Dr Ben Bray reviews the landscape for stroke services in the transformed NHS and talks to Dr Martin James, who chairs the national stroke services peer review scheme based at the Royal College of Physicians
Stroke is a major challenge for the NHS, affecting 150,000 people in the UK each year. It remains one of the biggest killers and is the leading cause of adult-onset disability. In addition to this human cost, it is a major burden on health and social care services, with annual direct and indirect costs of at least £7bn (using 2005 prices).
People with stroke occupy 5 per cent of all hospital bed days, and their care presents a particular challenge for acute providers with long lengths of stay, and specialist rehabilitation needs. Stroke is one of the priority areas in the NHS Outcomes Framework and the clinical commissioning groups’ outcomes indicator set. It is clear that NHS England regulators and commissioners will expect providers, in particular acute trusts, to continue to deliver significant improvements in stroke care quality and outcomes.
Better stroke care
National audits have shown major improvements in stroke care over the past decade. Eighty-six per cent of people with stroke now spend more than 90 per cent of their in-hospital stay in a specialist unit, and over 10 per cent of patients now receive stroke thrombolysis (clot-busting therapy), overtaking the US in providing access to this National Institute for Health and Care Excellence-approved treatment.
‘We’re very aware of the evidence that producing expert guidelines is not enough on its own to result in quality improvement’
Outcomes have also been improved by several major regional reconfigurations of stroke services, creating flagship “hyperacute” stroke services in London and Greater Manchester. However, stroke services are complex and delivering improvements can be challenging for acute trusts. For this reason, in 2006 the Royal College of Physicians, the British Association of Stroke Physicians (BASP) and the Stroke Association charity set up a joint stroke peer review scheme.
The scheme gives trusts the opportunity to receive assistance and support in improving their stroke services. Participating trusts receive a site visit and detailed report from a small multidisciplinary group of experts. The remit of the advisory visit is agreed with the trust in advance, and this can vary from a broad review along the entire stroke pathway to a focus on one particular aspect of the stroke service (see box below).
Objectives of the stroke services peer review scheme
- To advise clinical teams, hospitals and trusts on the appropriate facilities and staffing to provide a safe and comprehensive stroke service
- To establish that arrangements and protocols are in existence to meet service specifications and standards produced from time to time such as those identified by the National Stroke Strategy, the British Association of Stroke Physicians and the Royal College of Physicians
- To support hospitals and trusts’ implementation of change in response to findings of relevant local, regional and national audits
- To promote discussion and the exchange of ideas between the reviewers and the reviewed, to offer advice on solutions to problems, to identify areas of good practice and to offer general support to trusts to help improve their stroke services
- To reassure the public and the government that stroke medicine is being practiced to a high standard and to assist with the promotion of equitable access to stroke services
Dr Martin James, stroke physician at Royal Devon and Exeter Foundation Trust, recent president of BASP and an associate director of the RCP stroke programme, says: “We’re very aware of the evidence that producing expert guidelines is not enough on its own to result in quality improvement. We could see from the national audit figures that there were certain providers that changed very little in their relative performance from one audit to the next, and simply brow-beating them with their poor results wasn’t going to be enough to bring about change.
“So we developed the stroke services peer review scheme to allow trusts to invite a small multi-professional team of stroke experts and lay people to visit and give their independent advice on any number of difficult issues.
“The team is able to provide the external view that is sometimes missing when the local health economy is bogged down with the effort to improve.”
Creating action plans
‘We have managed to avoid being labelled as a ‘hit squad’ − the invitation for a visit is always sanctioned by the chief executive’
Since its launch, the scheme has carried out 26 visits to trusts and networks across the country, working with local providers to produce detailed action plans for progress, and securing agreements on timescales for implementation. The composition of the visiting team varies according to the requirements of the trust, but typically includes stroke physicians, nurses and allied health professionals, managers and stroke survivors.
Dr James highlights this collaborative approach to quality improvement: “We have managed to avoid being labelled as a ‘hit squad’ − the invitation for a visit is always sanctioned by the chief executive, usually with the support of their local cardiac and stroke network, and we recognise that most trusts have tried long and hard to improve their services before turning to us for assistance. So our approach is strictly by invitation and is very deliberately supportive and collaborative.”
The response to external support and advice seems to be uniformly positive, Dr James explains.
“The peer review process involves the engagement of clinicians and managers, and local commissioners, so there is widespread commitment to getting the most out of the visit and that in itself can act as a catalyst for progress where it has proved too difficult before. When we have followed up on our visits a year later, over 75 per cent of our recommendations have been partly or fully implemented, and feedback highlights how the peer review process has helped to jump-start improvement,” he adds. (See case study below.)
Case study: Anglia Heart and Stroke Network
“In 2008 the East of England strategic health authority (via the three stroke networks) commissioned the stroke peer review scheme to review stroke services in all 18 East of England acute trusts − principally to review their acute service and “readiness” for 24/7 thrombolysis. The schedule of visits was spread over more than a year to allow for different states of readiness among the acute centres. There was a fair amount of scepticism about the process from many centres.
“In most hospitals the impending visit stimulated positive changes in stroke pathways and services even before the review itself. Often for the first time, members of trust boards, chief executives and in some places commissioners started to engage with stroke service improvements.
“On the day, the format of each review provided several really effective ways of getting ‘underneath the skin’ of a stroke service. Walking the stroke pathway provided an immediate overview of how the stroke service works for real. It also enabled the review team to meet staff out with the stroke unit but crucial to its function, such as staff in A&E and radiology. Once within the stroke unit the team made a point of asking staff not directly involved with the visit such as ward care staff, junior doctors and ward clerks about the local stroke service.
“They also spoke to patients. This often gave revealing insights into the cohesion and purpose of the stroke teams. Staff in positions of leadership were interviewed separately or in pairs. By the very nature of being external, the review team were able to address ‘historical’ issues in stroke care often difficult to change from within an institution − in one trust a long-standing age cut-off for entry into the stroke unit; in another, intransigence to early CT scanning. In one trust, the walk through demonstrated clear issues of patient safety culminating in a suspension of thrombolysis altogether.
“The verbal feedback provided an instant overview of key issues − often taking board members by surprise. In some cases the feedback was hard hitting but always supportive, and all resulted in positive plans for action. The written feedback then provided an individualised set of recommendations for each trust on which to effect change. These were invaluable to the networks in framing their improvement plans.”
Dr Liz Warburton is stroke physician at Addenbrooke’s Hospital, Cambridge, and clinical lead at the Anglia Heart and Stroke Network
A job to do
So what of the future? While the quality of acute stroke care has improved dramatically over recent years, progress is still uneven and many providers lag behind the best. In addition, quality improvement in stroke care is likely to increasingly focus on rehabilitation and recovery, with integrated care provided across a variety of providers.
Commissioners and providers will be supported by the new sentinel stroke national audit programme, which will for the first time measure quality along the whole stroke pathway, including in the community.
Trusts and other providers will find that the stroke peer review scheme offers an effective and independent way of helping to deliver quality improvement in stroke services. As Dr James puts it: “We’ve always seen external peer support as an essential component of the process of national audit and continuous quality improvement, and we’re not anywhere near thinking the job is done yet.”
Find out more
Anyone interested in inviting a stroke services peer review visit can contact the scheme at the Royal College of Physicians’ stroke programme office at firstname.lastname@example.org
Dr Ben Bray is a quality improvement fellow at the Royal College of Physicians