Business Case / Ref: 1.3
Current Stage: Final
Author: Sab Kaur Jenner
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Proposal: Community Stroke PILOT Rehabilitation Service for Bexley Residents
Document Reference: 2011/12
Version: 1.3
Issue Status: Final
Date Last Updated: 17th October 2011
File Reference:
Author: Sab Kaur Jenner
Directorate: Clinical Redesign
CONTENTS LIST
Distribution List 3
Issue/Amendment Record 3
Executive Summary 5
1.0 Executive Summary 5
2.0 Background 6
3.0 Proposed solution 9
4.0 Assumptions 9
5.0. Risks 11
6.0. Key Stakeholders 11
7.0. Communications 12
Supporting Information 13
8.0. SCOPE 13
9.0 CRITICAL SUCCE SS FACTORS / KPIs 15
10.0 DEPENDENCIES 15
11.0 CONSTRAINTS 16
12.0 APPROACHES 16
13.0 TIMESCALES 16
14.0 EQUALITY IMPACT ASSESSMENT 18
15.0 CONSIDERATION OF GREEN ISSUES – “Saving Carbon, Improving Health” 18
16.0 IT REQUIREMENTS 18
17.0 INFORMATION GOVERNANCE REQUIREMENTS 18
18.0 BEXLEY BSU - AIMS & OBJECTIVES 18
19.0 QUALITY CONTROLS AND AUDIT 19
20.0 POST IMPLEMENTATION REVIEW 20
Service Options 21
21.0 Options appraisal 21
Appendix
Appendix 1
cost benefit analysis
Appendix 2
scehule of matters delegated
Appendix 3
community stroke rehabilitation service specification (attachment)
DISTRIBUTION LIST
Refer to Care Trust Scheme of Delegation to identify who should review the Business Case
Role / Name / Position / ScopeManaging Director / Jo Medhurst/Pam Creaven / Managing Director / BBSU Strategic Meeting
Clinical Quality Lead / David Parkins / Clinical Quality Lead / Clinical Quality and Assurance
Clinical Lead / Liz Cameron / GP / Clinical Lead
Director of Finance / Theresa Osborne / Director of Finance / Finance
Clinical Cabinet
(Formal) / Howard Stoate / Clinical Cabinet Chair / Clinical Cabinet
Clinical Cabinet Chair / Howard Stoate / Clinical Cabinet Chair / Clinical Cabinet (Informal)
Assistant Directors / Julie Witherall
Clare Ross / Assistant Directors / BBSU Corporate Meeting
Cluster / Donna Kinnair / Chief Nurse NHS SEL / NHS South East London
Social Care / Catherine Searle, Helena Moran, Alison McLaughlin / London Borough of Bexley
Issue/Amendment Record
Status / Version / Issue Date / Reason For Issue/Changes Made12th August 2011 / 0.1 / 11th August / Draft
15th August 2011 / 0.2 / 15th August / Draft
16th August 2011 / 0.3 / 16 August / Draft
17th August 2011 / 0.4 / Re-draft following meeting on 16th August
2nd September 2011 / 0.5 / 2nd September / Edited following recent stroke rehab sub group meetings
6th September / 0.6 / 6th September / Edited following meeting with LBB leads for reablement
9th September / 0.7 / 12th September / Edited following stroke round table meeting 08.09.11
19th September / 0.8 / 19th September / Edited following comments from carer representative following stroke round table meeting 08.09.11
21st September / 0.9 / 21st September / Edited following comments from meeting with Stroke network.
26th September / 1.0 / 26th September / Edited following discussion with AD of Service in regards to stroke rehab model and costing’s.
7th October 2011 / 1.1 / 7th October / Edited following discussion with Clinical Quality Assurance Group in regards to risk section.
14th October 2011 / 1.2 / 14th October / Edited following discussion from Finance.
17th October 2011 / 1.3 / 17th October / Edited following discussion from Finance.
Executive Summary
1.0 Executive Summary
This document outlines a proposed solution to gaps in service provision on the Bexley stroke pathway. These were highlighted in a recent national review of stroke services[1] undertaken by the Care Quality Commission (CQC) where Bexley was ranked in the lowest quartile nationally, described as ‘least well performing’.
This business case is an application and recommendation for a stroke specialist pilot community rehabilitation service within Bexley. The aim is to ensure access to this service for all stroke patients, as is clinically appropriate. This will:
· Maximise rehabilitation and recovery after illness or injury.
· Minimise premature dependence on long term institutional care.
· Promote independence in daily living e.g. skills such as walking and dressing.
· Help stroke survivors to re-establish their status and personal autonomy.
· Provide bespoke and committed stroke rehabilitation care for patients, expediting recovery and/or discharge.
· Improve integrated care pathways for enhanced patient experience.
Service objectives
· Enable stroke patients to achieve mutually agreed, realistic rehabilitative goals to maximise their recovery in the community as soon as is possible.
· Ensure carers and families are involved in the development of stroke services and their needs are considered.
· Provide a highly skilled and experienced workforce supported by stroke specialist rehabilitation assistants.
· Develop strong relationships with referrers and supporting services, including acute multi-disciplinary meetings, social care, dietetics and voluntary sector organisations.
Proposed outcomes
· Improved health and well being outcomes as measured against specific criteria (e.g. quality of life measures).
· Improved patient and carer experience
· Timely discharge from acute services and seamless transfer from hospital to home.
· Reduction in unnecessary hospital admissions.
· Reduction in hospital length of stay.
· Quality improvements and subsequent achievement of national and local performance outcome measures[2].
· Reduced incidence and/or problems from secondary risk factors (e.g. pressure sores, chest infections, contractures).
The approach proposed by the Bexley stroke round table rehabilitation sub group is that a pilot should be undertaken, with a full procurement to be undertaken informed by the results of this pilot.
Important note - this service is not expected to deliver early supported discharge (ESD) during the pilot, as it is recommended that this should be commissioned once a robust community stroke rehabilitation service is in place[3]. This will be included in the full business case and specification for the procurement of the service post pilot.
2.0 BACKGROUND
Stroke services are a priority area for Bexley Business Support Unit, (Strategic Plan 2010-13) and work continues with local stakeholders to drive improvements along the stroke care pathway, in response to the National Stroke Strategy (2007). Bexley BSU are also prioritising elderly care services, focusing in particular on management of long term conditions and meeting the needs of the ageing population. Rehabilitation services for stroke fit well with this agenda.
Figure 1 below summarises the proposed stroke care pathway in Bexley.
In January 2011 the Care Quality Commissioning published the results of their review of stroke services[4]. This review looked at the pathway of care for patients with stroke (or transient ischaemic attack) and their carers from the point where they prepare to leave hospital through to long term care and support in the community. Bexley ranked in the lowest quartile, identified as ‘least well performing’ due to the lack of community stroke specific services in the borough.
Evidence shows that continued co-ordinated multidisciplinary rehabilitation in the community setting improves long term outcomes for patients and can help to reduce hospital admissions[5]. Specialist, co-ordinated community rehabilitation and supported discharge delivered by a multi-disciplinary team (MDT) with highly developed stroke-specific skills; started early after stroke and provided with sufficient intensity reduces mortality and long term disability.
At present a limited service is provided to Bexley patients by the general rehabilitation service, commissioned from Oxleas NHS Foundation Trust. The team that deliver this service do not have stroke specialist skills, lack the capacity to manage patients in a timely manner to support discharge from hospital, and are therefore not able deliver a service that meets the London performance standards[6].
Provision of stroke rehabilitation services across SEL is currently inequitable. Table 1 below outlines provision as at August 2011:
Table 1
Borough / Community specialist stroke rehabilitation provisionBexley / No specialist service, limited service provided by general rehabilitation, but this is generally accessed by people who have had old strokes rather than on discharge from the SUs.
Bromley / Bromley specialist community neuro rehab service (SCRehN) was commissioned in 2011/12 (from Lewisham Healthcare). This service is currently not providing access for stroke patients.
Greenwich / A community neuro rehabilitation service is commissioned in Greenwich providing limited access for stroke patients being discharged from QEH
A pilot was undertaken to deliver ESD to stroke patients through the social care funding allocated from the Department of Health, which ended on 31st March 2011.
Lambeth / Community neuro rehabilitation service in place providing ESD and community rehabilitation to stroke patients in their usual place of residence. This service has merged with Southwark community services and is currently provided by GSTT
Lewisham / Integrated service provided by Lewisham Healthcare NHS Trust
Southwark / Community neuro rehabilitation service in place providing ESD and community rehabilitation to stroke patients in their usual place of residence. This service has merged with Lambeth community services and is currently provided by GSTT.
Since the CQC review and report, Dr Joanne Medhurst, Managing Director for Bexley BSU has expressed a commitment to supporting the development of specialist community stroke rehabilitation services for the Bexley population.
Establishing a specialist community stroke rehabilitation service is expected to reduce length of stay for stroke patients, by providing the support they need to leave hospital at an earlier point than they do at present. However, there is not sufficient evidence to indicate what the potential decrease might look like at this stage, and the potential for cost savings is limited by the tariff structure for stroke. Length of stay will be monitored closely during the pilot to help inform the future service. It is important therefore to note that the key drivers for change are around equal access to a high quality patient centred service. This service will provide a platform for the future development of early supported discharge services, which are likely to decrease length of stay further. Work is underway on a London wide basis to look at the potential for splitting the acute stroke tariff from April 2012 to help resource ESD services. The SLCSN team will work closely with BCT and the pilot provider to establish the best way forward and agree timescales for implementing ESD.
3.0 PROPOSED SOLUTION
The Bexley stroke round table rehabilitation sub group propose that the funds identified should be used to commission a community stroke specialist rehabilitation service. The service would need to deliver high quality stroke specialist rehabilitation to Bexley patients in line with the London stroke rehabilitation performance standards. The basis for this service is the service specification supplied by the South London Cardiac and Stroke Network, which has commissioning and clinical sign-off across the south east London cluster.
The options appraisal in section 21 analyses the following options:
Option 1 – Do Nothing, Continue with the Current Service
Option 2 – Improve Current Services with this proposal
a) Pilot and procure
b) Procure only
The recommendation of the Bexley rehabilitation workshop/sub group and stroke round table is that option 2 should be progressed, taking the pilot and procure approach.
The rationale for this recommendation is as follows:
· Evaluation of a pilot service will give greater understanding of the need for stroke rehabilitation services in Bexley, and how this service can best be established to suit the local population.
· Changes in acute service provision during the last 12 months are still embedding (with SUs going live from October 2010 and the PRUH HASU launching in May 2011), and a pilot will provide the opportunity to ensure the future service can fit well within the local stroke pathway.
· Piloting a service for Bexley, commissioned to meet London and national performance standards may lead to options for joint working with neighbouring South East London boroughs in future.
· Piloting a specialist community stroke rehabilitation service in Bexley will provide an opportunity to establish a robust approach to joint working with social care. Coordinating effectively the work of the stroke rehab team and the Bexley reablement service will avoid gaps in provision and / or duplication of effort for this group of patients.
4.0 ASSUMPTIONS
4.1 Indicative activity Data from secondary care
KCH / GSTT / QEH / PRUH / DVH / TotalNumber of Bexley patients discharged alive with diagnosis of stroke in FY2010-11 / 95* / 55** / 102 / 26 / 44
(66)*** / 267
* includes 14 patients who were transferred to the Kings SU and discharged directly home from there. This data is based on patient’s postcode rather than GP
** almost all of these patients will have been transferred to QEH SU as discharge directly from GSTT HASU is rare where no specialist community stroke service is in place to support patients (as advised by stroke clinical lead)
***total non elective spells provided from SUS data in brackets, modelled in line with potential death rate at 30%[7] this indicates that around 44 patients would have been discharged alive from DVH in this period
Vital signs data 2010-11
2010-11 Q1 / 2010-11 Q2 / 2010-11 Q3 / 2010-11 Q4 / TOTAL / Modelled*Number of Bexley people admitted to hospital following a stroke / 85 / 88 / 79 / 111 / 363 / 254
*based on inpatient death rate of 30%[8]
Hospital Episode Statistics (HES) data
Spells / Modelled*Number of provider spells for Stroke admissions 2006-7 (ICD10:I60-I69) / 384 / 269
*based on inpatient death rate of 30%
** note this is spells not patients so number of patients potentially would be lower
Source: PHAST report commissioned by the SLCSN
The number of Bexley patients that is forecast to be potentially eligible for this service is therefore 260-270.
For the avoidance of doubt, the forecast activity does not represent an intention on the part of the Commissioner to enter into contract at this level of activity. During the trial period 2011/12, the Provider shall report on a monthly basis on all stroke rehabilitation cases seen, outcomes and KPIs agreed.
It is important to note that there is a lack of robust data to support a procurement process at present, and a key outcome of the pilot will be to inform the modelling for future procurement of the service. In addition, the provider and commissioner will work closely with the South London Cardiac and Stroke Network to capture information about the demand for rehabilitation through the evaluation and performance monitoring of South London stroke services. The network’s service specification and performance monitoring framework will be used as these ensure monitoring against all key performance standards for stroke rehabilitation.