Stroke Managed Clinical Network

NHS GRAMPIAN

STROKE MANAGED CLINICAL NETWORK

IMPROVING STROKE CARE IN GRAMPIAN

ANNUAL REPORT

1 October 2005 to 30 September 2006 IMPROVING STROKE CARE IN GRAMPIAN

CONTENTS

1. Forward

2. Highlights and Executive Summary

3. Turning Strategy into Action

4. Education and Training

5. Patient/Public Involvement

6. Quality Assurance, Clinical Governance, and Performance Review

7. Investment Plans

8. Plans for the Coming year

Enquiries

Website

2 IMPROVING STROKE CARE IN GRAMPIAN

1. FORWARD

Grampian Stroke Managed Clinical Network (MCN) continues to meaningfully involve staff, patients and carers in promoting improvements for stroke. We aim to take every opportunity to identify gaps and improve the quality of care. Patients and carers have told us about some ways in which the services are unequal and not available to everyone. We know that historical developments mean that services differ. We aim to change this and to provide expert support for local staff to ensure that we make the best possible use of the resources that are already in place and any new resources that become available.

‘Building A Health Service Fit For The Future’ said that they (MCNs) should continue to be the engine room of quality and clinical improvement and redesign. We feel that the Grampian Stroke MCN is well placed to take this on and to help NHS Grampian to deliver the targets which the Scottish Executive have set.

The past year has enabled us to deliver or make significant progress on the improvements we hoped for last year and this report highlights what is new this year. We have been measured in several ways so we now have clear plans for what we need to do next.

We would again wish to take this opportunity to thank all staff across the MCN for their hard work and goodwill in the last year, as without this we would not have made such considerable progress.

The website at http://www.nhsgstrokemcn.scot.nhs.uk/ keeps everyone up to date with our work. We wish to continue to encourage further discussion and involvement in the way services develop in Grampian. Should you wish to be more involved or simply to make contact with the Stroke MCN we would be delighted to hear from you.

Dr Steve Hamilton Dr James Black MCN Lead Clinician Lead GP Stroke MCN

Thérèse Jackson Mr Sandy Reid Consultant OT – Stroke MCN Manager

Lead GP, Stroke MCN

The Stroke Managed Clinical Network brings together professionals from Primary, Secondary and Tertiary care with patients, carers, the independent sector and local authorities to work in a co-ordinated way across geographical, organisational and professional boundaries.

The MCN aims to ensure equitable provision of high quality clinically effective care for stroke patients throughout Grampian.

2. HIGHLIGHTS AND EXECUTIVE SUMMARY

The ultimate aim of MCNs is to improve patient care in terms of quality, access and appropriateness.

This has been another very successful year for the Stroke Managed Clinical Network in Grampian. Highlights have included:-

 Further progress in meeting QIS Standards for Care

 Allocation of £115,000 (non-recurring) for Training, Travel and Equipment

 Allocation of £82,000 recurring funding

 Appointment of a Neuro-Psychologist for Stroke

 Development of a Moray Stroke Action Plan

 Invitation to participate in a number of Protected Learning Time opportunities with GPs

 Proposal for the development of a North Aberdeenshire Stroke Unit

 Neurovascular Clinic Electronic Referral and added guidance

 Establishment of Research Network

 Improved linkages within the MCN

3. TURNING STRATEGY INTO ACTION

The CHD and Stroke Strategy for Scotland was produced in 2004 and made recommendations for several service developments, which were supported with extra funding. Since then other national policy has influenced the direction of service developments and this report highlights the activity undertaken by the Grampian, Stroke Managed Clinical Network (MCN) to implement those strategies.

Stroke Neuro-Vascular Clinic

The Neurovascular Clinic was set up some years ago to identify patients suspected by their GPs as having suffered from a Transient Ischaemic Attack. The clinic has however become a convenient place to refer patients with vague and bizarre neurological symptoms including light-headedness and dizzy turns. At present only about 50% of referrals in a recent audit were considered to have a vascular problem.

Recent evidence has made it clear that all patients with a suspected TIA, who are considered fit enough for investigation and treatment, should be assessed as soon as possible following the event. There is a window of 14 days between the event and carotid surgery, which provides the best outcome in relation to the prevention of subsequent stroke. It is therefore imperative that GPs refer urgently stating suspected TIA to the Neurovascular Clinic, and to help triage these patients GPs are being asked to include the ABCD score which is a proven indicator of increased likeliness of TIA.

A age >60 1 <60 0

B BP >140/90 1 <140/90 0

C Clinical Limb weakness 2 Loss of speech 1 Any other neurological loss 0

D Duration >60mins 2 10-59mins 1 <10mins 0

Scores of 5/6 are highly indicative of TIA. Details of this can be accessed by all GPs on the Clinical Guidance Intranet. Other referrals sent to the neurovascular clinic considered not due to a vascular cause will be seen at the General Medicine clinic.

We are now therefore recommending that GPs, when presented with a patient who has symptoms suggestive of TIA, carry out an ABCD score and refer electronically to the neurovascular mailbox where consultants will daily triage and arrange rapid investigation. This system is due to go live on Monday 30th October 2006 and all GPs have been informed.

Clinical Neuropsychology Service to Stroke

Who are Clinical Neuropsychologists? Clinical Neuropsychologists specialise in how cognitive abilities (e.g. memory, executive functioning, attention etc.) influence a person’s everyday functioning and behaviour whilst considering the possible contributions of other psychological factors to presentation. They have the necessary training, skills and expertise to address the increasingly recognised cognitive and emotional changes that commonly occur following stroke.

Background to Service As part of its wider remit, The Clinical Neuropsychology department, NHS Grampian, (comprising two full-time Clinical Neuropsychologists, Dr Fiona Summers and Dr Maggie Whyte) has always provided a neuropsychological service to Stroke covering Grampian, Shetland and Orkney. Additionally, since 2004, there has been a Clinical Psychologist, Dr Sonia Dyson, working in stroke (one day a week) specifically addressing psychological problems that have developed as a direct result of stroke such as anxiety and depression. This will continue, however, since December 2005 new funding via the Scottish Executive has meant that additional neuropsychological input has been provided specifically for stroke in the form of an additional Clinical Neuropsychologist (Dr Jackie Hamilton). This is in line with stroke SIGN guidelines recommendations that clearly state that:

(a) a full understanding of the patient’s cognitive strengths and weaknesses should be an integral part of the rehabilitation plan and (b) in order that cognitive impairment can be assessed fully, stroke patients should have access to neuropsychological expertise.

Role within the MCN The Clinical Neuropsychology Service for stroke undertakes many roles including: -  direct work with individuals after stroke (e.g. detailed neuropsychological assessment of cognitive impairment and its impact on behaviour, daily functioning and interpersonal relationships; teaching of cognitive rehabilitation strategies)  providing a service to carers and other professionals (e.g. working with Multi- Disciplinary Teams to develop appropriate care programmes which consider neuropsychological functioning; consultancy. )  education and training (e.g. working with families on adjusting to and understanding neuropsychological deficits; in addition to providing other stroke training, the service contributes regularly to both introductory and intermediate stroke courses run by the Stroke MCN Education Co-ordinator.)  research and audit (e.g. service evaluation and audit to identify psychological needs within the service; provide information about service use and outcome)

Referrals At present the Clinical Neuropsychology service for stroke is provided Grampian wide for in and outpatients within the Acute and Rehabilitation Stroke services.

Currently this service does not operate an in-patient waiting list but weekly provision is available (further information can be provided upon request). The approximate waiting time for outpatients is currently 2 months.

Priorities Service is still developing and aims to: -

 continue to provide a service to stroke patients and their families advising on cognitive rehabilitation strategies, approach to behaviour, return to work, and education about cognitive deficits and changes  continue to develop links with other specialists in stroke and professionals working with this patient group enhancing their knowledge of the neuropsychological consequences of stroke  through working with individuals who have suffered a stroke, their families and other professionals identify gaps in practise/knowledge and investigate how these may be met using an evidence based approach (e.g. currently research into use of appropriate measures of anxiety/depression in stroke population)  further consider ways to develop neuropsychological services in North Aberdeenshire and Moray as appropriate. Liasing with other MCN professionals will be key to this and discussions are ongoing.

Dr Gray’s Hospital, Elgin

Extensive work has been undertaken at Dr Gray’s Hospital involving discussions with management and clinicians with the aim to identify a suitable area in one of the wards, which could be used as a dedicated Stroke Unit.

The first steps were:-

1. The Consultant OT Stroke and Network Manager met with the Moray Different Strokes Group and Chest, Heart and Stroke Scotland who had expressed concern that nothing had progressed towards the setting up a Stroke Unit at Dr Gray’s Hospital

2. A working group formed to drive the practical steps in order to make this happen. They first met in June 2006 for a wider discussion.

3. The Consultant OT Stroke and Network Manager met again with the Patients and Carers Group towards the end of June 2006 along with medical and management representatives from Dr Gray’s to inform the Group of progress to date.

At the end of September 2006, a detailed Moray Stroke Action Plan was agreed and the focus for the year ahead will be to ensure it’s implementation. In the same month, a Consultant General Physician, Dr Louise Millar, was appointed and in her job plan she has responsibility for stroke locally and will lead progress in Moray along with the MCN.

Proposed North Aberdeenshire Stroke Rehabilitation Unit (Fraserburgh Hospital)

North Aberdeenshire CHP were reviewing their services in January 2006 and one of the proposals was to develop a Stroke Rehabilitation Unit for North Aberdeenshire, as part of the redesign of services.

Members of the MCN have met regularly with Aberdeenshire CHP to support this, and a proposal has been produced by Thérèse Jackson, Consultant OT in stroke and Shona Strachan, Lead OT at Fraserburgh Hospital

Points to consider are as follows:-

 The Unit would deliver a stroke rehabilitation service which is equitable to that delivered on Wards 6 & 12 at Woodend Hospital.  Patients living north of river Don e.g. Ellon patients could be transferred to this Unit in order to assist patient throughput at ARI and Woodend.  The Consultant OT & Stroke and the Stroke Training Co-ordinator would have input to develop services and support training.  A Community Geriatrician will be in post in the near future and the job plan would incorporate a regular session at Fraserburgh.  It was anticipated that, subject to approval, the new Unit would open in April 2007.

North Aberdeenshire CHP await approval for this service redesign in Fraserburgh Hospital.

Stroke Rehabilitation Centre – Woodend Hospital

The Stroke Rehabilitation Centre at Woodend Hospital has 22 beds and deals with people of any age.

About 85% of patients go back to live in the community, either to their own homes or to new houses with either family back up or social support.

All patients are seen after discharge by the Stroke Nurses, if required, who are jointly funded by Chest Heart and Stroke Scotland and this has proved to be a very valuable service.

The Stroke Rehabilitation Centre has a large inter-disciplinary team who are nearly all based within the ward. The close proximity of all the team means that there is good carry over of therapeutic interventions by the nursing staff through the 24-hour period.

Major Developments:

 Commencement of music therapy  Commencement of Reiki therapy  Commencement of pet therapy, known as therapet  Goal setting for patients per discipline  Monthly pub lunch for the patients  Stroke club once per week. This consists of 1 hour of supported communication and 1 hour of activity. This is an auxiliary led group.  Development of various ward protocols, i.e. weekend pass, driving. DVT propylaxis, osteoporosis risk management  Neuropsychologist session once per fortnight.  Improved referral system to Horizons  Purchase of a new vehicle for SRC patients  Sleep audit completed and recommendations implemented

Ward 6, Woodend Hospital

Ward 6 has 16 beds and provides assessment and rehabilitation for older patients with strokes. Length of patient stay In Ward 6 could vary from a few weeks to several months. Members of the Multi-Disciplinary Team – dietitian, occupational therapist, physiotherapist and speech and language therapist – work with the patients to provide the best possible individual rehabilitation outcomes.

Some of the work/developments of the last year,

1 Staff Training – taking 2 places on every CHSS course to ensure as many staff as possible receive this training

2 Produced a stroke specific information booklet and learning objectives for student nurses on placement within the ward.

3 Have initiated multi disciplinary bi-monthly management meetings to provide a forum for discussion and progression of issues relating to the running of the unit.

4 Physiotherapists have been providing an evening appointment service for relatives for one evening on alternate months, this has been extended to include an Occupational Therapist and a Speech and Language Therapist. Take up for the first of these sessions has been very encouraging.

5 An Upper Limb Group has been trialed to teach and encourage participants in the care of their weak hand/arm, this includes skin care and massage techniques.

6 Much closer working links between wards 6 & 12, ie for staff training, sharing of developments, sharing of staff when one area is short.

Flexible Therapy Stroke Team

The Flexible Therapy Stroke team provides enhanced input to patients on Wards 6 and 12 at Woodend Hospital, and seeks to facilitate effective discharge and transition into the community Each discipline also provides services which are specific to the areas of service need in their professional remit. This includes the OT providing services to DOME, the physiotherapist providing a tone management service, speech and language services to outpatients, and dietetic services for people with stroke in Horizons. The team also provides stroke specific education and support across NHS Grampian. The team comprises Elaine Austin, Dietitian, Jenny Hill, Occupational Therapist, Lorna Cotter, Physiotherapist and Geesmiek Geldof, Speech and language therapist. The clinical lead for the team is Thérèse Jackson, Consultant O.T. in Stroke.

Consultant Occupational Therapist in –Stroke

Thérèse Jackson has been in post since Sept 06 and has four main areas of responsibility. Activity this year has included:-

Expert Practice Consultancy, with therapists working with people with complex disability across Grampian. This comprises up to four clinical sessions per week and encompasses mentoring, practice based learning and delivery of equitable services for people with stroke across the region. Also includes facilitation of the clinical effectiveness programme with senior therapists working in stroke/neuro practice who have this year produced guidelines for splinting, & driving, and have completed an audit and review of occupational therapy stroke services Education and professional development Chair of the Stroke MCN Education sub group; facilitation of the occupational therapy stroke education programme; provision of local and national training and provision of `Best practice in Stroke` research conference Leadership and Innovation Scoping existing occupational therapy stroke services across Grampian to identify service gaps and areas for development Chair of the discharge sub group of the Stroke MCN, which is now reformed in Moray to develop patient discharge information for NHS Grampian and progress stroke service developments. Clinical lead for the Mobile Stroke team (ARI), The Flexible Therapy Stroke Team, and the Community Living Skills Team (project completed in July 06) Research and Development Develop research culture and activity e.g. Best Practice in Stroke – research day at Robert Gordon University. Incorporate research into practice through practice based consultation, development of clinical guidelines, education and facilitation of research activity. e.g.publication in the Australian Occupational Therapy Journal Dec 05 – critical appraisal; & development of a pilot project for occupational therapy in the management of upper limb oedema post stroke.

Acute Stroke Unit – Ward 11, Aberdeen Royal Infirmary

The Acute Stroke Unit is based in ward 11 in Aberdeen Royal Infirmary. It has 20 beds for the assessment and management of stroke patients in the early phase of their illness, with dedicated nursing, therapy and medical staff. Patients commence their rehabilitation in this unit and continue until discharge home or transfer to either one of the stroke rehabilitation units (wards 6 and 12 Woodend Hospital) or to a more general rehabilitation area e.g. Community Hospital, Maple or Links Unit. Patient progress is monitored via a weekly multidisciplinary meeting. Patients are referred to the unit via a ‘Stroke Pager’ usually held by one of the Consultant medical staff. As well as for admission, the pager is a route for Stroke advice for GPs, A&E and other hospital areas both in Grampian and Orkney/Shetland. A weekly Neurovascular clinic and Stroke Prevention clinic are held in ARI. Details regarding Acute Stroke Unit admissions policy and clinical protocols can be obtained from the Grampian Intranet website.

Community Living Skills Team

This was a two year pilot project funded by ‘The Big Lottery’ to enhance therapy services to people on Ward 12, Stroke Rehabilitation Centre, Woodend Hospital. Patients received therapy directed to enhance ‘community living skills’ with the aim of improving independent living on discharge and an effective transfer of care to community services. The team was staffed by a part-time occupational therapist (Shelagh Matthews) physiotherapist (Sarah Coghill) and initially by a speech and language therapist, although it was not possible to sustain this after 6 months. Clinical lead for the team was Thérèse Jackson, Consultant OT in Stroke and Business support was provided by Lesley Berry (Therapy Services Manager) The evaluation and report was produced with support from the clinical effectiveness team.

The project found that community living skills were identified and dealt with by OT and PT staff prior to the introduction of the project, although not fully. The results indicated the effectiveness of specific CLS interventions, but recommended integrating them into existing services, rather than as a separate intervention. In order to do that the staffing levels on the Stroke Rehabilitation unit would need to be increased, and this is an issue for the Stroke MCN to address in future planning of services.

The project ended on 31st July 2006. A full report can be found on the NHS Grampian website.

Orkney, Shetland and Highland

The Stroke MCN in Grampian provides a scanning service for patients of the above areas and tertiary surgical interventions.

Mobile Stroke Team, ARI The Mobile Stroke Team (MST) began in August 2004. The team provides a specialist stroke service, to assess, treat and support people with a stroke who are not admitted to the acute stroke unit at ARI. The team is multidisciplinary, comprising a dietitian (Yvonne Kinghorne), an occupational therapist, (Jenny Hill – but now being replaced as Jenny has moved to the FTST) a physiotherapist (Anne Belton) and a speech and language therapist (Annette Cameron). The clinical lead for the team is Thérèse Jackson, Consultant occupational therapist in stroke. We are pleased to announce that we have secured funds for a nurse to join the team. The MST nurse will support stroke patients at ARI, and staff on non stroke unit areas, to provide specialist care for people with stroke on their wards. Other activities by the MST this year have included, revision of the data collection and audit process for MST activity, development of a patient information leaflet for patients, and for those with communication difficulties about the MST; and production of an annual report.

Mobile Doppler Service A Technician was in post and has now completed his training. A room was converted in Ward 36, Aberdeen Royal Infirmary and this was where the technician is operating as a permanent location.

Research and Development The MCN will continue to support the work of the National Initiative and the people working actively locally in this area. This included support from the MCN for separate Events considering research and best practice, which will be held in November 2006.

Dr Mary-Joan MacLeod was appointed as Local Lead to Research Network for Scottish Stroke in November 2005. A list of ongoing and previous research/audit projects to be made available on the MCN Website.

Acute Stroke Sub Group – Chair, Dr Mary Joan MacLeod This Sub Group is currently undertaking work involving “fast tracking” referrals to the Neurovascular Clinic. One of the aims for future meetings is to look at the surgical side of acute stroke.

The group had been also looking at the patient discharge letter to meet QIS Standards. They were also looking at and monitoring their QIS Standards in line with the QIS Standards in the Acute Hospital setting.

A Consultant Vascular Surgeon and Consultant Radiographer have undergone training in carotid angiography and carotid stenting.

The Acute Stroke Unit had produced a poster for A&E to help them identify potential thrombolysis patients.

Information also given to Acute Medical Assessment Unit (AMAU) on suspected stroke referral procedure. A modified protocol is being developed by G-Meds.

Stroke Discharge Sub Group – Chair, Thérèse Jackson

This sub group produced the `stroke discharge process` in 2005 (available on the NHS Grampian website) As a result of developing this process it was recognised that further activity was required to ensure that discharge processes were streamlined across Grampian. In order to engage with professionals involved in developing stroke services, it was decided to hold the meetings in Moray, alongside the `practitioner group` , who would focus on discharge information for Grampian and progress stroke service developments in Moray. Chest Heart and Stroke Scotland have also held a consultation day about the discharge process with service users, and as a result have produced a version, which can be used for people with communication difficulties.

Secondary Prevention Sub Group – Chair, Dr David Williams

The Sub Group has produced an agreed Protocol, which requires annual review. http://www.nhsgstrokemcn.scot.nhs.uk/index.php?id=1237

It had been decided that the Secondary Prevention Sub Group would meet again when further evidence on the secondary prevention of stroke became available. The group has since met on 31 August 2006 as a result of the publication of new data on the secondary prevention of stroke and has agreed a revised set of guidelines which will be forwarded to the Stroke Project Board for approval.

4. EDUCATION AND TRAINING

Education Sub Group – Chair, Thérèse Jackson

Membership of this group includes patient and service users, members of the public and healthcare professionals from the acute sector, CHP`s and social services, all with and interest in stroke education.

The sub group considers and advises on stroke education needs and implementation across Grampian, and meets every two months.

Some of the discussions/topics to date include:-

Integration of Stroke core competencies into existing training programmes Stroke Training Courses in Grampian – run by the stroke training coordinator and Flexible Therapy Stroke Team Education in remote and rural areas Carer Education/Support Groups – how to take forward in Grampian Profession specific courses Examples of good practice and application in Grampian e.g The Lochaber Education Programme (Highland) Driving Assessment information following Stroke Post Discharge Stroke Rehabilitation and Education Programme – see below:- Use of stroke slippage funds for education in Grampian

Stroke Training Co-ordinator employed by Chest, Heart and Stroke Scotland (CHSS)

Stroke Training Programmes

“Members of the multidisciplinary stroke team should undertake a continuing programme of specialist training and education.” (SIGN 64, 2002)

Stroke training programmes have been running throughout Grampian since September 2005. The training programmes are aimed at health professionals, social service staff and informal carers working with stroke. The aim of each programme is to build on knowledge and skills and increase confidence when working with stroke.

The training programmes have been held in Aberdeen, Elgin, Keith and Fraserburgh. Between 1st October 2005 and 30th September 2006, 17 programmes have been completed, resulting in 277 people receiving training. A breakdown of these training programmes is shown below.

Title Length Number completed (1st Oct – 30th Sep) Introductory Course in 3 days 7 Stroke Care Intermediate Course in 3 days 2 + 1 with 3rd day in Stroke Care November Advanced Course in 1 day 1 (Secondary Prevention Stroke Care in Stroke Care) Social Service Staff Study 1 day 2 Day Care Home Staff Study 1 day 1 Day Stroke Awareness 2 hours 2 Session Student Nurse Session 2 hours 2

Three discipline specific training programmes have also been organised throughout the year. Harrison Associates have provided two training programmes for occupational therapists and Connect have provided one for speech and language therapists. All of these programmes were funded by the Grampian Stroke managed Clinical Network.

The training programmes have proven very beneficial this year and as a result 19 training programmes are planned for 2007. Details of these are available from: Lynsey Duncan Stroke Training Co-ordinator Stroke Office Westholme, Woodend Hospital Aberdeen Tel: 01224 (5)56150 E-mail: [email protected] www.chss.org.uk/education

Training can be arranged to meet the needs of individual areas. Please see contact details above.

The MCN has also participated in several CHP Protected Learning Time events and attended various other meetings to discuss it’s role and raise overall capacity within Grampian for Stroke Care. Invitations for these events/meetings are always welcome.

5. PATIENT/PUBLIC INVOLVEMENT

This area of development is still a very high priority for the MCN.

Public Involvement Sub Group – Chair, Margaret Somerville

A Stroke Public Involvement Sub Group has been meeting every three months. The group is chaired by Margaret Somerville, Deputy Director of Advice & Support, Chest, Heart and Stroke Scotland (CHSS). The membership includes three members of the public who have had experience of stroke, one of whom lives in Moray and two members who are carers of someone who has experienced a stroke.

One public involvement member of the Group represents patients nationally on the National Advisory Committee for Stroke (NACS) MCN Sub Group, which meets in Edinburgh.

In March this year the remit of the Group was revised and approved by the MCN Project Board. The remit now states that the main aim of the Group is to ‘act as Advisory Group to the Stroke MCN on any relevant issues, contributing to steering the agenda and strategy for Grampian’

The Group have been considering  staff training involving patients and carers: outcome - the Introductory Course includes a session where a recent patient talks of their experience, the Intermediate Course includes a session where a carer talks of their experience. These sessions have evaluated highly.  Protocol development: this involves ensuring a version of a protocol is in a format suitable for service users. Work has been done regarding the Stroke Discharge Protocol by consulting with people whose stroke has affected their communication.  Patient/Carer Leaflet development: Work is in progress advising on Driving Assessment Information.  Information given to carers: activities going on elsewhere in Scotland are contemplated

6. QUALITY ASSURANCE, CLINICAL GOVERNANCE AND PERFORMANCE REVIEW

The ultimate aim of MCNs is to improve patient care in terms of quality, access and appropriateness. To achieve this, the clinical governance agenda and quality issues will be set by quality assurance programmes agreed with local clinicians, patients and Quality Improvement Scotland (QIS). This will ensure that high standards of care can be demonstrated.

This puts quality assurance firmly at the centre of all managed clinical network activity. The Stroke Quality Assurance Framework includes:-

 a document scoping the outline of the MCN and the services it will provide  a set of standards for the services provided by the network, ratified by NHS QIS  agreed arrangements by which performance against the standards will be reviewed and monitored

Stroke Protocols/Stroke Proformas

It was agreed that all Stroke Protocols be submitted to the MCN Project Board. The next stage would be for them to be placed on the Stroke website.

Stroke Quality Assurance Sub Group – Chair, Dr Stephen Lynch

The Stroke Quality Assurance Sub Group has been meeting approximately every 3 months. From October 2005 last, work of the group has included:-

1. Drafting a template to be issued to the other stroke subgroups where any items of relevance to do with quality assurance could be brought to the attention of the group. 2. Looking at the QIS unmet Standards in the Acute Hospital setting and working through addressing these issues.

QIS Accreditation

To note that as QIS would no longer be accrediting MCNs at a local level – a local procedure was being set up and details are awaited.

Future activity:

 To look at Clinical Governance remit at the October 2006 meeting.  Suggest yearly update QIS Standards  Expand to look more generic  Clinical governance / case note reviews  Look at involvement from Public Involvement  What information was available in Primary Care? To explore QOF information  To approach the Consultant in Public Health and inviting his involvement or could he suggest a Public Health representative  Look at Primary Care and Secondary Care

QIS – Aberdeen Royal Infirmary and Woodend only – Dr Grays Hospital, Elgin, figures not available NHS Quality Improvement Scotland (NHS QIS) was established in 2003 with the purpose to improve quality of healthcare in Scotland. Each Trust has a responsibility to audit it’s performance against the standards on a regular basis. NHS Grampian were visited by the NHS QIS in October 2004.

QIS Standards Period Period Period Period 1/12/04- 1/6/5- 1/12/5- 1/6/6- 31/5/5 30/11/5 31/5/6 30/9/6 % % % % 1.1 70% of patients diagnosed with stroke are admitted to Acute Stroke Unit within 24 hours of admission to hospital

Admitted to ASU at any time during admission 44 48 63 64 Admitted to ASU within 24 hours of admission 36 38 55 56 Patients admitted to ASU at any time or seen by Mobile Stroke Team 62 61 68 68

1.7 80% of new patients are seen within 14 days of referral to Neurovascular clinic

Seen within 14 days of receipt of referral N/A 35 58 90*

1.8 (Desirable) 80% of new patients are seen within 7 days of Referral to Neurovascular Clinic

Seen within 7 days of receipt of referral N/A 18 23 60

2.2 80% of patients have CT/MRI imaging performed within 48 hours of admission

Scanned at any time during admission 73 73 86 86 Scanned within 48 hours of admission 47 55 69 66

2.3 Aspirin treatment initiated within 48 hours for all patients unless contraindicated

Started on aspirin at any time during admission 70 73 77 76 Started on aspirin within 48 hours of admission 55 61 71 69

2.4 All patients have an initial swallow screen test performed unless contraindicated

Swallow screen performed at any time during admission 68 61 74 76 Swallow screen performed on day of admission** 17** 45 57 31

(*Manually calculated by logging date referral received at ASU – this was picked up recently as some referrals taking up to 5 days to be sent from GP Referrals Section to ASU for booking. New electronic referral system commenced 1 November, electronic referral protocol was sent to GP’s June 2006. However prompt attention to referrals by Stroke Consultant is major factor in this increase.) (**Date swallow screen performed was not recorded until 1/8/5 onwards which accounts for difference in figures)

Stroke Register Co-ordinator

Grampian Stroke Audit

The Grampian Stroke Audit was set up in September 2000 under the name of Grampian Stroke Register to capture details of patients suffering a stroke within Grampian and primarily to identify where they were being treated. The role has diversified over the years and the Stroke Audit now supports the work of the Stroke MCN, the 4 Chest, Heart and Stroke nurses across Grampian and also has an active role in the provision of research support to various ongoing research projects – an example being the Study of Visual Impairments run by Aberdeen University.

There are now 5000 patients held on the database and ongoing developments allow our local stroke service to be monitored closely against QIS Standards for Stroke Care in Scotland .

If you would like to know more about the audit then please contact: Elaine Horne Stroke Audit Coordinator Acute Stroke Unit Ward 11 Aberdeen Royal Infirmary Email [email protected] Tel 01224 (5)59505

Stroke Links Sub Group

The Sub Group was Chaired by the Network Managed MCN for Stroke and meetings held every six months. The Sub Group was set up to explore ways to strengthen links and improve networking within the MCN. The first meeting was held in February 2006 and the group again met in June 2006.

Discussions to date included:-

Improve Links between Wards 6 & 12 Woodend, ARI and Elgin.

The Ward Managers at Woodend and ARI have met to discuss opportunities for improved links such as work site visits and rotations. It was hoped to improve communication so that staff would feel more integrated between both ARI and Woodend. It would help with staff career progression and staff “shadowing”. Staff rotation could give a greater opportunity for staff from Woodend to learn about stroke in the Acute setting and staff from ARI would learn more about Stroke Rehabilitation and discharge from Woodend.

The next stage was to meet with management at ARI to decide a way forward with staff rotation.

Stroke MCN Newsletters

The Stroke MCN were regularly producing Newsletters: Issue 1 – June 2005 Issue 2 – December 2005 Issue 3 – May 2006 Issue 4 – August 2006

Back copies are available on the Stroke MCN Website. http://www.nhsgstrokemcn.scot.nhs.uk/index.php?id=1410

Positive reports from staff had been received regarding the Newsletters which kept staff informed of what was currently happening within the MCN. Newsletters were also circulated to all participants in the Stroke Training Courses run by the Stroke Training Co-ordinator.

Achievements of the 12 Core Principles for MCNs

No. Twelve Principles of MCN (as specified in NHS HDL Met/Not Met (2002) 69 1. Each Network must have clarity about Network Met management arrangements, including the appointment of Lead Clinician and a person who is recognised as having overall Manager in post. responsibility for the operation of the Network, whether a Annual Report for lead clinician, a clinical manager or otherwise. Each 2004/05 has been written Network should produce a written annual report to the and published on the appropriate Health Board or Trust, which would also be website. The Annual available to the public; Report for 2005/06 is to be published in November 2006. 2. Each Network must have a defined structure which sets Met out the points at which the service is to be delivered, and the connections between them; Patient pathway published 3. Each Network must have a clear statement of the specific Met clinical and service improvements which patients could expect as a result of the establishment of the Network; Standard 6 of QAF

4. Each Network must use a documented evidence base, Met such as SIGN guidelines where these are available, and QAF refers to evidence must be committed to expansion of the evidence base base through appropriate R & D;

5. Each Network must be truly multi-disciplinary/multi- Met professional and there must be clarity about the role of All subgroups have each health professional in the Network, particularly multidisciplinary where new or extended roles are being developed as part membership from across of the Network. Each Network should include Grampian, and patient representation from patients’ organisations in its membership, where management arrangements; needed.

6. Each Network must have a clear policy on the Met dissemination of information to patients, and the nature of CHSS Stroke Liaison that information, bearing in mind the role of primary care nurses use tailored in helping to lead the patient through the system; information packs. Continuing work on discharge documents. 7. All the health professionals who would make up the Met Network must indicate their willingness to practice in All staff working with accordance with the evidence base and with the general stroke patients are principles governing Networks; welcome to be part of the MCN 8. An integral part of each Network must be a quality Not Met assurance programme acceptable to the Clinical Standards Board for Scotland, which also has a role in ensuring consistency of standards and quality of treatment across all Managed Clinical Networks;

9. The educational and training potential for Networks should Met be used to the full, through exchanges between those working in the community and primary care an those working in hospitals/specialist centres. Networks’ potential to contribute to the development of the intermediate specialist concept should also be kept in mind, and Networks should develop appropriate affiliations to universities, the Colleges and NES; 10. All health professionals in the Network must produce audit Not Met data to required standards and participate in open review of results;

11. All Networks must include arrangements to circulate staff Met in ways, which improve patient access, and enable professional skills to be maintained. Each Network should have an appropriate programme of continuous professional development in place for every member of the Network as well as a mechanism for ensuring the programme is being followed;

12. There must be evidence that the potential for Networks to Met generate better value for money has been explored. MCN involved in investments and prioritising pressures

7. INVESTMENT PLANS

What Funding has there been to support MCNs?

The CHD/Stroke Strategy in Scotland has been supported by an annual funding allocation of £15m from the Scottish Executive. This funding which has been made available since 2003/04 has facilitated the establishment of MCN Networks, the development of Stroke and Heart Disease databases and has provided funding to implement a number of local developments. A proportion of the funding is continuing to be top-sliced for various national initiatives (£1.5m).

NHS Grampian receives just over 9% of the total funding available for distribution which means that we receive £1.2m per year, to be shared equally between CHD and Stroke.

A significant amount of slippage has been generated over a number of years and detailed plans on the use of this funding have been agreed with relevant MCN Project Boards. The Stroke monies includes repayment of slippage in the 2003/04 and 2004/05 allocations that was used to support certain CHD developments during these years.

The funding plans for financial years 2005/06 through to 2009/10 are detailed in the table below.

Allocations specifically approved in 2006/07 are as detailed below

Stroke To note that a paper was submitted to the Stroke MCN Project Board Meeting on 27th June 2006 indicating that there was £82,000 recurring funding and £127,000 of non- recurring funding available for distribution.

Priorities agreed were as follows:-

Recurring Funding

1. Stroke Hypertension Nurse £38,000 2. Clinic Nurse £18,000 3. Mobile Stroke Team Nurse £16,000 4. CHSS Nurse hours £7,000 5. Training Fund £3,000

Non-Recurring Funding

1. Equipment £76,000 2. Training £36,000 3. Travel £3,000 4. CHSS Nurse Dr Grays £12,000

Further non-recurring monies will be available for distribution in 2007/08.

STROKE STRATEGY FUNDING FOR NHS GRAMPIAN - 2005/06 to 2009/10

2005/06 2006/07 2007/08 2008/09 2009/10 FUNDING £'000 £'000 £'000 £'000 £'000

Stroke Stroke MCN 60 60 60 60 60 Stroke Database 30 24 24 24 24 Gait Trainer 0 0 0 0 0 Expansion Neurovascular Clinic 25 30 30 30 30 Early Stroke Rehab 113 110 110 110 110 SpR Training 28 28 28 28 28 Neuropsychology services 58 56 56 56 56 Stroke Flexible Therapy Team 107 150 150 150 150 Mobile Doppler 22 41 41 41 41 Beds 25 0 0 0 Stroke AHP Consultant 28 50 50 50 50 Stroke Vascular Prevention 10 10 10 10 10 CHSS Nurse Dr Grays 15 12 0 7 7 Training Courses 16 36 13 3 3 Clinic Nurse 0 6 18 18 18 Mobile Stroke Nurse 0 6 16 16 16 Cardiovascular Risk Nurse (NOF) 0 0 38 38 38 CHSS Stroke Training Co-ordinator 50 0 0 40 40 IT Equipment - New Neuropsychology 6 0 0 0 0 Stroke Travel Fellowship 6 3 6 0 0 Stroke Minor Refurbishment and Equipment 11 0 0 0 0 Stroke Equipment 42 78 36 90 90 Total Stroke Expenditure 652 700 686 771 771

8. PLANS FOR THE COMING YEAR

KEY OBJECTIVES Every Health Board in Scotland is being asked to deliver the following key objectives:

Health Improvement for the people of Scotland – improving life expectancy and healthy life expectancy;

Efficiency and Governance Improvements – continually improve the efficiency and effectiveness of the NHS;

Access to Services – recognising patients’ need for quicker and easier use of NHS services; and

Treatment Appropriate to Individuals – ensure patients receive high quality services that meet their needs.

The Grampian MCN can help with all these objectives and is building them into its prioritised workplan which will be available in full on the MCN website. We expect to deliver the following new improvements:

 The MCN is working on a vision describing the ideal for the development of stroke services in Grampian over the next decade.  A group is developing Grampian-wide pathways for patients with suspected stroke and TIA to ensure that they receive appropriate assessment and treatment. This will provide guidance for local GPs, NHS 24, ambulance services and those working in A&E departments. It is likely to involve quite a lot of change in consultant work patterns and therefore will take time to introduce. It is hoped that the introduction of these changes will help the service to meet NHS QIS standards for the waiting times to access a neurovascular clinic, the time taken for a stroke patient to access a stroke unit bed and the time to be given aspirin if appropriate.  We will continue to reduce waiting times for carotid endarterectomy intervention.  We will contribute to prevention of stroke and TIA in the community through working with GP practices. We are involved with several primary care initiatives to improve prevention.  The MCN will seek to accredit for its quality and will do ore to develop efficiency. We will review each area of our work and develop improved links with the Community Health Partnerships.  We will assess the impact of various strategies and review which concern servics for older people as so many living with the consequences of stroke are elderly and we will implement stroke related actions.  We want to make more use of the information we already collect in the NHS by feeding it back to staff so they can benchmark themselves and learn from others.  We expect to build on our successful staff training and pilot new learning methods for taking forward the national guidance on Core Competencies for all staff.  We want to strengthen our involvement with patients and carers and our links with CHSS.  This year we should complete a number of initiatives, which involve new IT.

ENQUIRIES

Headquarters: CHD & Stroke MCN Office, Westholme, Woodend Hospital Site, Eday Road Aberdeen, AB15 6LS, Telephone: (01224) 556713

Dr Steve Hamilton, Lead Clinician, Stroke MCN (1 session) [email protected]

Dr Jim Black, Lead GP, Stroke MCN (1 session) [email protected]

Mr Sandy Reid Network Manager (from October 05) (1½ days per week) [email protected]

Mrs Christine Gray (2½ days per week), Secretary [email protected]

Ms Thérèse Jackson, Consultant Occupational Therapist in Stroke [email protected]

Ms Lynsey Duncan, Stroke Training Co-ordinator [email protected]

PROJECT ORGANISATION

The MCN for Stroke in Grampian has:

Steering Group and Sub Groups Chairperson:

 Project Board Dr Steve Hamilton, [email protected]  Acute Services Sub Group Dr Mary-Joan MacLeod, [email protected]  Discharge Sub Group Ms Thérèse Jackson, [email protected]  Secondary Prevention Sub Group Dr David Williams, [email protected]  Education Sub Group Ms Thérèse Jackson. [email protected]  Public Involvement Sub Group Ms Margaret Somerville, [email protected]  Quality Assurance Sub Group Dr Stephen Lynch, [email protected]  Stroke Links Sub Group Mr Sandy Reid [email protected]

PROJECT BOARD MEMBERSHIP

Alastair Cozens (Dr) Consultant in Rehabilitation, Woodend Hospital Alison Hamilton Head of Service, Speech and Language Therapy Alison Sands, (Dr) Consultant, Ward 9, Dr Gray’s Hospital, Elgin Clark Paterson Finance Manager, Ashgrove House, ARI David Williams Consultant, Clinical Pharmacology, Ward 12, ARI Elaine Brown Service Planning Lead, Spynie Hospital Elaine Horne Stroke Register Co-ordinator, Ward 11, ARI Elaine Morrison Ward Sister, Stroke Rehab, Woodend Elizabeth Squires Temp Nurse support Fred Christie, Service Manager, Elderly & Rehab, Woodend Hospital George Downie, Director of Pharmacy & Medicines Management, Woodend Gillian Lewis, Public Health, Health Promotions Gregory Poon, Lead Nurse, Aberdeen CHP Jack Stuart, General Manager, Aberdeenshire CHP, Jackie Hamilton (Dr) Neuropsychologist, ARI Jim Black, Lead GP, CHD & Stroke MCN Jon Cresswell, (Dr) Consultant in Public Health Medicine Service Manager, Therapies, ARI Kathleen Sinclair Project Manager, Joint Future Aberdeen City Council Linda Bailey, Physiotherapist, Physiotherapy Dept., Dr Gray’s Hospital, Elgin Margaret Somerville, Regional Manager, Chest, Heart & Stroke Scotland Marie Munro, Nurse Manager, Ward 9, ARI Mariel Purcell (Dr) Specialist Registrar, Rehab. Woodend Mary-Joan MacLeod Consultant, Acute Stroke Unit, ARI Niall Hughes, Specialist Registrar, Medicine for Elderly, Woodend Hospital Nicola Farquhar Ward Manager, W12, Stroke Rehabilitation Centre, Woodend Rose McKechnie Ward Sister, Ward 40, ARI Sandy Reid Network Manager, CHD & Stroke MCN Sheena Paterson, Sister, Stroke Unit, Ward 11, ARI Steve Brockman Ward Manager, Ward 16, Woodend Hospital Steve Wilkinson Consultant Physician , Woodend Hospital Thérèse Jackson, Consultant Occupational Therapist in Stroke

MCN Stroke Project Board Meetings

Thursday 24 November 2005 at 2pm Thursday 26 January 2006 at 2pm Thursday 30 March 2006 at 2pm Thursday 27June 2006 at 2pm Thursday 28 September 2006 at 2pm

WEBSITE Website http://www.nhsgstrokemcn.scot.nhs.uk

Minutes, agendas, newsletter, forthcoming events, local and national policies, protocols and guidelines are all available on this website. Links to other websites include the Grampian Intranet and the GP Portal.