PRESENTATION TITLE Stroke Services Cheshire & Merseyside

Dr Deborah Lowe Consultant Stroke Physician SCN Clinical Lead for Stroke

Why are we here?

• We all want to deliver high quality stroke care to our patients

• Most would support services at local Trust, but only if this is deliverable, affordable and sustainable

• How can we ensure that the majority of patients receive the best quality stroke care?

• What are we accepting as our core standards?

• Which services currently fall below that standard?

• What reconfigurations are needed within Cheshire & Merseyside to provide equitable access whilst not diluting quality of care?

Background

• Cheshire & Mersey - 9 Acute Trusts supported by 12 CCG’s

• Population of approx 2.5 million people

• All have ‘Acute Stroke Units’

• 34 Stroke Consultants / Associate Specialists working within Stroke

• 5 Trusts currently provide 24/7 hyper-acute stroke unit (HASU) services with approx 610 strokes per year • 3 Trusts have support from other units for 24/7 cover including use of telemedicine • 1 Trust doesn’t have access 24/7 thrombolysis, despite support from two other large stroke units outside this SCN

Travel times

trusts trusts

between between

(minutes)

Drivetime

Salford

Aintree

Chester

RLBUHT

Whiston

Leighton

Southport

Warrington

Countess of of Countess Staffs North

Arrowe ParkArrowe

Macclesfield Hill Stepping Wythenshawe Aintree * 36 49 48 14 25 14 24 25 55 31 45 40 Countess of 36 * 48 33 31 51 31 29 20 47 39 44 39 Chester Macclesfield 49 48 * 35 50 59 44 39 53 38 33 20 29 Leighton 48 33 35 * 49 58 43 38 44 26 41 43 38 RLBUHT 14 31 50 49 * 34 18 25 17 57 32 47 42 Southport 25 51 59 58 34 * 34 38 44 66 41 56 51 Whiston 14 31 44 43 18 34 * 19 33 51 26 40 36 Warrington 24 29 39 38 25 38 19 * 36 46 21 36 31 Arrowe Park 25 20 53 44 17 44 33 36 * 58 46 50 45 North Staffs 55 47 38 26 57 66 51 46 58 * 48 50 45 Salford 31 39 33 41 32 41 26 21 46 48 * 23 19 Stepping Hill 45 44 20 43 47 56 40 36 50 50 23 * 17 Wythenshawe 40 39 29 38 42 51 36 31 45 45 19 17 *

Data source: Microsoft Mappoint Cheshire and Merseyside comparisons

Cheshire and Greater London Merseyside Manchester Population 2,510,884 2,807,005 8,818,097 Geographical area 1150 sq miles 493 sq miles 700 sq miles % pop over 40 yrs 24%/27% 23%/25% 19%/21% (M/F)

Incidence of AF 45,020 (1.8%) 38442 (1.4%) 795572 (0.9%)

Data source : QOF Cheshire and Merseyside demographics Population Prevalence of Prevalence of Prevalence CHADS2>1 CVD stroke of AF anticoagulated Eastern Cheshire 194,793 10.4% 2.10% 2.1% 81.6%

Halton 125,722 9.7% 2.24% 1.7% 77.2%

Knowsley 145,903 10.4% 2.62% 1.5% 81.3%

Liverpool 465,656 9.8% 2.37% 1.5% 81.7%

South Cheshire 175,943 10% 2.07% 1.9% 79.9%

South Sefton 159,764 10.7% 2.52% 1.9% 80.9%

Southport and 114,205 11.7% 2.59% 2.2% 82% Formby St Helens 175,405 10.4% 2.33% 1.8% 81.3%

Vale Royal 102,144 9.5% 1.98% 1.7% 86.1%

Warrington 202,709 9.2% 1.86% 1.5% 80%

West Cheshire 227,382 10.1% 2.12% 1.9% 78.6%

Wirral 319,837 10.9% 2.53% 2.1% 81%

England 53,107,169 9.5% 2.07% 1.5% 81.3%

Data source: Cardiovascular intelligence network Trust catchment populations

Trust Catchment Population Aintree 330,000 Countess of Chester 445,000 Macclesfield 450,000 Leighton 280,000 RLBUHT 750,000 Southport 225,000 Whiston 350,000 Warrington 500,000 Arrowe Park 400,000

Data source: Individual trust websites RCP SSNAP data

1000

600

Who delivers Stroke Care?

• Medical workforce predominately Geriatricians with specialist training / experience in stroke • Mostly Consultant delivered thrombolysis service • 3 Trusts use telemedicine out of hours • 32 Consultants, 2 Associate Specialists • Consultants at most Trusts also part of general medical rota • 41 Stroke Nurse Clinicians / Stroke Specialist Nurses within the region

How is stroke specialist assessment delivered?

Trust In Hours Out of Hours

Aintree Face to Face Face to Face

Countess of Chester Face to Face Telemedicine

Macclesfield N/A N/A

Leighton Face to Face Face to Face – at North Staffs

RLBUHT Face to Face Face to Face (occasionally telemedicine) Southport Face to Face Telemedicine

Whiston Face to Face Face to Face (occ telephone to SpR) Warrington Face to Face Face to Face – at Whiston

Arrowe Park Face to Face Face to Face Thrombolysis assessment?

Trust Initial Initial Subsequent Subsequent Assessment In Assessment Out Review In Hours Review Out of Hours of Hours Hours Aintree Consultant Consultant Consultant / Stroke Nurse Stroke Nurse Clinicians Clinicians Countess of Consultant Consultant via Consultant Medical SpR Chester Telemedicine Macclesfield 24/7 thrombolysis at North Staffs for 10% of the population & 7am – 7pm M – F at Stepping Hill otherwise Leighton Consultant / ED Consultant / Consultant Medical SpR Specialist Nurse Specialist Nurse RLBUHT Consultant / Consultant / Consultant / Consultant / Specialist Nurse Specialist Nurse Specialist Nurse Specialist Nurse Southport Consultant / Telestroke / Consultant / On Call Consultant Specialist Nurse Specialist Nurse Specialist Nurse / Specialist Nurse Whiston Consultant / SpR / Consultant / SpR / Consultant Consultant Specialist Nurse Specialist Nurse Warrington Stroke Specialist ED Consultant Consultant Consultant Nurse Arrowe Park Consultant with Specialist Nurse Consultant / Consultant / Specialist Nurse then Consultant Medical SpR Medical SpR HASU services provided at other trusts

• Stepping Hill provide a 7am-7pm weekday service for 90% of East Cheshire (Macclesfield) population and North Staffs provide a 24/7 service for 10% (South Sector) of East Cheshire population

• RLBUHT provide a HASU service for Liverpool Heart and Chest

• Whiston provide an out of hours service for Warrington (8pm-8am weekdays and all weekend)

• North Staffs provide ‘out of hours’ service for Mid Cheshire population

• Lancs & Cumbria telemedicine network provide out of hours service for Southport

Ward rounds and ring fenced stroke beds

Trust Ward rounds 7/7 by a Ring fenced HASU beds stroke specialist

Aintree Yes Yes

Countess of Chester Yes Yes

Macclesfield No No

Leighton No No

RLBUHT Yes Yes

Southport No No

Whiston Yes Yes

Warrington Yes Yes

Arrowe Park Yes Yes Number of beds and nursing workforce

Trust Total stroke bed no. Number of stroke Nursing to Stroke Specialist (HASU beds/subacute) specialist nursing bed ratio – for nursing available *rehabilitation staff (band 6-8) wte 10 beds 24/7 Aintree 29 (12/17) 7 ? Yes

Countess of 28 (14/14) 1 ? No Chester Macclesfield 24 (0/24) 1 ? No

Leighton 28 (8/20) 2 ? No

RLBUHT 48 (10/18) *20 8 ? Yes

Southport 28 (4/24) 3.8 ? No

Whiston 39 (8/8) *23 7 ? Yes

Warrington 29 (7/12) *10 1 ? No

Arrowe Park 46 (10/16) *20 9 ? Yes CT and MRI scanning

Trust Do you have Do you have rapid rapid access to access to MRI ‘in CT 24/7? hours’?

Aintree Yes Yes

Countess of Yes Yes Chester Macclesfield No No

Leighton Yes Yes

RLBUHT Yes Yes

Southport Yes Yes

Whiston Yes No

Warrington Yes Yes

Arrowe Park Yes Yes TIA Services: Week days

Trust Do you Do you Do you Do you Do you Do you have Do you provide have access have access have access have access to have TIA clinics to same day to same day to same day access to same day access to every CT? MRI? carotid same day ECG/Bloods? same day week day? doppler? Echo? CTA/MRA?

Aintree Yes Yes No Yes No Yes Yes Countess of Yes Yes Yes Yes No Yes Yes Chester Macclesfield No* No No No No No No

Leighton Yes Yes Yes Yes No Yes Yes RLBUHT Yes Yes Yes Yes Yes Yes Yes Southport Yes Yes No Yes No Yes No Whiston Yes Yes Yes Yes No Yes Yes

Warrington Yes Yes Yes Yes Yes Yes Yes Arrowe Park Yes Yes Yes Yes No Yes Yes

* Macclesfield Hospital: TIA services provided by Wythenshawe Hospital weekdays only. No TIA service at weekends TIA Services: Weekends

Trust Do you Do you have Do you have Do you have Do you have Do you have Do you provide access to access to access to access to access to have TIA clinics same day same day same day same day same day access to Saturday CT? MRI? carotid Echo? ECG/Bloods? same day and doppler? CTA/MRA? Sunday? Aintree Yes No No No No Yes Yes Countess of Yes Yes Yes No No Yes Yes Chester Macclesfield No No No No No No No

Leighton No Yes No No No Yes No RLBUHT Yes Yes Yes No No Yes Yes Southport No Yes No No No Yes No Whiston Yes Yes No Yes No Yes No

Warrington Yes Yes No Yes Yes Yes No Arrowe Park Yes Yes Yes No No Yes Yes Data collection

Trust Do you Do you do Who inputs data Do you have Will you be have a real time to SSNAP? other reporting using dedicated data entry requirements? Capture stroke for Stroke? data SSNAP? clerk? Aintree Yes Not always Combination No Yes

Countess of No No Nurse / Data KPIs No Chester Clerk Macclesfield Yes No Nurse / Data KPIs / Other No Clerk Leighton No No Nurse / Admin KPIs / IPMR / AQ / Yes Staff Trust Report RLBUHT Yes Not always Combination KPIs / IPMR Yes

Southport No No Nurse KPIs / IPMR / AQ Yes

Whiston Yes No Nurse / Data AQ Yes Clerk Warrington Yes No Nurse / Data KPIs / IPMR / AQ Yes Clerk Arrowe Park Yes Almost Nurse / Data No Already in use Clerk ESD service Trust Do you Is your ESD Who What is the Who Is ESD a have and service stroke provides duration of continues 7 day ESD specific? your ESD your ESD therapy post service? service? service? pathway? ESD discharge? Aintree Yes Yes CCG 3 months Community No therapy Countess of Yes Yes Acute trust 6 weeks Community No Chester therapy Macclesfield No

Leighton Not currently in place but recently commissioned RLBUHT Yes Yes Acute trust 6 months Community No neurorehab Southport No but well developed Community Neurorehab service

Whiston Yes Yes Community Depends on Community No trust needs of neurorehab patient Warrington Yes Yes 6 weeks Community No therapy Arrowe Park Yes Yes Acute trust 6 – 12 Community Partially weeks therapy

Other quality markers

Trust Do you have a Do you have a Does your neuropsychology voluntary inpatient rehab service? organisation team provide a 7 working with day service? you? Aintree Yes (1.5 WTE) Yes Yes

Countess of Chester No Yes No

Macclesfield No Yes No

Leighton No Yes No

RLBUHT No Yes Yes

Southport Yes (0.4 WTE) Yes No

Whiston Yes (0.6 WTE) Yes Yes

Warrington No Yes No

Arrowe Park Yes (~1 WTE) Yes Yes SINAP vs SSNAP

Q4 2012 Quartile Q4 2013 Grade SINAP SSNAP total average of 12 key indicator indicators score Aintree 65 4th 44 D Countess of No data - 44 D Chester Macclesfield 74.9 2nd 49 D Leighton 71.7 3rd 41 D RLBUHT 81.1 2nd 64 C Southport 62.8 4th 58 D Whiston 68.3 3rd 42 D Warrington 62.3 3rd 54 D Arrowe Park 72.6 3rd 71 B National 74.7 45 Average North of England- Cheshire and Mersey SCN Performance

North of England- Cheshire and Mersey SCN Jul- Sept 13 Oct- Dec 13

SSNAP SSNAP Score Rank Score Rank Score Score Wirral University Teaching Hospital NHS Foundation Arrowe Park Hospital D 55.8 1 C 63.9 1 Trust Royal Liverpool and Royal Liverpool University Broadgreen University D 45 4 D 51.7 2 Hospital Hospitals NHS Trust Warrington and Halton Hospitals NHS Foundation Warrington Hospital D 47.5 3 D 48.6 3 Trust

Southport and Ormskirk Southport and Formby D 51.3 2 D 44.4 4 Hospital NHS Trust District General

Macclesfield District East Cheshire NHS Trust D 43.3 5 D 44.2 5 General Hospital

St Helens and Knowsley Whiston Hospital E 34.7 8 E 35.7 6 Teaching Hospitals NHS Trust

Mid Cheshire Hospitals NHS Leighton Hospital D 42.5 6 E 34.9 7 Foundation Trust

Aintree University Hospitals University Hospital E 39 7 E 29.9 8 NHS Foundation Trust Aintree

Countess of Chester Hospital Countess of Chester X 0 9 E 23.8 9 NHS Foundation Trust Hospital

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