PRESENTATION TITLE

Stroke Services

Cheshire & Merseyside

Dr Deborah Lowe

Consultant Stroke Physician

SCN Clinical Lead for Stroke

Why are we here?

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

• Most would support services at local Trust, but only if this is

deliverable, affordable and sustainable

• How can we ensure that the majority of patients receive the best

quality stroke care?

• What are we accepting as our core standards?

• Which services currently fall below that standard?

• What reconfigurations are needed within Cheshire & Merseyside to

provide equitable access whilst not diluting quality of care?

Background

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

• Population of approx 2.5 million people

• All have ‘Acute Stroke Units’

• 34 Stroke Consultants / Associate Specialists working within Stroke

• 5 Trusts currently provide 24/7 hyper-acute stroke unit (HASU)

services with approx 610 strokes per year

• 3 Trusts have support from other units for 24/7 cover including use

of telemedicine

• 1 Trust doesn’t have access 24/7 thrombolysis, despite support from

two other large stroke units outside this SCN

Travel times D

rive

tim

e

betw

een

trus

ts

(min

utes

)

Ain

tree

Cou

ntes

s of

Che

ster

Mac

cles

fiel

d

Leig

hton

RLB

UH

T

Sout

hpor

t

Whi

ston

War

ring

ton

Arr

owe

Park

Nor

th S

taff

s

Salf

ord

Step

ping

Hill

Wyt

hens

haw

e

Aintree * 36 49 48 14 25 14 24 25 55 31 45 40

Countess of

Chester36 * 48 33 31 51 31 29 20 47 39 44 39

Macclesfield 49 48 * 35 50 59 44 39 53 38 33 20 29

Leighton 48 33 35 * 49 58 43 38 44 26 41 43 38

RLBUHT 14 31 50 49 * 34 18 25 17 57 32 47 42

Southport 25 51 59 58 34 * 34 38 44 66 41 56 51

Whiston 14 31 44 43 18 34 * 19 33 51 26 40 36

Warrington 24 29 39 38 25 38 19 * 36 46 21 36 31

Arrowe Park 25 20 53 44 17 44 33 36 * 58 46 50 45

North Staffs 55 47 38 26 57 66 51 46 58 * 48 50 45

Salford 31 39 33 41 32 41 26 21 46 48 * 23 19

Stepping Hill 45 44 20 43 47 56 40 36 50 50 23 * 17

Wythenshawe 40 39 29 38 42 51 36 31 45 45 19 17 *

Data source: Microsoft Mappoint

Cheshire and Merseyside

comparisons

Cheshire and

Merseyside

Greater

Manchester

London

Population 2,510,884 2,807,005 8,818,097

Geographical area 1150 sq miles 493 sq miles 700 sq miles

% pop over 40 yrs

(M/F)

24%/27% 23%/25% 19%/21%

Incidence of AF 45,020 (1.8%) 38442 (1.4%) 795572 (0.9%) Data source : QOF

Cheshire and Merseyside demographics Population Prevalence of

CVD

Prevalence of

stroke

Prevalence

of AF

CHADS2>1

anticoagulated

Eastern Cheshire 194,793 10.4% 2.10% 2.1% 81.6%

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

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

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

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

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

Southport and

Formby

114,205 11.7% 2.59% 2.2% 82%

St Helens 175,405 10.4% 2.33% 1.8% 81.3%

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

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

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

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

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

Data source: Cardiovascular intelligence network

Trust catchment populations

Trust Catchment Population

Aintree 330,000

Countess of Chester 445,000

Macclesfield 450,000

Leighton 280,000

RLBUHT 750,000

Southport 225,000

Whiston 350,000

Warrington 500,000

Arrowe Park 400,000

Data source: Individual trust websites

RCP SSNAP data

600

1000

Who delivers Stroke Care?

• Medical workforce predominately Geriatricians with

specialist training / experience in stroke

• Mostly Consultant delivered thrombolysis service

• 3 Trusts use telemedicine out of hours

• 32 Consultants, 2 Associate Specialists

• Consultants at most Trusts also part of general medical

rota

• 41 Stroke Nurse Clinicians / Stroke Specialist Nurses

within the region

How is stroke specialist

assessment delivered?

Trust In Hours Out of Hours

Aintree Face to Face Face to Face

Countess of Chester Face to Face Telemedicine

Macclesfield N/A N/A

Leighton Face to Face Face to Face – at North Staffs

RLBUHT Face to Face Face to Face (occasionally

telemedicine)

Southport Face to Face Telemedicine

Whiston Face to Face

(occ telephone to SpR)

Face to Face

Warrington Face to Face Face to Face – at Whiston

Arrowe Park Face to Face Face to Face

Trust Initial

Assessment In

Hours

Initial

Assessment Out

of Hours

Subsequent

Review In Hours

Subsequent

Review Out of

Hours

Aintree Consultant Consultant Consultant /

Stroke Nurse

Clinicians

Stroke Nurse

Clinicians

Countess of

Chester

Consultant Consultant via

Telemedicine

Consultant Medical SpR

Macclesfield

Leighton Consultant /

Specialist Nurse

ED Consultant /

Specialist Nurse

Consultant Medical SpR

RLBUHT Consultant /

Specialist Nurse

Consultant /

Specialist Nurse

Consultant /

Specialist Nurse

Consultant /

Specialist Nurse

Southport Consultant /

Specialist Nurse

Telestroke /

Specialist Nurse

Consultant /

Specialist Nurse

On Call Consultant

/ Specialist Nurse

Whiston Consultant / SpR /

Specialist Nurse

Consultant / SpR /

Specialist Nurse

Consultant Consultant

Warrington Stroke Specialist

Nurse

ED Consultant Consultant Consultant

Arrowe Park Consultant with

Specialist Nurse

Specialist Nurse

then Consultant

Consultant /

Medical SpR

Consultant /

Medical SpR

Thrombolysis assessment?

24/7 thrombolysis at North Staffs for 10% of the population & 7am – 7pm M – F at Stepping Hill otherwise

HASU services provided

at other trusts

• Stepping Hill provide a 7am-7pm weekday service for 90% of East

Cheshire (Macclesfield) population and North Staffs provide a 24/7

service for 10% (South Sector) of East Cheshire population

• RLBUHT provide a HASU service for Liverpool Heart and Chest

• Whiston provide an out of hours service for Warrington (8pm-8am

weekdays and all weekend)

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

population

• Lancs & Cumbria telemedicine network provide out of hours service

for Southport

Ward rounds and

ring fenced stroke beds

Trust Ward rounds 7/7 by a

stroke specialist

Ring fenced HASU beds

Aintree Yes Yes

Countess of Chester Yes Yes

Macclesfield No No

Leighton No No

RLBUHT Yes Yes

Southport No No

Whiston Yes Yes

Warrington Yes Yes

Arrowe Park Yes Yes

Number of beds

and nursing workforce

Trust Total stroke bed no.

(HASU beds/subacute)

*rehabilitation

Number of stroke

specialist nursing

staff (band 6-8) wte

Nursing to

bed ratio – for

10 beds

Stroke Specialist

nursing available

24/7

Aintree 29 (12/17) 7 ? Yes

Countess of

Chester

28 (14/14) 1 ? No

Macclesfield 24 (0/24) 1 ? No

Leighton 28 (8/20) 2 ? No

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

Southport 28 (4/24) 3.8 ? No

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

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

Arrowe Park 46 (10/16) *20 9 ? Yes

CT and MRI scanning

Trust Do you have

rapid access to

CT 24/7?

Do you have rapid

access to MRI ‘in

hours’?

Aintree Yes Yes

Countess of

Chester

Yes Yes

Macclesfield No No

Leighton Yes Yes

RLBUHT Yes Yes

Southport Yes Yes

Whiston Yes No

Warrington Yes Yes

Arrowe Park Yes Yes

Trust Do you

provide

TIA clinics

every

week day?

Do you

have access

to same day

CT?

Do you

have access

to same day

MRI?

Do you

have access

to same day

carotid

doppler?

Do you

have

access to

same day

Echo?

Do you have

access to

same day

ECG/Bloods?

Do you

have

access to

same day

CTA/MRA?

Aintree Yes Yes No Yes No Yes Yes

Countess of

Chester

Yes Yes Yes Yes No Yes Yes

Macclesfield No* No No No No No No

Leighton Yes Yes Yes Yes No Yes Yes

RLBUHT Yes Yes Yes Yes Yes Yes Yes

Southport Yes Yes No Yes No Yes No

Whiston Yes Yes Yes Yes No Yes Yes

Warrington Yes Yes Yes Yes Yes Yes Yes

Arrowe Park Yes Yes Yes Yes No Yes Yes

TIA Services: Week days

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

Trust Do you

provide

TIA clinics

Saturday

and

Sunday?

Do you have

access to

same day

CT?

Do you have

access to

same day

MRI?

Do you have

access to

same day

carotid

doppler?

Do you have

access to

same day

Echo?

Do you have

access to

same day

ECG/Bloods?

Do you

have

access to

same day

CTA/MRA?

Aintree Yes No No No No Yes Yes

Countess of

Chester

Yes Yes Yes No No Yes Yes

Macclesfield No No No No No No No

Leighton No Yes No No No Yes No

RLBUHT Yes Yes Yes No No Yes Yes

Southport No Yes No No No Yes No

Whiston Yes Yes No Yes No Yes No

Warrington Yes Yes No Yes Yes Yes No

Arrowe Park Yes Yes Yes No No Yes Yes

TIA Services: Weekends

Trust Do you

have a

dedicated

stroke

data

clerk?

Do you do

real time

data entry

for

SSNAP?

Who inputs data

to SSNAP?

Do you have

other reporting

requirements?

Will you be

using

Capture

Stroke?

Aintree Yes Not always Combination No Yes

Countess of

Chester

No No Nurse / Data

Clerk

KPIs No

Macclesfield Yes No Nurse / Data

Clerk

KPIs / Other No

Leighton No No Nurse / Admin

Staff

KPIs / IPMR / AQ /

Trust Report

Yes

RLBUHT Yes Not always Combination KPIs / IPMR Yes

Southport No No Nurse KPIs / IPMR / AQ Yes

Whiston Yes No Nurse / Data

Clerk

AQ Yes

Warrington Yes No Nurse / Data

Clerk

KPIs / IPMR / AQ Yes

Arrowe Park Yes Almost Nurse / Data

Clerk

No Already in use

Data collection

Trust Do you

have and

ESD

service?

Is your ESD

service stroke

specific?

Who

provides

your ESD

service?

What is the

duration of

your ESD

pathway?

Who

continues

therapy post

ESD

discharge?

Is ESD a

7 day

service?

Aintree Yes Yes CCG 3 months Community

therapy

No

Countess of

Chester

Yes Yes Acute trust 6 weeks Community

therapy

No

Macclesfield No

Leighton Not currently

but recently

in place

commissioned

RLBUHT Yes Yes Acute trust 6 months Community

neurorehab

No

Southport No but

Community

well developed

Neurorehab service

Whiston Yes Yes Community

trust

Depends on

needs of

patient

Community

neurorehab

No

Warrington Yes Yes 6 weeks Community

therapy

No

Arrowe Park Yes Yes Acute trust 6 – 12

weeks

Community

therapy

Partially

ESD service

Trust Do you have a

neuropsychology

service?

Do you have a

voluntary

organisation

working with

you?

Does your

inpatient rehab

team provide a 7

day service?

Aintree Yes (1.5 WTE) Yes Yes

Countess of Chester No Yes No

Macclesfield No Yes No

Leighton No Yes No

RLBUHT No Yes Yes

Southport Yes (0.4 WTE) Yes No

Whiston Yes (0.6 WTE) Yes Yes

Warrington No Yes No

Arrowe Park Yes (~1 WTE) Yes Yes

Other quality markers

SINAP vs SSNAP

Q4 2012

SINAP

average of 12

indicators

Quartile Q4 2013

SSNAP total

key indicator

score

Grade

Aintree 65 4th 44 D

Countess of

Chester

No data - 44 D

Macclesfield 74.9 2nd 49 D

Leighton 71.7 3rd 41 D

RLBUHT 81.1 2nd 64 C

Southport 62.8 4th 58 D

Whiston 68.3 3rd 42 D

Warrington 62.3 3rd 54 D

Arrowe Park 72.6 3rd 71 B

National

Average

74.7 45

North of England- Cheshire and Mersey SCN Performance

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

Score SSNAP

Score Rank Score

SSNAP

Score Rank

Wirral University Teaching

Hospital NHS Foundation

Trust

Arrowe Park Hospital D 55.8 1 C 63.9 1

Royal Liverpool and

Broadgreen University

Hospitals NHS Trust

Royal Liverpool University

Hospital D 45 4 D 51.7 2

Warrington and Halton

Hospitals NHS Foundation

Trust

Warrington Hospital D 47.5 3 D 48.6 3

Southport and Ormskirk

Hospital NHS Trust

Southport and Formby

District General D 51.3 2 D 44.4 4

East Cheshire NHS Trust Macclesfield District

General Hospital D 43.3 5 D 44.2 5

St Helens and Knowsley

Teaching Hospitals NHS Trust Whiston Hospital E 34.7 8 E 35.7 6

Mid Cheshire Hospitals NHS

Foundation Trust Leighton Hospital D 42.5 6 E 34.9 7

Aintree University Hospitals

NHS Foundation Trust

University Hospital

Aintree E 39 7 E 29.9 8

Countess of Chester Hospital

NHS Foundation Trust

Countess of Chester

Hospital X 0 9 E 23.8 9

Every minute counts ! Time is Brain