamilies. Where stroke survivors are ofworking age and with support couldreturn to work, costs result fromfailure to support this area ofrehabilitation. The Confederation ofBritish Industry (CBI) estimates thatthe cost to the economy of a workingday lost to sickness is approximately£77 (2008).18

Opportunities to realiseeconomic benefits throughcommunity rehabilitation

Creating well organised servicesWell organised high quality servicesare the most cost efficient.Commissioners have a particularlyimportant role in ensuring thatservices are appropriately organised.Some of the efficiencies that can beachieved arise from altering whereand how services are delivered (RCP2008). In many instances there will bepotential costs associated with startup or with changes in practice, butthe evidence suggests that wellorganised services generally deliver anequal or better outcome at about thesame cost (HfL 2009).

Effective stroke rehabilitation canbring wider economic benefit (HfL2009) in terms of hospitalreadmissions, reduction in hospitallength of stay, reduced GPconsultations and inappropriatefurther secondary care referrals. Morecostly interventions such asmanagement of pressure damage andvenous ulcers or surgical treatment ofjoint contractures may be engenderedthrough a failure to provide timelyrehabilitation. Enabling a greaterdegree of independence at home hasan impact on the costs of communitysupport from health and socialservices.

The Blackburn communitystroke team demonstratedsavings for social care byreducing the amount andfrequency of care packages. In2010 final packages of carefor patients undergoingcommunity rehabilitation withthis team were reduced by240 hours of care per week,equating to savings of£93,600 per year.

Stroke care coordinators fromhealth and social care withinSouth Tees have developedjoint partnership working toreview the care needs ofstroke survivors in care homesettings at around six monthsto ensure an equitable serviceprovision to all strokesurvivors. They were able todemonstrate savings of£36,000 by returning twopatients form care homes totheir own home, and areduction in nursing resourcesand medication costs byidentifying and managingpotential complications inother patients.

More details are available at:www.improvement.nhs.uk/stroke/CaseStudies/CasestudiesQM14/tabid/151/Default.aspx

17Progress in improving stroke care. National Audit Office, 201018Working for a healthier tomorrow. Dame Carol Black’s review of the health of Britain’s working age population. March 2008.


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Working for a healthier tomorrow18,advised that, ’Healthcare professionalsshould consider a return toappropriate work as an importantoutcome in the treatment and supportof patients where possible. The NHS iscurrently considering patientpathways for those with major long-term conditions. For those of workingage, this should, where appropriate,include a consideration of work-related health and the steps necessaryto help the patient to move back intoemployment’.

A study of 3,000 younger strokesurvivors by Different Strokes19 (astroke charity for younger strokesurvivors) found that 75% of therespondents wanted to return towork, and gave a range of reasonswhy this was not possible. Theseincluded being forced to retire by theiremployer, being unable to drive or usepublic transport, fear of losingbenefits and feeling unable or not fitenough to do their previous job.

A more recent study also suggeststhat stroke survivors who have notreturned to work, might have been beable to do so with more support. Ofthe 339 people in the study who werein employment immediately beforethey had a stroke, only 59 (17%) wereknown to be in employment one yearon. Appropriate rehabilitation andlonger term support specificallyfocused on improving stroke survivors’fitness for work, had the potential toachieve higher rates of return toemployment.

More information is available fromwww.differentstrokes.co.uk/research/was.htm

18Working for a healthier tomorrow. Dame Carol Black’s review of the health of Britain’s working age population. March 2008.19 Getting back to work after stroke. Different Strokes and the Stroke Association, 2006.

An innovative service led byoccupational therapy in WestPark Hospital was able todemonstrate successfullyreturning 50% of their clientsto employment in 2010. Withshorter waiting lists andspeedier access clients wereable to retain and return toexisting employment.

More information can befound at:www.improvement.nhs.uk/stroke/CommunityStrokeResource/CSRLifeafterstroke/CSRLifeafterstrokereturntowork/tabid/246/Default.aspx

The Department of Health’sworkstep employment supportprogramme for people withdisabilities is delivered byBootstrap Enterprises inpartnership with Blackburnwith Darwen BoroughCouncil. This service isaccessed by the localcommunity stroke team forsupport with return to work.

More detail is available atwww.improvement.nhs.uk/stroke/CommunityStrokeResource/CSRLifeafterstroke/CSRLifeafterstrokereturntowork/tabid/246/Default.aspx

Reinvesting the fundingReview of current commissioningarrangements in light of the evidenceand guidance and assessing whetherthe right service is being provided inthe right place may enable someinvestment to be redirected towardscommissioning more suitable servicesfor the population. The experience insome London PCTs suggests there ispotential for cost savings throughsimplification and redesign of existingprocesses to ensure that only effectiveand efficient treatment is given (HfL2009). Consideration to movingresources between providers mayenable savings to be made.


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The Portsmouth communitystroke service resulted fromthe closure of an inpatient faststream stroke rehabilitationward. Pay and non-pay costswere redirected to develop acommunity strokerehabilitation team (CSRT), forPortsmouth City and south ofEast Hants. Inpatient strokerehabilitation was retained inthe form of a 20 beddedslower stream stroke ward.Around £2,000 per patientwas saved initially in 2004with savings of £3,748 foreach patient per year in socialcare costs. The team managemore than half of all strokepatients discharged fromhospital, contribute to theyear on year fall of hospitallength of stay anddemonstrate positive clinicaloutcomes.

Useful tools to helpunderstand the local picture

Estimating the financial benefits ofimproved rehabilitation is difficultbecause there is little evidence tosupport rigorous cost/benefit analysis.This can complicate thecommissioning picture for communityservices, where funding is tied up inblock contracts, and where there is anabsence of robust data collection oroutcome measurement.

The costs of training a genericteam to support stroke patientsNHS Improvement - Stroke is workingwith the UK Forum for Stroke Training(UKfST) to identify more specific detailaround the costs associated withdeveloping a generic community teamto meet the aspirations within theNational Stroke Strategy for strokepatients. The information will beavailable on NHS Improvement –Stroke website.

Unpicking block contractsAnglia Heart and Stroke Network haveundertaken work across their healthcommunity to unbundle the blockcontract, to try to understand thedistribution of cost of stroke acrossthe pathway. They wanted tounderstand the contribution towardsstroke care in hospital and in thecommunity from the block contractand to understand the contribution ofthe block contract to support the tariffpayment, Therefore they developedan approach for quantifying theamount of funding dedicated tostroke in both the hospital andcommunity setting. This has provedinvaluable when working withcommissioners and providers to

improve the provision of strokespecific services in the community. Asa result, a cost modelling tool wasdeveloped that allows providers torecognise the interdependenciesbetween staffing, income, bedoccupancy rate and length of stay.Using this, it is possible for providersto understand exactly the costwindow in which they are operatingand to identify what funding isavailable to follow the patient at anypoint of transfer to another settingduring the episode of care.

Details of the cost modelling tool are available at: www.improvement.nhs.uk/stroke/Stroketariff/Stroketariff1pathways/tabid/260/Default.aspx

Scenario generator toolScenario generator is a modelling toolthat uses pathway design to mapagainst population projections andprevalence, together with dataentered on duration, capacity andcosts, to predict future requirementsfor services, giving detail year on yeardown to step (or intervention) level.

www.improvement.nhs.uk/stroke/Stroketariff/Stroketariff1pathways/tabid/260/Default.aspx

NHS Northamptonshire usedthis method in 2010 to modeldifferent clinical scenarios tobest evaluate the impact ofthe Stroke SpecificCommunity RehabilitationTeam including an ESD. Excelwas used to do furtheranalysis of the results and tocreate a simpler way to modelthe data once the pathwayhad been designed. It was alsoused to present results.


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Bed modelling toolIn Essex, a stroke bed capacity andESD impact evaluation model hasbeen used by commissioners tounderstand and support their workaround commissioning ESD services. It can be applied to communityrehabilitation models.

www.improvement.nhs.uk/stroke/ESD/ESDsupportingcommissioning/tabid/168/Default.aspx

Data gathering It is crucial to gather as much strokespecific data as is available for analysisto work out the patient flows in theacute stroke unit and the income thatthis currently generates from tariff.Clinical engagement is essential at thisstage so that teams can provideadditional information that cannot becaptured through Secondary UsesService (SUS) data i.e. mimic strokedata and bed consumption for thosepatients that do not end up beingcoded as AA22z or AA23z in the data set.

Assumptions then need to be madearound the impact that the ESDservice will have on the acute bedlength of stay. It is advisable as perthe model tool to establish a best casescenario, baseline impact and a worstcase scenario in order to reassure theacute trust of the impact by cohortrather than on a case by case basis;the benefits of ESD on the acute staywill only be realised when it hasimpacted on length of stay.

Staff calculator toolThe UKfST have created a workforcecalculator. This electronic tool canassist users to work out staffing andskill mix requirements to deliverservices and support calculationsaround amount of clinical timeavailable from varying skill mixcombinations.

More information is available at:http://breeze01.uclan.ac.uk/SSEF/

More information to supportworkforce analysis and design can be found on the NHS Improvement -Stroke website at:www.improvement.nhs.uk/stroke/Increasingaccesstotherapy/IncreasingaccesstotherapyMeasuring/tabid/301/Default.aspx

Developing an integratedapproach between healthand social care

Where health and social care serviceswork together to facilitate a smoothreturn home for patients it can helppeople recover quickly, reduce thepressure on the individual and theirfamily and prevent unnecessaryreadmissions to hospital or carehomes (National Stroke Strategy,2007). Involving social workers in the multidisciplinary team at an early stage is an effective way toachieve this.

To achieve safe and timely dischargesof patients from the acute sector intoESD/community stroke services it isessential that health teams integratewith social care teams. Ideally strokeskilled social workers should beembedded into the ESD with aninreach role onto the acute strokeunit, to enable early identification ofpatients needing social care packagesand the mitigation of socialcircumstances that may precludetimely discharge.

A key role of the social worker shouldbe to elicit the support of reablementteams to work alongside the ESDteam at the point of discharge forthese patients. Those receiving ESDsupport should not be restricted fromaccessing reablement funding andsupport. ESD teams may workalongside reablement colleagues toensure the patient is getting thetherapeutic care they require todevelop their rehabilitation plan. Thesimultaneous benefit of this is thatreablement colleagues learn strokespecific skills and handling by working alongside the experiencedESD clinicians and rehabilitationworkers.


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In North East Essex, socialwork colleagues have beenpart of the ESD team since itsinception and commencement,and reablement packages havebeen successfully put in placefor the six week period directlyafter discharge. Social carecolleagues reported that byworking in this integrated waythe size and complexity ofsocial care packages hasreduced. The packages havebecome less complex forstroke patients and are easierand quicker to arrange.

As organisations are required tofacilitate and commission services,greater integration of health andsocial care from the centre is essential.

In Stoke on Trent, the citycouncil’s adult social servicesteam has redesigned thestroke care pathway fromrehabilitation into thecommunity.

Details of their experiences can be found at:www.improvement.nhs.uk/stroke/CaseStudies/CasestudiesQM15/tabid/152/Default.aspx

Care homesThe National Stroke Strategy alsorecommends that ‘commissionersshould also consider providing trainingon stroke to a wider range oforganisations that come into contactwith individuals who have had astroke, for example care home staff.Allied health professionals and strokevoluntary organisations are particularlywell placed to carry out this training.’

Where true integration has occurredteam are becoming up-skilled and thepatient receives the progression theyrequire through all daily tasks whichenables higher levels of independenceand reduced impairments. Cost canbe calculated around the reduction insize of care packages and carerburden, savings would directly benefitsocial care budgets and thus would besufficient to fund a social worker perESD team on an invest to save basis.

A small scale study carried outusing the Northwick Parkdependency assessment for 71patients in Leeds where thereis established joint workingbetween the communitystroke team and theintermediate care andenablement teams producedan average reduction betweenstart and end care costs of£271 per person per week.


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Chapter 3: Planning for improvement

Making any changes to existingcommunity service either to includeESD, or to deliver a new pathway forstroke survivors requires a thoroughunderstanding of where you are now,where you want to be, sign up, and arealistic action plan. Adopting a clearand transparent approach canencourage all stakeholders to buy in.This is especially important whereservices are currently being deliveredby community hospitals, or where anew service has implications for acuteproviders, requiring them to ‘let go’ ofpatients much earlier in their stay.

Achieving agreement between acuteand community providers around ‘risk’may require much discussion and hardwork to build professional trust acrossthe pathway. Anecdotal evidencesuggests that this is one of the biggestobstacles to improving timely flowinto ESD and community rehabilitationservices. Engaging social care in theprocess can be very challenging, butwhere services have persevered andhave achieved joined up working withsocial care within the hospital strokemultidisciplinary team, it has producedpositive effects on patient communityrehabilitation experience.

In some instances, it may be necessaryto develop confidence within acuteservice providers and amongcommissioners in the ability ofcommunity services to step up to thetask of delivering ESD. This can beassisted by benchmarking existingcommunity services and obtainingrelevant performance data.

Community stroke services that candemonstrate a service model offeringall patients a timely service withflexibility to deliver appropriate levelsof frequency and intensity based onneed (a pathway approach) withrobust data measurement ofoutcomes are more likely to make apersuasive case for delivering ESDwithin their service.

Engaging stakeholders

CommissionersThe evidence states that ESD can savemoney, although its primary rationaleis around delivering better outcomesfor patients. Most services report thatthe major costs are those associatedwith managing patients with morecomplex needs and disabilities;patients typically with a longer lengthof stay in hospital and in communityrehabilitation with more expensivecare costs. Greater impact on costsmay therefore be achieved throughimproved opportunities for thesepatients within communityrehabilitation; thereby reducinghospital length of stay and offering amore effective community service thatwill achieve more in less time – thusdelivering an overall shorter totalpathway length of stay and lowerfinal package of care costs.

CliniciansThe question for clinicians is how todeliver the best outcomes for patientsin their care with the resources thatare available. This involvesconsideration of the researchevidence, understanding localresources (both existing andpotential), alongside the intendedoutcomes of the ESD service.Opportunities to identify how toincrease access to therapy, intensityand frequency (such as demand andcapacity work) should be explored.

There will be an expectation that anyadditional resources to an existingcommunity team to support ESD willbe required to demonstrate maximumeffect across a range of qualitystandard related metrics and not justmore of the same. Communityservices that can offer clear pathwaysfor patients according to need arebetter able to demonstrate this.

Patients and carersThe NHS operating framework (2011)says, ‘Patients and carers should feelthat services are integrated and co-ordinated. The need for goodsystematic engagement with staff,patients and the public is essential sothat service delivery and change istaken forward with the activeinvolvement of local people.Organisations should also listen closelyto patient feedback and complaints,using this information to improveservices’.

Successful services are those thatunderstand their local needs.Consequently they have selected aservice model that works because it islocally relevant. Within their model areclear exit strategies that are relevantto their service users, and activelysupport meaningful social integration.This has been achieved through fullyincluding patients and carers in servicedesign. These services have embeddedthemselves within the localcommunity and constantly seekopportunities to further consolidatethis.


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In Haringey, the stakeholdersworked from the back of thepathway, forwards. Theyworked with patients andcarers to identify and agreelocal priorities for strokesurvivors and then developed arange of options in thecommunity. For some, strokeclubs offer long term supportwhile for others they are aspringboard to further groupsand activities that are lessstroke specific and morebroadly integrated.

Social careLocal authorities are facing anunprecedented financial and servicedemand challenge. They may wish tosee evidence that any money theyspend realises real benefits, either incost savings or reduced demand. Thisis not just about value for money.With less to spend and tighter fiscalpressures they will want to knowwhat will be realised in the short tomedium term from an investment,even if this is jointly with health. Alocal authority will need to be able toclearly see benefits for theirorganisations in joint working withcommunity rehabilitation services.

Opportunities and benefits from integrating health and social care across the stroke pathway

ACUTE CARE ANDREHABILITATION

Effective communication to jointly identify future care and rehabilitation needs.

May avoid repetition and duplication of effort.

Enables more efficient use of social care time

on ward.

Potentially improves patient and carer experience.

TRANSFER FROMHOSPITAL

COMMUNITY REHABILITATION

AND INTEGRATION

Establishment of clear joint health and social

care plans.

May reduce frequency and quantity of delayed discharges.

Enables shared use of community resources between

health and social care.

Potentially improves patient and carer

experience.

Improved carer support to manage the stroke patient’s

transition home.

Effective joint rehabilitation/enablement.

Promotes access to stroke skilled training and

support for social care staff, and enables greater

competence of care agency and care home staff.

More timely integration into the community.

Facilitates more effective use of intermediate care

beds for stroke.

Enables reduction in levels of care packages required.

May lead to increase in patients returning home from care

home beds.

Increase in number of patients remaining in own home

for longer.

Enables reduction in number ofre-referrals for additional care.

Potentially improves patientand carer experience.

REVIEW

Joint review at six months.

Increases numbers of patients returning homefrom initial placement

to care homes.

Enables reduction innumber of re-referrals

for additional care.

Fewer complications.


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There are no quick fix solutions orprescriptive answers around securingengagement and commitment fromall stakeholders. Successful outcomesin terms of an agreed servicespecification and model are derivedfrom locally agreed definitions andplans, using the evidence as a startingpoint. Understanding where you areand what already exists may bechallenging, but can yield benefit.Many areas have more potential thanmay be apparent initially, so effortspent finding out what already existsis worthwhile. It may take time toreach agreement locally around theshape and vision for communityrehabilitation but when it is achieved,clear plans can be developed to movethe service forward.

Some working examples• Evidence highlighting benefits of joint training for health and social care staff on the stroke pathway

• Savings due to a joint commissioning approach, funding a well-resourced ESD team, including therapy service provision integrated with an enabling care approach to provide intensive stroke rehabilitation within the person’s home: £315 per week saving in social care packages

• Evidence of joint working to enable timely discharge for the more complex stroke patients

• Improved patient experience and quality of life

• Achieving the aspirations of the stroke strategy for in-patient intermediate care around delivering better outcomes when professionalswith stroke expertise are part of the rehabilitation team and specialist input remains

• Joint working to reduce long term care home placement: Potential fivepatients per year case studies (Blackburn/Leeds).

More details with supporting evidencefor these examples are available onthe NHS Improvement – Stroke website at: www.improvement.nhs.uk/stroke/ESD/tabid/160/Default.aspx

Tools to support the process

There are many tools and techniquesthat can assist with analysing servicesand to help plan for improvements.These include process and valuestream mapping, understandingcapacity and demand, usingmeasurement or improvement andinvolving patients and carers.

NHS Camden used demand andcapacity work to support the businesscase for their ESD service model. Moreinformation is available at:www.improvement.nhs.uk/stroke/Increasingaccesstotherapy/IncreasingaccesstotherapyMeasuring/tabid/301/Default.aspx#workforce

In Northampton, they used processmapping with a QIPP twist to engageall stakeholders and develop apathway for their community strokerehabilitation service. Moreinformation is available at:www.improvement.nhs.uk/stroke/CaseStudies/CasestudiesQM10/tabid/147/Default.aspx

Northumbria have developed astrategy for including patients andcarers throughout their pathwayincluding education of staff. Moreinformation is available at:www.improvement.nhs.uk/stroke/CaseStudies/CasestudiesQM4/tabid/141/Default.aspx

Further resources are available fromthe Improvement Leaders’ Guidesproduced by the NHS Institute forInnovation and Improvement at:www.institute.nhs.uk/Products/ImprovementLeadersGuidesBoxSet


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An effective system for capturing andanalysing information is essential tounderstand how well a service isfunctioning and to establish theimpact of changes and proposedimprovements. Establishing systems,and then analysing the information,can be challenging in a busy clinicalenvironment.

Further information can be found onthe measuring for local improvementpages of the NHS Improvement –Stroke website at:www.improvement.nhs.uk/stroke/MeasuringforImprovement/Measuringforlocalimprovement/tabid/188/Default.aspx

Why measureTo understand the current state of the service.

Establishing a true baseline of currentservice delivery is a major part ofservice improvement. Unless the prechange position is known, it will bedifficult to know if changes are animprovement and have had anyimpact on the process or outcomesfor patients. The baseline is ameasure of how well the pathway isworking, in terms of efficiency,effectiveness and patient and carerexperience.

Measuring for improvement

• Establish a baseline - this avoids dependence on assumptions about improvement priorities

• Engage all key stakeholders - including Clinical Commissioning Groups, at the outset

• Measure what matters -agree meaningful measures at the outset and include in initial commissioning intentions

• Develop reliable systems for data collection including technical solutions

• Protect resources to collect accurate and reliable data.

To understand the direction of travelRegular monitoring and analysis ofinformation will inform the impact ofany changes on the service. It caninform decisions about whetheradjustments to the service are needed.

To determine progressWhen data is used as continuousfeedback about the effectiveness ofthe service and any improvements, itobjectively demonstrates whatprogress is being made in terms ofbenefits, return on investment,avoiding the need for assumptions.

Aligning stroke data with the outcome domains

Domain 1Preventing people from dyingprematurely

Informationabout theunder 75mortality ratesfromcardiovasculardisease willapply tostroke

Domain 2Enhancingquality of lifefor peoplewith longtermconditions

Includesmeasure of‘theproportion ofpeople feelingsupported tomanage theircondition’ and‘health relatedquality of lifefor carers’

Domain 3Preventing people from dyingprematurely

Measures‘improvingrecovery fromstroke’ usingthe modifiedRankin scoreat six months

Domain 4Ensuring thatpeople have apositiveexperience ofcare

Genericpatientexperiencemeasures ofhospital andprimary careare included

Domain 5Treating andcaring forpeople in asafeenvironmentand protectingthem fromavoidableharm

No strokerelatedindicators


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The Stroke Sentinel National AuditProject (SSNAP) audit This is the new national stroke auditintended to be the single source for allnational stroke data, and incorporatesNational Institute for Health andClinical Excellence (NICE) qualitystandards for stroke. It will includecore data about every stroke patient,mainly about their acute care butimportantly for communityrehabilitation teams will include dataabout joint care planning,psychological care after stroke, earlysupported discharge and six monthreviews. Some patient reportedmeasures are planned to be included.

More information is available at:www.rcplondon.ac.uk

The commissioning outcomesframework (COF) This will be an accountabilityframework for clinical commissioninggroups (CCGs) to enable the NHSCommissioning Board to identify thecontribution of CCGs to achieving thepriorities for health improvement inthe NHS Outcomes Framework. TheCOF will contain a number ofindicators developed from NICEevidence-based.

The measure which has the mostsignificance for communityrehabilitation teams is the modifiedRankin score at six months - afunctional recovery score. Thismeasure is planned to be collected inthe SSNAP audit.

What are the strategic, regionalindicators? These indicators currently determinedby Strategic Health Authorities, willsubsequently be determined by CCGsand will potentially be based on theCOF. These indicators tend to be morelocally defined and can include:

• Key performance indicators used to incentivise provider performance when used in association with incentive payments, such as the CQUIN scheme

• The need for commissioners to alignservice specifications with NICE quality standards.

What should local databasesinclude?Effective local service delivery isdependent upon accurate informationabout the quality of the service.Services with robust data collectionprocesses, and regular evaluationusing the information will be able todemonstrate outcomes and unmetneeds and understand the clinical andcost effectiveness of the service.Availability of this informationarticulates the value of the communityrehabilitation team and supports thefuture commissioning of the service.

Local databases should be:• Simple - collect only data which is important and will be regularly usedto develop the service where possible be consistent with national stroke data requirements to avoid duplication

• Robust - take steps to validate the data

• Patient-focussed - include regular patient and carer feedback about their experience of the service

• Part of the team culture - involve all of the team in the collection, validation or use of the data for improving the service

• Shared - make the information openly available for staff and patients to understand the level of care provided and intentions for improvement.

Lancashire Healthcare NHSTrust community stroke teamin Blackburn have developed acommunity dashboard tocollect and report on keystroke rehabilitation data inorder to evaluate and managetheir service.

More information on this canbe found at:www.improvement.nhs.uk/stroke/Increasingaccesstotherapy/IncreasingaccesstotherapyMeasuring/tabid/301/Default.aspx

Team levelThe CLAHRC ESD consensus (2011)recommends the use of standardisedassessments to monitor strokeseverity, dependency, activities of dailyliving and satisfaction as well as theimpact of the ESD service on length ofstay and readmission rates.

Some examples of outcome measuresused by individual services are detailedwithin the community stroke resource,www.improvement.nhs.uk/stroke/CommunityStrokeResource/tabid/204/Default.aspx


32

Effective leadership,management and workforce

Leadership and management

‘Clinicians with leadershipskills have the greatestability to deliver betterservices for patients andfoster innovation, qualityand safety.’

National Allied Health Professionalleadership challenge, DH, 201020

An effective strategic profile for anyrehabilitation service requires that theservice is led by an individual who caninfluence the decisions of seniormanagers and commissioners. Thisimpacts positively on service outcomesand the progress of the service locally.Anecdotal feedback and learning fromthe national rehabilitation projects2009-1021 and 2010 -1114 showedthat strong leadership withincommunity rehabilitation is crucial to success.

In most places these services are ledby an allied health professional (AHP),working with business managers atoperational level. The absence of amedical lead may be viewed as adisadvantage.

However, many of these servicesdemonstrate strong leadership fromAHPs who have access and a voice atthe highest strategic level where theycan articulate how their service alignswith national policy drivers and thebigger picture. They may not operatewithin their team as the most expertclinician, but have skills in effectiveservice management and financialacumen, and confidence with datamanagement.

Many community services haveevolved from a core group ofclinicians. They have grown over timeinto bigger services, with seniorclinical staff juggling additionaladministrative responsibilities thatcould reasonably be carried out by lessexpensive non-clinicians. Typicallyvacancies are used as opportunities torevisit the staffing matrix, and improvethe number of unqualified staff ratherthan in improving administrativesupport.

Community rehabilitation teamscommonly report difficulties in theestablishment, funding andmaintenance of administrativesupport, yet there is an essentialrequirement for any service to runsmoothly, in managing the transfer ofinformation between secondary andprimary care, and between health andsocial care.

Similarly the increasing essentialrequirements of data reporting andaudit necessitate the provision ofadequate and appropriate support.These requirements should be builtinto the specifications for strokerehabilitation services in thecommunity in order to make the mosteffective use of clinical resources, andmeet the administrative demands.

Workforce

’Specialist teams may bemore important in the earlystages of rehabilitation,while generic teams can beappropriate for the laterstages. However, theconfiguration ofcommunity teams is lessimportant than ensuringthat these teams aremultidisciplinary and allstaff have the rightspecialist skills to helprehabilitate people whohave had a stroke.’

National stroke strategy 2007

21Going up a Gear: Practical steps to improve stroke care. NHS Improvement, 2010.14Mind the Gap: Ways to increase access to therapy and rehabilitation. NHS Improvement, 2011.


33

Anecdotally, some stroke servicesreport difficulties in reconciling thiswith their commissioner focus onstrategic implementation programmesfor transforming community services.

Commissioners may have investedmoney in developing theirintermediate care services and canneed persuasion that these genericintermediate care services cannot,with some training deliver the bulk ofsupportive rehabilitation within thecommunity, for both ESD and nonESD services. Stroke services andproviders will need to be able toarticulate clearly the evidence base forstaffing and how this can align withlocal services cost effectively. It iscrucial to gain agreement among allstakeholders about how theopportunities from existingcommunity and intermediate carestaff can be realised, withoutcompromising the need for ESD orcommunity services to comprise strokeskilled staff, including strokespecialists.

Further discussions between allstakeholders may be needed in thesesituations, to agree the pathway forrehabilitation in the community, andhow ESD fits with this. Teams,including commissioners, may find ituseful to talk with, or visit otherservices who have resolved this, andusing resources such as workforcepathway analysers and the strokespecific education framework can alsoinform the process. It may then bepossible to agree the local definitionsaround stroke specific, stroke exclusiveand stroke skilled and develop aspecification to deliver an appropriate,safe service.

Establishing the current pathway and associated costs will helpcommissioners understand how theircurrent resource is used, and providean opportunity to refocus thisresource in stroke skilled care.

Rural workforceIn more rural and remote areas theemphasis has been on developingservices that can deliver the bestoutcomes for patient care within theresources that are available. In some,but not all areas, a modest additionalinvestment to support ESD may beavailable. Their preference may be onidentifying and developing skillswithin any part of their existingresources to support an equitableservice for all stroke patients. This caninclude social care staff.

Agenda for Change22 allows for thecreation of new job roles, multi-skilling of staff outside oftraditional professional boundaries,the devising of new ways of workingand the redefining of the skills andknowledge of staff to meet patientneeds rather than focusing on thegrades of staff. This alters the balancearound content and structure ofteams, allowing teams to bespecialised and skilled beyondtraditional professional boundaries,according to local needs, and alsoleads to a greater mix and overlapwith non-health providers of care,with greater emphasis on partnershipworking between differentagencies.23,24

In turn, staff time can be optimised. By integrating provision, patients withneeds that can be met by less highlyskilled staff can access theseindividuals, freeing the time of morehighly skilled clinicians to attend topatients with more complex needs.

Education and training are essential tounderpin the roles of the whole teamand staff should hold appropriatecompetencies for the delivery of carefor which they are responsible,particularly in rural areas.

Useful information is available at:www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098352

http://ukfst.org

www.improvement.nhs.uk/stroke/Increasingaccesstotherapy/IncreasingaccesstotherapyMeasuring/tabid/301/Default.aspx#workforce

22 How Agenda for Change Works, NHS Employers'. January 2011.23 Rural Proofing For Health. Swindlehurst, 2005.24 Department for Communities and Local Government. 2006.


34

Chapter 4: Examples of innovations in strokerehabilitation in the community

Buy in and ownership of a servicemay play a significant part inaccess to and uptake of ESDservices.

Improving access and uptake

Some ESD services, predominantly ofmodel type one and two, reportdifficulty achieving the 40% uptake ofESD. Anecdotally a number of factorsare thought to be relevant to this.

Acute provider confidence in the ability of community teams to ensure patient safety so early in the process.

• This can occur where acute therapy teams have limited community experience and the ESD service is community provider based and when the selected model requires hospital based therapy teams to identify suitable patients and the community team to providethe service. It may be due to historical perceptions of community services associated with long waiting times for access, and traditionally providing a ‘supportive’ rather than ‘rehabilitative’ function creating reluctance or hesitation within the acute providers. Possible solutions include closer joint working and rotation of therapy staff between services.

When the service is delivered by an acute outreach service in a trust that already has a short length of stay and where there is already a responsive community stroke service.

• These services have found it difficult to identify a cohort of patients suitable for an additional ESD service. This is typically resolved through merging ESD with the existing community stroke/neurology service.

Therapist anxiety around perceptionsof role loss and a changing jobemphasis in the hospital setting.

• In some areas where whole pathwayreconfiguration has been undertaken these staff have been encouraged to recognise that this work is more relevant in a community setting, and have been supported to move into services where rehabilitation is the priority.

There are instances of ESD serviceshaving been commissioned initially asmodel type one or two that haveevolved into models type three andfour. These models allow a greatercohort of patients to access earliersupported discharge within theprinciples of ESD from within acommunity rehabilitation team withstroke skills.

Haringey initially had tworehabilitation teams in thecommunity for stroke; the ESD(seven day team) for eligiblepatients and stroke (five dayteam) for patients with lessintensive needs. The teamshave now merged into oneservice that can see all patientsleaving hospital through anapproach that includesworking with an enablementteam for support with theintensive rehabilitation work.Analysis of their data hadshown them that there wasnot a need for two separateteams due to insufficientpatient numbers for ESD (lessthan 40%) requiring sevendays intensive rehabilitation.By reconfiguring the servicemodel into one team over fivedays, supported by enablingcare over seven days, they areable to see all patients. Thismodel is more effective,exceeds the 40% standardand has delivered cost savings.

One ESD service within Greater Manchester found that that theircriteria only enabled them to recruit 20% of stroke patients. The rest ofthe patients had long waits for the other community rehabilitationservices (either generic or neurology single profession services) whichthey felt was not equitable or acceptable. They reorganised the servicesso that all patients could access the same team, but via two streams,one for ESD and the other, a stroke specific hospital to home. Patientscan have six weeks ESD over five days or both depending on need. Theteam are currently working on a closer working partnership with thelocal authority re enablement team. All patients can now access timelystroke skilled community rehabilitation with the result that referral rateshave increased and the service is delivering more with no change infunding.


35

Using telemedicine

The use of telemedicine to supportrehabilitation is in its infancy, so therehas been little time to establish areliable evidence base to support itsuse. However, there is some evidencethat occupational therapy,physiotherapy and speech andlanguage therapy assessments can beundertaken reliably using telemedicinetechnologies25. Telerehabilitation,including telephone follow up careand teleconferencing and may providean alternative when direct follow up isimpractical.26 Other studies havedemonstrated using gamingtechnologies as an adjunct torehabilitation.27 The inspiration formuch of the work is taken from rurallychallenged areas such as Australiawho are adopting telemedicine withinrehabilitation; much can be applicableto remote rural services in England.

Providing stroke services inrural areas

Rural areas account for approximately9.5 million residents or 35.6% of theUK population28 and present theirown challenges to providers ofcommunity rehabilitation services.They have a higher proportion ofelderly residents than urban areas andtherefore a higher proportion ofstroke patients. They tend to havepoorer transport infrastructures, andare less densely populated, resulting ingreater travel times from work base topatient homes and between patients.

Additionally, they may have morechallenges around the recruitment ofstaff, especially those from the alliedhealth professions, although staff thatare recruited do tend to stay forlonger spells.

The national picture is of most ruraland remote areas struggling to findsolutions to delivering the aspirationsof the national stroke strategy. Apragmatic approach adopting theprinciples of ESD, within an equitableservice, delivered by stroke skilledpeople offers a positive way forward.

The principles of planning the serviceare no different from those previouslydescribed. The difference lies in howdelivery can be achieved from within asmaller number of qualifiedpractitioners, across a widergeography.

25A review of the evidence of use of telemedicine. Schwamm et al, 2009.26 Tele-rehabilitation a new model for community based stroke rehabilitation. Lai et al, 2009.27 Effectiveness of virtual reality using Wii gaming technology in stroke. Saposnik, 2010.28 Office of National Statistics, 2009.

For most, a stroke excusivecommunity and ESD service is costprohibitive, and in the very rural andremote areas, a community neurologyservice is not viable. In these situationslooking at how to best enable existinggeneric teams has to be considered.

High quality care and services forpeople with stroke or at risk of strokeneed to be delivered by staff withstroke specialist knowledge. Thechallenge is how to ensure capability,capacity, and collaborative workingboth within stroke teams and acrossproviders and commissioners so thatthere is an overall focus on delivery ofhigh quality stroke care and servicesfor stroke survivors.

This requires an identified person tobe responsible for leading servicedelivery and development, includingdevelopment of staff as well asdeveloping mechanisms for, and anethos of, shared responsibility.(National Stroke Strategy, 2007).Education, training and support withoversight from a stroke lead canfacilitate the delivery of appropriaterehabilitation for stroke patients inthese circumstances. They cancoordinate the pathway andopportunities for stroke patients, andprovide the specialist expertise.

Partnership working with social careand integration with all existingservices is essential for long termsustainability. Building relationshipswith the local hospital- based stroketeam can facilitate peer support,stroke expertise and improvedcoordination.

• Services must be well coordinated

• Integration with existing services promotes sustainability

• Planning of services should include provision for all patients, including the support and rehabilitation of non ESDpatients in primary care settings

• New services should not destabilise existing provision or disadvantage another patient group.


36

Key considerations within a ruralcommunity service for strokePlanning and coordination of staffactivity is therefore essential to ensureeffective utilisation of resources, whendelivering any rural communityservices to allow for:

• Inreach and liaison with acute providers

• Attendance at multidisciplinary team meetings (MDTs)

• Journey planning and timetabling visits

• Clustering of workload around localities

• Flexible working patterns to supporthome working for data inputting, note writing and other activities.

Possible modelsSome very rural and remote areas areconsidering adopting the hub andspoke model approach, throughseveral small hubs of highly skilledgeneralists with additional stroketraining aligned very closely with localcommunity services with a definedstroke lead and overseen by strongleadership with a strategic voice.

Examples of provision of follow uprehabilitation in truly remote areas canbe found in New South Wales,specifically and more widely acrossAustralia.

Information about the models ofprovision can be found at:

www.healthnetworks.health.wa.gov.au/modelsofcare/docs/Stroke_Model_of_Care.pdf

www.ruralceti.health.nsw.gov.au/documents/initiatives/rural_stroke/Evaluation_of_NSW_Rural_Stroke_Services_2006_Phase_1_of_the_NSW_Rural_Stroke_Program_Gill,_Cadilhac,_Pollack__and__Levi.pdf on page 49

The Australian view is that communityrehabilitation can be equally effectiveif delivered in the hospital viaoutpatients, or day hospital, or in the community.

They have adopted pragmaticsolutions and their experiences canoffer useful lessons to servicesstruggling to deliver stroke skilledservices in some of the remote ruralareas of England. This includesidentifying the key principles foreffective ESD within communityrehabilitation and establishing howthis may be achieved by betterutilisation of existing resources, andthrough more extensive and specialisteducation and training.

In Cumbria work has been undertaken to implement ESD in a very ruralarea through an existing generic community team. Through limitedresources of the stroke supported discharge service to support theexisting generic community team they are managing the more complexstroke patients outside the criteria for ESD. To achieve this they havefocussed on cross training and providing specialist support to theexisting community generic team and outpatient neurology services. Thishas been achieved through a certified education programme of up-skilling for all of the rehabilitation support workers. Consequently thereis an increase in referrals to the generic community team, which theyfeel is due to more local confidence in the service, and the appreciationof the support from the stroke supported discharge service. These staffin reach to provide assessment and make the decision about whichpathway is suitable. Those patients appropriate for slow streamrehabilitation are referred to the neurology therapists who also supportthe generic community team. This creative and pragmatic approachmakes good use of local resources, demonstrates effective team work,communication and a cost effective use of education.


37

In rural Dorset, community rehabilitation services are piloting a strategyto deliver ESD across a huge geographical area, covered by ten small,community rehabilitation teams. Their data shows that each week oneor two new patients could be transferred from the acute hospital to anyof these teams, therefore each team needs to be prepared to “catch’ theESD patient. They have adopted an integrated approach with the localstroke unit to jointly identify suitable patients, and share the transferprocess. The stroke unit specialist staff are available during the twoweek ESD period for additional support as required. The ESD pilot Leadneeded to identify therapists who had sufficient stroke or neurologytraining and experience within each of these generic teams to devise aprogramme of education and a mechanism of support for them. Tosupport the service requirement for 45 minutes of therapy, they had todevise a similar approach to developing their support for staff to deliverstroke therapy and care, including competency based online packages. Itis envisaged that qualified therapists will visit the patient as often asrequired for assessment and therapeutic intervention. They will devisesufficiently detailed intervention plans and goals to allow the supportstaff to deliver functional activities and therapy up to four times per day,with availability seven days a week. The ESD Lead oversees the processof the pilot implementation, coordinating activity and measuring theimpact on patients, acute providers and the community teams, across arange of metrics, and data gathered during the first six weeks of thepilot shows very favourable results.

Capitalising on pathwayredesign

Some successful ESD and communitystroke services have developed on theback of bigger local changesassociated with local pathwayredesign or service reconfiguration,turning potential threats intoopportunities and successes.

Major changes in the locationand configuration of strokerehabilitation were plannedacross Northumbria. Thisafforded an opportunity todevelop an ESD service in thecommunity to support thenew pathway. The service wasdesigned by a widestakeholder group includingpatients to include a range ofbespoke support, - providedby stroke skilled staff - thatcould be supported to enrichthe rehabilitation opportunityfor patients in their home. Theservice reduced length of stayin acute care by seven daysand contributed significantlyto a release of £500,000 backto commissioners.


38

Chapter 5: Commissioning stoke rehabilitation in the community

The practicalities

While studies have concluded that theopportunity savings from hospital beddays released is greater than the costof the ESD service, releasing thesesavings can be difficult. Many areasare undertaking this work, but it iscomplex and requires recognition ofthe many potential implications foracute services beyond those forstroke.

For many community services, the costof rehabilitation is tied up within blockcontracts. For others, costs can bespecifically identified. Some servicescollect data showing the allocation ofresources within the differentcomplexity groups, for exampleservices in Camden and Blackburn.Such services have the potential tocost their service interventions based on severity of disability (see’Measuring for improvement, page30). However, for most communityrehabilitation teams, it is not possibleto identify costs, or cost the value ofthe service due to an absence ofmetrics, or the sensitivity of datacollected.

Traditionally stroke patients have hadlong lengths of stay in an acutesetting and in communityrehabilitation beds. Evidence nowshows that stroke patients benefitfrom a less institutionalised approachto care and that deliveringrehabilitation in the patient’s ownhome (an enriched environment)improves outcomes. The principle ofsplitting the stroke tariff is designed toallow the financial flows to follow thepatient through their patient journeyand associated pathway of care,supporting this.

The acute tariff for stroke (AA22z andAA23z HRG) is driven by the collectionof reference costs and mandatorydata. Reference costs capture thevalue of the resources (cost) in theacute setting that provides support fora patient with a particular healthproblem. For stroke this is divided intoan infarct related stroke (AA22z) or ahaemorrhagic stroke (AA23z). Tariffsinclude staffing costs, overheads,investigations and hotel costs.

The collection and statistical analysisof all associated data across acutehospitals in England is a major task. Itis compounded by the variance inreturns that reflect different pathwaysof care and access to local services. Therefore, tariffs are derived from thecosts associated within the financialyear, three years prior to the year ofrefresh/release of the tariff. So,2009/10 costs inform the 2012/13tariffs.

Three years ago a substantial amountof rehabilitation was being deliveredin the acute setting because lengthsof stay were significantly longer thannow. The National Stroke Strategy(2007) raised the profile for stroke butfew ESD services were established andthe medical model of care, rather thantherapy or rehabilitation prevailed.

The rehabilitation costs were includedwithin the acute tariff. However,where ESD services or stroke skilledcommunity teams exist, patients areleaving the acute environment muchearlier resulting in some tensionaround allocation of the resourcescurrently contained within the tariff.

The tariff splitting process is designedto reflect the localised approach to apathway of care.

There is no simple answer resolvingwhere a tariff should be split but itshould be determined by the localisedarrangement of services and financialanalysis of health care systems. Workbetween commissioners and providersto analyse the commissioner spendand provider costs, and capacity anddemand work within the acute strokepathway, should be completed beforeany local discussions about splittingthe tariff are instigated.

A potential starting point is the tarifffor the first three days of the strokepathway; where patients may or maynot receive thrombolysis. In regionswhere stroke services have shared24/7 thrombolysis that crosses PCTboarders, financial flows have beenagreed to support repatriation ofpatients to step down facilities, whenmedically fit. Details around how thishas been achieved in Anglia areavailable at:www.improvement.nhs.uk/stroke/Stroketariff/Stroketariff1pathways/tabid/260/Default.aspx


39

Unbundling the stroke tariff

There are three approaches tounbundling tariffs that are applicableand have been used with stroke:

• Unbundling the acute tariff based on the cohort that are suitable for and access ESD only

• Unbundling the acute tariff based on overall average length of stay on the acute stroke unit

• Splitting the acute tariff on a patient by patient basis.

Another alternative is to agree anominal percentage split that reflectsthe first three days of care that isaccurately costed toreflect theinterventions that needto take place duringthat time. This relatesto the repatriationwork done in the Eastof England and in theEast Midlands. PbRguidance in 2008/09indicated that apercentage tariff splitto 55:45 would beappropriate to reflectthe acute care ofstroke patients and thesub-acuterehabilitation phase(time and motionstudies should beconducted to evidencethis split if referencecosts are not collectedto specifically capturerehabilitation in theVC04 Group 3definition).

Therefore percentages may vary as inthe following worked examples.

1.Unbundling the tariff based onthe cohort that are suitable forand access ESD only

This is based on a tariff that isunbundled with a percentage ratio of48 : 52, where 48% of the tariff isretained by the provider and 52% ofthe tariff is retained by thecommissioner in order to fundrehabilitation including an ESD service.NB. 100% of eligible patients hererelates to patients that meet the ESDcriteria, therefore approximately 40%of all stroke patients.

Tariff unbundling: Example 1

414

414

100%

£520,396.12

£2,113.80

£1,257.00

£856.80

£354,717.08

414

165.6

40%

£520,396.12

£2,113.80

£3,142.49

-£1,028.69

-£170,350.84

414

327

79%

£520,396.12

£2,113.80

£1,591.43

£522.37

£170,816.48

414

414

100%

£475,492.90

£2,113.80

£1,148.53

£965.27

£399,620.30

414

165.6

40%

£475,492.90

£2,113.80

£2,871.33

-£757.53

-£125,447.62

414

327

79%

£475,492.90

£2,113.80

£1,454.11

£659.69

£215,719.70

Including Social Worker LA Funding Social Worker

ESD team staffed to see 100% eligible patients

No. of eligiblepatients

No. of patientsaccessing the service

Percentage of eligiblepatients accessing the service

Total cost of servicerequired for eligiblepatients

Unbundled fromtariff (per patient)

Per patient costof service

Per patient saving

Full service/full yearsaving


40

Tariff unbundling: Example 2 - Pessimist/Realist2.Unbundling theacute tariff based onoverall average lengthof stay on the acutestroke unit

This approach takes intoaccount the short staytariff referenced inHRG4 and applies thenational tariff to thosepatients with thenational average lengthof stay. It is based on apopulation where theaverage length of stayfor eligible patients is 16days and the averagereduced length of stayfor eligible patients iseight days. The examplehas therefore beencalculated assuming theaverage resulting lengthof stay for eligiblepatients is eight days.

NB. 100% of eligible patients hererelates to patients that meet the ESDcriteria, therefore approximately 40%of all stroke patients.

A letter template has been created tosupport the process of retrieval andredistribution of the tariff followingadoption of this method. It is basedon a practical example that has beenused by commissioners with their localacute provider. It may be a useful startpoint for commissioners consideringhow to begin this process.www.improvement.nhs.uk/stroke/Stroketariff/Stroketariff4createimplement/tabid/263/Default.aspx

414

414

100%

£520,396.12

£1,789.77

£1,257.00

£532.77

£220,568.66

414

165.6

40%

£520,396.12

£1,789.77

£3,142.49

-£1,352.72

-£224,010.21

414

327

79%

£520,396.12

£1,789.77

£1,148.53

£641.24

£265,471.86

414

414

100%

£475,492.90

£1,789.77

£1,148.53

£641.24

£265,471.88

414

165.6

40%

£475,492.90

£1,789.77

£2,871.33

-£1,081.56

-£179,106.99

414

327

79%

£475,492.90

£1,789.77

£1,454.11

£335.66

£109,761.89

Including Social Worker LA Funding Social Worker

ESD team staffed to see 100% eligible patients

No. of eligiblepatients

No. of patientsaccessing the service

Percentage of eligiblepatients accessing the service

Total cost of servicerequired for eligiblepatients

Unbundled fromtariff (per patient)

Per patient costof service

Per patient saving

Full service/full yearsaving

Tariff unbundling: Example 2 - Pessimist/Realist

5,000

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0

PRIC

E

1 4 7 10 16 19 22 25 28 31 34 37 40 43 46 49 52 56 58 6113

LENGTH OF STAY

Tariff unbundling: Example 2


41

3. Splitting the tariff on a patientby patient basis

Through this approach the tariff issplit on a patient by patient basis.Costs are derived proportional to thelength of stay for the individualthrough all pathway optionsdeveloping multiple trim points withinthe pathway. This includes stagedcommencement of excess bed days todisincentivise patients being heldlonger in the acute setting than needsbe. This is a pragmatic approach,through developing a proportionalcost in line with the reduction ofaverage length for the unit, and hasbeen used successfully. The short staytariff would be paid in line with PbRguidance.

Time period

<1 day

0-3 days (fixed tariff)

4-7 days (bed day)

Post 7 days (bed day)

Post 18 days

Tariff % paid at each range

0% (funded by A&E tariffwith high cost investigation)

20%

Up to 32%

Up to 48%

Cumulative % tariff

0%

20%

52%

100%

XBD

The process for achieving unbundling of the stroke tariff

Ensure Clinical Commissioning Group (CCG) executive sign up and support for the intention to split the stroke tariff. The process of splitting the tariff is challenging and strongnegotiation is required.

Express the intention to split the stroke tariff to the acute trust and to the wider health economy via the process ofcommissioning intentions by 1st October in order to effect thecommencement of the next contractual year 1st April as thisconstitutes the required six months’ notice to change tocommissioning and financial arrangements.

It is advisable to split the tariff in advance of commissioning local ESD or stroke specific community service.

Work closely and in partnership with the acute trust to amicablyachieve a tariff split. The principle of this process should be toensure sustainability in the acute stroke unit but a financialcontribution to the ESD service.

Evaluate and understand the local stroke pathway fully in terms of data, financial flows (block contracts or unit prices cost per casepayment structure), resource allocation, contractual framework and provider performance along with patient experience.

Split the tariff locally and ensure this is added to the acute hospitalcontract by variation to an existing contract or captured in Section B.

Step 1

Step 2

Step 3

Step 4

Step 5


42

Ensure that there is:

1. A clear strategy to monitor the effect of ESD and the stroke community service on acute stroke length of stay and the rehabilitation service outcomes. A minimum data set is required for both services.

2. A method of flagging up in SUS* the patients that have qualified for a tariff split, if the chosen approach is that of an individualised patient approach to financial flows. Otherwise acute average length of stay analysis will drive financial movements.

3. Key performance indicators thatare clearly articulated to monitor quality in acute and community services.

4. A process of financial flow with clear budgetary movement, to release and redirect revenue.

Achieving quality and valuethrough procurement

Commissioners secure services tomeet the health needs of their localpopulations, seeking to deliver thebest combination of quality topatients and value for taxpayers.Procurement enables this by securingservices through transparentengagement with providers, normallyculminating in the award of a newcontract to a new provider or theaward of a new contract to anexisting provider.

Procurement is an integral part of thecommissioning cycle. It must betransparent (open and fair)demonstrate proportionality(procurement proportionate to thevalue, complexity and risk of theservice being procured), demonstratenon-discrimination and equality i.e.open to all appropriate providers tocompete on an equal opportunitybasis, with due diligence checksaccordingly. The provision of healthcare must be compliant withEuropean procurement laws and openand competitive tender is deemedappropriate following a thoroughcontestability assessment.

An effective procurement process canhelp to improve quality and ensurevalue for money. This is particularlypertinent in times of austerity, whenthere is a need to deliver savings, topreserve stroke specificity andsimultaneously deliver improvementsand increase productivity. Whateverthe local rationale for procurement, it can also be an effective tool foropening up the market to a widerrange of providers. A morecompetitive market is seen to increasechoice for patients, as well asencouraging improvements in servicequality and innovation.29

Where service redesign is not possibleand procurement is required, fullyexecuted and successful procurementdocumentation may help to guidecommissioners through theprocurement process.

An example of procurementdocumentation, to supportcommissioning where service redesignis not possible, can be found here:www.improvement.nhs.uk/stroke/ESD/ESDsupportingcommissioning/tabid/168/Default.aspx

More information can be found at:www.ccpanel.org.uk/content/DH.pdf

A new strategy for NHS procurementis being developed and will bepublished at the end of March 2012.

*Secondary Uses Service. A nationaldata warehouse managed by NHSConnecting for Health. It providesanonymous patient based data forpurposes other than direct clinical care.

29 NHS Confederation Briefing, February 2011, Issue 215.


43

Conclusion

• ESD can be the impetus for change to rehabilitation in the community

• Agreeing a local definition of ESD is prerequisite to developing a service

• Identifying existing local services and joining up specialist and non-stroke specialist expertise creates the foundations of an effective service

• Community rehabilitation services should be organised around local patient need

• Considering the perspectives of all stakeholders can mean taking a flexible approach

• Community services should be commissioned for all stroke survivors not just ESD to avoid inequity

• Identify quality community data and protect resources to sustain the process

• ESD requires a process of financial flow to follow the patient and clear budgetary movement to release and redirect revenue.

Developing an ESD service can becomplex. It supports patients to movefrom a hospital setting back into theirhomes, and therefore means buildingeffective relationships with colleaguesacross the pathway between acutecare and the community andbetween health and social careservices. Early on, care needs to betaken to ensure that all stakeholdershave a common understanding ofwhat the service can achieve and howit interacts with existing services. Thisbuy in is crucial to success andsustainability.

There is no one size fits all model, oroff the peg solutions to eachchallenge, and despite the existenceof an evidence base, agreeing acommissioning model and establishingthe funding mechanisms can be farfrom straightforward. Despite thesechallenges, ESD services have and

continue to be developed. As a result,more stroke patients are experiencingan improved pathway of rehabilitationin the community, reduced time in thepathway and better outcomes.

The creation of an ESD service can bethe impetus for change to strokerehabilitation in the community.Irrespective of the model selected,simply having discussions aroundimplementing ESD and including allpotential stakeholders can be a meansof focussing attention on the existingpathway for community rehabilitationservices for stroke, and how ESD canimprove this. ESD can be the catalystfor change and improvements incommunity services for all strokepatients. In some localities it hasprovided the missing link joining upacute and community providers, andhealth and social care.

Different models are emerging to fit inwith local need and existing qualityservices. Identifying those existinglocal services, and joining up specialistand non- stroke specialist knowledgeare the foundations of an effectiveESD service. Achieving an agreed localdefinition of ESD is prerequisite toagreeing the local pathway and howESD will fit and improve it. These processes can be challengingbut also enlightening, as they mayresult in the identification of a muchgreater potential pool of resourcesthat can be realised and harnessed tosupport improvements to the pathwayfor all stroke patients, and theevolution of a service that is morerelevant to local needs. This in turnenhances buy in, uptake of theservice, cost effective use of resources,value for money and therefore, thesustainability of the service.

This process is important in resolvingthe tensions between the need tominimise costs for commissioners andlocal authorities, and the aspirationsfor achieving clinical excellence andownership of the service amongclinicians and providers. Attention tothe evidence and guidance canprovide the framework and awillingness to adapt this to localneeds, can help to align and realiselocal resources. Successful serviceshave typically required some degree ofpragmatism by all stakeholders, butwithout any compromise of patientoutcomes and safety.


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Local finances and perspective onmanaging the tariff can influence theprocess significantly. Organisationshave tackled this challenge in variousways, and some are now beginning tosplit the tariff. But understanding thefull impact of this on services, thepathway, or how monies releasedhave been used to fund ESD, is still inits infancy.

Good quality data is crucial for allstages of the process. The value ofreliable data, to inform the process ofcommissioning ESD should not beunderestimated. Access to baselinedata, can facilitate the planning,selection and costing of a model forESD and support the mechanisms forevaluation. Where services haveundertaken work to collect thisinformation, it has provided clarityand facilitated the process ofdeveloping and framing their ESDservices.

Although the challenges are many,they can be resolved through amixture of engagement, discussion,transparency, pragmatism anddetermination. In this way successfulESD services can be commissionedand delivered offering stroke survivorsbetter outcomes in the community.

‘Achieving sustainable improvement will also meantaking on the challenge of service change, to provideservices closer to patients wherever appropriate and toimprove integration between services.... real change canbe achieved where managers and clinicians worktogether with courage and skill where change is neededin the interest of patients and taxpayersfor example tothe organisation of care for long term conditions eg theconfiguration of stroke services. As well as truly clinicallyled commissioning and a robust and diverse providersector, service change requires the right environment atlocal level, an environment in which patients, the publicand communities are highly engaged.’

NHS Outcomes Framework, 2012 -13. Department of Health, 2011


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References

1. NHS Outcomes Framework 2012 -13. Department ofHealth, 2011.

2. The National Stroke strategy – Department of Health,2007.

3. Fisher R et al. A Consensus on Stroke: ESD. Stroke. AHA110.606285, published on line before print, March 2011.

4. Stroke Rehabilitation Guide: Supporting LondonCommissioners to commission quality services in 2012 -11.Healthcare for London, 2005.

5. Supporting life after stroke. Review of services for peoplewho have had a stroke and their carers. Care QualityCommission, January 2011.

6. Langhorne P.et al. For the ESD Trialists. Services forreducing duration of hospital care for acute stroke patients(review).Cochrane database of systematic reviews. Stroke2005: issue 2.

7. Langhorne P et al. For the ESD Trialists. ESD after stroke.Journal of rehabilitation Medicine. 2007;39:103 -8

8. National clinical guidelines for stroke, 3rd Edition. RoyalCollege of Physicians, July 2008.

9. Life after Stroke: commissioning guide. NHSCommissioning support for London, 2010.

10. NICE Quality Standards for Stroke. National Institute forClinical Excellence, July 2010

11. Equality and Excellence. Liberating the NHS. Departmentof Health, July 2010.

12. Transforming community services: enabling new patternsof care. Department of Health, 2009

13. A simple guide to Payment by Results .Department ofHealth, 2011.

14. Mind the Gap. Ways to increase access to therapy andrehabilitation. NHS Improvement, 2011.

15. Equality for All: delivery of safe care seven days a week.NHS Improvement, 2012.

16. Psychological care after stroke. Improving stroke servicesfor people with cognitive and mood disorders. NHSImprovement, 2011.

17. National Audit Office. Progress in improving stroke care.Department of Health, 2010.

18. Working for a healthier tomorrow. Dame Carol Black’sreview of the health of Britain’s working age population.March 2008.

19. Getting Back to Work after Stroke. Stroke Associationand Different Strokes, 2008.

20. National Allied Health Professional Leadership Challenge.A Toolkit. Department of Health, 2010.

21. Going Up A Gear; practical steps to improve stroke care.NHS Improvement, 2010.

22. How Agenda for Change Works [Homepage of NHSEmployers], NHS Employers', 31 January 2011, 2011 - lastupdate [Online]. Available at:www.nhsemployers.org/payandcontracts/agendaforchange

23. Rural Proofing For Health: A Guide for Primary CareOrganisations. Swindlehurst H.: Institute of Rural Health.Wales, 2005.

24. Supporting People for Better Health: A Guide toPartnership Working. Department for Communities and Local Government, 2006.

25. Schwamm L, et al. A Review of the Evidence for the Useof Telemedicine within Stroke Systems of Care. Stroke.2009.Volume 40 pages 2616-2634.

26. Lai J, et al. Telerehabilitation - a new model forcommunity-based stroke rehabilitation. Journal ofTelemedicine and Telecare. Vol.10, no.4, pages 199-205.

27. Saposnik G, et al. Effectiveness of Virtual Reality UsingWii Gaming Technology in Stroke Rehabilitation. (2010)Stroke 41, pages 1477-1484.

28. Rural and Urban Statistics Notes. [Homepage of Office ofNational Statistics] ,Office of National Statistics., 17 April2011, 2009 - last update, [Online]. Available at:www.healthnetworks.health.wa.gov.au/modelsofcare/docs/Stroke_Model_of_Care.pdf

29. NHS Confederation Briefing. Feb 2011, Issue 215


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Publication Ref: NHSIMP/Stroke0001 - July 2012

Stroke rehabilitation in the community: commissioning for improvement

Health & Medicine