Feature / Grand designs

Redesigning Leicester’s stroke services will offer an improved patient journey, but for Sue Bishop it will also mean the end of a personal odyssey. NHS Leicester City’s director of finance reflects on her secondment as stroke lead.

Stroke is one of Leicester’s biggest killers, accounting for a quarter of deaths in the city. Every year about 500 people are hospitalised following strokes or, as they are sometimes known, ‘brain-attacks’.

 No pressure then, as I took on a project to analyse every part of the current stroke pathway and to work with stakeholders to establish how we could deliver improved patient experience and outcomes.

From the outset, I knew I would need to call on my influencing and networking capabilities to drive the project forward. I hoped my strategic overview would inform the operational processes of stroke care and I planned to use the stroke project as a template for how we could improve the effectiveness of our organisation’s redesign methodology.

Yet I wasn’t prepared for the richness of learning I would receive from this process and how timely these lessons would be.

Across the NHS we are exploring ways to deal with real terms reductions in financial allocations, without failing public expectations or ignoring rising demand for services. The project taught me the ideal lesson for these times – the importance of always asking what can the frontline teach those of us driving the strategic direction of patient care?

Capturing the ideas and indeed momentum for change from those closest to patient care was an integral part of my work. Indeed, I started the project spending several days as a healthcare assistant on the stroke ward, shadowing staff and observing patients’ hospital routine, their needs and wants.

This experience and other analysis showed the pathway around stroke was complex, involving a range of interventions from emergency care to short- or long-term rehabilitation and a number of providers from the acute trust to social care partners.

Individuals enter the pathway via a number of routes. First, a patient may suffer a transient ischaemic attack (TIA), also known as a mini-stroke, and seek emergency medical help. A specialist TIA clinic at University Hospitals of Leicester NHS Trust offers diagnostics and fast access to a consultant. GPs can refer into this service if they suspect a patient has suffered a mini-stroke.

Yet for many patients, suffering a major stroke is their entry to the pathway. They will be taken to Leicester General Hospital’s stroke unit for treatment. A 24/7 thrombolysis service – the procedure that breaks down the blood clots responsible for brain attacks – will eventually be suitable for about 15% of patients who meet the clinical criteria.

Patient journeys converge during recovery and rehabilitation. Following medical stabilisation many patients stay in the specialist stroke unit. The average inpatient stay is about 20 days and most stroke survivors in Leicester are cared for exclusively in the acute sector.

Benchmarking against other trusts and the exemplar quality markers of the national stroke strategy showed that while there were many areas in which our services performed well, there was more we could do to improve patients’ choice and experience. For example, community capacity for those who have suffered stroke was limited and we were keen to offer more stroke-specific rehabilitation.

The opportunities to improve the pathway were crystallised when we began a programme of engagement that involved a group of more than 50 clinicians, carers and stroke survivors. The insight they brought to the redesign was invaluable and I found myself adding sessions to our timetable to ensure we captured every nuance of the stories that stroke survivors in particular were generous enough to share.

Involvement of patients and their carers generated areas where it would be particularly beneficial to incorporate their views and ideas to improve the patient experience. Patients told us they wanted to have input in creating discharge information, so stroke survivors and their carers would receive the information they want when it matters. They also asked for the use of a patient-held record that stays with the individual so baseline information is always available and up to date for all health and social care professionals who might need it.

To continue to build on these ideas and find others, we’ve formed a Leicester, Leicestershire and Rutland stroke participation group to make these developments happen and incorporate them into the new stroke service.

The clinical components of our redesign have been led by innovative and enthusiastic health and social care professionals, who have spent time understanding the whole pathway and its issues. They worked through options to produce a final model of care framework that incorporates best practice. This clinical input to the model of care gave it a credibility that facilitated swift clinical and patient support for the redesign.

Our new model of care creates choice for patients depending on their needs. This is demonstrated in a ‘step down process’ for those who are ready to leave hospital. They will now be able to go into a bed run by a provider or get assistance at home. We are looking at developing skilled rehabilitation assistants who work right across traditionally defined health and social care services. These staff will carry out care interventions in one trip to a stroke survivor’s home and will build up a thorough understanding of the patient’s needs through these regular visits.

The project demonstrated there is an overwhelming need for health and social care to work together across organisational boundaries and to make use of the enabling mechanisms we already have, such as pooled budgets and direct payments. Our redesigned service will pilot a formal ‘keeper of the pathway’ approach that coordinates and oversees the delivery of care across agencies.

The approach will reduce the duplication or omission of tasks identified as a risk in the current pathway at the interfaces when care transfers from one organisation to another. We intend to use contractual levers and CQUIN quality targets to incentivise the lead provider to resolve such matters as part of day-to-day management. Further, a care bundle approach to the service specification will promote consistent quality.

A key element of the redesign was to find a way to redistribute resources along the pathway – by using savings in longer term social care costs to fund prevention work in health settings, say. This is a strong feature of intense rehabilitation services in the early days after stroke, which help survivors meet safe but challenging goals in their home setting and gain independence as they recover. Work with our social care partners will ensure we channel resources so that time invested with the patient has the greatest possible impact on their rehabilitation.

By harnessing the skilled input of numerous stakeholders over an extended period it has been possible to co-create the new pathway of care and adopt the concept of continuous improvement – plan, study, do, act. The process we followed demonstrated that significant service development demands the use of specially skilled people with the dedicated time to deliver.

We’ve trialled the idea of a multi-stakeholder team reviewing and co-creating services and found that a multitude of perspectives leads to a better solution.