Allied Health Professions Art, Music and Drama Therapists ... · Decubitus ulcers and delayed recovery. Aspiration pneumonia. Dietitians, speech and language therapists and physiotherapists

Art, Music and Drama Therapists

Dietitians

Physiotherapists

Orthoptists

Prosthetists and Orthotists

Occupational Therapists

Podiatrists

Paramedics

Radiographers

Speech and Language Therapists

Allied Health Professions

Stroke toolkit

Maximising allied health professionals’ contribution to the delivery of high quality and cost effective patient care.

A guiDe fOR heALThcARe cOMMiSSiOneRS

preventionassessment

treatmentrehabilitation

re-ablementlong-term gain

how AhPs improve patient care and save the nhS money >

This toolkit is one of a series of toolkits developed by NHS London on behalf of the Strategic AHP Leads Group (SAHPLE)

Click to enter toolkit

Home Stroke toolkit 2

Opening narrative

In line with NHS Improvement for Stroke’s stated aim, Allied Health Professions (AHPs) are proactively supporting initiatives and service redesign which is evidence based and addresses the QIPP (Quality, Innovation, Productivity and Prevention) challenge.

The Strategic Health Authority Allied Health Profession Leads (SAHPLE) commissioned a project to identify clinical pathways where AHPs make a significant difference in the clinical outcomes for a group of vulnerable patients including those affected by stroke.

AHPs include a number of professions who work both in uniprofessional teams and, often, in stroke care, as part of a Multidisciplinary Team (MDT), for example as part of a coordinated rehabilitation team as highlighted in redesign in the Lewisham integrated stroke project: see www.improvement.nhs.uk/stroke/

“Service users have given high praise for the rapid response, motivating and caring manner of the staff, and the reassurance of having rapid access to equipment and adaptations enabling them to manage independently at home.”

This success story is one of a number highlighted by NHS Improvement for Stroke.

For further information please contact:

Lesley Johnson SHA Allied Health Professions Lead NHS London Southside 105 Victoria Street London SW1E 6QT

[email protected]

This toolkit has been endorsed by:

http://www.improvement.nhs.uk/stroke/

mailto:Lesley.Johnson%40london.nhs.uk%20?subject=AHP%20toolkit

prevention>assessment>

treatment>rehabilitation>

re-ablement>long-term gain>


introduction

What does this toolkit do for you?

This toolkit has been developed by a range of clinicians working in stroke care. The information has been provided by a national collaboration of clinicians in conjunction with their professional bodies and is based on available research evidence.

The work has been reviewed by a range of specialists including Professor Tony Rudd, Clinical Director for Stroke. A range of resources are available on the NHS Improvement stroke website > The toolkit has been endorsed by the Professional Bodies.

This toolkit provides information on the following:

• Which interventions most positively benefit patient care

• What range of interventions over time will reap the most benefits during illness and lead to independence

• How do the interventions match to the Outcomes Framework

• Which interventions are able to save money to the system

• How is the functional ability of patients enabled by using Allied Health Professionals (AHPs).

Audience

This information is aimed at those involved in commissioning or developing stroke care.

The toolkit will provide an interactive method of ensuring that patient care is meeting quality standards and providing essential elements of the QIPP agenda

If you are looking to re-design or provide stroke care services this information will assist you meet the needs of your local population:

Contents

1. List of interventions by Allied Health Professions

2. A pathway graphic highlighting where each profession significantly contributes to value-for-money high quality care

3. QIPP (Quality, Innovation, Productivity and Prevention) – key facts

4. Matching interventions to the Outcomes Framework

5. Research evidence

6. Case studies

7. General information

We hope you find it valuable.

Art, Music and Drama Therapists Dietitians

Physiotherapists

Orthoptists

Prosthetists and Orthotists

Occupational Therapists

Podiatrists

Paramedics

Radiographers Speech and Language Therapists

Rehabilitation Re-ablement Long-term gainPrevention Assessment Treatment

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patient journey

Key AHP inTeRvenTion PoinTs in THe sTRoKe PATHWAy

Click on one of the intervention stages below to find out more about AHPs’ input

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Presenting condition Health risk Referral to Risk mitigated outcome Framework

domain<download>

Cost saved

Diabetes, hypertension, atrial fibrillation, deep vein thrombosis (DVT), smoking, alcohol and drug use and obesity

Transient Ischaemic Attack (TIA), stroke

Paramedics, dietitians, physiotherapists, arts therapists, occupational therapists and speech and language therapists can observe and recognise motor function, cognitive and behavioural changes which could signal a stroke risk

Prevention of TIA and stroke 1,5 The Stroke Association estimates that over 150,000 people have a stroke in the UK each year.

The National Stroke Strategy estimated that 20,000 strokes a year could be avoided through preventive work. Department of Health website >

Suspected stroke

‘FAST’ positive

Disability post-stroke, avoidable if suitable for thrombolysis

Paramedic Prompt response to assess symptoms and facilitate urgent transfer to Hyper Acute Stroke Unit (HASU)

1,3 Research shows that a fast response to stroke reduces the risk of death and disability. Download Department of Health report: Reducing Brain Damage: Faster access to better stroke care >

NHS Choices website: Stroke. Act F.A.S.T >

Potential stroke Delayed assessment/ diagnosis

Reporting radiographer Speedy CT scan reporting to facilitate accurate diagnosis and ‘door to needle’ time of less than 30 minutes. Allows for thrombolysis and reversal of stroke effects.

1,3 Radiographers are a vital part of the specialist stroke care team. Patients with acute brain attack require rapid access to high quality and appropriate imaging in order to diagnose the type of stroke. Download The Role of the Radiographer in Stroke Management >

NHS Improvement imaging case studies >

Initial Stroke Assessment, Hyper Acute Stroke Unit (HASU)

Aspiration, Pneumonia

Speech and language therapist (SLT)Radiographer Physiotherapist

Prompt assessment of dysphagia with advanced level skills such as videofluoroscopy. Allow for accurate diagnosis and treatment.

3,5 In the UK the annual benefits generated by SLT compared to usual NHS care for post acute stroke dysphagia (swallowing problems) patients exceed the annual cost of the therapy by £13.3 million.

Every £1 invested in SLT generates £2.3 in health care cost savings through avoided cases of chest infection View the RCSLT matrix report: An economic evaluation of speech and language therapy >

Physiotherapist Works with SLTs to assess swallowing.

Accurate diagnosis/ Rehabilitation delayed

Physiotherapist Occupational therapist Speech and language therapist

Early assessment as part of HASU expert team facilitates intensive rehabilitation, establish agreed goals, minimise long term disability

3 The importance of workforce development and recruitment has been highlighted and realised in the success story of London Stroke Services Stroke Association website > NHS London press release >


commissioning principles: which AhPs do you need?

Click this link to find out how AHPs save the nHs money, and the evidence and case studies that support claims about the benefit of their interventions.

Commissioners may not presently know how to maximise the use of a range of AHPs to add to patient benefit and the QIPP agenda. This toolkit illustrates the logic and clinical argument around onward referral to multi-disciplinary AHP teams and outlines appropriate use of AHP professions so that patient quality is enhanced and independence wherever possible is gained.

AHPs are not optional but integral to the necessary treatment of patients. There are clinical and financial risks in patients not receiving AHP input.This toolkit aims to show what the appropriate response is to a presenting condition and how a range of AHPs work together to reach the outcomes aspired to in the National Outcomes Framework.

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131724.pdf





http://www.stroke.org.uk/document.rm?id=1641



http://www.nhs.uk/actfast/pages/stroke.aspx

http://www.sor.org/public/document-library/sor_role_radiographer_stroke_management_2nd_edition.pdf

http://www.sor.org/public/document-library/sor_role_radiographer_stroke_management_2nd_edition.pdf

http://www.improvement.nhs.uk/qipp/MenuLevel1/Diagnosis/Imaging/tabid/155/Default.aspx

http://www.rcslt.org/giving_voice/news/matrix_report

http://www.rcslt.org/giving_voice/news/matrix_report

http://www.stroke.org.uk/applications/site_search/search.rm?term=Rehab+in+HASU&submit.x=12&submit.y=10

http://www.stroke.org.uk/applications/site_search/search.rm?term=Rehab+in+HASU&submit.x=12&submit.y=10

http://www.london.nhs.uk/news-and-health-issues/press-releases/latest-press-releases/stroke-victims-in-london-have-better-access-to-life-saving-treatment-than-anywhere-else-in-the-world



domain <download>

Cost saved

Initial stroke assessment Post-stroke recovery delayed, unable to return home

Early Supported Discharge team including occupational therapists, physiotherapists, dietitians and speech and language therapists

Specialist clinicians facilitate early discharge home, releasing acute beds, providing intensive therapy to achieve rehabilitation goals

4 Acute bed days saved, eg. Camden REDS reduced the average length of stay for 32% of all Camden strokes in 2009 by 10 days on average, leading to a potential £307,161 saving in acute bed day costs

NHS Evidence website >

Download Camden REDS case study >

Delay in provision of adequate nutrition and hydration

Dietitian Prompt assessment of nutritional status, allowing for accurate provision of diet and fluids, either orally or non-orally. Provision of nutrition in form appropriate for texture modification and for the management of patients with complex nutritional needs

Inappropriate prescribing of oral nutritional supplements

Visual disturbance post stroke Prone to falls and fragility fractures

Orthoptist Provide expert vision and visual acuity assessment and provision of aids which facilitate rehabilitation and minimise risk of falling

2,3 Poor visual acuity has a negative impact on rehabilitation. Patients with disorders of eye movements should be referred for orthoptic assessment

Download NHS Quality Improvement Scotland report >

Poor nutrition and swallowing difficulties post stroke

Decubitus ulcers and delayed recovery. Aspiration pneumonia.

Dietitians, speech and language therapists and physiotherapists

Appropriate nutrition and dietary advice given by specialist clinicians in consultation with stroke care team maximising rehabilitation potential, avoidance of preventable aspiration pneumonia and PEG insertion

2,5 Developing strength after a stroke: a patient story highlighting benefits of AHP team rehabilitation, and facilitating early return home saving hospital bed days

Download London Cardiac and Stroke Network newsletter: see page 4 >

Foot drop following stroke Serious risk of falling and mobility fractures

Orthotists and physiotherapists

Provision of expert assessment and prescription of Ankle Foot Orthosis (AFO) with appropriate goal-oriented rehabilitation

2,5 Fragility fractures for people over 60 years account for more NHS bed-days than those for stroke patients >60 years, cardiac ischaemia, heart failure, chronic obstructive pulmonary disease (COPD), and diabetes patients for all ages combined

Download NHS Atlas of Variation in Healthcare: see page 71 >

commissioning principles: page 2 of 3






http://www.evidence.nhs.uk/search?q=Camden+REDS

http://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?path=Cardiac%2fNational%2fWebsite%2fStroke%2fCase%20studies%2fCamden%20case%20study%20-%20ESD%2c%20Sep%2010.pdf

http://www.sign.ac.uk/pdf/sign118.pdf

http://www.londonprogrammes.nhs.uk/wp-content/uploads/2011/03/Stroke-News-Jan-2011.pdf

http://www.londonprogrammes.nhs.uk/wp-content/uploads/2011/03/Stroke-News-Jan-2011.pdf

http://www.rightcare.nhs.uk/atlas/qipp_nhsAtlas-LOW_261110c.pdf




domain <download>

Cost saved

Neurological deficit following stroke

Delayed recovery and dependence on long term social care package

Neurological Rehabilitation team including occupational therapists, physiotherapists and speech and language therapists

Review identifies patient need and targets appropriate intervention to maximise rehabilitation potential and minimise complications

2,3 Royal College of Physicians National Clinical Guidelines for Stroke 2008 identifies the importance of a team approach in successful rehabilitation

Order National clinical guideline for stroke >

Lewisham Integrated Stroke Project is an example of AHPs working across agencies to maximise patient benefit and address the QIPP challenge

NHS Improvement (stroke improvement) website >

Communication difficulties post-stroke

It is estimated that around 53,000 adults per year in the UK suffer post stroke aphasia requiring speech and language therapy

Speech and language therapist

View case study: an innovative approach using telemedicine supported by speech and language therapists to deliver a greater intensity of therapy to more patients post stroke >

Aphasia is a language disorder caused by neurological damage. Symptoms include difficulty with one or several forms of communication including speech, comprehension, reading and writing. In addition SLT practitioners are skilled in addressing complications of dyspraxia and dysarthria.

2,3 In the UK the annual benefits generated by an extra hour of SLT per week for 12 weeks for post acute stroke aphasia (communication problems) patients exceed the annual cost of the therapy by £15.4 million.

Every £1 invested in SLT generates £1.3 – the equivalent in monetary terms to the benefit generated in terms of quality adjusted life years.

Download the RCSLT matrix report: An economic evaluation of speech and language therapy >

The Royal College of Physicians (RCP) guidelines, produced by the Intercollegiate Stroke Working Party, incorporate the NICE guideline and also cover recovery and rehabilitation, secondary prevention, and long-term care. Importantly, they have new sections on commissioning and resources.

Access the Royal College of Speech and Language Therapists website >

commissioning principles: page 3 of 3






http://bookshop.rcplondon.ac.uk/details.aspx?e=250


http://www.improvement.nhs.uk/stroke/Increasingaccesstotherapy/Technology.aspx





http://www.rcslt.org/giving_voice/matrix_report


http://www.rcslt.org/about/campaigns/stroke_care_publications

http://www.rcslt.org/about/campaigns/stroke_care_publications

Home Stroke toolkit 7Home

Benefits of AhP input: prevention stage

AHPs’ contributions at the prevention stage.

Paramedics

Paramedic assessment at point of contact enables patients to receive BP checks, ECGs, hyperglycaemia checks and orientation assessment. They can advise on physiological risks, such as hypertension and atrial fibrillation, and encourage the patient to book a health check with their GP, or access falls services.

Dietitians

Dietitians can review diabetic and cardio-vascular risks, and monitor BMI and nutritional status and provide support and guidance on lifestyle changes to help people to lose weight, improve their general health and to manage their diabetes.

Orthoptists

Visual screening by an Orthoptist will detect visual changes and defects, and prevent unnecessary falls. This can lead to referrals for vascular workup and prevention of further TIA/Stroke, and onward referral to GPs and consultant physicians. Early intervention and self management can therefore reduce drift into increased ill health and the risk of stroke.

Podiatrists

Podiatrists will routinely check for ischaemic and cardiovascular risks and refer on for preventative treatment.

Occupational therapists

Occupational therapists have a role in primary and secondary stroke prevention through focusing use of time on meaningful daily life activities, including leisure, which promotes self management and impacts positively on health and well being.

Art, Music and Drama Therapists work with users of mental health services to maintain emotional health which is closely linked to physical well being. Changes may signal a change in physical health.

Prevention >

Assessment/diagnosis >

Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

navigate to:

navigate to:

Stroke literature review and analysis

Appendix 1: Improving outcomes, the economic arguments and case studies

References

Stroke toolkit 7

Physiotherapists

Physiotherapists promote the health and well being of individuals and the general public emphasising the importance of physical activity and exercise. There is evidence to support the role of exercise and activity in primary prevention of stroke and TIA’s and physical activity is an important aspect of lifestyle that patients at risk of recurrent stroke can modify.

Chartered Society of Physiotherapy, Physical Activity: Evidence Briefing (2012). See website >

Introduction

Patient education on stroke risks – including advice on diabetes, hypertension, atrial fibrillation, deep vein thrombosis (DVT), smoking, alcohol and drug use and obesity – is provided by AHPs at various stages of the patient journey.

The importance of AHP input to health promotion and stroke prevention is underestimated, and is not generally understood.

self-referral is appropriate for AHP services. Autonomous practitioners, working together on a shared pathway, provide initial assessment through to pain management which can reduce, and in some cases eliminate, care costs and waiting times.

Therapists, including arts therapists, occupational therapists and speech and language therapists, can observe and recognise motor function, cognitive and behavioural changes, which could signal a stroke risk.

http://www.csp.org.uk/sites/files/csp/secure/2-physical_activity_evidence_briefing.pdf

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Benefits of AhP input: assessment / diagnosis stage

AHPs’ contributions at the assessment/diagnosis stage. navigate to:

Key fact Improving vision prevents falls which can result in significant cost savings for the NHS.

The NHS Atlas of Variation in Healthcare, Nov 2010. Download >

Stroke toolkit 8

Paramedics

A Paramedic will perform FAST/Rosier assessment to determine whether a stroke has occured or not. Assessment of TIA or other risks are also picked up by paramedic assessment on scene. TIA’s can be referred to specialist clinics rather than to the Emergency Department.

Radiographers

Reporting radiographers can save time by accurately imaging and reporting on the patient’s status and suitability for thrombolysis. Reporting radiography is quicker and less costly, and also means that the patient is being assessed by a specialist clinician.

Radiographers working with speech and language therapists assess video fluoroscopy techniques to diagnose and assess a range of feeding and swallowing problems that could lead to aspiration pneumonia and death.

Other assessment techniques include the monitoring of oxygen saturation and cervical auscultation to assess the status of stroke victims’ swallow.

Radiographers can also provide and interpret CT scans. Download How to implement best practice in stroke and TIA imaging.


A range of standardised and functional assessments takes place in the acute phase to reduce the possibility of severe complication at a later stage.

Occupational therapists assess patients’ motor function, sensory, cognitive, perceptive and interactive functional abilities. This includes assessment of mood and emotional well being, including their personal, family and social circumstances and environments. This provides a baseline of previous functional performance in relation to the person’s abilities, interests and life roles prior to their stroke.

Download: A good example of an occupational therapist led mood and cognition assessment and rehabilitation pathway. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust.

Orthoptists

By assessing vision for evidence of neurological damage, orthoptists act preventatively to dampen the effects of double vision and other visual field disturbances, thereby reducing the risk of falls.

The restoration of binocular vision can speed rehabilitation and allow people to return to work. The risk of loss of visual acuity is particularly seen in the number of falls in the over 65 age group.

Speech and language therapists

Speech and language therapists provide information in an accessible way for people who have suffered stroke and need help to comprehend language.

Assessment by a speech and language therapists and/or physiotherapists within the first 24 hours will eliminate risk around aspiration. Nurses and others are trained by speech and language therapists to be aware of aspiration risk and take appropriate action.

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

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References

Key fact Malnutrition is an under-recognised and under-treated issue which affects three million people. It is estimated to cost the UK health economy £13bn pa. Improving the identification and treatment of malnutrition is estimated to have the third highest potential to deliver cost savings in the NHS

British Association of Parenteral and Enteral Nutrition (BAPEN) A Toolkit for Commissioners and Providers in England 2010.

Dietitians

Dietitians assess and manage the risk of re-feeding problems.

Assessment of nutritional status prevents delay in provision of adequate nutrition and hydration in appropriate form.

Dietetic assessment addresses all associated dietary issues such as renal diets, coeliac diets, low residue and high calorie diets as required to achieve and maintain appropriate BMI.

Physiotherapists

Physiotherapists are important members of the multidisciplinary team.

Physiotherapists use their specialist knowledge of the respiratory and neuro-musculoskeletal systems to assess patients using specific objective measures. This informs the diagnosis of respiratory dysfunction, motor, sensory and cognitive impairment and activity limitation.

A process of clinical reasoning is then used, which incorporates information from the multidisciplinary team, to inform prognosis and plan of intervention. The physiotherapy assessment also identifies those patients who are at risk of developing secondary complications such pneumonia, pressure sores, clotting disorders and contractures due to immobility.


http://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?path=Diagnostics%2fNational%2fWebsite%2fArticles%2fSN99%20Nov11%20p15_17.pdf



http://www.improvement.nhs.uk/stroke/Psychologicalcareafterstroke/Psychologicaltherapycasestudiesusefulinfo/tabid/182/Default.aspx









Treatment by a speech and language therapist will reduce the risk of aspiration pneumonia.


Occupational therapist assessment generates vital knowledge on stroke survivors’ motor function, cognitive, sensory and dynamic balance capabilities. Awareness and description of loss of function is importanr in helping patients to gain an understanding of their abilities and how they might enhance their own recovery. OTs would plan early discharge, facilitating patients to return home and aim to achieve as much independence as possible, despite disabilities.

Physiotherapists

Physiotherapists will use a variety of interventions to prevent the development of complications identified in the assessment stage. These include respiratory techniques, positioning and early mobilisation.

According to the Royal College of Physicians (2008) all patients identified as having a mobility limitation should be assessed by a specialist to determine the most appropriate and safest method of transfer and mobilisation.

Specialist physiotherapy practitioners use specific moving and handling methods to mobilise patients in the acute stages of stroke. They provide advice, information and training about positioning, movement and handing to relevant carers and other multidisciplinary team members to optimise return of function and the prevention of secondary musculoskeletal and respiratory complications.

Intercollegiate Stroke Working Party (2008). National Clinical

Guidelines for Stroke. 3rd edition. Royal College of Physicians. London

AHPs will begin to plan care and set goals at the earliest possible point.

Orthoptists

Orthoptists treat patients with stroke and refer to sensory teams in local authorities. This helps prevent falls, encourages people to read (so they can maintain independence and return to work) and saves the NHS money.

Dietitians

Dietetic treatment is vital to long-term stroke outcome and needs to be established as soon as possible. NICE suggests that the treatment of malnutrition has the third highest potential to deliver cost savings for the NHS.

Dietitians ensure non-oral feeding is delivered to meet patients’ requirements. They also maximise food intake, facilitating long term recovery and nutritional health as nutritional status is likely to be compromised by stroke.

£13m savingsImproved nutritional care could result in significant financial returns. Saving 1% would equate to a saving of £13 million across London.

GOLDen nuGGeT

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Benefits of AhP input: treatment stage

navigate to:AHPs’ contributions at the treatment stage.

Stroke toolkit 9

Key fact (HRG at £2k/day in ITU). High quality rehabilitation should start as soon as possible to target aphasia and motor communication impairments. Treatment by a speech and language therapist will reduce the risks of social isolation and the reliance on non-oral feeding.

RCSLT matrix report: An economic evaluation of speech and language therapy. Download >

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

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References

Key fact Very early mobilisation is currently being investigated and preliminary results found that very early mobilisation (VEM) may improve the ability to walk unassisted and functional recovery compared with those who received standard physiotherapy. It was thought that as a consequence this may lead to a shorter length of stay and an increased likelihood of being discharged home rather than to a rehabilitation unit. The phase III trial will hope to bring greater certainty around the efficacy of VEM.

Cumming TB, Thrift AG, Collier JM, Churilov L, Dewey HM, Donnan GA, Bernhardt J. (2011) Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke. Jan;42(1):153-8. Epub 2010 Dec 9.



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Benefits of AhP input: rehabilitation stage

navigate to:AHPs’ contributions at the rehabilitation stage.

Stroke toolkit 10

Orthotists

Orthotists working alongside physiotherapists and podiatrists assess gait and appropriate footwear, and provide ankle-foot orthosis to prevent trips and falls.

Physiotherapists

Physiotherapists play a significant role in the patient’s rehabilitation in a stroke unit and after discharge home or to intermediate care settings.

Specialist physiotherapists work with the client towards the achievement and evaluation of shared goals. Goals may be expressed in terms of movement dysfunction or may encompass categories of impairments, activity limitations, participatory restrictions, environmental influences or abilities. Specialist physiotherapists will use task specific interventions to improve strength, movement, balance and functional activities, such as transfers, walking and upper limb function in order to improve functional independence and participation.

Specific interventions could also include the provision of falls prevention programmes, pain management, splinting and postural advice. Early supported discharge requires specific assessment of moving and handling requirements and liaison with family and carers in order to ensure a successful early transition from hospital to home.

Critical goal setting with realistic outcomes will ensure that patients receive the most cost effective treatment. For example, ‘step down’ facilities, which look after patients who are not ready for rehabilitation, increase the productivity of stroke units and reduce the potential for re-admission. Co-ordinated care with the right skills in the right place along the pathway also reduces delays and improves access to rehabilitation therapy.

Advanced AHP Practitioners maintain the best route for patients by outlining good outreach to community practice and also inreach into the acute setting. The leadership skill set needed for this are found in the National Occupational Standards for AHP Advanced Practitioners.


Speech and language therapists provide rehabilitation for language comprehension and spoken communication problems following stroke. Users may need to be provided with hardware or software to gain access to alternative or augmentative communication aids. These can be vital to the process of gaining confidence and reaching personal goals in regaining function following stroke.

Key fact For every £1 spent on orthotic services the NHS saves £4.

York Health Economics. Orthotic Service in the NHS: Improving Service Provision. Download >

Dietitians

Dietitians provide information on long-term management and feeding processes and expert cost-effective advice on appropriate nutritional supplements. Dietetic assessment and planning facilitates long-term recovery and nutritional health.

48% of patients fed by tube are fed this way as result of a neurological problem, such as stroke. Incorrect management of enteral feeding is extremely expensive. An AHP multi-disciplinary approach to tube-feeding patients will enable a quicker return to oral intake. Many PEG patients inappropriately remain on PEG feeding for the rest of their lives in cases where community teams have not been commissioned.

Key fact SAHPLE QIPP evidence reduction in spend of 23% over four years could save £110m.

NHS North West: Quality and Productivity report. Download >


Occupational therapists provide expert assessment of the home environment which can include installation of bathing, toileting and walking aids, which helps facilitate a safe and sustainable discharge home.

OTs coordinate discharge planning with social workers and care agencies to inform and guide provision of an appropriate care package. They can refer to the local authority or may be employed by local authorities to provide social and vocational support once the stroke survivor is home.

OTs also provide therapy for the effects of motor, cognitive and perceptual impairment following stroke. They will work with families to help the stroke survivor focus on self management and utilise their time to be spent on meaningful life after stroke focusing on personal, family and community life roles if appropriate.

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

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References

Orthoptists

Orthoptists follow-up to adapt treatment plans for changes in double vision, low vision and visual field loss to enhance adaptation, particularly for reading and navigation to improve functional mobility and aid return to work.

Key fact Approximately one third of stroke survivors are left with rehabilitation needs.

Chartered Society of Physiotherapy (2011). Physiotherapy works: Stroke. View website >

Patients who have some ability to move their arms should be given every opportunity to practice movements with techniques such as constraint induced movement therapy.

Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D, Giuliani C ,Light KE, Nichols-Larson D & EXCITE I (2006) Effect of constraint-induced movement therapy no upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial JAMA: the journal of the American Medical Association, vol 296, no 1 , p 2095-2104.

Diagnostic radiographers

Diagnostic radiographers follow up CT brain scans to monitor progress. Images are taken, evaluated and reported.

http://www.hkscpo.org/10download/York_Report_Orthotic_Service_in_the%20NHS.pdf



http://www.ahpnw.nhs.uk/?page=17



http://www.csp.org.uk/sites/files/csp/secure/csp_physioworks_2011_stroke_0.pdf

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Benefits of AhP input: re-ablement stage

navigate to:AHPs’ contributions at the re-ablement stage.

Stroke toolkit 11

Physiotherapists

Physiotherapists provide client centred assessments in the community to negotiate longer term measurable goals in collaboration with clients, carers and the multidisciplinary/interagency team.

Community based physiotherapy re-ablement programmes focus on exercise, and self-management, in relation to individual functional goals. Physiotherapists provide specialist support and advice on tailored exercise to improve strength, range of movement, balance, walking and cardiovascular fitness, and may deliver this on an individual basis, in group settings and/or locally provided ‘exercise on prescription’ schemes.

Physiotherapists also provide training and on-going support in self-management to maintain functional independence, participation, inclusion, and quality of life. This includes skills for maintenance of a healthy lifestyle, self-initiated exercise, and prevention of secondary complications and /or readmission.

Advanced AHP Practitioners can provide the link to social care and psychological support, vocational opportunities and other long term support. This is a difficult gap to bridge and carries huge cost risks. The skills necessary are found in advanced practitioners assessing and treating patients requiring advanced clinical reasoning and communication skills.


Occupational therapists provide expert assessment of a person’s engagement and performance in their activities of daily life. This includes holistic assessment of their health and well being including mood, emotion and general mental health.

OTs also assess and provide adaptations to home and work environments to maximise potential recovery and facilitate as much independence as possible. Goal setting and regular reviews are developed in line with the Accelerating Stroke Improvement Programme.

By working alongside primary care colleagues such as GPs, practice nurses and district nurses, patients achieve their potential and further complications from stroke are minimised.

Key fact A&E falls teams have prevented potential admissions which have saved the NHS £33m nationally.

NHS North West: Quality and Productivity report. Download >

Chartered Society of Physiotherapy: Moving on: a vision for community based physiotherapy after stroke in England. Download >

Orthotists

Orthotists provide follow up care, specialist footwear and in-shoe orthotics, such as ankle-foot orthoses, which help increase confidence in walking and prevent trips and falls.

Podiatrists

Podiatrists provide supportive treatment to stroke survivors working closely with orthotists, physiotherapists and associated disease specialists such as diabetic consultants. Podiatrists encourage walking and prevent foot-related complications such as ulceration.

Orthoptists

Orthoptists provide valuable follow up to monitor visual function and provide corrective spectacles to aid confidence in gait, fall prevention and reading.


Speech and language therapists set up local groups run by users who offer feedback on therapy inputs and assist in working out ways to adapt them.

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

navigate to:



References

Key fact Gait may improve in both the acute and chronic stage of stroke with physiotherapy input.

Green J ,Forster A, Bogle S, Young J (2002) Physiotherapy for patients with mobility problems more than 1 year after stroke: a randomised control trial Lancet. Jan 19;359(9302):199-203.



http://www.csp.org.uk/publications/moving-vision-community-based-physiotherapy-after-stroke-england



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Benefits of AhP input: long-term gain

navigate to:AHPs’ contributions to long-term gain.

Stroke toolkit 12


Communication is vital to social effectiveness and re-integration into family and social situations. Speech and language therapists provide long term support to families with communication issues and work with others agencies such as the Stroke Association to provide local, appropriate care.

Many stroke survivors are at risk of becoming users of mental health services and gaining access to socially enjoyable activities significantly decreases this risk. Building self-esteem in those who have suffered stroke is vital to future well-being.

It is the role of AHP to add “life to years not just years to life.”

AHPs provide long-term benefit for stroke survivors facilitating return to work and vocational activity. Dame Carol Black report: ‘Working for a healthier tomorrow’

AHPs are vital to world class stroke care in London which has eight specialist Hyper Acute Stroke Units (HASUs) – implemented in 2010 as part of the redesign of London Stroke Services.


Occupational therapists contribute to the reduction of disability, effectively improving participation and activity, helping people reach functional independence in daily life, and reducing the risk of deterioration in people after they have survived a stroke.

Trombly et al. 2002, Trombly and Ma 2002, Jette et al. 2005, Steultjens et al. 2005, Legg et al. 2006, Govender and Karla 2007, Legg et al. 2007.


Often cognitive capacity is impaired following stroke and OTs and SLTs will assess such loss so that patients and families understand and deal with the implications of this change post stroke.

Helping families to manage the effects of stroke is essential to reducing costs for both social services and NHS organisations.

Arts therapists

Arts therapists help with emotional issues related to ‘living with stroke’, eg: loss, depression, anger, anxiety, helplessness, powerlessness; shame as well as adjustment/coping, socialisation, relationships and communication.

Key fact 587 patients were thrombolysed between February and June 2010 compared to 174 in same period in 2009.

AHPs are gaining recognition in the Stroke Multidisciplinary Team (MDT) in the acute, primary care and voluntary sectors.

AHPs are also well positioned to be at the forefront of reinvestment in reablement following a health crisis such as stroke.

Key fact (AHPs’ contributions create) “dramatic benefits in helping people regain their independence after a crisis and cutting emergency readmission to hospital. This will save money across the health and social care system.”

Andrew Lansley MP, 20 October 2010

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

navigate to:



References

Dietitians

Dietitians reduce inappropriate prescribing of oral nutritional supplements. Improving nutritional care can reduce admissions, readmissions and shorten hospital stay. It could also improve quality of life and promote independent living. Dietitians can reduce long term dependence on artificial nutrition.

Dietitians maximise food intake facilitating long term recovery and nutritional health.

British Association of Parenteral and Enteral Nutrition (BAPEN) A Toolkit for Commissioners and Providers in England 2010.

Physiotherapists

Physiotherapist’s role in Health Promotion emphasises the importance of lifelong participation in programmes of exercise and physical activity, to facilitate improved health, well-being, quality of life and secondary prevention of stroke.

Physiotherapists support individuals and carers in sustained participation and inclusion in community life, return to work, social activities and life roles. This involves advice and training in relation to exercise, ergonomics, posture and movement and the transference of skills to other staff, carers and community members to achieve the fulfilment of client goals and maintain health and well-being, as required.

Regular reviews should be offered to individuals who have residual impairment and clear information about how to access further advice from a physiotherapist is given.



The Strategic Allied Health Professionals Leads Group (SAHPLE) commissioned York Health Economics Consortium (YHEC) to carry out economic analysis of the impact of AHP interventions across stroke care pathways. AHP practitioners provided YHEC with a framework which highlighted a series of specific interventions by AHPs classified under six categories:

• Prevention• Assessment/Diagnosis• Treatment• Rehabilitation• Re-ablement• Long-term gain.

introduction

YHEC reviewed literature around each of the interventions included in the framework with around 30 interventions being identified. We carried out broad searches for literature using databases including Medline, the Cochrane Database of Systematic Reviews and NHS Evidence. We sought evidence from a range of sources in the following sequence: DH/NHS policy documents; clinical guidelines; case studies; published literature; individual NHS organisations; and expert opinion. We were also provided with a range of literature references from a range of Allied Health Professional (AHP) clinicians which we reviewed.

These searches represent an extensive but not exhaustive search of the available literature. We contacted the Chartered Society of Physiotherapy, the Royal College of Speech and Language Therapists and the College of Occupational Therapists who provided some clinical guidelines.

our approach

YHEC has used the data obtained to present the evidence in two ways:

n Examples of economic analysis across the pathways where AHPs can make a significant impact on patient care and, potentially, costs. Three scenarios are presented below:

• Prevention of stroke and recurrence of stroke through education and lifestyle management

• AHP inputs to stroke units

• AHP inputs to stroke rehabilitation across the care pathway.

n Evidence to support the effectiveness and potential economic benefits for each of the interventions included in the SAHPLE framework. This is provided at Appendix A. We have colour-coded the evidence obtained to provide an indication of the level of robustness of the evidence as follows:

• Evidence supported by published study or literature in GREEN

• Evidence supported by observational study or case study in AMBER

• Evidence supported by clinical opinion or assumption in RED.



scenario 1: Prevention of stroke and recurrence of stroke through education and lifestyle management

A systematic review of the role of AHPs in health promotion describes how AHPs are involved in primary prevention of stroke.1

This includes the roles of:

• Paramedics – interpret diagnostic tests, undertake basic procedures and assess patients with long-term conditions.

• Dietitians and physiotherapists are able to play a broad role in health promotion, health education and self-care. This can include teaching and advising carers, other health professionals and support workers.

• Arts therapists, occupational therapists (OTs) and speech and language therapists (SLTs) can observe and recognise cognitive and behavioural changes which could signal a stroke risk.

1 The Allied Health Professions and Health Promotion: a systematic literature review and narrative synthesis. J Needle et al. NIHR 2011.2 National Stroke Strategy. Department of Health, 2007).3 The Economic Burden of Stroke in the UK. P Youman et al. Pharmacoeconomics, 2003.4 Map of Medicine. Stroke – rehabilitation, 2011.

The National Stroke Strategy estimates that 20,000 strokes a year could be avoided through preventative work.2 The cost of a stroke to the NHS was estimated at around £15,000 over five years in 2001/02, and around £29,400 including informal care costs.3

The prevention of 20,000 strokes a year for five years could therefore potentially save the NHS around £900 million. Any additional costs of recruiting AHPs would need to be offset against these savings.

In terms of secondary prevention, the Royal College of Physicians recommends long term monitoring for secondary prevention including lifestyle advice.4



intervention A:Patients who have had a suspected stroke should have a specialist assessment and investigation within 24 hours of onset of symptoms and be transferred to an acute stroke unit.5 The use of reporting radiographers to conduct and report CT scans helps to improve the speed with which CT scans can be turned round and frees up the time of radiologists and neuroradiologists.6

The difference in hourly cost of a reporting radiographer and a radiologist is around £120, based on the cost of a radiographer at the mid-point of Agenda for Change Band 7 and a consultant radiologist.

See page 6 of London Cardiac and Stroke Network’s Stroke-News

intervention B:Clinical guidelines recommend that patients admitted to A&E should receive a physical assessment including:

• Facial weakness• Arm weakness• Leg weakness• Speech disturbance• Visual field defects.7,8

Physiotherapists, SLTs and orthoptists involvement at this stage can help to ensure that patients are correctly diagnosed and admitted to stroke units promptly.

intervention C:Clinical guidelines recommend the screening of patients’ swallowing before giving any oral food, fluid or

medication. Dehydration can cause problems for people with stroke because of dysphagia. This can cause aspiration pneumonia and malnutrition. Assessment by SLT and dietitian should include a swallow test, assessment of nutritional status and screening for malnutrition.9,10

intervention D:Multidisciplinary teams in stroke units should include access to physiotherapy (including respiratory physiotherapy), OT, SLT (including assessment and management of swallowing), and dietetic services including nutrition screening.11 Interventions by this team include early positioning and mobilisation, the maintenance of hydration and nutrition and the assessment and management of

complications. In addition Orthoptists form a vital part of the Stroke team.

Download Visual dysfunction following Stroke: Benefits of Orthoptic input into Stroke care

Avoided costsFor interventions B, C and D, the stroke unit is shown to be effective for patients by reducing the length of stay in hospital and the avoidance or alleviation of complications such as dysphagia and aphasia. The positive impact of the London stroke programme is highlighted by the South London Cardiac and Stroke Network: Download 2010-11 annual report

60% of stroke patients are treated for 90% of their hospital stay in a stroke unit.12 Patients admitted to a stroke unit within four hours have a

median length of stay of nine days in hospital compared to 12 days for those who were not directly admitted to a stroke unit. The national average daily cost of inpatient care for non-transient stroke was £292 so a three day reduction in length of stay would save almost £900 per patient.13

Enhanced SLT to treat aphasia has been shown to result in a gain of quality adjusted life years for each patient. The benefit is estimated to generate £1.30 for every £1 spent due to the monetary benefit associated with the quality of life gain. Similarly, SLT interventions to treat dysphagia have been shown to generate £2.30 for every £1 spent due to the monetary benefit associated with the quality of life gain.14

Diagnostic and reporting radiographer

A

Standardised assessment: Physiotherapist, SLT, Orthoptist, OT

B

Avoided costReduced length of stay. Avoidance of

complications and improved patient outcomes

Improved outcomes

scenario 2: AHP inputs to stroke units

Admission for stroke

Assessment of swallowing, communication, cognitive ability and hydration: SLT, Dietitian

C

Multidisciplinary stroke unit team:Physiotherapy, OT, SLT, Dietitian, Physiotherapist, Orthotist

D

Admission to stroke unit

5 National clinical guidelines for stroke. Third edition. Royal College of Physicians. 2008.6 National Stroke Strategy. Department of Health, 2007.7 National clinical guidelines for stroke. Third edition. Royal College of Physicians. 2008.8 The diagnosis and acute management of stroke and transient ischaemic attacks. Clinical guideline 68. NICE. 2008.9 Ibid.10 National clinical guidelines for stroke. Third edition. Royal College of Physicians. 2008.11 National Stroke Strategy. Department of Health, 2007.12 National Sentinel Stroke Clinical Audit 2010. Intercollegiate Stroke Working Party. May 201113 NHS Reference costs 2009/10. AA22Z.14 An economic evaluation of speech and language therapy. Royal College of Speech and Language Therapists.

http://www.slcsn.nhs.uk/files/newsletters/stroke-news/stroke-news-oct2011.pdf

http://www.slcsn.nhs.uk/files/newsletters/stroke-news/stroke-news-oct2011.pdf

www.stroke.org.uk/document.rm?id=916



http://www.slcsn.nhs.uk/files/newsletters/annual-report-2010-11.pdf



Stroke rehabilitation can last from a few days to longer than six months. It should start as soon as possible after emergency treatment and stabilisation, preferably within 24-48 hours.

intervention A:Specialist stroke rehabilitation services should have an education programme for all staff providing the service and should have access to support services, including orthotics and orthoptics. Care should be provided where possible in a specialised stroke unit including dietitians, OTs, physiotherapists and SLTs. Stroke units should hold at least one multi-disciplinary meeting per week. This meeting should include the setting of rehabilitation goals.

early rehabilitation:Multi-disciplinary team

A

Rehabilitation during treatment: Dietitian, Physiotherapist, SALT, OT

B

Avoided costAvoidance of complications. Prevention of recurrence of stroke.

scenario 3: AHP inputs to stroke rehabilitation across the care pathway

Rehabilitation on discharge:Specialist stroke rehabilitation team

C

ongoing support:SALT, OT, Physio

D 15 National clinical guidelines for stroke. Third edition. Royal College of Physicians. 2008.16 Ibid.17 Ibid.18 Ibid.19 Early supported discharge service for stroke patients: a meta-analysis of individual patients’ data. P Langhorne et al. Lancet 2005.20 Cost-effectiveness of stroke unit care followed by early supported discharge. O Saka et al. Stroke. 2009.intervention B:

Dietitians should assess patients with difficulties in self-feeding; manage the nutrition of patients with dysphagia (in conjunction with SLTs); co-ordinate the multi-disciplinary team to ensure screening for malnutrition is repeated weekly; and provide guidance to carers and staff.

OTs should assess any patient whose activities have been limited using activity analysis; assess and redevelop any impairments in skills; assess the patient’s social and physical environments; assess the patient’s cognitive impairments; assess for any adaptations required; and advise patients on the consequences for driving.

Physiotherapists should assess patients within 72 hours of admission; be involved in appropriate investigations; carry out physiotherapy assessments; and provide advice on lifestyle

measures. SLTs should assess patients within 72 hours of admission; assess patients with difficulties in swallowing; specialise in dysphagia; and observe patients with aphasia.

intervention C:Early supported discharge (ESD) is the early discharge of stroke patients from inpatient care to their homes, supported by a package of home-based physiotherapy, occupational therapy and speech therapy. Research from randomised trials in 2005 found that ESD had benefits for patients. Patients with ESD showed significant improvements in scores on the extend activities of daily living scale and in the odds of living at home and reporting satisfaction with services. The greatest benefits were seen in trials involving co-ordinated multidisciplinary early supported discharge teams and in stroke patients with mild to moderate disability.

intervention D:Continuing rehabilitation should go on for at least six months after discharge. Patients should be referred to vocational services where patients are of working age. Ongoing rehabilitation should provide lifestyle advice and monitoring for secondary prevention and provide ongoing care to manage physical and psychological complications.

An example of such long term rehabilitation is highlighted in the joint publication by the Chartered Society of Physiotherpy and the Stroke Association. A 41 year old father of 3 had a Stroke, his wife and carer is quoted as saying: “He spent six months in hospital and had regular inhouse neuro-physiotherapy. Once he came out he continued to receive a lot of occupational therapy and

physiotherapy – usually around two to three times a week. This has lasted for over a year and I feel that it has been hugely beneficial to Nick.” See pages 16-17 of the Moving on report

Avoided costs

The avoided costs of interventions A and B are part of the good management of stroke through stroke units. The avoided costs are described in Scenario 2. Ongoing rehabilitation can help to prevent recurrence of stroke, the avoided costs of which are described in Scenario 1.

Early supported discharge (ESD) has been shown to be cost effective. The Camden REDS team has shown that well managed ESD can reduce inpatient stays but up to ten days.

Avoided costReduced length of stay.

Avoided costReduced length of stay.Avoidance of complications.

Admission for stroke Admission to stroke unit Early supported discharge Long-term gain

http://www.csp.org.uk/sites/files/csp/secure/moving_on.pdf

http://www.csp.org.uk/sites/files/csp/secure/moving_on.pdf


stroke pathwayPrevention (1 of 3)

inTeRvenTion in PATHWAy imPRoving ouTComes THe eConomiC ARgumenT CAse sTuDies

Patient education on stroke risks – including advice on diabetes, hypertension, atrial fibrillation, deep vein thrombosis (DVT), smoking, alcohol and drug use and obesity – is provided by AHPs at various stages of the patient journey.

The importance of AHP input to health promotion and stroke prevention is underestimated, and is not generally understood.

Lifestyle factors that increase the risk of a recurrence of stroke include smoking, unhealthy diet, excessive alcohol consumption and physical inactivity. Lifestyle information delivered as an element of a secondary prevention intervention can help people to instigate and maintain lifestyle changes. This may save lives and reduce the extension of disability, thus diminishing disruption to individuals and their families, and also the economic burden for public services. Surveys of stroke patients report that significant numbers receive no lifestyle advice..

An exploration of lifestyle beliefs and lifestyle behaviour following stroke: findings from a focus group study of patients and family members. M Lawrence et al; BMC Family Practice 2010, 11:97.

The Stroke Association estimates that over 150,000 people have a stroke in the UK each year. The National Stroke Strategy estimated that 20,000 strokes a year could be avoided through preventive work.

National Stroke Strategy. Department of Health, 2007.

The cost of a stroke over five years has been estimated at £15,306 to the NHS and £29,405 including informal care costs (2001/02 prices).

The Economic Burden of Stroke in the UK. P Youman et al: Pharmacoeconomics, 2003.

If 20,000 strokes were prevented a year for five years then the potential gross savings to the NHS would be around £900 million. If informal care is included then the savings would be around £1.75 billion over five years.

This does not include the additional cost to the NHS of prevention, such as training for healthcare professionals (not just AHPs) in stroke and TIA risk factors, symptoms and lifestyle modifications, and drug or other treatments.

There is some evidence in a systematic review that people found information useful and that trends favour reduction in anxiety at three and six months.

J Needle et al. The allied health professions and health promotion: a systematic literature review and narrative synthesis. NIHR. 2011.

Paramedic assessment at point of contact enables patients to receive BP checks, ECGs, hyperglycaemia checks and orientation assessment. They can advise on physiological risks and encourage the patient to book a check health with their GP, or access falls services.

The role of the paramedic has shifted from its focus on basic first aid and patient transportation, to include higher levels of patient care and the treatment of a wide range of conditions. Many paramedics have undertaken additional training and moved into specialist practitioner roles, combining extended nursing and paramedic skills and supporting the first contact needs of patients in unscheduled care. Specialist practitioners are primarily employed by ambulance service trusts and undertake a range of activities, including carrying out and interpreting diagnostic tests, undertaking basic procedures and assessments of patients with long-term conditions in their homes, and prescribing a wider range of medications.


Research suggests that specialist practitioners have had a significant positive impact on emergency services’ workloads, leading to reductions in referrals to other health professionals and the use of emergency transport, and in associated costs.

The indications are that the specialist practitioner model delivered through the 999 service may yield cost savings of approximately £291 per patient. This saving comes primarily from lower staff costs at incident, avoided Emergency Department attendances and lower use of non-inpatient follow-up services.

However, the validity of this finding and its generalisability to other models of care need to be confirmed in a larger study.

S Mason et al. Effectiveness of emergency care practitioners working within existing emergency service models of care. Emerg Med J. 2007.

A review of specialist practitioners in three areas of England found that specialist practitioners carried out fewer investigations, provided more treatments and were more likely to discharge patients home than the usual providers. Patients were satisfied with the care received from specialist practitioners, and this was consistent across the three different settings. It was found that specialist practitioners are working in different settings across traditional professional boundaries and are having an impact on reconfiguring how those services are delivered locally. Costs information (based on one site only) indicated that specialist practitioner care may be cost effective in that model of working.

S Mason et al. Effectiveness of emergency care practitioners working within existing emergency service models of care. Emerg Med J. 2007.

Appendix A


Appendix A



Dietitians can review diabetic and cardio-vascular risks, and monitor BMI and nutritional status.

Dietitians can reduce the length of stay in hospital by up to 5.5 days by working with SLTs to manage nutritional intake.

Policy statement: The specialist contribution of speech and language therapists along the care pathway for stroke survivors. Royal College of Speech and Language Therapists. (2007).

The national average daily cost for inpatient care for non-transient stroke or cerebrovascular accident (AA22Z) was £292. (Reference costs 2009/10). A reduction of length of stay by 5.5 days could potentially save around £1,600 per episode.

Visual screening by an orthoptist will detect visual changes and defects, and prevent unnecessary falls. This can lead to referrals for vascular workup and prevention of further TIA/Stroke, and onward referral to GPs and consultant physicians. Early intervention and self management can therefore reduce drift into increased ill health and the risk of stroke.

Orthoptists are concerned with the assessment, diagnosis and treatment of ocular motility defects and problems relating to vision, such as amblyopia (lazy eye), defective binocular vision, abnormal eye movements and diplopia (double vision). They are the recognised experts in childhood vision screening and undertake primary (and sometimes secondary) screening of children aged four and five. They also assess the use of visual aids for partially sighted children and adults, and teach the use of paediatric contact lenses to patients and parents. Their patients are of all ages, but particularly the very young and the elderly, who have a higher incidence of ocular pathology. They include those with special needs, specific learning difficulties, maxillofacial injuries, stroke, cancer, diabetes, cataract, glaucoma, low vision and neurological conditions.


Falls cost the NHS and social care an estimated £6m per day or £2.3bn per year in hip fractures alone. This figure does not take into account other costs associated with falls that do not result in hip fracture but that may still require treatment or care. There are also other costs involved, for example, falls cost £115 per ambulance call-out There is growing evidence to show that investing in falls prevention services is cost-effective. The Department of Health currently estimates that if every strategic health authority in England invested £2m in falls and bone health early intervention services they could each save £5m (net £3m) each year through reduced NHS costs, such as 400 fewer hip fractures.

Age UK. Stop Falling: Start Saving Lives and Money. 2010.


Appendix A



Podiatrists will routinely check for ischaemic and cardiovascular risks and refer on for preventative treatment.

Podiatrists deal with the assessment, diagnosis and treatment of the lower limb and are qualified to treat people with arthritis, diabetes, nail surgery and sports injuries. Though they work with people of all ages and with a wide range of podiatric problems, they play a particularly important role in helping older people to stay mobile and independent. Many podiatrists specialise in working with patients who are classed as high risk, suffering from an underlying condition, such as diabetes, rheumatoid arthritis, cerebral palsy, peripheral arterial disease and peripheral nerve damage, that puts their legs and feet at increased risk of injury and disability.


AHPs are taking on a bigger role as stroke coordinators and stroke navigators in regards to QM14 where reviews should occur at six weeks, six months and annually.

www.londonhp.nhs.uk/publications/stroke/ Life after stroke commissioners guide pages 9 and 33

www.improvement.nhs.uk/stroke/Reviewsforstrokepatients/tabid/171/Default.aspx

Physiotherapists promote the health and well being of individuals and the general public emphasising the importance of physical activity and exercise. There is evidence to support the role of exercise and activity in primary prevention of stroke and TIA’s and physical activity is an important aspect of lifestyle that patients at risk of recurrent stroke can modify.

Physiotherapists play a broad role in health promotion, health education and self-care. This can extend to advising and teaching carers, other health professionals and support workers in order to provide a coherent approach to maximising independence and well-being..


A meta analysis of observational studies looking at primary prevention indicated that physical activity may reduce the risk of stroke. Increased occupational activity was associated with a lower risk of ischaemic stroke compared to a moderate or inactive occupation.

Wendel Vos et al 2004.

http://www.londonhp.nhs.uk/publications/stroke/

http://www.improvement.nhs.uk/stroke/Reviewsforstrokepatients/tabid/171/Default.aspx

http://www.improvement.nhs.uk/stroke/Reviewsforstrokepatients/tabid/171/Default.aspx


Appendix A

stroke pathwayAssessment/Diagnosis (1 of 5)


A Paramedic will perform FAST/ Rosier assessment to determine whether a stroke has occurred or not. Assessment of TIA or other risks are also picked up by paramedic assessment on scene and can be referred to TIA clinics or other specialist pathways as appropriate.

Standard assessment scales based on face, arm and speech impairments are simple tools to improve the speed and accuracy of diagnosis in patients with suspected stroke, although there is a small risk of wrong diagnosis. The three signs most diagnostic of stroke (facial paresis, arm drift, abnormal speech) are assessed by FAST (face arm speech test). Many paramedics also use the Rosier test which is more effective and specialist paramedics will conduct a systemic neurological examination to:

• increase the accuracy of the initial stroke diagnosis• assist with more rapid diagnosis• speed up consideration for treatment • assist with more rapid referral to specialist services.

Presentation by Peter Langhorne, Professor of stroke care, University of Glasgow: Management of suspected stroke or TIA.

Reporting Radiographers can save time by accurately imaging and reporting on the patient’s status and suitability for thrombolysis. Reporting radiography is quicker and less costly, and also means that the patient is being assessed by a specialist clinician.

The use of reporting radiographers to conduct and report CT scans helps to improve the speed with which CT scans can be turned round and frees up the time of radiologists and neuroradiologists. The implications for patients are reduced waiting times for scans and quicker results from scans. This helps to speed up diagnosis and potentially shorten the patient pathway which the National Stroke Strategy acknowledges as important in improving stroke outcomes.

National Stroke Strategy - Department of Health, 2007.

The difference in hourly cost of a reporting radiographer and a radiologist is around £120, based on the cost of a radiographer at the mid-point of Agenda for Change Band 7 and a consultant radiologist.

The potential saving from substituting radiographers for radiologists is only a realisable cash saving to the hospital if they subsequently reduce the number of radiologists they employ. It is more likely that this will be an opportunity cost saving, ie. the freeing up of this resource in the form of time available to radiologists to carry out other work.

Kingston Hospital NHS Trust faced increased demand and required a quicker response time for CT examinations, and needed to free up the reporting time of the consultant neuroradiologist with the introduction of an MRI scanner in 2003. In 2004, the Trust allowed a CT radiographer to report on CT scans.

Since 2004, 30% of adult CT head scans have been reported by a radiographer rather than a consultant radiologist (4,500 out of 14,750). Patients’ CT scans are now turned round more quickly and radiologists time is freed up to report more complex body scans. The Trust reports greater awareness of CT brain pathologies by all CT radiographers, which gives a higher pick up rate for when to suggest contrast administration, thereby reducing the numbers of recalls. GPs are now able to access the CT head service directly with 24 hour turnround of reports.

Implementation of radiographer for CT head reporting for stroke. www.improvement.nhs.uk. May 2009.


Appendix A



Radiographers working with Speech and Language Therapists assess using video fluoroscopy techniques to diagnose and assess a range of feeding and swallowing problems that could lead to aspiration pneumonia and death.

Other assessment techniques include the monitoring of oxygen saturation and fibreoptic endoscopic evaluation of swallowing (FEES) to assess the status of stroke victims swallow.

The Royal College of Speech and Language Therapists policy statement on the speech and language therapy (SLTs) contribution to the provision of VFS states that where SLTs are leading clinics they must be appropriately trained, they must not act alone and there must be a clearly defined and limited remit agreed with the delegating radiologist and other key professionals.

VFS is a modification of the standard barium swallow examination used in the assessment and management of oropharyngeal swallowing disorders. It can be used for assessment, treatment and management of swallowing in a range of client populations, including patients with stroke, where the suspected condition or disease process impacts on swallow function and may result in a risk of death, pneumonia, dehydration, malnutrition and psychosocial issues related to discomfort and difficulty eating and drinking.

Videofluoroscopic Evaluation of Oropharyngeal Swallowing Disorders (VFS) in Adults: The role of Speech and Language Therapists – Royal College of Speech and Language Therapists, January 2007.

At Glasgow Royal Infirmary clinic costs were reduced from £345 (consultant radiologist + speech therapist) to £215 (radiographer + speech therapist). At five clinics per week the annual saving for the hospital was 5 x £130 x 52 = £33,800. 124 hospitals in England treat acute stroke so if these savings were replicated across each, there is potential for national annual savings to the NHS of £4.191 million. These savings could be in the form of cash through a reduction in the number of radiologists employed or as opportunity cost savings whereby the time of radiologists can be used for additional activity.

Stroke pathway – delivering through improvement – www.evidence.nhs.uk/qualityandproductivity, November 2009.

At Glasgow Royal Infirmary clinic costs were reduced from £345 (consultant radiologist + speech therapist) to £215 (radiographer + speech therapist). At five clinics per week the annual saving for the hospital was 5 x £130 x 52 = £33,800. 124 hospitals in England treat acute stroke so if these savings were replicated across each, there is potential for national annual savings to the NHS of £4.191 million. These savings could be in the form of cash through a reduction in the number of radiologists employed or as opportunity cost savings whereby the time of radiologists can be used for additional activity.

Stroke pathway – delivering through improvement – www.evidence.nhs.uk/qualityandproductivity, November 2009.

Physiotherapists are important members of the multidisciplinary team. Practitioners use their specialist knowledge of the respiratory and neuro-musculoskeletal systems to assess patients using specific objective measures. This informs the diagnosis of respiratory dysfunction, motor and sensory impairment, activity limitation and participation, and cognitive impairment.

A process of clinical reasoning is then used, which incorporates information from the multi-disciplinary team, to inform prognosis and plan of intervention. The physiotherapy assessment also identifies those patients who are at risk of developing secondary complications such pneumonia, pressure sores and contractures due to immobility.

Physiotherapy assessment identifies patients who are at risk of developing secondary complications such pneumonia, pressure sores, clotting disorders and contractures and enables early intervention in order to address these complications which may otherwise impact negatively on rehabilitation and prolong length of hospital stay

Home


Appendix A



A range of assessment takes place in the acute phase to reduce the possibility of severe complication at a later stage. Occupational Therapists assess patients’ functional ability and sensory skills and also assess mood and cognition. The social circumstances of the family pre-admission will be assessed to help future therapy.

Using allied health professionals in the stroke pathway contributes to improving clinical processes, productivity, quality and effectiveness of the service to stroke patients. The provision of co-ordinated care along the pathway can reduce delays and improve access to rehabilitation therapy. Examples of benefits from the use of advanced AHPs include:

• Faster access to initial treatment – with improved paramedic involvement from the ambulance service and the reporting advanced radiographer

• Faster and more effective access to discharge support and rehabilitation

• More effective use of beds in stroke units which helps to improve productivity.

Modernising AHP Careers – Advanced AHP practitioner roles in the stroke pathway. Skills for Health/NHS London, October 2010.

Examples of financial benefits include:

• Critical goal setting with realistic outcomes will ensure that patients receive the most cost effective treatment, for example the use of ‘step down’ facilities;

• Good early discharge, reducing the length of stay;• Potential for the avoidance of Readmissions.


In Tower Hamlets, several Advanced Practitioners work in the Stroke pathway, including OTs and Physios. For both OT and Physiotherapy they lead on the entire pathway from HASU to community care ensuring a smooth journey for patients. Repatriation of stroke survivors to their local hospital /area has improved significantly since appointment of an 8A OT who works as a discharge coordinator. Before this role was in place, it was difficult to discharge within 72 hours from the HASU at the Royal London Hospital. With better understanding of the local pathway and more effective links with the community via the discharge coordinator, the discharge process has significantly improved and patients are now discharged within the 72 hours. The North East Stroke Network paid for this initiative. Additionally, the early supported discharge team has helped with reduction in the length of hospital patient stays.


By assessing vision for evidence of neurological damage, orthoptists act preventatively to dampen the effects of double vision and other visual disturbances, thereby reducing the risk of falls.

The restoration of binocular vision can speed rehabilitation and allow people to return to work. The risk of loss of visual acuity is particularly seen in the number of falls in the over 65 age group.

Orthoptists are concerned with the assessment, diagnosis and treatment of ocular motility defects and problems relating to vision, such as amblyopia (lazy eye), defective binocular vision, abnormal eye movements and diplopia (double vision). They are the recognised experts in childhood vision screening and undertake primary (and sometimes secondary) screening of children aged four and five. They also assess the use of visual aids for partially sighted children and adults, and teach the use of paediatric contact lenses to patients and parents. Their patients are of all ages, but particularly the very young and the elderly, who have a higher incidence of ocular pathology. They include those with special needs, specific learning difficulties, maxillofacial injuries, stroke, cancer, diabetes, cataract, glaucoma, low vision and neurological conditions.





Appendix A



Speech and Language Therapists provide information in an accessible way for people who have suffered stroke and need help to comprehend language.

Aphasia is a language disorder caused by neurological damage. Symptoms include difficulty with one or several forms of communication including speech, comprehension, reading and writing. It is estimated that around 53,000 adults per year in the UK suffer post stroke aphasia requiring SLT. In comparison to routine SLT, enhanced SLT results in an estimated 0.057 Quality Adjusted Life Years (QALY) gain per patient. The benefits of SLT are derived from reduced symptoms of aphasia leading to improved ability to perform daily living activity and health related quality of life gains.

Marsh et al. An economic evaluation of speech and language therapy. Royal College of Speech and Language Therapists. Go to website >

The associated annual benefits from the gain in quality adjusted life years for patients with aphasia are estimated to exceed the cost of the enhanced SLT by £13 million in England. Every £1 invested in enhanced SLT is estimated to generate £1.3 due to the monetary benefit associated with a quality of life gain.


RCSLT finds that SLT is effective for people with aphasia. More intense therapy of longer duration results in greater gains for aphasic individuals.”

Aphasia. RCSLT resource manual for commissioning and planning services for speech, language and communication needs. Royal College of Speech and Language Therapists (2009).

SLTs provide:

• Stroke specialised rehabilitation within hospitals;• Transfer of care from hospital to community;• Resources to support long-term needs;• Reviews after 6 week, 6 months and a year.

Aphasia. RCSLT resource manual for commissioning and planning services for speech, language and communication needs. Royal College of Speech and Language Therapists (2009).




Appendix A



Assessment by a Speech and Language Therapists within the first 24 hours will eliminate risk around aspiration. Nurses and others are trained by Speech and Language Therapist to be aware of aspiration risk and take appropriate action.

Dysphagia is a swallowing disorder caused by neurological damage. Symptoms include difficulty swallowing food and liquids which can lead to health consequences. It is estimated that approximately 63,000 adults per year in the UK suffer post stroke dysphagia requiring SLT. In comparison to usual care by a non-specialised nurse, SLT is estimated to prevent 4,300 cases of chest infections requiring hospital care and 9,200 cases of chest infections requiring community care. The economic analysis is likely to underestimate the benefits of speech and language therapy. Other benefits of SLT for dysphagia include improved quality of life and avoidance of malnutrition and death..


The reduction in chest infections through SLTs addressing dysphagia results in cost savings that exceed the staff cost by £11.2 million in England. Every £1 invested in low intensity SLT is estimated to generate £2.3 in health care cost savings through avoided cases of chest infections.


Following a stroke in 2010, Peter Hardy was unable to eat or drink, or even to swallow his own saliva. He was told he had suffered a brainstem stroke and would probably have to stay in the hospital for the next three months. Peter had a tube feeding him through his nose and was coughing up his secretions. He determinedly said to his stroke consultant, ‘No way. I’m getting out of here in a month.’

Peter was highly motivated and completed the daily exercises to improve his swallowing as instructed by his speech therapist. Perhaps it was the pint of Guinness that the doctor promised him upon recovery, but Peter consistently demonstrated his bravery and drive to the Northwick Park stroke team. In less than a month, Peter was eating and drinking as normal, no longer using a tube through his nose for nutrition. He was released from hospital to go home.

Relating his experience on the Stroke Unit at Northwick Park Hospital Peter says, ‘It was a great team. The speech and language therapist and physiotherapist coached me on exercises to get my swallowing back. The dietician monitored my tube feeding. The occupational therapist sorted out my return to work. And the doctors oversaw it all to make sure everything was under control. I always felt I was a member of the team. You know, the team would not achieve the goal without me being positive and ready to fight.’

Stroke news, January 2011. London Cardiac and Stroke Networks.

Malnutrition – Using a sustained integrated approach, led by dietitians, and which ensures all aspects of malnutrition identification, treatment and training are addressed in primary care, can lead to a reduction in expenditure of up to 23%.

AHP key facts. AHPF.



Stroke toolkit 25

stroke pathwayTreatment (1 of 2)


Physiotherapists will use a variety of interventions to prevent the development of complications identified in the assessment stage. These include respiratory techniques, positioning and early mobilisation.

Ongoing management of stroke should take place in a specialised stroke unit comprised of a team of professionals with access to physiotherapy, including respiratory physiotherapy.


Treatment by a Speech and Language Therapist will reduce the risk of aspiration pneumonia.

Dysphagia is a swallowing disorder caused by neurological damage. Symptoms include difficulty swallowing food and liquids which can lead to health consequences. It is estimated that approximately 63,000 adults per year in the UK suffer post stroke dysphagia requiring SLT. In comparison to usual care by a non-specialised nurse, SLT is estimated to prevent 4,300 cases of chest infections requiring hospital care and 9,200 cases of chest infections requiring community care. The economic analysis is likely to underestimate the benefits of speech and language therapy. Other benefits of SLT for dysphagia include improved quality of life and avoidance of malnutrition and death.


The reduction in chest infections through SLTs addressing dysphagia results in cost savings that exceed the staff cost by £11.2 million in England. Every £1 invested in low intensity SLT is estimated to generate £2.3 in health care cost savings through avoided cases of chest infections.


Following a stroke in 2010, Peter Hardy was unable to eat or drink, or even to swallow his own saliva. He was told he had suffered a brainstem stroke and would probably have to stay in the hospital for the next three months. Peter was highly motivated and completed the daily exercises to improve his swallowing as instructed by his speech therapist. In less than a month, Peter was eating and drinking as normal, no longer using a tube through his nose for nutrition. He was released from hospital to go home.

Relating his experience on the Stroke Unit at Northwick Park Hospital Peter says, ‘It was a great team. The speech and language therapist and physiotherapist coached me on exercises to get my swallowing back. The dietician monitored my tube feeding. The occupational therapist sorted out my return to work.’


Dietetic treatment is vital to long-term stroke outcome and needs to be established as soon as possible. NICE suggests that the treatment of malnutrition has the third highest potential to deliver cost savings for the NHS.

Dietetic advice must be regarded as an integral part of stroke patients management in hospital. It should be sought early to assess the most appropriate method of meeting individual nutritional requirements of stroke patients at risk.

S Gariballa. Assessment and treatment of nutritional status in stroke patients. Postgrad Med J. 1998.

Oral nutritional supplements (ONS) are prescribed to treat malnutrition. They are cheap in hospital (1p per carton) but expensive in the community setting (£1.71 - £1.85 per carton) and increasing. Inappropriate prescribing (57-75% of prescriptions) has led to £28-37 million of wasted spend in London PCTs over the last 4 years and the annual national spend is £89 million. If NICE guidelines were met then there is a chance of saving between £51-67 million annually. One of the reasons for inappropriate prescribing is a lack of dietetic capacity to provide effective care.

www.evidence.nhs.uk/qualityandproductivity.

Home next

Appendix A




Appendix A

stroke pathwayTreatment (2 of 2)


Occupational Therapist assessment would generate vital knowledge on stroke survivors and cognitive, sensory and dynamic balance capabilities. Awareness and description of loss of function is helpful in helping patients to gain an understanding of their abilities and how they might enhance their own recovery. OTs would plan early discharge motivating patients to return home and achieve independence despite disabilities.

One of the recommendations in the National Stroke Strategy is that there is a need to develop ongoing rehabilitation in the community, provided by stroke skilled people. The strategy stresses the importance of these teams being multidisciplinary with the right specialist skills to rehabilitate people after a stroke. The strategy emphasises the importance of allied health professionals such as physiotherapists, OTs and SLTs as well as other services such as podiatry, continence services and community mental health services.


The impact assessment for the National Stroke Strategy estimated that if the recommendation were fully implemented 1,500 more stroke survivors would be independent each year resulting in an annual saving of £38 million. In terms of resources it was assumed that 138 centres would require a community stroke team as the 2006 National Sentinel Audit reported that only 32 per cent of centres had a team at that point. Each team could run a caseload of 85 patients and dependency could be avoided in 1 of 13 patients treated.

National Stroke Strategy Impact Assessment - Department of Health, 2007.

In Tower Hamlets, several Advanced Practitioners work in the Stroke pathway, including OTs and Physios. For both OT and Physiotherapy they lead on the entire pathway from HASU to community care ensuring a smooth journey for patients.

Repatriation of stroke survivors to their local hospital /area has improved significantly since appointment of an 8A OT who works as a discharge coordinator. Before this role was in place, it was difficult to discharge within 72 hours from the HASU at the Royal London Hospital. With better understanding of the local pathway and more effective links with the community via the discharge coordinator, the discharge process has significantly improved and patients are now discharged within the 72 hours. The North East Stroke Network paid for this initiative. Additionally, the early supported discharge team has helped with reduction in the length of hospital patient stays.


Orthoptists treat patients with stroke and refer to sensory teams in local authorities. This helps prevent falls, encourages people to read (so they can maintain independence and return to work) and saves the NHS money.

Orthoptists are concerned with the assessment, diagnosis and treatment of ocular motility defects and problems relating to vision, such as amblyopia (lazy eye), defective binocular vision, abnormal eye movements and diplopia (double vision). They are the recognised experts in childhood vision screening and undertake primary (and sometimes secondary) screening of children aged four and five. They also assess the use of visual aids for partially sighted children and adults, and teach the use of paediatric contact lenses to patients and parents. Their patients are of all ages, but particularly the very young and the elderly, who have a higher incidence of ocular pathology. They include those with special needs, specific learning difficulties, maxillofacial injuries, stroke, cancer, diabetes, cataract, glaucoma, low vision and neurological conditions...





Appendix A

stroke pathwayRehabilitation (1 of 3)


Critical goal setting with realistic outcomes will ensure that patients receive most cost effective treatment. For example, ‘step down’ facilities, which look after patients who are not ready for rehabilitation, increase the productivity of stroke units and reduce the potential for re-admission. Co-ordinated care with the right skills in the right place along the pathway also reduces delays and improves access to rehabilitation therapy.

Advanced AHP Practitioners maintain the best route for patients by outlining good outreach to community practice and also inreach into the acute setting. The leadership skill set needed for this are found in the National Occupational Standards for AHP Advanced Practitioners.

Early supported discharge (ESD) is the early discharge of stroke patients from inpatient care to their homes, supported by a package of home-based physiotherapy, occupational therapy and speech therapy. Research from randomised trials in 2005 found that ESD had benefits for patients. Patients with ESD showed significant improvements in scores on the extend activities of daily living scale and in the odds of living at home and reporting satisfaction with services. The greatest benefits were seen in trials involving co-ordinated multidisciplinary early supported discharge teams and in stroke patients with mild to moderate disability.

Early supported discharge service for stroke patients: a meta-analysis of individual patients’ data, P Langhorne et al. Lancet 2005; 365: 501-506.

A study published in 2009 concluded that the combination of stroke unit care followed by ESD is both an effective and cost-effective strategy with the main gains in years of life saved. The incremental cost–effectiveness ratio of stroke unit care followed by ESD is £10,661 compared with general medical ward care without ESD care and £17,721 compared with stroke unit care without ESD.

Cost-effectiveness of stroke unit care followed by early supported discharge. O Saka et al. Stroke 2009; 40; 24-29.

The Camden Stroke REDS (Reach Early Discharge Scheme) was developed from a fully functional community rehabilitation team that offered a stroke pathway. Stroke REDS accepts patients from acute and inpatient stroke units that are suitable for ESD and assists in identifying patients requiring further inpatient stroke rehabilitation. It is a specialist interdisciplinary team, operating through an ’in-reach’ model that can assess, facilitate and complete a discharge within 24 hours of referral, including escorting the stroke survivor home. This enables seamless transfer of care from the hospital base right to the patient’s home. The team also includes enabling carers, that follow directions from the therapists, to ensure provision of care is focused on enabling the stroke survivor to regain as much functional independence as possible.

Between January and December 2009, 178 Camden residents had a stroke. In that time the service had discharged and rehabilitated 57 patients which equates to 32% of stroke survivors (the target set prior to start of the service was 30%). 580 acute and inpatient bed days had been saved. On average the service has reduced inpatient stays by 10 days across acute and inpatient stroke units when compared to the national length of stay average.

www.improvement.nhs.uk/qipp

The Camden REDS case study claimed savings of more than £200,000 or £83,000 per 100,000 population.

www.improvement.nhs.uk/qipp

Home

Appendix A



Orthotists working alongside physiotherapists and podiatrists assess gait and appropriate footwear, provide ankle-foot orthosis to prevent trips and falls.

Physiotherapists may also provide clients with devices such as specialist splints, functional electrical stimulation and other adjuncts to aid gait re-education and improve the patient’s walking ability. Gait may improve in both the acute and chronic stage of stroke with physiotherapy input.

Green J ,Forster A, Bogle S, Young J (2002) Physiotherapy for patients with mobility problems more than 1 year after stroke: a randomised control trial Lancet. Jan 19;359(9302):199-203.

To individual patients the correct supply and fitting of orthotic devices can be a major factor in the management of their condition or the prevention of future problems. The selection and fitting of the most appropriate device requires detailed knowledge of the functioning of the musculo-skeletal system. Many orthotic devices have to be fitted specifically for the individual patient. Delivery of a service of this kind can only be carried out by those with a proper professional training in orthotics and a broad experience of the range of products available.

Orthotics services can assist in the achievement of major policy objectives of the NHS, including reducing referral to treatment times; developing stroke care services; facilitating choice for people with long term conditions; and providing seamless health care with service provision by those best placed to meet patient needs. Orthotic services can play an important role in meeting the NHS objective of keeping people mobile and independent and therefore reducing the need for acute treatment or social care services.

Hutton and Hurry 2009, Orthotic Service in the NHS: Improving Service Provision. York Health Economics Consortium.

A survey of 6 trusts involved in the 2004 Pathfinder project which highlighted that for every £1 spent on orthotic services the NHS saves £4. With current expenditure on orthotic service provision estimated at £100 million this represents a saving of £400 million to the NHS.


The West Midlands Regional Orthotic Project in 2007 was designed to develop orthotic services in one region of the English NHS, along the lines proposed in the Pathfinder report. The key recommendations were aimed at commissioners, orthotic service managers and contracted service providers in order to improve service delivery. The report also recommended collaboration between commissioners and senior management in providing trusts. Similarly, there was a need for more coordination between management levels within providing trusts, from the orthotic service manager upwards. Six key factors central to the achievement of change were identified:

• Clear service specifications• Valuing health care professionals• Companies acting responsibly• A clinical evidence base• Cost savings from appropriate provision to fund

further developments• Whole system change to gain maximum benefit from

orthotic services.


Physiotherapists play a significant role in the patient’s rehabilitation in a stroke unit and after discharge home or to intermediate care settings. As well as improving a patient’s ability to walk, physiotherapists alongside other members of the MDT enable stroke survivors to be able to stand up, move from one place to another and use their arms in a meaningful way. Patients who have some ability to move their arms should be given every opportunity to practice movements with techniques such as constraint induced movement therapy (Wolf 2006).

Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D, Giuliani C ,Light KE, Nichols-Larson D & EXCITE I (2006) Effect of constraint-induced movement therapy no upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial JAMA: the journal of the American Medical Association, vol 296, no 17 , p 2095-2104

Results from a systematic review show that EDHR can reduce the length of time spent in hospital and improve patients’ instrumental activities of daily living and quality of life. Early discharge and home rehabilitation seems to be cost-effective if rehabilitation at home is provided by a multidisciplinary team from a hospital.

Winkel et al 2008.

Northumbria Healthcare NHS Foundation Trust established ESD with patients being seen seven days a week and visits of up to three times a day. This reduced the average length of stay by half and saved £500k by replacing inpatient beds with early supported discharge.

Chartered Society of Physiotherapy (2011). Physiotherapy works: Stroke. See website >

Stroke toolkit 28

http://www.csp.org.uk/sites/files/csp/secure/csp_physioworks_2011_stroke_0.pdf


Appendix A



Occupational Therapists provide expert assessment of the home environment and installation of bathing, toileting and walking aids, which helps facilitate a safe and sustainable discharge home. OTs coordinate discharge planning with social workers and care agencies to provide an appropriate care package. They can refer to Local Authority or may be employed by Local Authorities to provide social and vocational support. OTs also provide therapy for the effects of cognitive and perceptual impairment following stroke. They will work with families to help manage behavioural changes.

One of the recommendations in the National Stroke Strategy is that there is a need to develop ongoing rehabilitation in the community, provided by stroke skilled people. The strategy stresses the importance of these teams being multidisciplinary with the right specialist skills to rehabilitate people after a stroke. The strategy emphasises the importance of allied health professionals such as physiotherapists, OTs and SLTs as well as other services such as podiatry, continence services and community mental health services.


A randomised controlled trial evaluating a multi-professional stroke team found that compared to routine care, patients treated by the community stroke team were more satisfied with the emotional support they received and had equivalent outcomes in terms of independence in activities of daily living and mood. Their carers were under less strain and were more satisfied with their knowledge of stroke recovery, the emotional support they received and overall satisfaction with services. The results supported the provision of rehabilitation by a community-based specialist multi-professional team.

Evaluation of a multiprofessional community stroke team: a randomised controlled trial. N Lincoln et al. Clinical Rehabilitation 2004; 18; 40-47.

Speech and Language Therapists provide rehabilitation for language comprehension and spoken communication problems following stroke. Users may need to be provided with hardware or software to gain access to alternative or augmentative communication aids. These can be vital to the process of gaining confidence and reaching personal goals in regaining function following stroke.

Aphasia is a language disorder caused by neurological damage. Symptoms include difficulty with one or several forms of communication including speech, comprehension, reading and writing. It is estimated that around 53,000 adults per year in the UK suffer post stroke aphasia requiring SLT. In comparison to routine SLT, enhanced SLT results in an estimated 0.057 Quality Adjusted Life Years (QALY) gain per patient. The benefits of SLT are derived from reduced symptoms of aphasia leading to improved ability to perform daily living activity and health related quality of life gains.


The associated annual benefits from the gain in quality adjusted life years for patients with aphasia are estimated to exceed the cost of the enhanced SLT by £13 million in England. Every £1 invested in enhanced SLT is estimated to generate £1.3 due to the monetary benefit associated with a quality of life gain.


The Blackburn with Darwen and NHS Camden REDs community teams both have robust data collection systems. This supports extensive analysis which enables them to identify the effect of 45 minutes of therapy on clinical and service outcomes.

This has resulted in improved multidisciplinary team goal setting, predicting outcomes and devising effective packages of intervention on an individual basis, maximising the use of their skill mix.

Both organisations are able to demonstrate a positive financial impact on the acute service through reducing length of stay, and for social care by reducing final packages of care. Blackburn with Darwen community stroke team (2010) reduced final packages of care per week by 240 hours of care/week, equating to £93,600 savings per year

Download the NHS Improvement report here >



http://www.improvement.nhs.uk/stroke/Increasingaccesstotherapy/tabid/300/Default.aspx


Appendix A

stroke pathwayRe-ablement (1 of 2)


Specialist AHP Practitioners can provide the link to social care and psychological support, vocational opportunities and other long term support. This is a difficult gap to bridge and carries major cost risks. The skills necessary are found in advanced practitioners assessing and treating patients requiring advanced clinical reasoning and communication skills.

The Lewisham integrated stroke project has demonstrated reduced average length of hospital stay, an increase in stroke patients spending more than 90% of their stay on the stroke ward, and a reduction in waiting times.

Service users have given high praise for the rapid response, motivating and caring manner of the staff, and the reassurance of having rapid access to equipment and adaptations enabling them to manage independently at home.

NHS Improvement. The best of clinical pathway redesign: Practical examples delivering benefits to patients. 2011.

In the Lewisham integrated stroke project, the average length of hospital stay prior to implementation was 22.5 days. This has decreased to 19 days and has made a significant impact on access to community waiting times for therapy, which have fallen by 10 days or more for some therapies, even before the planned early supported discharge team was in place.


In the Lewisham integrated stroke project, colleagues across health and social care worked together to improve the service for stroke patients on transition from hospital to home and after they had left hospital.

Through engagement with senior management and clinical staff and consultation with service users, bottlenecks in the transfer of care and rehabilitation process were identified and a collaborative approach across health, social care and voluntary organisations used to aspire to best practice. The pathway was re-designed, there was a focus on joint working and systems of communication and a reconfiguration of the workforce to include some new therapy posts and new ways of working and to integrate provision of stroke rehabilitation from several teams into a single integrated team.


Find out more about a psychology national project where the service improvement manager from the network and the stroke service leads (both physios) led an improvement for the community MDT, mainly AHPs, to be trained in recognising psychological issues and providing low level support for psychological issues.

Link

Physiotherapists provide client centred assessments in the community to negotiate longer term measurable goals in collaboration with clients, carers and the multidisciplinary/interagency team.

There is a growing body of evidence that physical fitness after stroke can be improved. The Cochrane systematic review of physical fitness training after stroke (24 trials, 1,147 patients) has demonstrated that physical fitness training, including walking as a mode of aerobic exercise, improves aerobic fitness.

G Mead. Physical fitness raining after stroke: time to translate evidence into practice. J R Coll Physicians Edinb. 2011.

Findings from a randomised controlled trial investigating regular exercise with self-initiated training v intensive exercise group with scheduled intensive training identified that the former led to a greater degree of HRQOL. The degree of motor function, balance, walking capacity and independence in activities of daily living was also identified as important for perceived HRQoL.

Langhammer et al 2008

The Stroke Association and the CSP surveyed 1160 stroke survivors in 2009 and “40% of stroke survivors who indicated a positive experience of community based physiotherapy felt that it had helped them be less reliant on carers (Stroke Association and CSP 2009)

Training caregivers in basic skills reduces the burden of care and improves quality of life for patients and carers.

Kalra et al 2004.


Appendix A

stroke pathwayRe-ablement (2 of 2)


Orthoptists provide valuable follow up to monitor visual function and provide corrective spectacles to aid confidence in gait, fall prevention and reading. They also screen for fitness to drive post-stroke.

The Royal College of Physicians Intercollegiate Stroke Working Party state that visual field loss is common and that specialist stroke rehabilitation centres should have easy access to orthoptic services. Every patient should receive a practical assessment of visual acuity, examination of visual field and provision of information on techniques. The position statement by the British and Irish Orthoptic Society for the national stroke strategy states that orthoptists can advise on the strategies available to cope with visual field loss and can arrange ophthalmology referrals for partially sighted registration where applicable. Research around vision restoration therapy, a home-based rehabilitation programme that generates visual stimuli, has concluded that it improves visual functions in a large clinical sample of patients with visual field defects.

Intercollegiate Stroke Working Party. National clinical guidance for stroke 3rd edition. Royal College of Physicians, 2008.

Orthoptists can speed rehabilitation and return to work for RTA and stroke victims. Double vision often follows stroke increasing recovery time and reducing the capacity for returning to work. The investment cost of one diagnostic test and three follow up appointments with a Band 7 Orthoptist totalling approximately £800 could save the much larger cost of six weeks sick pay or state benefit.

AHP key facts. AHPF.


Appendix A

stroke pathwayLong-term gain (1 of 2)


Arts Therapists help with emotional issues related to ‘living with stroke’, eg: loss, depression, anger, anxiety, helplessness, powerlessness; shame as well as adjustment/coping, socialisation, relationships and communication.

Strokes can result in depression and speech maybe affected or confidence to talk impaired. Low mood can also impede speech. As a non-verbal treatment method Art Therapy can address issues around the illness in a less confrontation way to verbal therapies. It also allows space and time in which patients can come to term with the illness and its effects and find ways to manage. Achievements can be seen in changes in patients’ mental state, improvements in mood, increases in motivation and function and a gradual coming to term and adjusting to changes through support from the Art Therapist.

Towards a national stroke strategy – good practice examples. Download report >

The British Association of Art Therapists recommends that each Health Authority area should have two specialist posts (art and music therapy) to cover all parts of the pathway. These need to be integrated into the multi-disciplinary approach for stroke rehab and should be available across the pathway. Art therapy is especially appropriate in community settings and music therapy in hospital settings.

The cost of employing two therapists would be approximately £40,000 (hospital) and £39,000 (community). This is based on the median full time equivalent basic salary for Agenda for Change Band 5 (for fully qualified AHPs) plus on-costs and overheads.

Arts therapies in the stroke pathway. BAAT. Unit costs of health and social care 2010. Personal Social Services Research Unit.

Art Therapy at the Chamberlain Day Hospital, London, provides assessment and treatment in the medium to long term work for individuals and groups. The work addresses issues around mental health problems relating to the person referred.

A space for linking: Art therapy and stroke rehabilitation. D Michaels. International Journal of Art Therapy, December 2010; 15(2): 65-74.

Other research suggests that, as part of a multidisciplinary approach, psychodynamic art psychotherapy may be particularly appropriate for stroke survivors who struggle to make use of standard treatments and solely verbal forms of psychological help.


Physiotherapists play a significant role in the patient’s rehabilitation in a stroke unit and after discharge home or to intermediate care settings.

Participation and enhanced HRQOL (CSP & Stroke Association 2009). Prompt access to physiotherapy assessment in the event of a deterioration in functional performance may be an important factor in preventing the need for hospital admission.

http://www.baat.org/ATOLLStrokeStrategy.pdf


Appendix A

stroke pathwayLong-term gain (1 of 2)


AHPs provide long-term benefit for stroke survivors facilitating return to work and vocational activity.

10,000 people under 55 suffer a stroke every year, 1,000 of whom are under 30 years of age. Longer terms survivors with stroke are likely to encounter problems with weakness spasticity, contracture, incontinence, pain, sensory loss and reduced function; there are estimates that 40-60% of stroke survivors will have problems with spasticity, providing further evidence for specialist physiotherapy services to be available at all stages of the patient pathway.

Healthcare for London: Consulting the Capital – Response by the Chartered Society for Physiotherapy.

A survey in 2000 found that 58% (292/503) of stroke survivors who expressed a desire to work had not worked since their stroke. Of those 82% (239) stated that they would like to work but did not feel fit enough. If these people were able to return to work, they would gain economically and there would be a reduction in Employment and Support Allowance benefit payments.

Work After Stroke project. www.differentstrokes.co.uk /research/was.htm

Comment of a stroke survivor in response to ‘A New Ambition for Stroke – a consultation on national strategy’:

“Without physiotherapy, instead of walking and driving my car I would still be in a wheelchair. Thanks to my physios I have been able to become a school governor of a primary school where I do voluntary work half a day a week. I am a street leader and report any environmental problems to the council. I am a resident member of the [XX] Partnership Board that tries to improve the area. I am a member of the Stroke Peer Support Group and go to visit people who are recovering from a stroke. All of these things are voluntary but give me a lot of satisfaction. I can only do these things because I had physiotherapy.”


The provision of effective co-ordinated rehabilitation services, while requiring resources to pump prime, in the longer view across the health economy, may result in transforming potential benefit recipients into tax payers, reducing sickness absenteeism and thus increasing productivity within UK service and production industries, and for those less able to return to work, to be more independent at home and reduce the costs of community support from health and social services.

Dame Carol Black’s Review of the health of Britain’s working age population.


References

economic scenarios

The Allied Health Professions and Health Promotion: a systematic literature review and narrative synthesis. J Needle et al. NIHR 2011.


The Economic Burden of Stroke in the UK. P Youman et al. Pharmacoeconomics, 2003.

Stroke – rehabilitation, Map of Medicine. 2011

National clinical guidelines for stroke. Third edition. Royal College of Physicians. 2008.

The diagnosis and acute management of stroke and transient ischaemic attacks. Clinical guideline 68. NICE. 2008.

National Sentinel Stroke Clinical Audit 2010. Intercollegiate Stroke Working Party. May 2011.

NHS Reference costs 2009/10. AA22Z.

An economic evaluation of speech and language therapy. Royal College of Speech and Language Therapists.

Early supported discharge service for stroke patients: a meta-analysis of individual patients’ data. P Langhorne et al. Lancet 2005.

Cost-effectiveness of stroke unit care followed by early supported discharge. O Saka et al. Stroke. 2009.

Prevention

An exploration of lifestyle beliefs and lifestyle behaviour following stroke: findings from a focus group study of patients and family members. M Lawrence et al; BMC Family Practice 2010, 11:97


The Economic Burden of Stroke in the UK. P Youman et al. Pharmacoeconomics, 2003.

The allied health professions and health promotion: a systematic literature review and narrative synthesis. J Needle et al. National Institute for Health Research. 2011.

Effectiveness of emergency care practitioners working within existing emergency service models of care. S Mason et al. Emerg Med J. 2007.

Policy statement: The specialist contribution of speech and language therapists along the care pathway for stroke survivors. Royal College of Speech and Language Therapists. (2007)

Stop Falling: Start Saving Lives and Money. Age UK. 2010.

Khemthong, S., Posawang, P., & Thimayom, P. (2009). Effectiveness of health system program with occupational therapy on quality of life and self-efficacy after stroke. [Thai]. The Journal of Occupational Therapist Association of Thailand,14(3):26-34.

J Rehabil Res Dev. 2008;45(7):1019-26. Prevention of secondary stroke in VA: role of occupational therapists and physical therapists. Schmid AA, Butterbaugh L, Egolf C, Richards V, Williams L.

Assessment/Diagnosis

Management of suspected stroke or TIA. Presentation by Peter Langhorne, Professor of stroke care University of Glasgow.


Implementation of radiographer for CT head reporting for stroke. www.improvement.nhs.uk. May 2009.

Videofluoroscopic Evaluation of Oropharyngeal Swallowing Disorders (VFS) in Adults: The role of Speech and Language Therapists. Royal College

of Speech and Language Therapists, January 2007.

Stroke pathway – delivering through improvement. www.evidence.nhs.uk/qualityandproductivity, November 2009.




An economic evaluation of speech and language therapy. Marsh et al. Royal College of Speech and Language Therapists.

Aphasia. RCSLT resource manual for commissioning and planning services for speech, language and communication needs. Royal College of Speech and Language Therapists (2009)

AHP key facts. AHPF

Stroke news. January 2011. London Cardiac and Stroke Networks.

Treatment


An economic evaluation of speech and language therapy. Marsh et al. Royal College of Speech and Language Therapists.

Stroke news. January 2011. London Cardiac and Stroke Networks.

Assessment and treatment of nutritional status in stroke patients. S Gariballa. Postgrad Med J. 1998.

Oral nutritional supplement prescribing review.

National Stroke Strategy Impact Assessment. Department of Health, 2007.



Rehabilitation

Early supported discharge service for stroke patients: a meta-analysis of individual patients’ data. P Langhorne et al. Lancet 2005; 365: 501-506.

Cost-effectiveness of stroke unit care followed by early supported discharge. O Saka et al. Stroke 2009; 40; 24-29.

Camden REDS case study.

Orthotic Service in the NHS: Improving Service Provision. Hutton and Hurry, 2009. York Health Economics Consortium: pg 12 - 13.


Evaluation of a multiprofessional community stroke team: a randomised controlled trial. N Lincoln et al. Clinical Rehabilitation 2004; 18; 40-47.

An economic evaluation of speech and language therapy. Marsh et al. Royal College of Speech and Language Therapists. http://www.rcslt.org/giving_voice/matrix_report

Re-ablement

The best of clinical pathway redesign: Practical examples delivering benefits to patients. NHS Improvement. 2011.

Physical fitness training after stroke: time to translate evidence into practice. G Mead. J R Coll Physicians Edinb. 2011.

National clinical guidance for stroke 3rd edition. Intercollegiate Stroke Working Party. Royal College of Physicians, 2008.

AHP key facts. AHPF

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Department of Health gateway Reference 17269

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