London Strategy for Life after Stroke

Tony Rudd

Story so far

2

HASUs • Provide immediate response • Specialist assessment on arrival • CT and thrombolysis (if appropriate) within 30 minutes • High dependency care and stabilisation• Length of stay less than 72 hours

Stroke Units • High quality inpatient rehabilitation in local hospital • Multi-therapy rehabilitation• On-going medical supervision • On-site TIA assessment services• Length of stay variable

30 min LAS journey* After 72 hours

Discharge from acute phase

Community Rehabilitation

Services

New acute model of care

1 year outcomes

40

45

50

55

60

65

70

75

80

85

90

Q1 Q2 Q3 Q4 Q1

2009/10 2010/11

% a

chie

vem

ent

London

England

Target

% of patients spending 90% of their time on a dedicated SU

1 year outcomes

0

2

4

6

8

10

12

14

16

18

20

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

2009/10 2010/11

Average length of stay

1 year outcomes

0%

2%

4%

6%

8%

10%

12%

14%

16%

3.5%

10%

12%

Feb-July 2009 Aim Feb-July 2010

Thrombolysis rates

14%

Jan-March 2011

Improvements in Community Services

Many more areas now have early supported discharge teams

Some increase in longer term stroke rehabilitation teams

We are reviewing in-patient rehabilitation services

London Stroke Survival vs Rest of England

Hazard ratio for survival in London 0.72 95%CI 0.67-0.77 p<0.001

The Stroke Association UK Stroke Survivor Needs Survey

Christopher McKevittReader in Social Science & Health

King’s College London

Aims

1. To estimate levels of self reported long term need in stroke survivors (1-5 years)

2. To compare levels of need between stroke survivors in England, Scotland, Wales & Northern Ireland

Results

• 51% reported having no unmet needs• Of those reporting unmet needs, total number

per respondent ranged from 1-13, median 3

Information• 54%: more information about stroke• No differences by age, gender, ethnicity, disability level

or time since stroke • Significantly different by nation (p=0.009):

Northern Ireland=66%Wales=65%England=54%Scotland=49%

Unmet health needs

Other unmet needs

Changes in social participation

• 52% unable to return to work or reduced hours• Significantly higher in Black and other ethnic groups

compared to Whites (p=0.006, population registers)

• 67% reported loss in leisure activities• Significantly higher in Black and other ethnic groups

compared to Whites (p=0.012, population registers)

Impact on finances

• 18% of those working at time of stroke reported a loss of income since stroke

• 31% reported increased expenses

• 16% (25% population registers) reported need for benefits advice

Family

• 42% reported a negative change in relationship with partner

• 26% reported negative changes in family relationships

Groups at higher risk?

• No differences by• age• gender• time since stroke

• Higher unmet need:• disability, including communication disability• ethnic minority stroke survivors• people living in poorest areas

Stroke survivors in London ‘denied recovery’ says new report calling for better coordination and support

‘Stroke survivors across London say they are being denied the chance to make their best recovery because of a lack of patchy post hospital care and confusion between health and social care services, states a new national report published today (Tuesday May 1st 2012) by the Stroke Association.’

•85% of stroke survivors say that the impact of stroke is not understood •Six out of ten (59%) said that health and social care services did not work well together resulting in families and carers having to take responsibility for coordinating care. •Almost a third (31%) reported services being reduced or withdrawn even though their needs had stayed the same or had increased.

Stroke Association Survey Findings

Stroke Association Survey Findings

38% felt they did not receive enough support from NHS services

Almost a third (31%) reported services being reduced or withdrawn even though their needs had stayed the same or had increased.

77% are unable to get out as much since they had their stroke.

Life After Stroke Commissioning Guide

London stroke strategy – where this fits

London stroke strategy (2008)

Public consultation (2008/09)

Rehab commissioning guide (2009)

Life after stroke (2010)

Principles

Active citizenship

Quality of life

Empowerment

Scale of need

• Prevalence ranges from 1.6% to 0.8% of registered GP population• 88,000 people across London on GP registers have had a stroke or TIA

Sum of stroke and TIA patients in a GP register in 2008/9

Diverse needs 15% have on-going continence

problems 25% of nursing home residents

have had a stroke 33% of stroke survivors report

depressive symptoms 20% “silent stroke” – underlying

cognitive problems

Regular review Needs change over time Recognise variability of needs and aspirations National guidance – 12 monthly review

Stroke survivor

Social care

GP

Therapist

Stroke navigator

Structured social group

Information Stroke care navigator

Single point of contact Direct role in delivering care Coordinate care packages Training stroke survivors and carers Work across different sectors

London stroke directorywww.londonstrokedirectory.org.uk

Engaging with community life Stroke survivors do not get

out of the home as much as they would like

Building confidence Addressing practical issues Community/social groups

have benefits beyond primary purpose

Peer support & peer-led services

Peer support

Improve emotional wellbeing

Build capacity

Sense of purpose

Range of functions

Confidence

Source of information

Improve functional

status

Carers and families

Carers have a right to their own needs review

Training and education should be provided

Local authority and charitable sector support is available

Conclusions Stroke care is better in London as a result of the

stroke reorganisation BUT......

Still failing to meet longer terms needs of people after stroke

There is no additional money for changing these services Need to persuade commissioners that these are services

that are worth investing in for both clinical and economic reasons

Major concerns that government cuts will negatively affect the resources available to people for longer term support