Published: 02/06/2005, Volume II5, No. 5958 Page 26 27 28

Seven years ago, London's Royal Free trust was one of the worst performers in the UK for stroke services. Now it leads the field. Ann Dix looks at the structural and cultural changes that have heralded this success

When London's Royal Free trust set up its specialist stroke unit back in 2000, staff joked that they measured their outcomes by boxes of chocolates and thank-you cards.

'It was exciting at the beginning because we were getting that sense of being a specialist unit, ' says the trust's deputy head of therapy services Cherry Kilbride.

Since then the gains have been spectacular.

Back in 1998, a national audit of stroke services by the Royal College of Physicians showed the trust's stroke services were among the worst 5 per cent in the country. But six years later, the Royal Free was providing a service second to none; the 2004 RCP audit published earlier this year places it joint first with stroke services at Chippenham community hospital, Wiltshire.

Before the turnaround, patients had no access to a specialist stroke service, care was unco-ordinated and scattered over 18 wards and there was inequality of service based on patients' age and where they were located in the hospital. Whereas patients aged over 70 could be admitted to one of three specialist elderly care wards offering a multidisciplinary model of care, younger patients could end up on any ward in the 12-floor tower block.

There was no rehabilitation for people under the age of 65, requiring patients to be referred outside the locality, with family and friends often having to travel for over an hour to visit them.

Today it is a different story. Now all the trust's stroke patients are treated in the specialist stroke unit. Stroke units are known to save lives and reduce disability; the unit at the Royal Free saves more lives than most. Giving patients the right checks and treatment, at the right time, has more than halved the trust's mortality rates - from 35 per cent at 30 days down to 16 per cent, compared with a 24 per cent national average. It has also resulted in shorter hospital stays and less institutionalisation.

Patients are discharged after an average of 15 days compared to 18 days nationally, and 43 per cent are discharged home alone compared with a national average of 33 per cent.

Consultant Dr Sheldon Stone, lead clinician for stroke, explains that these figures are all the more remarkable because of the unIt is policy of taking all patients rather than just those with a good prognosis. This is reflected by the fact that, 'patients are more disabled at discharge than the average, probably because the unit is saving patients who are more disabled to begin with'.

The Royal Free is not alone in improving its stroke services - although it is probably among the most dramatic. The 2004 RCP audit, funded by the Healthcare Commission and the first to publish results for individual trusts, shows there has been considerable progress over recent years.

But it also reveals that there is a long way to go, with some trusts still offering 'lamentable' care, and many patients suffering unacceptable delays in diagnosis and a lack of specialist treatment.

A major problem is lack of capacity. As the RCP highlighted in its 2001 audit, stroke units are just too small to cope with demand. But while the 2004 audit showed that more hospitals in England had a specialist stroke unit - 82 per cent compared to 74 per cent in 2001 - it showed no increase in the number of acute stroke beds.

The Department of Health says it is now close to meeting the milestone set by the national service framework for older people for all hospitals to have a stroke unit. The idea is that this will help towards the government target of a 40 per cent reduction in stroke mortality by 2010. The capacity problem identified by older people's czar Professor Ian Philp acknowledged in HSJ (interview, page 18, 9 December 2004) is an area in which the Royal Free stands head and shoulders above most trusts.

The RCP audit showed that all stroke patients are seen in the specialist stroke unit within 24 hours of being admitted, compared to an average of 46 per cent nationally. And all spend more than half their time in hospital on the specialist stroke unit, compared with a national average of 41 per cent.

Dr Stone says the starting point is 'to agree the principle that stroke patients should be regrouped in a single geographic location in the hospital because 'geographical concentration breeds expertise' - but there is also a need to ensure there is 'adequate capacity'.

At the Royal Free, specialist acute care and rehabilitation are on two different sites, but they operate as a single stroke unit. Once the unit had opened, beds had to be reconfigured to meet rising demand, which at 325 stroke patients a year is twice as much as originally estimated, says Dr Stone. The task was made easier by high-level support in the trust. 'Having demonstrated the success of it, management was able to agree to expand the resource.' As a result the acute unit went from eight to 13 beds, and the rehabilitation unit now has an average of 16 beds.

He stresses that flexible bed management is crucial. 'Basing your stroke unit on the general elderly ward in most places is the most sensible because You have got a multidisciplinary ethos, there are more geriatricians than neurologists and geriatricians are always interested in stroke.

But You have got to have flexible bed usage, and the key is that we liaise every day with the bed managers to say this is what we need.' But he adds that they are 'hampered' by the government's four-hour accident and emergency waiting target, which means patients admitted via A&E are taking up beds in the stroke unit. The trust awarded stroke similar priority to cardiac care to allow more patients to be admitted straight to the unit, maximising access to the specialist stroke team. 'But the four-hour wait means that if There is a bed here on the stroke unit, we no longer stick to the old rule of trying to keep it clear. So whereas before we had 75 per cent of patients come straight from A&E, now It is about 30 per cent, or even less. As soon as a bed becomes free on the stroke unit, they move into it. But it means there is a delay.

'The reason why we had such good outcomes in the RCP stroke audit is that patients all come on to the stroke unit. Well over 95 per cent of patients come here anyway still, but There is more of a time lag. If that continues to get worse our general standards will come down.

'Ringfence the beds if you possibly can because quality of care rises as a result. Not just your clinical outcomes; It is the whole quality.' Once the unit had been set up, he says, 'the second thing was the recognition that we needed the full compliment of multidisciplinary team members, from the obvious ones like doctors and nurses with an interest, to the rarer disciplines like speech therapy and clinical psychology. The third critical thing was appointing a stroke coordinator to bind it together.' Trust deputy head of therapy services Cherry Kilbride says the multi-professional approach has been key. But she stresses that 'you have to pay attention to the team-building process'.

'We had to build up the multidisciplinary team from scratch from what was primarily a general elderly care specialty, ' she says, 'And we had to do it on a split site located on wards that had previously been shut. So people have undergone a cultural shift and are on a steep learning curve.

'In the beginning we had pockets of resistance from various professional groups, but once the decision had been made to start the unit, it happened very quickly... so it was about working through some of those issues through education and team-building and practical projects.' Another aspect she identified as crucial was involvement in the Modernisation Agency clinical governance programme, which included nights away for members of the stroke team. 'It took people out of their professional moulds, so they could get to know each other as people.' Vital to sustaining all this is a weekly meeting for core members of the team. This is a time to take stock and plan ahead. 'It is something we try to protect regardless of how busy we are, ' says Ms Kilbride. 'If we do not give attention to process, to development, to thinking, we will stagnate. It is one of the reasons why we have demonstrated good sustainability, along with the fact that We have created a good infrastructure for our team.' The Royal Free's recently departed chief executive, Martin Else, cited the unit as an exemplar of multidisciplinary working. Ms Kilbride says this helped raise the profile of stroke in the trust and fostered pride in the unit.

Creating and maintaining that through events such as a national stroke conference has been very important, she says. 'It is about filtering through to professionals as well as lay people that stroke is a medical emergency, and being able to access scanning and make sure we get the appropriate priority within the system.' She adds that having senior management support at the outset was critical. 'A major impetus for change was the national RCP audit, which confirmed what clinicians had been saying for a long time. But we also had a forward-thinking general manager who foresaw the national service framework for older people.' Professor Carol Black, before becoming president of the RCP, was the trust's medical director, and a strong proponent of multi-professional working.

A multi-professional stroke oversight committee was established, bringing together senior decision makers across the trust, including consultants from neurology, elderly care and radiology. This ensured that 'a grass roots development had support from the upper level', says Ms Kilbride.

The special trustees have since awarded funding to evaluate the whole process and see what has made it so successful. Ms Kilbride is carrying out the work as part of a PhD, and hopes it may help others implement successful stroke services.

She says one advantage of it being a service reconfiguration is that 'it was all done pretty much from within existing resources'. She adds: 'We have staffing levels that are in line, or less than the national average. So it really is how We have tried to make the whole more than the sum of the parts.' Meanwhile, the results speak for themselves. Dr Stone says areas the unit excels in, such as nurses and therapists collaborating to ensure 'fast and safe nutrition', are 'why mortality has been halved'.

For staff it is a different way of working. Senior nursing sister Pauleen Baccarini says: 'The therapists are fragmented from the nursing staff on other wards. Here we work closely as a team.' As senior dietician Michelle Ras points out, this allows staff to manage patients pro-actively, instead of 'trying to get together at a point where It is too late'.

Strong teamwork also has other benefits, as Dr Stone testifies. 'We are pretty egalitarian here, ' he says. 'One advantage of this is that we hunt in a pack. So It is not seen as just another instance of a stroppy, whingeing consultant.' He says the next step must be to set up 'proper multi-disciplinary long-term follow-up in the community'. The unit established a one-stop transient ischaemic attack clinic back in 2003. It has also joined in a stroke prevention initiative between Camden, Islington and Barnet primary care trusts. 'But what we haven't got is a proper community rehab service.' He says rehabilitating people in their homes after initial management on a stroke unit has been shown to give much better outcomes at six and 12 months, 'because you are rehabilitating them in the environment in which they have to use those rehabilitative skills'.

'It is as simple as David Beckham practising putting free kicks in the top corner again and again, so when the time comes for it on the pitch he's ready because he's done it.

'There is no doubt that That is what we should be moving to, and if we did it would not only reduce the number of stroke patients in hospital beds but it would improve their outcomes long term.' .

Find out more

Royal College of Physicians. National Sentinel Stroke Audit 2004.

www. rcplondon. ac. uk/college/ceeu/ceeu_stroke_ audit_2004. htm

Department of Health: national service framework for older people.

Send your ideas and contributions for the Clinical Management section to ann. dix@emap. com


When it comes to joined-up thinking in the provision of stroke services, Medway and Swale primary care trusts are ahead of the game. The two PCTs and Medway (acute) trust have collaborated to set up a stroke service across the whole patient pathway, spanning primary, community and secondary care.

Since the 2001 Royal College of Physicians stroke audit the service has jumped from the bottom to the top quartile. But as nurse consultant Steve Duckworth explains, the real impetus for change came from a routine Commission for Health Improvement inspection that criticised standards.

A steering group was set up of representatives from Medway trust, Medway and Swale PCTs and social services, as well as ex-patients and carers to put together a strategy for improving stroke services.

'We cast our net quite widely in terms of stakeholders because we wanted to create a pathway that covered the whole health economy, ' he says.

The result was an injection of£750,000 for developing specialist stroke services. This included the establishment of an eight-bed acute unit at Medway trust, a reconfiguration of rehabilitation beds to provide a new eight-bed community unit in Swale and the creation of a dedicated multiprofessional stroke team in the community. A rapid-access transient ischaemic attack clinic was also established as a nurse-led service at Medway trust.

Since the service was set up, not only has patient care improved, but hospital stays have halved in length - from 13.5 days to six.

'I like to think this is because we are proactive in managing patients and because having a dedicated community team allows patients to leave hospital sooner, ' says Mr Duckworth.

He says it has required blurring professional boundaries as well as breaking down barriers between primary and secondary care. This includes staff working across organisational and geographical boundaries through the establishment of inreach/outreach services, and professionals being trained to take on additional roles, such as physiotherapists taking blood pressure.

'You need to challenge preconceived ideas. For example, if you haven't got a consultant physician available you ask if you can operate the clinic in a different way... It sounds a cliché, but It is about creating services around the patient.' He adds that 'patient and carer involvement is key because they highlight what is really needed. We hope that by setting up patient groups they will hold us to account'.