FINANCE RESOURCE COMMITTEE
Executive Summary Sheet
Date: 30 January 2014
Report Title:
Stroke Early Supported
Discharge
Item No.
1. Background and Context
Stroke is the third largest cause of death in England and the main cause of adult disability.
Stroke claimed the lives of more than 40,000 people in 2009 in England and over 12,000 in
the East Midlands. Around two thirds of people will survive their stroke, but half of stroke
sufferers are left with long term disability and dependency on others for everyday activities.
A whole pathway approach to the provision of stroke services is crucial to maximising the
clinical outcomes for patients, the resultant quality of life and their experience of stroke
services. The first 72 hours of care is vital to ensure the optimum clinical outcome for stroke
survivors. This needs to be underpinned by an effective whole system pathway for
assessment, discharge and repatriation to local stroke services, subsequent rehabilitation
and longer term support.
The National Stroke Strategy, published in 2007 by the Department of Health, pulled
together the key evidence and outlined what needed to be done to create effective stroke
services in England. The strategy set out a framework of Quality Markers (QM) for raising
the quality of stroke prevention, treatment, care and support. QM10 states that stroke
services should ‘enable patients who have been admitted to hospital with a diagnosis of
stroke to have early, fully supported specialist stroke care transferred and delivered within
their normal home environment.’
Stroke care costs the NHS and the economy approximately £8 billion a year. This
comprises of around £3 billion in direct costs to the NHS, £2.4 billion in informal care costs
(costs of nursing home care borne by the patients’ families) and £1.8 billion in income lost to
mortality and morbidity and benefit payments.
Stroke admissions in Erewash are increasing year on year. The following charts show our
activity over the last 4.5 financial years (including the first 6 months of 2013/14). This year
we have seen an increase in emergency stroke admissions of 3% on 2013/14. At this rate
we would anticipate an annual admission figure, across both providers, of 152 patients at
year end.
160
150
140
130
Estimated
Admissions
120
110
Erewash Stroke
Admissions
100
90
80
2009-10
2010-11
2011-12
2012-13
2013-14
This graph provides a breakdown of the split between providers and highlights the increase
in the proportion of Erewash patients being admitted to the relevant hospital:
100
Emergency Admissions for Stroke
88
90
78
80
80
Number of Admissions
71
70
60
50
56
56
56
45
40
32
30
21
20
10
3
0
2009-10
2010-11
2011-12
2012-13
2013-14
Derby Hospitals NHS Foundation Trust
45
32
56
56
21
2
Ilkeston Community Hospital
Local Providers
3
2
Nottingham University Hospitals FT
78
80
71
88
56
2. Existing Services
The Stroke Services Specification created by NHS East Midlands and East (2012) provides
the following diagram for the patient’s overall pathway. This is according to the patient
movement across the phases of care, since they are not necessarily linear and not all
phases or services are applicable to all patients:
Currently around half of stroke survivors nationally receive rehabilitation to meet their needs
during the first six months following discharge from hospital.
The most common transfer, and the most stressful to patients, is that from hospital inpatient
care back to their home. Early Supportive Discharge (ESD) or stroke community services
are based in patient’s homes where support is provided during this transition and specialist
rehabilitation is delivered within the first few days of discharge. ‘Early supported Discharge
teams are effective both in terms of clinical benefit and resource use and yet only 22% of
trusts have one. One of the most common complaints of patients is that they feel
abandoned when they leave hospital. The failure to provide specialist community stroke
teams may be contributing to this perception’ (National Sentinel Stroke Audit for 2006).
In Erewash there is an inequity in the services that patients are receiving.
Patients discharged receive ESD via the relevant provider, where appropriate. The ESD is
a specialist team of nurses, therapists, doctors and social care staff. Working collaboratively
as a team, and in conjunction with the patient and their family, they enable stroke patients to
leave hospital earlier and receive intensive rehabilitation at home. This decreases the risk of
readmission into hospital for stroke related problems, increases the patient’s independence
and quality of life, whilst also supporting families and carers.
Patients discharged in outside of Count do not have access to the ESD team. If appropriate,
they are either referred to the specialist neurological rehabilitation unit in Ilkeston as an
outpatient or they can receive domiciliary rehabilitation from the Integrated Community
Team. Neither are specialist stroke services. The outpatient service is not stroke exclusive,
but is a ‘specialist level’ service where neurological assessments, occupational therapy and
physiotherapy are undertaken. There is not a service specification for either service
provision at the present time.
3. Potential Solutions
3.1 Do nothing
This is not an option because we need to address the inequity in our current service
provision. Patients registered with the same Erewash GP receive vastly contrasting care
depending simply upon which local hospital they are admitted to.
3.2 Establish a standalone Erewash service
This is not an option because the overheads (including Team Leaders, administrative staff,
premises) would make the service too expensive to be viable.
3.3 Expansion of the current service (links to Amber Valley)
We are currently funding per annum on a block contract for ESD at for an expected 17
patients discharged from. Please note that the calculations within this paper reveal that a
projected 19 patients will use the existing service provided by at year end. This mitigates the
risk of under investing in the current block contract service; especially when recent reports
highlight that the provider is rejecting 35% of patients due to capacity issues.
It is an option to expand this existing service to include those patients discharged from. The
benefits of using this provider specifically would be:





Current provider: already provides this service for our Erewash patients and they
would be able to expand the existing team of stroke specialists
Continuity of care: joint working and visits when transferring care
Relationships: there are strong, established working relationships between this team,
the community team and the neuro rehabilitation outpatient service. This would also
provide a more integrated approach for the longer term rehabilitation, and as a
discharge strategy, from the 6 week ESD pathway
Established procedures: easy access to equipment and/or services as systems are
already established
Service model: one service provider for Erewash patients. This provides equity and
consistency for patients and also assists GPs as all their patients are being treated in
accordance with one service specification


GP relationships: practices have existing connections and relationships with the
provider
Economies of scale: savings to be realised by one provider e.g. increased patient
activity due to less travel time as patients are in close proximity to each other.
The provider would need, however, to build relationships with the teams at the relevant
hospital in order to coordinate seamless patient transfers for our patients.
The financial assumptions within this paper are based upon a projected 152 patients being
admitted across both providers. In accordance with national standards, 40% of patients
require ESD; which equates to 61 patients per annum. In the first half of 2013/14 we have
seen 70% of patients admitted; which results in an anticipated unmet need of 42 patients.
This is in line with the costs of the existing block contract.
3.4 Provision of the service by
It is an option to offer a pilot and the team at the Trust are very keen to provide a high quality
service to our patients; particularly as year to date 72% of Erewash Stroke patients have
attended.
The benefits of using this provider specifically would be:






Facilitation of discharge: the effective discharge is enabled through the ‘pulling’ of
patients out into the community
Continuity of care: this prevents clinical duplication and promotes more effective
treatments as the team already knows the patient
Relationships: the patient will have met the staff on the ward; which is reassuring and
helps with their transfer to the community
Joint sessions: there is an ability to carry out joint sessions with ward therapists for
complex patients
Consultant input: ease of access to Consultants to discuss concerns or problems
Connection: established links with the in-patient therapy teams and the wider MDT
and also the ability to attend family meetings and home visits whilst the patient is on
the ward.
Based upon an anticipated 42 patients being eligible for treatment per annum and the
assumptions previously detailed, the financial implications would be:
We have requested clarification on the costs of the service provision and whether they
include on-costs but have not yet received clarification; therefore there is a risk that the costs
could increase by c. £20k.
3.4 Alternative Providers
4. Implications on existing contracts
By proceeding with either option 3.3 or 3.4 we would need to decommission the provider
specialist rehabilitation element of the existing pathway for patients discharged from hospital.
We currently pay for this as part of the overall block contract and therefore would need to
unbundle the costings to extract this component.
The quality, patient experience and financial impact of the service would need to be
estimated within the contracts with baselines and KPIs set. This would also include the
expectation of 100% of all eligible patients referred to the service to be treated in order to
ensure we do not fund the shortfall of other commissioners.
6. Actions and Recommendations
The following recommendations are made:

The group considers the request for the funding of for ESD patients being discharged
from from 2013/14 transformational funds. We would seek to work with the provider
to reduce these costs where possible; without impact upon the quality of the service.

Based upon the need to ensure the equity of service provision for the patients of
Erewash, we would recommend the pilot being awarded to

The group considers how best to mobilise the pilot:
o .
o Seek expressions of interest from both providers within the agreed financial
envelope and consider the best bid. This could be done in a relatively short
period of time i.e. before the end of the financial year
Name:
Alli Silverwood, Contracts and Performance Manager
Sponsor:
Lynn Wilmott-Shepherd, Commissioning and Delivery
Director
Date:
22 January 2014