mind the gap

Stroke

NHSNHS Improvement

MINDGAPT

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WAYSENHANCETHERAPYPROVISIONSTROKEREHABILITATION

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HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Authors:

Jill Lockhart, National Improvement Lead,NHS Improvement - Stroke

Ina James, Team Leader Physiotherapist, StrokeServices, York Hospitals NHS Foundation Trust

Gail Linstead, Stroke Service ImprovementManager, North of England CardiovascularNetwork

With considerable thanks to the NHSImprovement - Stroke Increasing Access toTherapy National Project Teams:

Sheffield Teaching Hospitals NHS FoundationTrust, Stroke Therapy Service

Sheffield Primary Care Trust Speech andLanguage Therapy Service into SheffieldTeaching Hospitals NHS Foundation Trust

The Stroke Unit at St Thomas’ Hospital, Guysand St Thomas’ NHS Foundation Trust

Newton Abbot Hospital Teign Ward andTorbay and Southern Devon Care Trust StrokeTherapy Team and Community NeurologyService Team, South Devon

NHS Camden - stroke REDs team

The community stroke team in Blackburnwith Darwen, part of Lancashire Care NHSFoundation Trust

South Tyneside NHS Foundation TrustPhysiotherapy Stroke Team

Stroke Rehabilitation Unit, St Bartholomew’sHospital, Rochester, Kent, MedwayCommunity Healthcare

Chesterfield Royal Hospital NHS FoundationTrust Acute Stroke Unit Team

Acknowledgements

With additional thanks for their support,contributions and comments to:

Professor A Rudd, Stroke Physician, Guy’s andSt Thomas’ Hospital

Professor V Pomeroy, Professor ofNeurorehabilitation, University of East Anglia

National rehabilitation projects 2009-10Therapy Teams from Medway Healthcare andYork NHS Foundation Trust

Brighton Paradza, Senior Clinical SpecialistPhysiotherapist, Cardiothoracic AcuteServices, The James Cook University Hospital

Fiona Lunn, Nurse Consultant Stroke and theStroke Team at University Hospital of NorthStaffordshire NHS Trust

Foreword

Executive summary

Introduction

National guidelines

Who can deliver more rehabilitation?

When - a seven day service?

How long - getting more out of the whole week?

Where can more therapy make a difference?

How - bridging the gap?

Conclusions

References

Case studies

NHS Camden – stroke REDsImproving access to 45 minutes of therapy for stroke patients

The community stroke team in Blackburn with Darwen,part of Lancashire Care NHS Foundation TrustRetrospective evaluation of therapy need and provision

Medway Community Healthcare Stroke Rehabilitation Unit,St Bartholomew’s Hospital, Rochester, KentImproving access to 45 minutes of therapy for stroke patients

South Tyneside NHS Foundation TrustIncreased stroke physiotherapy provision on stroke wards

Sheffield Teaching Hospitals NHS Foundation TrustImplementing seven day occupational and physiotherapy services for stroke

Sheffield Primary Care Trust and Sheffield Teaching Hospitals NHS Foundation TrustSheffield stroke unit seven day working pilot for speech and language therapy

Chesterfield Royal Hospital NHS Foundation TrustDeveloping a seven day physiotherapy service on the acute stroke unit

Newton Abbot Hospital stroke unit with Torbay and Southern Devon Care TrustSouth Devon Stroke Services: Seven day working and 45 minutes of therapies

Guys and St Thomas’ NHS Foundation TrustSeven day service: Weekend rehabilitation support worker model

Stoke-on-Trent: University Hospital of North Staffordshire NHS Trust

Stakeholders

Contents

Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation

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Foreword

One thing we have learnt fromimplementation of the National StrokeStrategy is that the NHS cannot be aMonday to Friday service any more forpeople who have had a stroke. Thefaster you act, the more of the personyou save is the mantra for the medicalemergency response, and increasingly,we are seeing this is what is neededfor therapy services too.

The NICE Quality Standards for Strokegives therapists a standard to work tofor the first time. This report gives youlots of ideas and methods to getstarted to make those standards areality. It’s going to require hard workand soul searching to think carefullyabout what you do now and what canbe changed and improved. I urge youto embrace this as a way to describewhat you do and ensure it is valued byeveryone.

In a stroke team, rehabilitation iseveryone's business. The teamsfeatured in this report have learnt toshare skills and to make rehabilitationthe basis of the patient’s day.

And that’s the key message. We mustmake sure the service works to meetthe needs of the patient, not theother way around.

Professor Sir Roger Boyle CBE


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Executive summary

It is accepted that rehabilitation is anessential part of the management andtreatment for stroke survivors -

“Rehabilitation afterstroke works. Specialistco-ordinated rehabilitation,started early after stroke andprovided with sufficientintensity, reduces mortalityand long-term disability.”National Stroke Strategy 2007

There is much diversity across theshape, content and delivery ofrehabilitation and therapy servicesacross England and this presents achallenge for both serviceimprovement and research.

This project explored some of thedifferent models adopted by therapyservices to deliver more therapy/rehabilitation in the context of majorchange within the NHS nationally andlocally.

This publication discusses their effecton patients, services and organisations,provides some useful learning toinform the debate with further detailabout 45 minutes, process andoutcomes and asks further questionsfor therapy services to consider.

The commonly emerging themes werehow important it is to understandexisting services fully by usingaccurate data and relevant dataanalysis, that managing humandimensions is paramount with makingsuch huge cultural changes withintherapy services and the need tocontinue optimising workforcecombinations and work collectivelyalong the pathway is essential todelivering effective responsive andtimely services.

All patients can have a rest day if it isappropriate, but it doesn’t alwaysneed to be Saturday or Sunday forevery patient. Seven day therapyservices enable equity of access andthe opportunity for patients to begintheir treatment as early as possible.They support swifter multidisciplinaryteam engagement and speedierprogress, thereby capitalising on otherimprovements to the front part of thestroke pathway. Meanwhile, seven daycommunity stroke services can havemore influence on hospital length ofstay than weekend therapy inpatientservices.

Access to, and delivery of, 45 minutestherapy, improved when seven dayservices were available and followingdemand and capacity activity analysisacross the pathway. This improvementbrought different benefits reflectingthe service needs, patient stage ofrecovery and their goals. All modelsreceived very positive qualitativefeedback from patients regardless ofwho delivered it.


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Well organised and structuredadditional therapy services, deliveredover more days of the week impactpositively on patients and therapydelivery (frequency and intensity)across the whole week.

This work has, arguably, onlyscratched the surface of the issue oftherapy availability, yet hopefully,provides useful ideas and insights.Project teams have shown the benefitof applying systematic serviceimprovement analyses to theirfunctioning, processes and patientoutcomes. To support furtherdevelopment, more scientific researchin this area is also crucial. It is worthnoting that improved and efficientservices create an environment inwhich research can be betterfacilitated and enabled, and aneffective research culture withinclinical services enhances their abilityto care for theirpatients.

Project teams also wanted tounderstand more clearly whichpatients receive most therapy and whythis happens. The projects did not aimto examine the questions around adhoc or formalised organisation oftherapy services, whether moretherapy improved clinical functionaloutcomes, or the nature of the clinicalapproaches and modalities used.


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Introduction

There are many policy drivers for thisproject including the National StrokeStrategy (1), Royal College ofPhysicians (RCP) National ClinicalGuidelines for Stroke (2), NationalInstitute for Clinical Excellence (NICE)quality standards for stroke (3), andCare Quality Commission (CQC)report on stroke services (4).

In addition, the requirement toimprove quality and productivity toensure services continue to meetdemand within existing resourcesrequires all services to review andmaximise the use of their workforce.Therapy stroke services are facingincreasing pressure as researchsuggests that their services deliverpoorer outcomes, yet are betterresourced than some Europeancounterparts. (14) There is increasingpressure from commissioners todemonstrate the added value ofspecialist services, in comparison withgeneric ones.

This can be viewed by therapists as achallenge to their services, or as anopportunity to examine practiceobjectively and pragmatically, gain afuller understanding of how they canimprove patient contact time anddeliver higher quality rehabilitationacross the stroke pathway. This wouldenhance the significant changes thathave already taken place in stroke careand positively embrace the culturechange required to deliver aresponsive, flexible, timely andrelevant therapy service for strokesurvivors.

National standards set out theexpectations; however, services arestruggling to work out how toimplement them. This publicationsummarises some practical servicedelivery solutions and the ways inwhich these “Mind the Gap”.

Process of the projectsAimThe aim of this work was to:• Look at the impact of differentmodels that stroke services are usingto increase access to therapy andrehabilitation

• Understand how to affect deliveryof national quality standards,guidelines and aspirations for strokeservices

• See if there were any changes totreatment intensity or frequency,length of stay and other outcomes.


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MethodologyThere were two project streams:1. Delivering 45 minutes oftherapy

2. Providing a seven day service.

There were nine project sites whoparticipated in the project from bothhospital and communityenvironments.

Each site provided information on:• Population• Numbers of stroke patientsreferred

• Type of service• Bed numbers (if applicable)• Staffing• Length of stay and/or functionaloutcomes.

Each site also collected data onapproximately 30 patients. Thesamples were not comparable and areonly a snapshot of each site. Only onesite managed to collect data beforeand after a change in service deliverytook place. The data included some orall of the following:

• Admission to treatment• Frequency of treatment (i.e. howoften or on how many days therapywas given)

• Intensity of treatment (how long thetreatment session was for)

• Therapist opinion on frequency andintensity required

• Reason for 45 minutes of therapynot being received

• Staff, patient and carer satisfaction.

This publication builds on the learningfrom project sites in the nationalrehabilitation projects 2009-10 (25) byfurther work with the nine projectsites involved in delivering seven dayor 45 minutes of therapy services. It isnot presented as scientific research,but service improvement work, withmeasurement and commentaccordingly.

Observations are included from othersites across stroke and wider therapyservices in England, and stroketherapy services in USA, Canada andNew Zealand. The publication includessome of the research evidence andthe results of a consultation with awide range of relevant stakeholders.

Project teamsThe organisations taking part in theprojects were as follows:

• Sheffield therapy team, from theSheffield Teaching Hospitals NHSFoundation Trust

• Sheffield speech and languagetherapy, from the Sheffield PrimaryCare Trust speech and languageservice into Sheffield TeachingHospitals NHS Foundation Trust

• The stroke unit at St Thomas’Hospital, Guys and St Thomas’ NHSFoundation Trust

• South Devon - A combined teamof therapists on the strokerehabilitation unit at Newton AbbotHospital, and communityneurology service

• The NHS Camden - stroke REDsteam

• Community stroke team inBlackburn with Darwen,part of Lancashire Care NHSFoundation Trust

• South Tyneside NHS FoundationTrust physiotherapy stroke team

• Medway Community Healthcare,the staff on the stroke rehabilitationunit at St Bartholomew’s Hospital,Rochester, Kent

• Chesterfield Royal Hospital NHSFoundation Trust acute strokeunit team.

For ease of reading, teams will bereferred to by the emboldened titlesabove in the rest of the document.


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National guidelines

NATIONAL STROKE STRATEGY -DEPARTMENT OF HEALTH

“People who have had strokes accesshigh-quality rehabilitation and, with theircarer, receive support from stroke-skilledservices as soon as possible after theyhave a stroke, available in hospital,immediately after transfer from hospitaland for as long as they need it.” (QualityMarker 10: High quality specialistrehabilitation)

“Survival is strongly associated withprocesses of care… such as earlymobilisation, early feeding and measuresto prevent aspiration. Speech andlanguage therapists, physiotherapists,occupational therapists and dietitianshave specific contributions to make indelivering these particular aspects ofcare. The probable explanation forhigher survival and lowerinstitutionalisation rates (on stroke units)are the significant differences in bothmultidisciplinary team working – such asearly assessment, goal setting anddischarge planning.” (Quality Marker 9:Treatment)

“Existing staffing numbers and skill mixprofiles are insufficient to deliver therequired input in stroke care pathways.Workforce review is therefore needed,along with a workforce plan that definesthe care pathway, lists the functions ateach stage and the competenciesrequired to perform the functions, andthen ensures training is put in place tosupport staff to acquire thecompetencies. “ It recommends thatservices “consider new and more flexibleroles (i.e. expanding roles acrossprofessional boundaries)” (QualityMarker 18: Leadership and skills)

QUALITY STANDARDS FORSTROKE - NICE

Quality Standard - 5Patients with stroke are assessed andmanaged by stroke nursing staff and atleast one member of the specialistrehabilitation team within 24 hours ofadmission to hospital, and by all relevantmembers of the specialist rehabilitationteam within 72 hours, with documentedmultidisciplinary goals agreed within fivedays.

Quality Standard - 6Patients who need ongoing inpatientrehabilitation after completion of theiracute diagnosis and treatment aretreated in a specialist strokerehabilitation unit.

Quality Standard - 7Patients with stroke are offered aminimum of 45 minutes of each activetherapy that is required, for a minimumof five days a week, at a level thatenables the patient to meet theirrehabilitation goals for as long as theyare continuing to benefit from thetherapy and are able to tolerate it.

Quality Standard -10All patients discharged from hospitalwho have residual stroke-relatedproblems are followed up within 72hours by specialist stroke rehabilitationservices for assessment and ongoingmanagement.


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NATIONAL CLINICAL GUIDELINE FORSTROKE, THIRD EDITION – ROYALCOLLEGE OF PHYSICIANS

A) Patients should undergo as muchtherapy appropriate to their needs asthey are willing and able to tolerateand in the early stages they shouldreceive a minimum of 45 minutesdaily of each therapy that is required.

B) The team should promote the practiceof skills gained in therapy into thepatient’s daily routine in a consistentmanner and patients should beenabled and encouraged to practicethat activity as much as possible.

C) Therapy assistants may facilitatepractice but should work under theguidance of a qualified therapist.

Further assessments can and should beundertaken later, and this set ofrecommendations focuses on those thatare important in the first 48 hours; toidentify major impairments that may notbe obvious but that may have aninfluence on early management, guideprognosis and draw attention toimmediate rehabilitation needs.

“All patients with any impairment at 24hours should receive a fullmultidisciplinary assessment using anagreed procedure or protocol within fiveworking days, and this should bedocumented in the notes”.


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Who can deliver more rehabilitation?

Flexibility and creativity about staffingmay be needed to deliver improvedrehabilitation for stroke patients. Thissection describes the differentapproaches the projects took, and theimpact.

What the evidence saysThe NICE quality standards definetherapy services as physiotherapy,occupational therapy, and speech andlanguage therapy. Individual patientsmay require treatment from otherprofessionals such as clinicalpsychologists and dieticians. They arerelevant to all environments across thepathway. (3) Royal College ofPhysician (RCP) Guidelines state thattherapy assistants may facilitate thepractice but should work under theguidance of the qualified therapist. (2)

Practice outside the UKIn the US, state-funded Medicarerequires specifically physiotherapy,occupational therapy, and speech andlanguage therapy are delivered, butservices such as psychology are notincluded. Therapy services can besupported by rehabilitationtechnicians for administrative whosupport work and are not directlyinvolved in the provision of therapyservices. Qualified occupationaltherapy assistants and physicaltherapy assistants may providetherapy services directly to patientsunder the appropriate supervision oflicensed therapists, and families arevery engaged.

What the stakeholders sayThe general consensus from thestakeholders is that rehabilitationassistants are a cost effective way ofensuring that patients get a robustrehabilitation package, and may beessential to meeting both 45 minutesand seven day therapy provision.However services need to havemechanisms in place to ensure thatthese assistants have suitablesupervision and support to maintainthe competencies required to followprofessionally developed planseffectively.

Other time consuming tasks such ascompleting outcome measures,delivering equipment and someadministrative tasks could bedelegated to rehabilitation assistantsto free up qualified therapists’ time.

The stakeholders also suggest that toachieve both the access to seven dayservices and 45 minutes of therapy,teams should take a more integratedapproach to rehabilitation. Therapistsshould increase involvement with thepatient and the wider team, andwhere appropriate should includenursing staff and the family inpromoting a continuous rehabilitationculture. This can also support thepatient towards self-management inthe longer term.

• A flexible and creativeapproach to rostering cangain support from a widerpool of appropriate staff tokeep additional servicessustainable and enhanceclinical skills for therapists

• Weekend services that includeacute and community staffcan assist with a smoothertransfer of care experience forpatient and carers

• Additional rehabilitationprovided by a therapy teamhas more impact meetingrequired standards than whenit is delivered by suitablytrained nurses

• Stroke skilled support workerscan assist therapy serviceswith achieving 45 minutetherapy sessions and sevenday services and are integralto achieving the NICE qualitystandards

• Joint working with nurses hasa positive effect on cohesionand compliance and can beachieved in addition to directtherapeutic clinical contacttime

KEY MESSAGES


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Project findingsThe stroke unit at St Thomas’Hospital offers an additionalweekend rehabilitation service that isprovided by rehabilitation supportworkers who work as healthcareassistants during the week. Thecontent and structure of the weekendprogramme is selected by thetherapists from an ‘options menu’.

Whilst the 20 minute sessions therehabilitation support workers providedo not meet the NICE qualitystandards or RCP guidelinesspecifically, they do demonstrate aproactive multidisciplinary approach torehabilitation, and support workforceflexibility. Patients have a greaternumber of rehabilitation contactsduring admission, but not therapydirect contacts. Therapists feel thatpatients who use this service maintainbetter ‘carry over’ for Monday thanthose who do not.

The South Tyneside physiotherapystroke team provided a weekendservice for the stroke unit, byrecruiting an additional band 5physiotherapist and band 4 technicalinstructor to work five dayscomprising three during the week andtwo at the weekend. They solved therecruitment challenge by including thepost within the existing band 5rotation scheme, and gradually rolledout the changes in contracts witheach new member of staff.

To ensure competence, supervisionand support the band 5 therapist canliaise with the on call therapy team atweekends, and is supported duringthe rest of the week from within thestroke team. The stroke team actpragmatically and flexibly when thereis a vacant post to provide a six dayservice from within the existing staff.

Since the inception of the project,many more patients have received 45minutes of physiotherapy, and therapyhas been provided at the weekend.

Percentage of patients seen for 45 minutes of therapybefore and after the changes in South Tyneside

Before introduction ofproject (week days)

33.8%

Since August 2009(week days)

75.6%

Since August2009(weekends)

68%

Since Aug 2009average daily(seven day)

68%

This model enables the service tomeet the NICE quality standards 5 and6, the National Stroke Strategy andthe RCP guidelines for physiotherapy.Their admission to assessment timeimproved from 52% within 72 hours(2008) to 93%.

The South Devon team on the strokerehabilitation unit at Newton AbbotHospital reallocated existing fundingfor the band 5 physiotherapy post tofund three band 3 rehabilitationsupport assistants and four hours of aband 6 occupational therapist orphysiotherapist for Saturday. Theadditional rehabilitation supportassistants are rostered from Saturdayto Tuesday, and the qualified stafffrom a rota of stroke skilled therapistsfrom the team and communityservice.

Their new model demonstrated animprovement in admission totreatment time, with 100% ofpatients being assessed within 72hours compared to 80% in 2008. Allappropriate patients were able toaccess 45 minute treatment sessionscompared to 92% in 2008. Feedbackfrom patients and carers was alreadyvery good, but had highlighted a wishfor more therapy opportunities.

Staff felt that communicationbetween hospital and communityservices, and appreciation of thetransfer process for patients,improved. It also meant that weekendstaff had a reasonable frequency ofshifts to maintain their work-lifebalance, and enabled communitytherapists to keep their acuterehabilitation skills up to date.


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The benefits for the patients, serviceand carers with the new modeloutweighed the disadvantages of theloss of a band 5 rotational post on theservice.

In Sheffield Teaching Hospitals NHSFoundation Trust the occupationaltherapy and physiotherapy services,moved from five to seven day servicesas part of a major change acrosstherapy teams. The stroke serviceincluded an ‘away team’ comprisingtherapists from neurosciences, spinalinjuries and neuro-rehabilitationservices and a ‘home team’comprising staff from the stroke team.

It was felt that although there werecommonalities of clinical skills, thetransposition of staff into a differentgeographical location, with unfamiliarequipment, protocols, documentationand profiles, required considerablymore adjustment and settling in timethan had been anticipated. With up to28 staff within therapy servicesworking on a weekend a robustsupport system was required whichincluded the rostering of a dutymanager for therapy services atweekends to support staff and dealwith any staffing problems.

Before the seven day service,physiotherapy and occupationaltherapy were able to provide access to45 minutes of therapy for 76% of thetime, on average, for appropriatepatients. Post implementation thisincreased to 92% for physiotherapyand 91% for occupational therapy.NICE quality standards 5 and 6 wereachieved. The recommendations ofthe National Stroke Strategy aroundvital signs and early access to therapy,45 minute sessions and delivery ofRCP clinical guidelines improved.

In Blackburn with Darwen, thecommunity stroke team haveestablished support links with a poolof rehabilitation support workers andintermediate care support staff whichenables them to provide 45 minutesof therapy, daily and for as long asneeded to meet NICE qualitystandards. Their data showed thatmost of the 45 minute sessions weredelivered by the rehabilitationassistants with varied support fromqualified therapists.

SummaryAll the models demonstrated higherpatient and carer satisfaction, but onlythose that included additionalqualified staff were able to impact onassessment time and the NICE qualitystandards. Traditional concerns aroundusing band 5 therapists and sufficientsupervision at weekends were avoidedby the South Tyneside model and inSouth Devon the loss of the band 5was outweighed by the gains. Nomodel impacted negatively onrecruitment, supervision, retention ofstaff, or length of stay.

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Sheffield Teaching Hospitals NHS Foundation Trust -Ability to deliver 45 minutes

Assistant support staff, backed up bycompetency based education, canenable therapy services to improveassessment time, and 45 minutetherapy sessions, more readily thanhealthcare assistants (Blackburn withDarwen community stroke team).This is because of their contributionwithin the team across seven days.Healthcare assistants can bringdifferent benefits, such as a greaterunderstanding of the rehabilitationprocess when delivering nursingcare.(St Thomas’ Hospital).

The Sheffield therapy team projectdemonstrated the challenges facedwhen taking therapy staff withcommon core neurology skills into adifferent environment and the need tosupport and manage this carefully. InSouth Devon a creative and inclusiveapproach to rostering meant weekendstaff had the reasonable frequency ofshifts to maintain a work/life balanceand enabled community therapists tokeep their acute rehabilitation skills upto date.


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Where teams instigated specific jointworking, there were initialreservations from some therapy staffthat their skills would be diluted.However, it was found to havepositive effects not only on thepatients and nursing staff directly, buton compliance with therapytimetabling, as therapists still had timeto undertake their specific and highlycomplex therapy work. Joint workingmay improve communication; byworking in tandem, information ispassed on and there is less timewasted. In addition, there is greaterconsistency with handling and movingpatients, an area often highlighted asa concern by patients.


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When - a seven day service?

This section looks at the frequency ofrehabilitation required to meet NICEquality standard 7 to offer therapyinput ‘for a minimum of five days aweek’; and the potential alternativesfor delivery of additional services.

What the evidence saysStudies in US rehabilitation centresfound that factors such as function atadmission, length of stay and intensityof therapy collectively contributed togreater functional gains, but length ofstay and intensity of therapy alone didnot always [Chen et al] (20)

A single study found moderateevidence that the same therapiesdelivered more intensively, over ashorter period of time, resulted infaster recovery and earlier dischargefrom hospital [Teasell et al] (5).

A trial conducted in Japan comparedoutcomes for stroke patients admittedto a conventional stroke rehabilitationprogramme five days per week andpatients admitted to a programmeseven days per week. The intensityand frequency of treatment variedbetween the programmes andpatients were encouraged to remainactive outside of the structuredsessions. Additional weekend therapyresulted in significant improvements inFIM1 scores as well as a reduction inlength of stay. [Sonoda et al] (21][Teasell] (5).

Practice outside the UKIn the US, state funded Medicareservices adopt the ‘three hour rule’ -three hours a day of physiotherapy,occupational therapy and speech andlanguage therapy five to six days aweek. The staffing ratio is 7:1 patient:therapist each day, supplementedwith administrative rehabilitationtechnicians.

In addition to this there are one totwo hours daily of occupationaltherapy or physiotherapy groupsessions and weekly speech andcognitive group therapy sessions.

In Canada, the requirement is for aminimum of one hour of directtherapy for each relevant core therapy,for a minimum of five days a weekbased on individual need andtolerance. (10)

What the stakeholders sayAccess to therapy, and therapyassessments, should be consistent andcontinuous within rehabilitationsettings across seven days. In turn,patients are more likely to respondbetter to therapy, avoiding a loss ofmomentum over a weekend andtherapists could have more capacity tooffer 45 minutes of therapy. Somestakeholders felt that patients need tohave a day of rest and reflection, andthey agreed that patients risk losingout if this happens on a week day andno weekend service is available.

• Weekend therapy servicesimpact on service deliveryacross the whole weekpositively

• Seven day services can havegreater impact than six dayservices

• Additional days of therapyservices have a positive effecton admission to treatmenttimes and 45 minutes oftherapy

• Seven day therapy servicesenable patients to begin theirtreatment as early as possible

• Seven day community strokeservices can influence hospitallength of stay and vital signspositively and moresignificantly than singletherapy weekend inpatientservices

• Patients and carers welcomeadditional rehabilitationopportunities at weekends

KEY MESSAGES

1The Functional Independence Measure (FIM) scale assesses physical andcognitive disability, focussing on level of disability, the burden of care.


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In Chesterfield Royal Hospital, theseven day physiotherapy service onthe acute stroke unit found thatalthough they did not reduce lengthof stay significantly, there was agradual process of setting dischargesfor earlier in the week than before.They commented on an improved feelto Mondays due to the reducedpressure to catch up with the backlogfrom the weekend.

Blackburn with Darwen communitystroke team and NHS Camden -stroke REDs community stroketeams both operate through amultidisciplinary ‘in reach’ model andprovide occupational therapy,physiotherapy, speech and languagetherapy five days a week and‘enabling care’ (rehabilitation supportthrough suitably trained social carestaff) seven days a week. They meetNICE quality standards 7 and 10, theRCP guidelines and quality marker 10(rehabilitation) quality marker 12(transfer of care and health and socialcare joint working) and quality marker19 (workforce) of the National StrokeStrategy. NHS Camden - strokeREDs data showed a significantcontribution to reducing length ofstay in the acute hospital, now downto 10 days, and demonstrated to localorganisations the contribution ofcomprehensive and responsivecommunity stroke services toresolution of acute challenges.

Project findingsIn South Devon, the additionalservice over the weekend enabledpatients to have an increase innumber of sessions. This alsoimpacted positively on the team’sability to deliver 45 minute sessions.Patients’ length of stay was alreadyimproving and could not solely beattributed to the additional weekendservice.

For the South Tyneside team, theseven day physiotherapy serviceassessed all patients within 24 hoursand delivered 45 minute sessionswhere appropriate, although length ofstay was not significantly altered. Theteam agreed that to do that a similarservice from occupational therapywould be needed.

The Sheffield speech and languagetherapy team piloted Saturdaymorning working over three monthson the acute stoke unit. The servicewas provided by band 6 and 7 speechand language therapists, from a rosterof paid volunteers. In the pilot theyfound, from a small sample size, that80% of patients referred to speechand language therapy were seenwithin 24 hours, 25% of patientsrequired daily speech and languagetherapy at some point in their stay,but not consistently across their wholeinpatient spell, and more than 50%required 45 minutes on some days.

Qualitative data indicated that allspeech and language therapistsinvolved in the pilot felt that they hadimpacted positively on patients byhaving this service, and 50% felthappy to be working at a weekend.The team noted that there seemed tobe more clinical need for dysphagiaassessment than dysphasia treatment.

In the Sheffield therapy team, fundswere provided for seven day workingacross orthopaedics, stroke, ‘front ofdoor’ and respiratory services. Theadditional service for stroke comprisedan occupational therapist, aphysiotherapist and two assistantswho took their time back fromexisting services in the week.

At the weekend patients wereprioritised according to four criteria:

1. To facilitate discharge2. Eligibility for existing ESD3. New patients4. Other rehabilitation patients

The team noted that the effect ofseven day working within strokeseemed to be stronger for facilitatingdischarge. Their data showed apositive impact on admission toassessment times from 62 hrs(occupational therapy) and 47.4 hours(physiotherapy) pre change, to 25.6hours for occupational therapy and30.4 hours for physiotherapy postchange.


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SummaryThe project teams reported that thebiggest impact of a seven day servicewas on admission to treatment timeand the ability to provide an equitableservice. Once this had occurred, theyfound that the whole working weekbegan to change too, and therapistscould offer more contact time.

Services across seven days movedcloser to achieving the NICE qualitystandard than six day services.Findings of teams fromMedwayCommunity Healthcare and YorkHospital NHS Foundation Trust in thenational projects 2009 - 2010 whodelivered a six day therapy serviceimproved admission to treatmenttime, but could not achieve 100%(25). Seven day services in SouthTyneside and Chesterfield RoyalHospital achieved this standard. Thisis likely to be due to a removal of theweekend backlog of outstandingassessments on Mondays, freeing upmore time each day to allocate fordirect treatment and the effect of aseven day presence oncommunication between themultidisciplinary team, and withpatients and carers. Models that usedexisting therapy staff differently orover more hours in the week foundmore opportunities to deliver a greaterproportion of 45 minute sessions andfor joint working than in five days.

The findings of the projects showthat, once established, the cultureof a seven day service facilitatesmore timely decision making.(Chesterfield Royal Hospital) It hasthe potential to shorten length of stay

through whole pathway change,when all services operate across sevendays. Single professional changes, inone part of the pathway only, areunlikely to have a significant impacton length of stay or cost benefits foran organisation. (South Tyneside).However, they do have a positiveeffect on satisfaction levels, speedieraccess to assessment and frequencyand intensity of sessions for thosepatients who can tolerate it.

Patients also value opportunities formore therapy across the pathway.Therapy services may considerdeveloping seven day services as a firststep towards achieving 45 minutetherapy sessions, because of its impacton intensity as well as frequency.

However, any opportunity to enhancerehabilitation, by weekend sessionsfrom suitably trained healthcareassistants (St Thomas’ Hospital) or,by joint working (MedwayCommunity Healthcare and SouthDevon) or by having an additionalpresence (Sheffield speech andlanguage therapy) can bring benefit;either for multidisciplinary teamcohesion, mutual support, andeducation or simply improvingcommunication and reducing theneed for additional documentation.


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How long - getting more outof the whole week?

This section deals with the intensity ofa patient’s therapy, meeting the NICEquality standard of 45 minutes.

What the evidence saysThere is evidence to show that higherintensities of treatment can impactsignificantly on outcomes, activitiesfor daily living and reduceimpairments. [Langhorne et al] (7)[Kwakkel et al] (11) Patients may notbenefit equally, which makes specificguidance about intensity ofrehabilitation therapy harder toprovide. [Duncan et al] (9).Many therapists express concernabout how many patients can tolerate45 minutes of therapy. However,physiotherapists have been shown tooverestimate the duration of therapy,and that intensity of treatment is alsodependent on the ability and thewillingness on the part of the patient.[Teasell et al] (5).

Greater benefit may be achieved ifhigh-intensity therapies are providedin the early stages of rehabilitation.[Teasell et al] (5).

There is not conclusive evidence thatmore intensive speech and languagetherapy is better than less intensivetherapy, although for patients whocan tolerate it, more intensive therapyappears to result in improvedoutcomes. [Teasell et al] (5). Onaverage, positive studies provided atotal of 98.4 hours of therapy whilenegative studies provided a total of43.6 hours of therapy.

For example, one survey observed thata significant treatment effect wasachieved among studies whichprovided a mean of 8.8 hours oftherapy per week for 11.2 weekscompared to trials that only providedapproximately two hours per week for22.9 weeks. [Bhogal et al] (24). Onestudy that looked into the benefits ofaphasia therapy reported problemswith patients’ tolerance of intensivetherapy. However, patients whoreceived an average of 1.6 hours oftherapy per week had significantlyhigher scores than those who receivedonly 0.57 hours of therapy. [Bakheit etal] (23).

Practice outside the UKCanadian guidelines state that“Patients should receive the intensityand duration of clinically relevanttherapy defined in their individualisedrehabilitation plan and appropriate totheir needs and tolerance levels.”

In the US, a patient must be able tosafely tolerate the level ofrehabilitation therapy programmeprovided in an inpatient rehabilitationunit. The intensity of therapy providedmust further the patient’s progress inmeeting goals, rather than setting thepatient back by overtaxing them.Publicly funded stroke rehabilitationfacilities do not receive paymentunless they provide at least threehours a day of therapy, 55 minutes ofone-on-one therapy sessions withphysiotherapy, occupational therapyand speech and language therapy. Ifthe patient is unable to tolerate this,then it should be given in two 30minute sessions. (6)

What the stakeholders sayStakeholders indicated that therapyshould be available to patients as earlyas possible once they are medicallystable, and commented thatpsychology should be includedbecause if problems are leftunattended, they can become worseover time. Some suggested that if inthe early stages some patients areunable to tolerate a single 45 minutessession, services can deliver multipleshorter sessions over the course ofone day.

If two therapy staff are involved in ajoint session and are working ondifferent aspects of therapy, and thesession is goal directed, then this canbe counted as two sessions.

Stakeholders don’t yet agree whatconstitutes 45 minutes of ‘contact’time. For the first time therapists havebeen given a treatment time(intensity) guide of 45 minutes butneed to maintain a level of flexibilitywithin this to accommodate patientindividual needs. Some therapeuticinterventions, such as psychology, maynot fit well with a rigid time frame.Some academic stakeholderscommented that services should beoffering ‘up to’ 45 minutes. However,other front line stakeholders felt thatanything less than 45 minutes mightbe limiting and therefore lesseffective. This may be due to thedifferences in definition of whatcounts towards ’45 minutes oftherapy’ and the debate arounddirect/non-direct therapy.


18

Some people have started to refer tothe amount of time a patient has fortherapy as the ‘dose’, to start toformalise the requirement for a setamount of therapy time to beavailable per patient, per day.

Stakeholders felt that access to both45 minutes of each therapy and sevenday services should reduce length ofstay through faster completion ofassessments, more time for dischargeplanning, faster improvements inmobility, activities of daily living, andpatients managing at home morequickly.

Project findingsNHS Camden - stroke REDs agreedlocal definitions and clarified contactand non contact activities for theirservice and the team reviewed datafor 91 patients across six weeks ofrehabilitation, comparing the intensityof therapy received using valid clinicaloutcome measures. The data showedthat patients with lowest Barthelscores had the greatest need of, andbenefited most, from access to

• Patients do not all benefitequally from access to 45minute therapy sessions

• In the community, patientswith more severe disabilityimproved most with access to45 minute therapy sessions

• Patients’ need for, andtolerance of, 45 minutes canfluctuate, so services needto be sufficiently flexible andresponsive to meet this

• Joint working with nurses hasa positive effect on cohesionand compliance and can beachieved in addition to directtherapeutic clinical contacttime

• Multiple 45 minute episodesby individual disciplines duringa day may be difficult for apatient to manage; combined,goal orientated visits work

• Staff may need to collect datato challenge their ownassumptions about whyservices are not beingprovided, to be sure it isbecause patients cannottolerate it, and not because ofthe ability of the service toprovide it

• Services that operated overseven days had more successin meeting the 45 minuteguideline

KEY MESSAGES therapy, yet the same patient grouphad least success as recorded by thegoal attainment scale. Theyrecommend that therapy servicesshould adopt a menu of outcomes, toinform service development.

Using the NICE clinical standard of 45minutes of therapy per day, five days aweek, each patient should get 990minutes of therapy over the six weeksthey are with the team. The teamfound 17.5% of patients achieved therequired amount of therapy fromphysiotherapy, 21.5% fromoccupational therapy and 11.1% fromspeech and language therapy. Thosepatients who received 990 minutes ofoccupational therapy andphysiotherapy had an averageincrease in their Barthel scores of 6.4points, compared to an averageincrease of 3.4 points by those whodidn’t and an average increase in theirNottingham Extended Activities ofDaily Living (NEADL) scores of 12points, compared to 10 points forthose who didn't.

NHS Camden - stroke REDs -45 minutes - impact on Barthel score points gained

35

30

25

20

15

10

5

00-2 2-4 4-6 6-8 8-10 10-12 12-14 14+

Perc

enta

ge

Met Not met


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There is a significant difference withthe Barthel outcome measures, whencompared with the sample of patientswho get least therapy in terms of time(intensity) and number of visits(frequency). At the start ofintervention the Barthel for this groupwith most amount of therapy is lower.This suggests that people, whoreceived the most therapy in terms ofintensity, were functioning at a lowerlevel, based on the Barthel (averagescore of 11.8)

Regarding progress and change in theBarthel scores, this group of patientsmade significantly larger gains(average of 6.3) when compared tothose who received the least amountof therapy.

The team make joint decisions withthe patient about what level ofintensity is appropriate for them. Theycollected data to determine thereasons why 45 minutes of therapywas or was not achieved for eachpatient. Thirty percent of patientsreported fatigue as a major factoraffecting ability to participate in anintensive therapy programme athome. For many patients there weremultiple reasons why 45 minutes oftherapy was not achieved.

Blackburn with Darwen communitystroke team focuses on meetingpatient need rather than just earlydischarge for people in both hospitaland community through fourpathways of support.

1. High functioning – home with coreteam support only

2. Lower functioning but manageableat home – home with communitystroke team (CST)therapists anddomiciliary rehab team support

3. Non-manageable at home –residential intermediate care bedwith CST therapist support

4. Residential/nursing care – CST coreteam visit on discharge to checkcorrect patient management.

They defined therapy for their servicelocally, and analysed a database of 20patients to determine which patientsneeded or benefited from 45 minutesessions, and from which therapies,and examined the range from eachtherapy and the service.

They found that not all patientsneeded 45 minutes of therapy eachday, and that the need varied greatly.Patients with moderate to severelevels of disability (pathways two tofour) needed a level of support

ranging from 14 – 49 days of 45minutes of therapy, two to three timeseach day, over seven days. Patients onpathway one with mild and minimaldisability required much less intensivetherapy. People in care homes mayneed 45 minute sessions of therapyeach day to improve a particular task.

On the whole, there were more 45minutes of therapy contacts fromrehabilitation assistants with variedinput from therapists. Patients withmoderate to total dependency(Barthel) received most input fromsupport workers and intermediatecare support staff, enabling thecommunity stroke team to provide 45minutes of therapy daily for as long asneeded.

NHS Camden - stroke REDs- Reasons for not receiving 45 minutes of therapy

Declined daily therapy

Clinically not required

No SLT required

No occupational therapy required

No physiotherapy required

No staff capacity

Patient unavailable

Patient fatigued

Patient refused

Patient poorly

0% 10% 20% 30% 40% 50% 60%

‘Continuing to benefit’ and ‘able to tolerate’ should bedefined jointly by both patient/carer and MDT.

‘Therapy time’ is anything related to person focussedrehabilitation facilitated by a specialist stroke practitionerand evaluated using clinical outcome measures.NHS Camden - stroke REDs

Any assessment or treatment provided by the qualifiedtherapist from the community stroke team (CST)including physiotherapy, occupational therapy or speechand language therapy.

Any therapy intervention which is part of the programmeset by CST qualified staff and carried out by ourrehabilitation support workers, on one of our pathways.Blackburn with Darwen community stroke team


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Pathway 1

Pathway 2

Pathway 3

Pathway 4

Averagelength of stayin service

131

175

141

220

Range

22 - 265

110-243

84 -195

43 - 574

Average days 45minutes therapyfrom core stroketeam

50

68

42

86

Range

1 -149

52-97

41-69

9-225

Average other45 minutes daysfrom supportservice

43

29

38

Range

40 -49

14 -42

38

Blackburn with Darwen community stroke team - retrospective data on therapy need and provision

The Sheffield speech and languagetherapy team initially questionedwhether 45 minutes would be rightfor each patient and whether theirservice needed to be more flexible todeliver it. The project enabled them toidentify that 25% of patients requireddaily speech and language therapyintervention and over 50% needed 45minutes on certain days. The pilot wasnot long enough to demonstratewhether daily availability of speechand language therapy could impacton adverse effects for patients, e.g.incidence of aspiration pneumonia,but staff found that being available ona Saturday had a positive effect onpatients.

The South Devon team, as part of ademand and capacity exercise,showed that they had only smallnumbers of patients who couldtolerate 45 minutes of each activetherapy for five days a week and thatthey had a surprising number ofrefusals due to fatigue.

The issue of judging whether a patientcontinues to benefit and/or is able totolerate remains a subjectiveassessment on the part of thetherapists. The scatter plot, takenfrom data from the projects, showsthe percentage of patients thought tobenefit from or tolerate 45 minutes

Local definition of therapy

against the percentage that received45 minutes per therapy group acrossall project teams.

Those who were assessed as needing45 minutes of therapy, tended to getit when the services were increased.Within the therapies, speech andlanguage therapy is suggested as thearea where it is hardest to meetassessed need.


21

SummaryThe project teams’ findings mirroredinternational guidance aroundtolerance and therapy. NHS Camden- stroke REDs and Blackburn withDarwen community stroke team dataallowed detailed analysis of allocationand uptake of the 45 minute sessions.It supported the research findings thatone size does not fit all and of thecomplexities created by organisationsand priorities.

Their pragmatic approach basedon thorough assessment, goodmultidisciplinary team communication,shared skills and competencies,involving the patient and carers andSMART (Specific, Measurable,Attainable, Relevant and Timely)multidisciplinary team goals enabledthem to avoid unnecessary45 minute sessions withoutcompromising outcome andpreventing fatigue for people athome. This information is alsovaluable to inform the commissioningservices, and developing resources.

In the community, patients with moresevere disability improved most withaccess to 45 minute therapy sessions.

Where therapy services collected datafor when a 45 minute treatmentsession occurred, and if not, why not,it offered them valuable insight intotheir reasoning processes and fixedassumptions that may be derived frompractice or working to prioritisationprotocols. Some teams at each stageof rehabilitation reported that morepatients could tolerate 45 minutes ifit was available and the data showedthat where it was not possible todeliver it, it was often due to theservice organisation. This suggeststhat services might learn fromundertaking demand and capacityexercises and reviewing their practiceand processes, before makingchanges in staffing, or requestingadditional resources, endorsed by thefindings ofMedway CommunityHealthcare.

Seven day working enabled the workto be more equitably spread across aweek, which meant there were moreopportunities to achieve 45 minutetherapy sessions (Chesterfield RoyalHospital, South Tyneside, andSouth Devon).

Some of the teams’ initialpreoccupation with attempting todefine the detail around 45 minutesissues translated into attention tomethods of changing the shape oftheir service, and the ways in whichthey worked, so that they coulddeliver:

• More hands on treatment each day• A flexible response to patient need• More opportunities for therapy in avariety of forms.

Focussing more on improving servicedelivery may better enable therapyservices to provide a service thatmeets national guidelines and be ableto offer the right therapy at the righttime, for the right reasons to the rightpatients as and when they cantolerate it and need it.

The project findings demonstratedthat ‘therapy’ relates to allied healthprofessions, including assistants, butthat any opportunity to enhancerehabilitation, either by weekendsessions from suitably trainedhealthcare assistants (St Thomas’Hospital), by joint working (MedwayCommunity Healthcare and SouthDevon) or by having an additionalpresence (Sheffield speech andlanguage therapy) can bringbenefit.

Numbers of patients who could tolerate 45 minutes of therapy

100

80

60

40

20

00 20 40 60 80 100

% assessed as needing 45 minutes of therapy

%45

min

ute

sd

eliv

ered

SLT OT PT


22

Where can more therapy make a difference?

Projects were drawn from across thestroke pathway and demonstratedthat seven day services had a benefitin all settings.

What the evidence saysThe Collaborative Evaluation in Strokeacross Europe (CERISE) studiesconclude that whilst there is evidencefor the positive effect of intensivetask-specific exercise on the functionalrecovery of stroke patients, strokerehabilitation units in the UK are notorganised to optimise the amount oftherapy given to patients. Includedwithin this are aspects of environmentand culture, organisational priorities,different healthcare systems with theirdifferent barriers and incentives tochange, case mix and admissioncriteria. [Putman et al] (13,15)

However, it may also be worth notingthat although in internationalcomparisons, UK stroke units had thelowest therapy contact time and beststaffing, they also had rehabilitationunits with the least exclusion criteriaand decisions about therapy forpatients were more often made byclinicians.

What the stakeholders sayStakeholders felt that seven dayservices should be available across thepathway from hyperacute to earlysupported discharge teams in thecommunity, where patients continueto benefit.

• Patients can benefit fromaccess to seven day therapyservices in all settings acrossthe pathway

• The benefits and opportunitiesfrom seven day therapyservices vary along thepathway, reflecting thedifferent needs of the patient

• Individual requirements for 45minutes of therapy can varyduring the course of theirjourney along the pathway,not just depending on theirmedical status, but also ontheir goals

• Therapy support workers canassist with successful deliveryof 45 minutes and a seven dayservice at all stages

KEY MESSAGESProject findingsThe Chesterfield Royal Hospitalteam provided a seven dayphysiotherapy service on an acutestroke unit. Data showedimprovements in NICE qualitystandards 5 and 6 and the RCPguidelines for physiotherapyassessment times. There was nosignificant effect on length of stay, butsome individual reductions, whichsuggested planning discharges earlierin the week was having an effect.

The South Tyneside,Medway,South Devon and Sheffield therapyteams delivered their additionalservice on a stroke rehabilitation unit.The South Tyneside unit is now ableto achieve the NICE quality standards5, 6 and 7 and RCP guidelines forphysiotherapy and have identified thatthe next stage is to develop theoccupational therapy service. In SouthDevon andMedway CommunityHealthcare, the teams are working toidentify how to improve the servicefurther to be able to offer additionalopportunities for therapy, byreviewing their use of non contacttime, and developing sustainablegroup work.

The Sheffield therapy team reflectedon the experience and their data andidentified some questions for furtherdiscussion locally about organisationand distribution of therapy resourcesalong the stroke pathway.

Patient feedback in the Sheffieldspeech and language therapyproject indicated that during the acutestage of the pathway they want toreceive a seven day service, but areless keen when they are back at homeas they welcome a break atweekends.

The Blackburn with Darwen andNHS Camden - stroke REDscommunity teams both have robustdata collection systems. This supportsextensive analysis which enables themto identify the effect of 45 minutes oftherapy on clinical and serviceoutcomes. This has resulted inimproved multidisciplinary team goalsetting, predicting outcomes anddevising effective packages ofintervention on an individual basis,maximising the use of their skill mix.They are both able to demonstrate apositive financial impact on the acuteservice through reducing length ofstay, and for social care by reducingfinal packages of care. Blackburnwith Darwen community stroketeam (2010) reduced final packagesof care per week by 240 hours ofcare/week, equating to £93,600savings per year.


23

SummaryThe project teams crossed thepathway from hyperacute stroke unitto community teams, and in all casesthey made a difference.

However, in each setting, additionalservices bought other, slightlydifferent gains too, reflecting thestage of recovery and different needsof the patients from eachenvironment.

In South Devon andMedwayCommunity Healthcare, the teamshad developed joint working withnursing staff and were consideringgroup work. This is probably moreviable and sustainable on a strokerehabilitation unit than in an acutestroke unit where the focus was moreon developing an equitable serviceacross the week, and facilitatingspeedier and smoother transfer on(Chesterfield Royal Hospital, SouthTyneside and Sheffield therapy).

In the community, therapists wereable to look at resolving the challengeof overloading the patients withexcessive visits through developingshared competencies and multiskilledstaff delivering goal orientatedsessions (NHS Camden - strokeREDs and Blackburn with Darwencommunity stroke team).

Feedback from carers, and other staffwas positive regardless of location.

Seven day therapy services have avalue in all settings across thepathway; specifically to deliver equityof access to assessment and, wherethese exist, the project teams found apositive effect on direct contact timeand 45 minutes of therapy.


24

How - bridging the gap?

”The gap”- themes from theresearchCollaborative Evaluation in Strokeacross Europe (CERISE) studies haveshown that stroke patients in the UKspend much less time engaged intherapy than in Europeanrehabilitation units. Findings for theUK suggest one hour a day, comparedwith three in Switzerland. In allcentres, physiotherapy comprisednearly 40% of therapeutic time, butoccupational therapy comprised 20%- 30%, except in the UK unit where itwas 11.6%. In the UK, 35% oftherapy time consisted of nursingcare. After correction for case-mix,overall therapy time in the UK unitwas significantly less than the othercountries, and the differences intherapy time were not attributable todifferences in staffing. [De Witt] (14)(16) (17)

In a more recent study, therapystaffing levels were comparable withexisting literature, yet there was wideunexplained variation in contact timewith the patient. Seventy five percentof patients received less than an hourof therapy, and 25% less than half anhour of any therapy each day. Thelowest levels of therapy input werefrom speech and language therapists,with only 25% of patients having anycontact with a therapist, and amedian contact time of 30 minutes.[Rudd et al] (19)

Part of the CERISE study explored therelationship between the content oftherapy and the level of patient motorimpairment, expecting the content oftherapy to differ in patients withdifferent levels of motor impairment.They found significant differences induration of physiotherapy andoccupational therapy sessions and

some significant difference in content.They refer to the ‘black box’ ofchallenges around understanding andmeasuring what therapists do; such aslack of reporting the detailedcharacteristics of the interventions,the complexity and diversity ofinterventions and the potential rangeof different approaches used, alongwith the practice adopted bytherapists of reliance on clinicalexperience rather than on theoreticalframeworks, and the overlap andblurring associated with joint working.[De Witt] (12)

One possibility for increasing contacttime is through group work. Recentstudies have also shown that theefficiency of limited therapeuticresources can be increased by usingcircuit training programmes in which agroup of patients is allowed topractice at different workstations atthe same time, under the supervisionof a therapist. [Kwakkel et al] (8)

However, stakeholders and sometherapy services reported challengesembedding group work within strokeunit routines for various reasons,including lack of time, staff availabilityto transport patients and difficultygaining sustained nursing support.

Develop a seven dayrehabilitation cultureProject teams in the community(NHS Camden - stroke REDs andBlackburn with Darwen communitystroke team) and on strokerehabilitation units (South DevonandMedway CommunityHealthcare) have undertaken workspecifically to develop theirrehabilitation culture.


25

The stroke service in the UnitedHospital of North Staffordshire(UHNS) redesigned their servicesalong the lines of the Trondheimmodel in Norway following a visit tothe unit. (26) They have arehabilitation ward with joint workingbetween nurses and therapists, withjoint ward rounds and assessments.All the patient activities have arehabilitation focus and treatment isgoal orientated rather than processorientated. Some tasks remain nursingtasks, and the therapists contributetowards these.

To achieve this they reviewed therapistand nursing roles on the unit topromote blurring of boundaries,focusing on the needs of the patientwith family participation. Therapistsnow work solely on the stroke unitand are managed by the stroke unitmanager. They have introduced newroles that do not have professionrelated titles, but are focused onrehabilitation. All staff work shifts,nurses 24 hours and therapists sevendays, with band 2 staff alternatingtherapy and nursing rotas.

• Develop a rehabilitation culture in your team• Visit a successful site prior to making change to improve understandingand support for the process locally

• Consider a single management system for nursing and therapy whichcan improve line management consistency, provide better coordinationand enhance stroke specialist clinical governance

• Involve and include staff and establish good communication processes• Be prepared for staff objections and manage these through goodcommunication processes

• Understand the team’s true demand and real capacity to improveunderstanding, planning and control of the work, enabling moretherapy time to be offered.

KEY MESSAGES

TheMedway CommunityHealthcare team felt that the therapyculture should form the basis of thepatient’s day. One way of achievingthis was by partnering members ofthe nursing and therapy staff duringmorning washing and dressing, and atlunchtimes. This integrated approachalso meant moving the therapy teamto a base on the stroke rehabilitationunit alongside the nursing staff.

Project teams in South Devon,Medway Community Healthcareand Sheffield therapy serviceschanged the start time for therapiststo enable them to work moreinclusively with nursing staff, andmore effectively support the patients’routine, fostering the rehabilitationculture.

Whilst not part of the original NHSImprovement - Stroke project, theteam from the stroke service in Stoke-on-Trent undertook their own changeprogramme, addressing many of theareas of interest to those looking toenhance access to therapy.

Understand the dataBoth Blackburn with Darwen andNHS Camden - stroke REDscommunity stroke teams haveestablished comprehensive databaseswhich enabled them to thoroughlyunderstand their services andoutcomes, especially around access toand delivery of 45 minute therapysessions. Their systems workalongside, and in addition to, localdatabases which have limited ability toprovide useful qualitative andquantative information about therapyservices. The initial additional effortrequired for data entry is outweighedby the benefits derived fromcomprehensive analysis of a person’sprogress through a pathway orservice.

Manage the human dimensionsThe Sheffield therapy project teamwas part of a bigger initiativedelivering a seven day therapy serviceacross five clinical domains, with 26staff to cover the weekend strokeservice. It involved a majorconsultation process includingmeetings with stewards and humanresources staff to ensure clarity andequitable decision making.Communication systems were put inplace, including a reference groupwith a collection of staff across allgrades and all areas, which proved tobe a good barometer for staffexperience and gave the manageropportunities for regular and directcontact.


26

Staff fed back comments during theprocess that were reviewedimmediately. Actions were plannedand communicated to the teamsthrough the team leads, thenpublished so that everybody wasaware of the responses made. Trainingand in-service training sessions wereprovided as issues and concerns wereraised.

The short time frame forimplementation prevented the deliveryof the thorough training plan that hadbeen envisaged, but orientations wereprovided, including tours of the unit,clinical information and opportunitiesto ask questions and for shadowing.

A duty manager worked eachweekend to support the 26 staffacross two sites. This enabled staff tohave on the spot support, andshowed a management commitmentto weekend working. Some dutymanagers also contributed to theclinical workload at the weekend. Thiswas a valuable learning experience tohelp understand and manage theprocess of change and support staffbut did have cost implications.Possible alternatives are to provide anon-call phone support, or to allocatethe responsibility of a site lead to aband 7 or band 6 member of staffworking at the weekend.

St Thomas’ Hospital team needed toensure that the rehabilitation supportworkers could be supported with thecomplexities of a dual role atweekends, and recognised theirperceptions of split loyalties as part ofboth the rehabilitation and nursingstaff. Initially all staff were trained, butwith turnover and staff migration, agap emerged. This was managed bytaking a shared responsibilityapproach within the multidisciplinaryteam, through incorporating therehabilitation skills into thecompetency documents for all nursingand health care assistant staff. Theygained the sign up to the conceptfrom the team, adopting a differentuniform for rehabilitation supportworkers at weekends and devolvingresponsibility to the band 6 nurse forsupervision and support for therehabilitation support workers duringtheir shifts.

Analyse your workforce anddesign for the futureThe NHS Camden - stroke REDsservice carried out a demand andcapacity exercise to develop a realisticand appropriate business case for anearly supported discharge service,which suggested a ratio of patientcontact and non-contact time of50:50. By using this ratio, supportedby other crucial data, they couldaccurately identify the correct skill mixof staff and the model required.

Medway Community Healthcareundertook a demand and capacityexercise on the stroke rehabilitationunit. Challenges they faced weregetting the staff to appreciate theconcept of ‘true demand’, andunderstanding that the basic premisebehind the data collection was that allpatients should get 45 minutes ofeach therapy daily. By carrying out theexercise the team were able to

Moving and handling: non stroke-skilled staff need time to developconfidence and familiarity with the handing procedures, protocols andissues for stroke.

Data collection and paperwork: simplify administration andmeasurement. Be clear about data collection systems and how the servicewill be evaluated.

Variation in assistants’ skills: capitalise on the enthusiasm and goodwill of those working most frequently in the service, and be prepared tosupport peripatetic and part-time staff.

Time and rosters for staff: establish a consistent start-time foroccupational therapy to better support nursing staff, enabling longer termflexibility and consistency across all staff. Do this in stages, over thelonger term.

Staff engagement: Proper consultation is essential. It is particularlyimportant to focus on the benefits for the patients.

Challenges and solutions in SheffieldTeaching Hospitals NHS Foundation Trust


27

re-examine their service objectivelyand find time within the schedule toallow the occupational therapist torun a weekly carer clinic. They werealso able to introduce therapytimetables on the ward with improvedcompliance and support from thenursing staff. The insights they gainedfrom the exercise were so useful thatit has been rolled out across theirentire stroke pathway.

The South Devon team completed ademand and capacity exercise and asa result implemented group sessionsin the gym three times a week,timetabled to coincide with maximumstaff availability. They have allocated asenior member of staff on each daywith dedicated time to update ‘thebig pieces of paperwork’, includingdischarge summaries, overviewassessments and the continuinghealthcare screens. The remainingstaff can continue with the clinicalwork, confident that the paperwork isunder control.


28

Conclusions

Why do therapy services need to‘mind the gap’?Stroke is a 24 hour condition andtherefore requires a 24 hour pathwaywith supporting services andprocesses to deliver it, seven days aweek. It is what patients want, evenif they are not able to use it every day.Therapy services that operate onlyacross five days can, at times, create abacklog for patients and deliverinequality of care.

Research, national clinical guidelinesand the National Stroke Strategyagree that therapy delivered at theright time, by the right people and insufficient quantities makes adifference.

In the future, there will be increasingemphasis on quality outcomes andthis will shape the commissioning oftherapy services. In a climate of tighterfiscal scrutiny, therapy services willneed to be able to demonstrate thatthey can deliver better value andproductivity. This can only be achievedby understanding what they delivernow, their capacity, eliminating areasof inefficiency and ineffectiveness andimproving multidisciplinary working.

Where to startInitially, some project teams thoughtthat most patients would not tolerateand/or require seven days oftreatment, or would not be able totolerate 45 minute therapy sessions.However, collecting data about whatwas offered to patients, and thereasons they declined it, showed thatalthough not every patient couldtolerate 45 minutes or seven daytherapy, it was sometimes difficult toseparate out patient choice or clinicalneed from what the service was ableto deliver, or constraints imposed byestablished working practices.

Developing therapy services across seven days improves equity ofaccess to therapy

Understanding resources and how they are allocated is a prerequisiteto making changes to meet the national standards

Successful and sustainable service change requires effectivemanagement of staff

Any increase in access has an impact on quality outcomes

Not all patients need therapy seven days a week, but all services needto be available seven days

Increasing access to therapy and rehabilitation are not the same thing

This demonstrated the importance ofunderstanding how teams use existingresources, and how they are allocated.Project teams undertook demand andcapacity exercises to examine wheretherapists were spending their time,and to identify opportunities toincrease contact time with patients.Not only will such exercises supporttherapy services with how to defineappropriate staffing levels for newmodels and services, but will makebusiness cases significantly moreconvincing to commissioners.

Any service change requires effectivemanagement of the people involved,especially where professionals arelooking at their accepted practice,changing working hours and involvethe blurring of boundaries betweenprofessions. Teams foundcommunication and managementsupport were key. Teams alsoendorsed the importance of cleargoal-orientated multidisciplinaryworking, and shared competencies, inhelping them to deliver the rightinterventions from the right staff atthe right time.

Changing servicesEach of the project teams was, tovarying degrees, able to provideadditional therapy or rehabilitationopportunities, and found a variety ofimpacts on the existing service.

They found that therapy supportworkers could assist with successfuldelivery of the 45 minute therapystandard and seven day service at allstages along the pathway.

Those that offered more days oftherapy changed the content andstructure for the remaining days,particularly Mondays, and staff feltpositive about their experiences ofweekend working. All patients canhave a rest day, but it doesn’t need tobe on a Saturday or a Sunday or thesame day for every patient.

Flexible services are essential to beable to meet an individual’srequirement for 45 minutes oftherapy, as this can vary during thecourse of their journey along thepathway, not just depending on theirmedical status, but also on their goals.


29

1. Does spreading seven days workover seven days, instead ofprioritising it into five, offer therapyservices the chance to betterunderstand the daily ‘demand’and look further into how they usetheir resources to meet thisdifferently or better?

2. Why does Saturday and Sundayworking feel so much better? Is itrelated to the experience ofspending the majority of this timein direct patient contact andsupporting family and carers?What does this suggest aboutworking practices during the‘normal’ working week?

3. Is there a link between being ableto offer services across more days(frequency) and for 45 minutes(intensity)?

Recommendations forfurther workThis is an area where further work isneeded, from both serviceimprovement and researchperspectives. Improved and efficientservices create an environment inwhich research can be betterfacilitated and enabled, and aneffective research culture withinclinical services enhances their abilityto care for their patients.

Outcomes• Developing services across sevendays enables equity of access andopportunity

• Patients can benefit from access toseven day therapy services in allsettings across the pathway

• Any additional opportunity forrehabilitation is welcomed positivelyby patients, whether fromtherapists, nurses or both

• Seven day therapy services enablepatients to have earlier assessment,begin their treatment sooner, andsupport swifter multidisciplinaryengagement and speedierimprovement

• Weekend therapy services impact onservice delivery and access to 45minute sessions across the wholeweek positively

• Seven day community strokeservices can have more influence onhospital length of stay thanweekend therapy inpatient servicesalone.

Where next?This report is the result of the hardwork of eight project teams over arelatively short period of time,building on the learning from previousyears of project work. More workneeds to be done to be clearer aboutthe impact or effect on clinicaloutcomes from daily treatment and 45minute therapy sessions, and whatstructures need to be in place todeliver therapy. Therefore, there aresome key questions services shouldconsider as they use this report toimplement changes to their ownservices:

Service improvementProject teams have shown the benefitof applying systematic serviceimprovement analyses to theirfunctioning, processes and patientoutcomes. Demand and capacitystudies reveal much about the mannerin which services work, and identifyaspects for improvement in severaldomains including staff satisfaction,patient outcomes, service efficiencyand service delivery. This can be doneon a background of attention to the‘human dimensions’ of change whenimproving services, and allied to athorough understanding of patientperspectives and preferences.

ResearchTherapy intensity and frequency is anarea that would benefit fromincreased research scrutiny. Keyquestions that, if answered throughrigorous and robust research, improvethe ability of therapy services to meetpatient need include:

• The impact and effect of 45 minutesessions and seven day treatment onspecific clinical therapy outcomes

• Guidance around the percentage ofclinical contact time in relation tograde and banding of therapy staff.

This project findings endorse therecommendations in the Top TenPriorities for Stroke Service Researcharound ‘optimum delivery’ (frequency,duration, timing); and ‘optimumstructure’ (service provision andeconomic benefits). (27)


30

References

1.The National Stroke Strategy,Department of Health, December 2007.

2.National clinical guidelines for stroke,3rd edition, Royal College of Physicians,July 2008.

3. NICE Quality Standards for Stroke,National Institute for Clinical Excellence,July 2010.

4.Supporting life after stroke; review ofservices for people who have had a strokeand their carers, Care Quality Commission,January 2011.

5.Teasell RW, Foley NC, Salter K, BhogalSK, Jutai J, Speechley MR. Evidence-BasedReview of Stroke Rehabilitation (11thedition). Canadian Stroke Network; 2008.

6. Pauline M. Franko and Danna D.Mullins. Defining groups, three hour ruleand PTA treatment, US Guidelines.

7. Langhorne P, Wagenaar R, Partridge C.Physiotherapy after stroke: more is better?Physiother Res Int 1996; 1:75-88.

8. Kwakkel G, Wagenaar RC, KoelmanTW, Lankhorst GJ, Koetsier JC. Effects ofintensity of rehabilitation after stroke. Aresearch synthesis. Stroke. 1997 Aug; 28(8):1550–6.

9. Duncan PW, Lai SM. Stroke recovery.Topics Stroke Rehabil 1997; 4(17):51-58.

10. Patrice Lindsay BScN PhD, MarkBayley MD, Chelsea Hellings BScH,Michael Hill MSc MD, Elizabeth WoodburyBCom MHA, Stephen Phillips MBBS:Canadian Best Practice Recommendationsfor Stroke Care (2008).

11. Kwakkel G. Magnus R. Intensity ofpractice after stroke: More is better TheNetherlands Schweizer Archiv furneurologie und psychiarti 2009;160(7):295–8

12. De Wit l, Putman. K, Lincoln N ,Baert I,Berman P, Beyens H, Bogaerts K,Brinkmann N, Connell L, Dejaeger E, DeWeerdt W, Jenni W, Lesaffre E, Leys M,Louck F, Schuback B,Schupp W, Smith Band Hilde Feys. Stroke rehabilitation inEurope; what do Physiotherapists andOccupational Therapists Actually do.Stroke published online Apr 27, 2006.

13. Putman K , De Wit L, Schupp W,Beyens H, Dejaeger E , De Weerdt W,Feys H,, Jenni W, , Louckx F, and Leys Mon behalf of the CERISE-study . Inpatientstroke rehabilitation: a comparative studyof admission criteria to strokerehabilitation units in four Europeancentres. J Rehabil Med 2007; 39:21– 26.

14. Liesbet De Wit et Al. Motor andFunctional Recovery After Stroke: Acomparison of 4 European RehabilitationCenters Stroke 2007; 38; 2101-2107;

15. Putman K and De Wit L. EuropeanComparison of Stroke Rehabilitation Topicsin Stroke Rehabilitation. Jan- Feb 2009.

16. De Wit L, Putman K, Schuback B,Komarek A, Angst F, Baert I, et al. Motorand functional recovery after stroke: acomparison of four Europeanrehabilitation centers. Stroke 2001;38(7):2101-7.

17. De Wit L, Putman K, Dejaeger E, et al.Use of time by stroke patients: acomparison of four Europeanrehabilitation centers. Stroke 2005;36:1977-1983.

18 De Weerdt W, Selz B, Nuyens G, et al.Time use of stroke patients in an intensiverehabilitation unit: a comparison betweena Belgian and a Swiss setting. DisabilRehabil 2000; 22:181-186

19. Rudd A, Jenkinson D, Grant R andHoffman A. Staffing levels and patientdependence in English stroke units.Clinical Medicine Vol 9 No 2 April 2009.

20. Chen CC, Heinemann AW, GrangerCV, Linn RT. Functional gains and therapyintensity during subacute rehabilitation: astudy of 20 facilities. Arch Phys MedRehabil 2002; 83(11):1514-23.

21. Sonoda S, Saitoh E, Nagai S, KawakitaM, Kanada Y. Full-time integratedtreatment program, a new system forstroke rehabilitation in Japan: comparisonwith conventional rehabilitation. Am JPhys Med Rehabil. 2004; 83(2):88-93.

22. Kwakkel G, van Peppen R, WagenaarR, Wood Dauphinee S, Richards C,Ashburn A, Miller K, Lincoln N, Partridge CWellwood I and Langhorne P. Effects ofAugmented Exercise Therapy Time AfterStroke A Meta-Analysis. Stroke. 2004 Nov;35(11):2529–39.

23. Bakheit AM, Shaw S, Barrett L, et al.A prospective, randomized, parallel group,controlled study of the effect of intensityof speech and language therapy on earlyrecovery from post stroke aphasia. ClinRehabil 2007; 21:885-894.

24. Bhogal SK, Teasell R, Speechley M.Intensity of aphasia therapy, impact onrecovery. Stroke 2003;34:987-993.

25. Going up a gear: practical steps toimprove stroke care, NHS Improvement,June 2010

26. Indredavik B, Bakke F, Slordahal SA,Rokseth R, Haheril. Treatment in acombined acute and rehabilitation unit.Which aspects are the most important?Stroke 1999,30:907 - 923

27. Prof C. Wolfe, Dr A. Rudd, Dr C.McKevitt Dr P. Heuschmann, Prof L. Kalra.(King's College London) Top Ten Prioritiesfor Stroke Services Research. A summaryof an analysis of Research for the NationalStroke Strategy. For Department ofHealth. 19 December 2008.


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CASESTUDIES

AimsTo evaluate the Healthcare for Londonguidance (RC7) for early supporteddischarge intensity as per the servicelevel agreement against actual serviceprovision. To use this data to guidepractice, and to attempt to define theterms in the NICE quality standard 7(QS7) ‘continuing to benefit’ and ‘ableto tolerate’ based on the service users.

Objectives1. To analyse what does and what

does not constitute ‘therapy time’within the service.

2. To provide regarding duration oftherapy (frequency and intensity) for100 patients who had completed sixweeks of rehabilitation within theservice.

3. To compare the duration andintensity of therapy received withvalid clinical outcome measuresincluding goal attainment.

4. To compare clinical outcomes withthe amount of therapy received for asmall sample of patients who hadthe least therapy input in terms oftime, and also in terms of numberof visits.

5. To compare clinical outcomes withthe amount of therapy received for asmall sample of patients who hadthe most therapy in terms of timeand also in terms of number ofvisits.

6. To determine reasons why 45minutes of therapy provision is, oris not achieved.

7. To identify any barriers to NICEQS7 implementation in the serviceand any client groups with whomthis standard may not always applyto in practice.

Findings

Intensity• the team were able to provide therequired intensity of therapy from astaffing capacity perspective; however,it was not always possible for everypatient to receive this. The serviceaims to provide all patients with atleast 45 minutes of daily therapy onworking days; however analysis of

data showed that the decisions madewere based on individual patientsgoals and ability to participate inrehabilitation through a jointdecision making process betweenpatient and therapists to agree theappropriate level on input

NHS Camden – stroke REDs

Improving access to 45 minutes oftherapy for stroke patients


32

Monday - Friday Saturday - Sunday

Team Coordinator1 Band 8 whole time equivalent (wte)

Occupational Therapists1 Band 7, 1 Band 6

Physiotherapists1 Band 7, 1 Band 6

Speech and Language Therapist0.5 Band 7

Nurse1 Band 7

Psychologist0.5 wte

Dietician0.2 wte

Social Worker0.5 wte

Rehabilitation Assistant1 Band 3

Enabling CarersAs required


RC7 Percentage of appropriate patients receiving five sessions perweek within the first two weeks (ESD), and/or three sesionsper week for the first four weeks (non-ESD/postESD) - ofoccupational therapist, physiotherapy and speech andlanguage therapits. (Weeks start when treatment starts;ongoing to enable patients to meet goals).

70%90%

• Findings showed that, in order tomake this clinical judgement it was atfirst essential to attempt to try toprovide 45 minutes intensity

• The team were unsure whether 45minutes of therapy is sometimes toomuch or too little when attempting toquantify or set a standard toencompass all three professionalgroups and advocate for further work,research and analysis in this area.

Therapy contact time – inclusions• Time spent with therapists on the dayof discharge once the patient is home(education, transfer practice, homeenvironment and equipmentassessment)

• All therapy specific face to faceassessments and interventions

• Time spent carrying out specificoutcome measures: COPM (CanadianOccupational Performance Measure),UL (upper limb) outcomes

• Goal setting with patient present• Stroke education sessions withtherapists

• Telephone calls where therapistspecific advice is given

• If two therapists from one disciplineare required for a session, it iscounted as one therapy session

• Therapy carried out by a student, if atherapist (same discipline) is not present

• Sessions with rehabilitation assistanton behalf of therapists, if therapistfrom the same discipline is not present

• If it is a joint session by two or moredisciplines, therapy time is counted forboth disciplines i.e. 45 minutes timestwo

• Carer/family education relevant topatient’s care/rehabilitation needsdelivered by therapist.

Not therapy time• The time spent on the hospital wardon the day of discharge

• Assessment on the hospital ward• Time spent on the following outcomemeasures: SAQOL (stroke aphasiaquality of life), NeADL (Nottinghamextended activities of daily living)

• Telephone calls for purposes otherthan therapist specific advice e.g.making appointments

• Access visits, installation of equipmentprior to patient going home

• Discussion about a patient duringmultidisciplinary team meetings

• Time patient spends with enablingcarers

• Time patient spends with psychologist,nurse, social worker, or dietician.

Comparing the duration andintensity of therapy received withgoal attainment


33

Model specificsThe NHS Camden stroke reach early discharge scheme (NHS Camden - stroke REDs) wasdeveloped from a fully functional community rehabilitation team, Camden REACH, thatoffered a stroke pathway. NHS Camden - stroke REDS accept patients from acute and inpatientstroke units, that are suitable for ESD and assists in identifying patients requiring furtherinpatient stroke rehabilitation.

It operates through a multidisciplinary in reach model and provides therapy (occupationaltherapy, physiotherapy and speech and language therapy) five days a week, enabling careseven days a week. The team also includes psychological, nursing, dietetic and social workservice provision, but for the purpose of this project only the three core therapies wereevaluated.

The service level agreement recommends that during a six week period of rehabilitation, aperson could receive 22 sessions of each individual therapy, including use of rehabilitationassistant’s interventions. Length of stay is limited to six weeks, but this service has reducedinpatient length of stay in local acute trusts to 10 days.

45 minutes – RC7 standard for each patient is to receive 22 sessions, of 45 minutes over sixweeks. Data showed that 17.5% of clients achieved the required amount of therapy fromphysiotherapy, 21.5% from occupational therapy and 11.1% from speech and languagetherapy.

Frequency – The service should provide five days contact per week for the first two weeks anda minimum of three days for weeks 3-6.

Healthcare for London Guidance - Only 2.5% of patients received the RC7 level ofphysiotherapy, and both occupational and speech and language therapy recommendationswere not met for any patient. This was based on numbers of visits required. There is a processof joint clinical decision between the client and therapists, regarding the level of intensity thatis appropriate on an individual basis. At times up to 30% of patients reported that fatigue wasa major factor affecting ability to participate in an intensive therapy programme at home.

Percentage of clientswho met qualitystandard of 45minutes

Occupationaltherapist = 0%,Speech and languagetherapist = 0%,Physiotherapist =2.5%

Percentage of clientswho met equivalenttotal minutes oftherapy

Occupationaltherapist = 21.5%,Speech andlanguage therapist =11.1%,Physiotherapist =17.5%

The findings demonstrate the variabilityin the patient group regarding theduration of individual sessions a)tolerated, b) deemed to be of continuedclinical benefit, jointly agreed betweenthe therapist and client, and c) durationappropriate for different tasks, e.g.more than 45 minutes to undertake anoutdoor mobility session to doshopping.

Despite these relatively low percentages,87.41% of goals set across all 91patients were achieved. This clearlyshows that, for the majority of thepatients, 45 minutes of daily therapy isnot required to achieve all rehabilitationgoals.


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The team considered QS7 in terms ofthe phrases ‘continuing to benefit’ and‘able to tolerate’ and felt that if theywere to include all those patients whowere either judged to be not continuingto benefit or not able to tolerate, thepercentage of the clients who met thestandard would be significantly higher(see discussion on reasons why 45minutes was not achieved).

Comparing clinical outcomes withthe amount of therapy received fora small sample of clients which hadthe least therapy input in terms oftime (intensity) and number of visits≥ 45 minutes (frequency)Lowest number of visits – averagenumber of therapy visits = 9.3 (in a sixweek period).

There were no significant differences interms of the Canadian OccupationalPerformance Measure - Satisfaction(COPM S), Canadian OccupationalPerformance Measure PerformanceCOPM P) and Nottingham extendedactivities of daily living (NeADL). Onaverage those for whom the criteriawere met improved 12 points (for othersthe average improvement was 10points).

Most amount of therapy time spent –average number of therapy minutes =2413 (in a six week period).

Identifying the barriers to NICEQS7 implementation and patientgroups with whom this standardmay not applyThere were two groups; those withlower Barthel scores, (indicatingmoderate functional impairment) andthose with higher Barthel scores,(indicating a more mild functionalimpairment) for whom 45 minutes maynot always be applicable.

The team found that patients with mildfunctional impairments (higher Barthelscores) returned to their life rolessooner, and were more self directedwith activities of daily living/therapy.Many of them reached the jointlyagreed decision (based on goalattainment and improvements in clinicaloutcomes) to no longer benefit clinicallyfrom daily therapy; leading the team tohypothesise that once back in theirhome environment, this patient grouphave more opportunities to engage intask specific practice. The team havealso found that because they are moreindependent, they are busier, which inturn reduced their availability forappointments.

Those with lower Barthel scores tend torequire more therapist guidance andwere more likely to need skilled physicalassistance or supervision to enable themto practice and progress functionaltasks/exercise. Therefore, daily face toface therapy was often of greaterclinical benefit with this group.

Some patients experienced high levelsof fatigue. This symptom affected 30%of the patients and had an impact ontheir ability to participate in therapy.Many of these patients required shortersessions.

There were some patients who declineddaily therapy at home as a personalpreference.

Barthel

1.9

COPM P

3.5

N eADL

12.2

COPM S

3.1

Least amount of therapy time spent -average number of therapy minutes =643 (in a six week period).

Barthel

1.7

COPM P

2.6

N eADL

10.9

COPM S

2.6

For this group of clients it appears thatthere is a significant difference withBarthel and goal attainment scale (GAS)outcome measures when comparedwith the sample of people who getmost therapy in terms of time (intensity)and number of visits (frequency). At thestart of intervention, the Barthel scorefor the group with least amount oftherapy is higher, (average score of 17p=0.03) suggesting that the patientswho do not receive the same therapy(intensity and frequency) are the morefunctionally able. This patient groupmakes significantly smaller progressgains (average of 1.8 p=0.002)compared with the patients that receivemore therapy. This group of patientsachieved 100% of their goals set usingGAS.

Barthel

6.3

COPM P

2.8

N eADL

14.6

COPM S

3.1

Highest number of visits – averagenumber of therapy visits = 35.1 (in a sixweek period).

Barthel

6.3

COPM P

3.0

N eADL

11.6

COPM S

3.4

For this group of patients, there is asignificant difference with regards to theBarthel and GAS outcome measures,when compared to the sample ofpeople who get least therapy (frequencyand intensity). Patients who received themost therapy (intensity) werefunctioning at lower level, based on theBarthel (average score of 11.8 p=0.02)at the point of transfer into the service.In terms of progress and change, thisgroup made significantly larger gains(average of 6.3 p=0.005) whencompared to those who received theleast amount of therapy. In terms ofgoals set, they achieved 80% of goalsset using GAS.

There were no significant differences interms of the COPM satisfaction, COPMperformance and NeADL.


35

Patients who require input from multiplemembers of the multidisciplinary teammay not always be able to toleratedaily sessions from every discipline,necessitating prioritisation ofsessions (this should be guided bypatient-centred goals).

In cases of complex health needs, e.g.dual diagnosis, multiple medicalappointments or hospital admissions,some patients could not be availablefor daily therapy.

Reflective commentsWould it be more appropriate for NICEquality standards to measure patientoutcomes based on clinical outcomemeasures/goal attainment/other formsof evidence based practice, rather thanspecify intensity of treatment based ontime?

ContactMirek SkrypakStroke REDS, Navigator andREDS Co-ordinator, NHS Central andNorth West London NHS FoundationTrust, Camden Provider Services.Email: [email protected]


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ContactTracy WalkerClinical Specialist OccupationalTherapist, Clinical Lead Stroke,Stroke Service, Lancashire Care NHSFoundation TrustEmail: [email protected]

BackgroundThe community stroke team (CST)began in 2007, on a background of anabsence of any multidisciplinary teamcommunity rehabilitation service forstroke survivors, limited provision ofequipment, long waiting lists and lengthof stay in the acute trusts, substantialcare packages on transfer to thecommunity, and a limited, physiotherapyonly service into care homes. Since2007, the team has rapidly evolved intoa successful and comprehensive service,linked with local community servicesand building strong links with socialcare.

The team decided to review andevaluate their service against the 45minute quality standard and using theirextensive data base, tried to betterunderstand which patients receivedmost therapy, and the outcomes.

The community stroke team in Blackburn with Darwen,part of Lancashire Care NHS Foundation Trust

Retrospective evaluation of therapyneed and provision


Community Stroke Team Lead1 Band 8



Speech and Language Therapist1 wte

Nurse0.5 wte

Psychologist

Assistant Practitioner0.2 Band 4

Rehabilitation Assistants4 Band 3



Model specificsThe community stroke team provide a comprehensive service including ESD, for new andexisting stroke patients.

It in reaches into hospital within 24 hours of referral and coordinates early discharge home forall patients, regardless of destination, and provides a responsive assessment in the communityfor as long as needed. The enabling care workers have stroke specific skills and are from thewider intermediate care and social care teams.

Data collectionReview of 20 sets of consecutive patient data.

Length of stayNot time limited in the service. The team have reduced in patient length of stay locally from31 days in 2005 to 21 days in 2009, with a corresponding steady reduction in length of staywithin the community spell. There has been a reduction of length of stay across the wholepathway with improvement of patient outcomes and reductions in final packages of care.

45 minutes• Not all stroke survivors referred for community stroke rehabilitation needed 45 minutes oftherapy each day

• Patient therapy need varied greatly with length of stay, depending on dependency levels• There was a trend of greater number of 45 minute therapy contacts from rehabilitationassistants with varied input from occupational therapist/physiotherapist/speech andlanguage therapist depending on patient needs post stroke

• The patients with moderate to total dependence (Barthel score) required intensive 45minutes of therapy daily post discharge

• Mild and minimal dependency patients required less intense therapy.

Population: 162,000Team: Community stroke teamReferrals: 280 per year

Aims• To investigate ways to increase theamount of face to face therapy timewith patients, within currentresources

• Establish new ways of working on astroke rehabilitation unit

• Promote integrated working.

The pilot project looked at increasingtherapy contact time in line with theNICE Quality Standards; specificallyaround team working but also formedpart of bigger overall work to improveworking practices on the unit. Thisincluded occupational therapy/physiotherapy/speech and languagetherapy and nursing staff all based onthe stroke rehabilitation unit.

MeasurementThe team started to use the NorthwickPark dependency measure and goalattainment scale as outcome measureswhen the changes were introduced.

Medway Community Healthcare Stroke RehabilitationUnit, St Bartholomew’s Hospital, Rochester, Kent

Improving access to 45 minutes oftherapy for stroke patients


37


Stroke Services Manager (Clinical Lead)1 Band 8a (across whole stroke pathway)

Advanced Practitioner1 Band 7 (across whole stroke pathway)

Occupational Therapist1 Band 7

Physiotherapists1.6 Band 6, 0.5 Band 5

Speech and Language Therapists0.6 Band 6, 0.2 Band 5

Care Manager0.5 wte

Rehabilitation Assistants2 Band 3, 1 apprentice

Nurses (Day Shift)1 Band 7, 2 Band 2/3, 1 Band 5, 2 Band 2/3

Nurses (Night Shift)1 Band 5, 2 Band 2/3

Nurses (Day Shift)2 Band 2/3, 1 Band 5, 2 Band 2/3

Nurses (Night Shift)1 Band 5, 2 Band 2/3

Data collectionSample n=4 pre change; n=11 during change; n=6 after change.

Length of stayService changes have not been implemented for enough time to measure this.

45 minutesWithin the sample size (although small) there was already a trend of increased therapy deliveryacross physiotherapy, occupational therapy and speech and language therapy.

RCP guidelines/NICE quality standardsMoving the therapy staff onto the stroke rehabilitation unit, providing an integrated approachto therapy and initiating group therapy sessions are all improving the access to 45 minutes oftherapy on at least five days of the week.

CommentsQualitative staff feedback was very positive with all staff in favour of the changes to workingpractices, all staff feeling that they were working better as a team. A spot check Care QualityCommission (CQC) visit happened during the project and the feedback praised the integratedworking on the unit and recommended that the other wards at St Bartholomew’s Hospitalshould adopt the model being used.

Population: 275, 000Unit: 15 bedded strokerehabilitation unitReferrals: Approximately 80 peryear


38

Challenges• Low morale• Limited funding opportunities• Commissioners having differentpriorities, i.e. implementation of a7/7 TIA service

• Problems collecting and analysingdata

• Development of a business case• Speech and language therapy staffwith different line management didnot form part of these changes otherthan to assist in the data collectionand in facilitating the socialcommunication group. Otherwisethey continued with their normalworking practices and did not changetheir base.

Key learning• Ensure buy in from a senior manager/top level manager in the organisation

• Keep all staff involved and updated ona regular basis e.g. newsletter etc.

• Keep on top of things daily.

What we would have donedifferently• Carry out a demand and capacityexercise before the changes ratherthan during

• Plan and introduce the changes over alonger period of time

• Involve people at the top oforganisation earlier in the process.

Next stepsMedway Community Health areproducing a report to inform theexecutive team about the current levelof provision of therapy on the unit incomparison with that required. It willinclude information to show both theeffect of innovative ways of working ondelivering quality standards, and whythe service is unable to deliver 100% oftherapy required.

Service specifications are being reviewedand the report can support a clearrationale around the resources requiredto meet future measures, such as 45minutes of therapy and seven dayworking.

ContactTrudie FranceConsultant Practitioner – Stroke,Medway Community HealthEmail: [email protected]

BackgroundHistorically, there was no provision foraccess to specialist rehabilitation therapyat weekends. Previous service userfeedback had identified this to be asignificant gap in stroke serviceprovision.

The aims of the project were to providea service in line with RCP guidelines, tomeet the rehabilitation quality markersof the National Stroke Strategy andcomply with NICE recommendations onfrequency of treatment for strokepatients.

The pilot ran for a year, until August2010, with the extra staff working threedays during the week and at weekendson the stroke unit. The three week daysenhanced the existing service withaccess to training and support fromsenior staff.

Challenges and solutionsChallenges• Retention of staff, particularly band 5• Cost• Change in working practices forcurrent staff.

Potential solutions• Build seven day and flexible workingpatterns in contracts to supportsustainability

• Share the outcomes and feedback tostaff

• Promote the benefits andopportunities for flexible workingpatterns

• Adopt flexibility with staffing and skillmixing to support annual leave, studytime and, ideally, one weekend off amonth

• Implement a two month notice periodrequired for band 5 entering thegeneral rotation

• Agree secondment to current postuntil recruitment is completed toprevent gaps in service.

Next stepsA significant gap has been identified inthe lack of qualified occupational therapyat weekends. It has been recommendedthat funding should be sought forqualified occupational therapy weekendprovision.

How has the improvement benefitedstaff, patients and carers?“Over the bank holiday weekend Idid not receive any therapy for fourdays”

”I feel the therapy was good butthe ward needed more staff tocope with demand”

Patient quotes from the satisfactionquestionnaire 2009 pre pilot

“Physiotherapy in hospitalexcellent”

“Not enough occupationaltherapy”

Patient quotes from the satisfactionquestionnaire 2010

ContactHeather HunterTeam Leader Physiotherapist.South Tyneside NHS Foundation TrustEmail: [email protected]

South Tyneside NHS Foundation Trust

Increased stroke physiotherapy provisionon stroke wards


39


Physiotherapists0.8 Band 7, 0.6 Band 5 and 0.5 Band 2

Technical Instructors1.5 Band 4

Physiotherapist0.4 Band 5

Technical Instructor0.4 Band 4

Data collectionSample n=32 consecutive patients.

Length of stay10 days.

45 minutes75% of appropriate patients received 45 minutes of therapy.

FrequencyPatients were seen a mean seven days out of mean of 10 days length of stay.

RCP Guidelines/NICE quality standards100% compliance across physiotherapy for seven day service which has improved access to45 minutes of therapy.

CommentsThe quantitative data shows ongoing improvement and is supported by patient feedback.For staff there was cessation of the Monday morning syndrome. Funding for the project hasnow been made substantive.

Population: 155,000Unit: 20 bedded acute andrehabilitation stroke unitReferrals: 300 per year


40

BackgroundThe service was delivered to patientsthroughout the pathway that met theagreed criteria; the funding for theproject was targeted at hyperacutestroke unit (HASU).

Key objectives• To ensure that essential services canbe available to patients when they areneeded

• To improve the quality of patients’experience and the timeliness ofintervention

• To ensure working arrangements arein place to support consistent deliveryof essential developing services

• To explore in more detail a range ofmodels of additional therapy andexamine their different effects across aspectrum of specific outcomes.

Data collection• Admission to referral, referral to firstcontact, first contact to therapycomplete, and date of lastintervention, admission to treatmentlength of stay total, and length of stayuntil therapy complete date.

Key outcomesThe roster system implementing sevenday working was the logical way todeliver a service within the given timescales and initiate contracted seven dayworking in an equitable way acrosstherapy services. However,overwhelming feedback from all areassuggests weekend working is deliveredmore effectively and efficiently by thehome team members who are familiarwith local systems and processes andthe current clinical case load. Futurerecruitment strategies will be directed atdeveloping capability to sustain a sevenday service within the home team bythe following methods:

Sheffield Teaching Hospitals NHS Foundation Trust

Implementing seven day occupational andphysiotherapy services for stroke


Therapy Lead1 Band 7

Occupational Therapists1.6 Band 7, 1.6 Band 6, 3 Band 5

Physiotherapists1.6 Band 7, 2 Band 6, 3 Band 5

Generic Technical Instructor and Assistant1.6 Band 3, 1.8 Band 2

Occupational Therapists1 Band 5/6/7

Physiotherapists1 Band 5/6/7

Assistants2 Band 2/3

Model specificsThe service moved from a five day, Monday to Friday, working week to a five day workingweek which may include a day at the weekend or bank holiday: Weekend and bank holidaypay enhancements apply. Staff work a one in four weekend rota on the stroke wards. The rotais made up from a pool of staff working in specialist rehabilitation (brain injury and spinalinjury), neurosciences (neurology and neurosurgery), neuro rehab and stroke. Payback days aretaken from within the individual therapist’s directorate/division, which may not be stroke. Theseven day service was provided across the inpatient care pathway from the HASU to the acuterehabilitation ward.

Samples for the occupational therapy/physiotherapy data sets were different so not comparable.

Length of stayAnalysis of length of stay in connection to the introduction of a seven day service wasinconclusive. This is because at the same time the stroke service had a major reconfigurationas two stroke services on separate hospital sites were integrated into one, with a creation of anHASU.

Data collectionSample pre change n=20 for occupational therapy and physiotherapy; post change n=30 foroccupational therapy and physiotherapy. Samples for the occupational therapy/physiotherapydata sets were different so not comparable.

45 minutesPre seven day service physiotherapy and occupational therapy were able to provide access to45 minutes of therapy for 76% of the time, on average, for appropriate patients. Postimplementation this increased to 92% for physiotherapy and 91% for occupational therapy.

Admission to assessment time (ATT)Pre seven day service, occupational therapy was 62 hours and physiotherapy was 47.4 hours;post implementation occupational therapy = 25.6 hours, physiotherapy = 30.4 hours.

Population: 547,000Unit: 76 beds across hyperacute,acute and rehabilitationReferrals: 1,000 per year

• All vacancies for new staff basedpermanently within teams who delivera seven day service will be advertisedand recruited with a regular workingpattern which will include weekends

• All staff currently employed will begiven an opportunity to work at theweekend as part of their normalcontracted week if they wish to do so

• Review of working patterns forrotational staff and increasingrecruitment of division based staff toincrease the stability of rosters

• Resources will be moved permanentlyinto teams to support this process


41

• Patients with a shorter than averagelength of stay were seen byphysiotherapy for the majority oftheir stay

• Those who were in longer were seenfor a smaller percentage of their timein hospital. This may have been due tomedical issues, cognitive orbehavioural impairments or waitsfor other services

• The 90% vital sign for patientsspending 90% of their time on astroke unit is achieved.

ContactNatalie JonesManager – Neurology,Sheffield Teaching Hospitals NHSFoundation TrustEmail: [email protected]


42

Aims• To assess local clinical need andgather the views of patients, carersand staff to inform long-termplanning

• To establish whether speech andlanguage therapists workingSaturday mornings reduced referral totreatment time, improved access tospeech and language therapy (SLT)and enhanced the patient experience.

Challenges• Securing adequate funding to increasethe service. One option is to extendthe existing service over the wholeweek and evaluate the impact on thepatients during the week

• Recruitment of staff could beproblematic; experienced SLTs with apost graduate dysphagia qualificationare in short supply

• This pilot was undertaken at shortnotice and it was not possible tocollect all the baseline data. It alsoincluded two bank holidays when theservice was provided on Mondayrather than Saturday morning.

Key learning• Identify the right data for collectionand don’t underestimate thechallenges associated with collection

• The impact of seven day working maydiffer if the whole multidisciplinaryteam are involved.

Future plansReview the data and discuss how todeliver a SLT service over the weekends,in consultation with staff and patients.

ContactErica BradleySLT Adult Coordinator, Sheffield TeachingHospitals NHS Foundation TrustEmail: [email protected]

Sheffield Primary Care Trust and Sheffield TeachingHospitals NHS Foundation Trust

Sheffield stroke unit seven day working pilot forspeech and language therapy


Speech and Language Therapists2.2 Qualified SLTs Bands 5, 6 and 7

Therapy Assistants1.6 Band 2

Speech and Language Therapists0.1 Qualified SLT (Sat am only)

Model specificsA pilot service involving speech and language therapy service on Saturday mornings wasprovided for 12 weeks. The roster was staffed by volunteers, with funding for overtime agreedwith the trust and comprised speech and language therapists from acute ward teams inaddition to the stroke team. Staff completed an induction to familiarise them with procedures.All staff were competent with dysphagia management and communication skills. New referralswere seen along with existing patients who had been prioritised for a Saturday morningsession by the stroke unit speech and language therapist. On-call was not included as it wasfelt that this was unlikely to meet the clinical need, as dysphagia screening is already providedfor patients.

Data collectionSample n=21.

45 minutes25% of patients required daily speech and language therapy intervention and over 50%needed 45 minutes on certain days.

Admission to assessment time (ATT)80% of patients were assessed within 24 hours, 55% within 72 hours. Only one patient fromthe total (20) was first assessed on a Saturday. The referral to treatment time was thereforereduced for 5% of the sample.

FrequencyPatients were seen a mean three days out of mean of 15 days stay.

CommentsThe qualitative effects are still being evaluated through a patient questionnaire. The speechand language therapists felt that there was a positive effect on the duration of nil by mouthepisodes for some patients but did not collect data for this. The clinical need appeared to bepredominantly for dysphagia assessments, and qualified staff intervention. As the sample sizewas small, any conclusions must be cautiously drawn. Patients were seen for assessmentwithin the 24 hour standard, but had to wait longer for treatment. The incidence of patientswho had pneumonia during their admission was higher than the national average, with 20%of the sample experiencing pneumonia during their admission (13% from 2010 sentinel audit).However, this cohort were more likely to have dysphagia as they had all been referred tospeech and language therapy compared to the sentinel audit cohort who had not all beenreferred to speech and language therapy.

All the staff felt that there was a positive effect on patient care and that they received agreater amount of intervention during the pilot.

Population: 547,000Unit: 79 beds across hyperacute,acute and rehabilitationReferrals: 1,000 per year


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Background• No baseline data had been collectedbefore starting the seven day service

• A seven day service is only beingprovided on the acute unit, whilst therehabilitation unit has a five daytherapy service

• Challenges around assuring theoptimum number of staff with therequisite skill level are available for therotas were resolved by recruitingexisting part time staff who requestedextra work to the roster.

Key learning from this work• Be very clear about any datarequirements before engaging inproject work. Identify what data youneed and how to measure it whenidentifying how your service hasimpacted on an organisation (e.g.unlikely to have major effect onlength of stay)

• Ensure sufficient lead in time to collectappropriate baseline data forcomparison

• Promote the service and make surepeople are aware of any project workand share plans and outcomes. It isessential to have a team thatrecognises the value of the service andare consequently committed to it

• Have contingencies in mind to ensurea sustainable service when theunexpected occurs

• Have a flexible attitude whenplanning rotas.

How has the improvementbenefited staff, patients and carers?It has been a positive experience withgood feedback from all. Staffsatisfaction is high.

Chesterfield Royal Hospital NHS Foundation Trust

Developing a seven day physiotherapyservice on the acute stroke unit


Occupational Therapists1 Band 6, 0.6 Band 5

Physiotherapists1 Band 7, 2.7 Band 6, 1 Band 5 and 1 Band 2

Speech and Language Therapist1 Band 6

Physiotherapists1 Band 6/7, 1 Band 2

Model specificsPhysiotherapists plan and prioritise the weekend work. Staff work on a roster, with additionalstaff from the ‘bank’ list within physiotherapy. All have stroke skills. The service merged withthe rehabilitation service in April 2011, with a total of 36 beds; there was an increase infunding to staff it proportionately. The stroke service is part of a wider neuro team that alsoincludes neuro patients on other wards and outpatients. A seven day physiotherapy servicewas commissioned from April 2010 and implemented in October 2010.

Data collectionSample n=30

Length of stayNo significant impact with the seven day service. It was felt that a similar occupational therapyservice would be required to facilitate this effect. However, the team can now plan fordischarges earlier in week.

Admission to assessment time (ATT)100% for admission to assessment time (ATT).

FrequencyPatients were seen a mean six days out of mean of 11 days stay.

RCP guidelines/NICE quality standardsMeeting RCP at 100% for ATT. Compliance with seven day service delivery for physiotherapy

Population: 250,000Unit: 14 bedded acute stroke unitReferrals: 700 per year, 450 -500stroke

Future plansThe stroke services are currentlyundergoing a service review, includingconsideration of a similar occupationaltherapy weekend service and there areplans for an early supported dischargeteam.

ContactVictoria OscroftSenior Physiotherapist,Chesterfield Royal Hospital NHSFoundation TrustEmail:[email protected]


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BackgroundNewton Abbot Stroke Unit (Teign ward)provides post-acute rehabilitation aspart of a common pathway for strokeacross South Devon. The unit acceptspatients who are medically stable andare, on average, seven days post stroke.It provides inpatient care prior tosupported discharge into thecommunity. Over the last six years thatthe unit has been running, throughputand length of stay have continued todecrease and bed occupancy averages96%. The service had alreadyundertaken much background andpreparatory work prior to the NHSImprovement - Stroke project.

Baseline positionThe team collected baseline informationacross a range of aspects includingtherapists’ opinion on whether patientsrequired 45 minutes of therapy everyday, a user satisfaction questionnaire in2008 and review of previous audit data(2010).

• 33% of patients rate their overall careas ‘excellent’. 58% of patients ratetheir overall care as ‘very good’. 9%of patients rate their overall care as‘good’. (National figures: 33%excellent; 36% v good; 18% good;8% fair; 3% poor and 1% very poor.)

• Admission to assessment time was80% within 24 hours (but some waitup to 96 hours).

Newton Abbot Hospital stroke unit withTorbay and Southern Devon Care Trust

South Devon Stroke Services: Seven day workingand 45 minutes of therapies


Consultant Therapist1 Band 8 (across whole stroke pathway)



Speech and Language Therapists0.55 Band 8b, 0.4 Band 6

Rehabilitation Support Workers1.8 Band 3

Occupational Therapists0.2 Band 6/7 (Sat alternate weeks)

Physiotherapists0.2 Band 6/7 (Sat alternate weeks)

Rehabilitation Support Workers1.2 Band 3

Model specificsThe team reallocated existing funding for a band 5 post, to fund three band 3 rehabilitationsupport assistants (RSA).

Qualified staff were rostered to provide the Saturday service supplemented with stroke skilledstaff from the community team.

Data collectionSample n=30 each from occupational therapy and physiotherapy.

Length of stayReduced from 21 days (2008) to 17 days (2010) not attributable to this work.

45 minutesBoth therapies were able to provide access to 45 minutes of therapy for 100% forphysiotherapy and 87% for occupational therapy for appropriate patients.

Admission to assessment time (ATT)46 hours for occupational therapy and 23 hours for physiotherapy.

FrequencyPhysiotherapy patients were seen a mean 11 days out of mean of 22 days stay. Patientsneeding occupational therapy were seen a mean seven days out of mean of 22 days stay.

RCP guidelines/NICE quality standards100% of patients received a cognitive assessment, 80% a mood assessment, and 100% hadrehabilitation goals agreed with their input. Compliant with seven days services forphysiotherapy and occupational therapy.

CommentsStaff questionnaire and review showed a recognition of the positive impact on patient’s care.Feedback from staff included that they valued the consistency provided by rehabilitationsupport workers, and felt more confident to progress treatment plans in a more timely fashion.Generally, staff felt that there was some impact on personal life but counterbalanced by lowfrequency of commitment, and 100% agreed to continue supporting the service.

Unit: 15 bedded strokerehabilitation unitReferrals: Approximately 250 peryear


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Actions1. Reviewed skill mix of occupationaland physiotherapies and developedrehabilitation support worker (RSW)role to improve access to therapy andpractice on the stroke rehabilitationunit. Through reallocation of theexisting funding for the band 5 posts,were able to fund three band 3rehabilitation support workers acrossseven days (Saturday to Tuesday - 7.5hours) plus band 6/7 therapist (fourhours Saturday and bank holidays).

2. Included speech and languagetherapists in the discussions, althoughthere were no plans for them toparticipate at this stage.

3.Agreed the outcome measures,including ATT, care maps regardingtherapies delivered and length of stay.

Implemented the changeRehabilitation support workers began inOctober 2010, working Monday toFriday for induction and orientationbefore the weekend service startedformally in November 2010. Specialistcommunity physiotherapy staff werealso included in the qualified staffSaturday rota to allow an outreachservice into the community for newlydischarged patients or communitypatients that may require weekendinput. This meant qualified staff workinga 1:12 weekend pattern. Supportworkers would also be required tooutreach into the community ifnecessary.

Key outcomes45 minute treatment sessions;2008 = 92%. 2010 = 100%.Admission to treatment time;2008 = 80%. 2010 = 100%.

• Potential now to see communitypatients also at weekends

• Opportunity for community staff tojoin rota and keep up to date withacute work

• Positive carry over/continuity ofrehabilitation support workerinterventions from the weekend toMonday

• Very positive carer satisfaction aboutthe improvement in access/frequencyof therapy

• Improved staff confidence aroundprogressing treatment programmes ina more timely fashion

• Increase in Friday discharges aspatients could be followed up overthe weekend at their dischargedestination

• Positive feedback from communityteam regarding consistency providedby rehabilitation support workers.

NICE standards/RCP guidelines100% of 45 minute sessions forappropriate patients were achieved withphysiotherapy and 87% foroccupational therapy. 100% ofappropriate patients received a cognitiveassessment, 80% a mood assessmentand 100% had rehabilitation goalsagreed with the patients.

Top tipsCollection of data is massively timeconsuming and it is important tounderstand why you are collecting it.There has been a lot of debate aboutthe 45 minute standard and howpatients are assessed as being suitablefor this. The workshop provided locallyby NHS Improvement - Stroke teamfollowing the national meetings lookingspecifically at capacity and demand hashelped to clarify this although work isstill ongoing.

Next stages• Liaise with human resourcesdepartment to support long termsustainability of the changes

• Collect larger sample size and greaterdata collection

• If bed number increases, the team willreview need for band 5.

A demand and capacity exercise hasalready started and data has beencollected for patients over a two weekperiod during which the staff activitywas also measured using tools from theproductive hospital boxed set (NHSInstitute for Innovation andImprovement). It is hoped that from this,consensus will be reached on the besttimes for patients to receive theirtherapy in whatever format (includinggroups) and for staff to do theirpaperwork, meet with relatives, attendmeetings etc.

ContactKathryn BamforthClinical Specialist Physiotherapist,Torbay and Southern Devon Care TrustEmail: [email protected]


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Aims• Increase rehabilitation activities forpatients over weekends and bankholidays

• Train existing ward healthcareassistant staff to carry out prescribedrehabilitation activities on theweekends

• With achievement of above, create anongoing rehabilitation ethos on thestroke unit.

Challenges and solutionsStaffingChallenge: To ensure healthcareassistant jobs were not given to thesestaff by ward nursing staff when doingrehabilitation duties on the weekend.

Solution: The posts were designed to besuper numerate. Band 6 nurses agreedthe parameters, and the rehabilitationworkers, regularly feedback and wear adifferent uniform at weekends.

PayChallenge: There was some concerninitially that staff could perceive thisnew work as having ‘increasedresponsibility’ and therefore a higherbanding and pay scale.

Solution: This was resolved by aligningthe role into the key skills frameworkand ward competencies, emphasisingthat no new skills were being used, onlya change to allocation of time.

Guys and St Thomas’ NHS Foundation Trust

Seven day service: Weekend rehabilitationsupport worker model


Occupational Therapists1 Band 8, 1 Band 7, 1 Band 6, 1 Band 5, 0.5 Band 3

Physiotherapists0.5 Band 8, 1 Band 7, 2 Band 6, 1 Band 5, 0.5 Band 3

Speech and Language Therapists1 Band 8, 1 Band 7, 0.5 Band 6 (vac supported by SLTA)

Rehabilitation SupportWorkers0.4 Band 2/3 (HCA)

Model specificsThe rehabilitation support worker (RSW) delivers a prescribed series of exercises at theweekend, selected by the occupational therapist, physiotherapist and speech and languagetherapist during the week, under the supervision of a band 6 nurse.

Data collectionSample n=30 for occupational therapy, physiotherapy and speech and language therapy(sample not consecutive, in order to include patients who had physiotherapy, occupationaltherapy, and speech and language therapy).

Length of stayThe sample selected for data collection were those patients identified as needing two to threecore therapies, therefore a comment on length of stay cannot be made.

45 minutesThe rehabilitation support worker sessions are 20 minutes, therefore do not meet the 45minutes standard.

Admission to assessment time (ATT)This model does not influence ATT.

FrequencyMean days that patients were seen by speech and language therapist was three days,physiotherapist was eight days and occupational therapist was six days over an average lengthof stay of 18.5 days.

RCP guidelines/NICE quality standardsMeeting the spirit of the RCP guidelines by offering rehabilitation over seven days.

CommentsThe total number of rehabilitation contacts for the patient is increased with this model, but notthose delivered by qualified therapy staff. Patients value the service, and there is a strongerrehabilitation ethos during their normal duties.

Population: HASU -1,000,000,Stroke Unit - 250,000Unit: 29 bedded combinedhyperacute and rehabilitation unitReferrals: HASU - 700-800 and250-300 for stroke unit


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Competencies and line supervisionChallenge: Training provided bytherapists, but still managed by nursingteam. There was concern that linemanagement and responsibility may becompromised.

Solution: Competencies now included inrelevant nursing documentation andband 6 nurses are expected to have coreskills in rehabilitation and responsibilityto supervise rehabilitation supportworkers at weekends.

DocumentationChallenge: A solution for documentingthe input and outcome of rehabilitationactivities on the weekends was requiredas healthcare assistant staff do notdocument directly into the patientrecord at the trust.

Solution: Standardised, simple activitysheets with ‘tick box’ system offeedback were designed and are usedeffectively. These are reviewed bytherapists and filed in the patientrecord.

TrainingChallenge: How to deliver training for alleligible healthcare assistants, includingupdating skills and maintaining this.

Solution: All appropriate staff wererostered to attend an initial whole-daydidactic and practical training. Eachrehabilitation support worker wassupervised directly by a therapist toensure their first working weekend wassuccessful and any problems identified.Ongoing contact and discussion areencouraged in the week if staff havequestions or problems. Refreshertraining is scheduled yearly. New recruitswill be put through a similar training.

Top tipsThe importance of having wholemultidisciplinary teams on board fromthe beginning.

• Therapists to agree on consistentstructure of the exercises/trainingetc.

• Nurses to support the rehabilitationsupport workers to fulfil their role

• Rehabilitation support workers tobe willing to participate and open tonew ways of working.

Key outcomesThis service has been running for fouryears and was not introduced to supportseven day or 45 minute therapystandards. It delivers an increasednumber of rehabilitation contacts (butnot therapy contacts).

Feedback from patient and staff showsthat patients value having weekendinput and the rehabilitation supportworkers enjoy the work and havestronger rehabilitation ethos during theirnormal duties. This model has alsohelped to improve nursing awarenessof rehabilitative concepts andimplementation of strategies as part ofeveryday nursing.

ContactClaire EdmondsSpecialist Physiotherapist,Guys and St Thomas’ NHSFoundation Trust.Email: [email protected]


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Stoke-on-Trent: University Hospital of NorthStaffordshire NHS TrustThis service was not part of the cohortof project teams. However, they kindlyallowed us to visit their stroke serviceand share their learning and data fromseveral years of improvement. They havea well established and sustained sevenday therapy service for stroke patients.

HistoryStroke service in Stoke consisted of twocombined stroke units offering 39 bedsfor a population of 500,000 (tertiarypopulation of three million) within adeprived area with poor cardiovascularhealth, until 2008. The units weremanaged by two different trusts(combined Health Care NHS Trust andUniversity Hospital North Staffordshire(UHNS) with differing ward cultures,work practices, management styles,staffing establishments and roledevelopments.

Therapy cover was not always availableas the therapists were not solelyallocated to the units and A&E wassituated on a different site to the strokeunits.

An opportunity to evaluate the deliveryof care on the stroke units arose fromthe transfer of the ward to within theoperational management of UnitedHospital of North Staffordshire, and themove of both wards to one site withaccess to A&E.

Service redesignA radical overhaul of the existing servicewas needed. The proposed servicemodel was based on that delivered inTrondheim, Norway, which the teamvisited to understand their model for thestroke unit.

This comprised: an acute medicaltreatment programme with systematicobservation and examination; early andintensive stimulation and mobilisation;all underpinned by an integrated teamapproach focused on patient goals.Fiona Lunn (Nurse Stroke Consultant)

and John Cliffe (Deputy Director ofStrategy and Planning) worked closelytogether with help from Professor Roffe(Professor in Stroke Medicine) to puttogether the stroke service redesign.

Operational improvementsThere are two rotas, for nursing andtherapy (occupational therapy andphysiotherapy). The therapy rota coversseven days, running two shifts: 7.20-3.20 and 10.00-6.00. Nursing assistantsalternate between both rotas to givethem opportunities for developing skillsacross nursing and therapy.

The philosophy and principle of theward is on rehabilitation with jointworking from nursing and therapistsfrom admission, therapy and nursing

Action points• Medical stroke guidelines were reviewed and updated• Acute monitoring guidelines were reviewed and updated• Access to an early supported discharge team, which visits the ward daily, dohome visits and take patients home

• Review of therapist and nursing roles to promote blurring of boundaries,and focus on patient need

• Therapists work solely on the stroke unit and are managed by the stroke unitmanager

• Assessments are jointly done by nurse and therapist• Rehabilitation is functional and task orientated• Introduction of new roles without titles that are focused on rehabilitation(e.g. band 3 rehabilitation roles)

• Shift work for nurses 24/7 and therapists over seven days• Early mobilisation as principle practice on the unit was established• Evidence base for management of clinical symptoms (e.g. urinaryincontinence) was reviewed

• Nutritional pathway was put in place• There was an increased clinical focus for the stroke specialist nurse• Ward managers operate in a supernumerary capacity• Band 2 staff work alternate therapy and nursing rotas• Provision of an enriched environment to focus on stimulation, motivation,psychological support and training in groups

• Discharge planning implemented from day one• Review of housekeeper, discharge liaison and ward clerk roles• Training modules are being developed to meet the different needs of the staffworking in stroke. There are links with Keele University and University ofNorth Staffordshire, and there is support from the cardiovascular network

ward rounds and joint assessments. Allthe patient activities have arehabilitation focus, with treatmentbeing goal orientated rather thanprocess orientated (i.e. 45 minutes).Some tasks remain nursing tasks,and the therapists contributetowards these. Families are engagedearly to participate in therehabilitation tasks.

ContactFiona LunnNurse Consultant Acute Stroke,University Hospitals of NorthStaffordshire NHS TrustEmail: [email protected]


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Organisations and individuals whoprovided their opinions around theguidance and therapy services,

1. Those who responded to ourquestionnaire

• Dr Jane BartonConsultant Clinical Psychologist,Nether Edge Hospital, Sheffield

• Michael CarpenterCare Quality Commission

• Association of CharteredPhysiotherapists interested inNeurology

• Dawn GoodNational Stroke Nursing Forum

• Dr Cherry KilbrideRoyal College of Physicians,Intercollegiate Working Party

• Professor Michael BarnesBritish Society of RehabilitationMedicine

• Lorna Leyword and Joe KornerStroke Association

• The Consultant Nurse and AlliedHealth Professionals in StrokeGroup

• Julian CoombesAssociate Director of Rehabilitation,Florida Hospitals

• Dr Mark BayleyMedical Director of the NeuroRehabilitation Programme, Toronto

• National rehabilitation projectteams 2009 -10York Hospital NHS FoundationTrustMedway Community Healthcare

2. The seven day workingworkshop group

• Sue VarleyService Improvement Lead, DorsetCardiac and Stroke Network

• Dr Andrew Bateman PhD. MCSPAffiliated Lecturer, Department ofPsychiatry, University of Cambridgeand Manager of CambridgeshireCommunity NeurorehabilitationService

• Sally-Anne RichardsonTeam Leader Occupational Therapy,York Hospital NHS Foundation Trust

• Trudie FranceConsultant Practitioner, MedwayCommunity Healthcare

• Chris GedgeSpecialist Stroke Practitioner, MedwayCommunity Healthcare

• Elizabeth BennettStroke Project Manager, Anglia Heartand Stroke Network

• Fiona JenkinsStroke Services Manager, MedwayCommunity Healthcare.

• David BroomheadPhysiotherapy Service Manager, NorthLincolnshire and Goole NHSFoundation Trust

• Michelle GrahamProgramme Manager for the StrokeCollaborative, National Leadershipand Innovation Agency for Healthcare(NLIAH), Wales

• Jan MathewClinical Specialist Physiotherapist,Northampton General Hospitaland PCT

• Carol HaltonTherapy Manager, South TeesHospitals NHS Foundation Trust

• John MallettModern Matron, Norfolk CommunityHealth and Care

• Debbie LevineSenior Occupational Therapist, AintreeHospital NHS Trust

• Patricia ElmoreSenior Physiotherapist, AintreeHospital NHS Trust

• Pam MortimerAssociate Director, Commissioning,North East Essex

Stakeholders


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NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lungand stroke and demonstrates some of the most leading edge improvement work in Englandwhich supports improved patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health sector

partners, professional bodies and charities, over the past year it has tested, implemented,

sustained and spread quantifiable improvements with over 250 sites across the country as

well as providing an improvement tool to over 1,000 GP practices.

Delivering tomorrow’simprovement agendafor the NHS

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