London Strategy for Life after Stroke

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London Strategy for Life after Stroke

• Tony Rudd

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Story so far
New acute model of care
Community Rehabilitation Services
Discharge from acute phase
30 min LAS journey
After 72 hours

• Stroke Units
• High quality inpatient rehabilitation
• in local hospital
• Multi-therapy rehabilitation
• On-going medical supervision
• On-site TIA assessment services
• Length of stay variable

• HASUs
• Provide immediate response
• Specialist assessment on arrival
• CT and thrombolysis (if appropriate)
• within 30 minutes
• High dependency care and
• stabilisation
• Length of stay less than 72 hours

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1 year outcomes
of patients spending 90 of their time on a
dedicated SU
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1 year outcomes
Average length of stay
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1 year outcomes
Thrombolysis rates
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10
3.5
Feb-July 2009
Aim
Feb-July 2010
Jan-March 2011
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Improvements in Community Services

• Many more areas now have early supported
  discharge teams
• Some increase in longer term stroke
  rehabilitation teams
• We are reviewing in-patient rehabilitation
  services

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London Stroke Survival vs Rest of England
Hazard ratio for survival in London 0.72 95CI
0.67-0.77 plt0.001
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The Stroke Association UK Stroke Survivor Needs
Survey

• Christopher McKevitt
• Reader in Social Science Health
• Kings College London

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Aims

• To estimate levels of self reported long term
  need in stroke survivors (1-5 years)
• To compare levels of need between stroke
  survivors in England, Scotland, Wales Northern
  Ireland

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Results

• 51 reported having no unmet needs
• Of those reporting unmet needs, total number per
  respondent ranged from 1-13, median 3

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Information

• 54 more information about stroke
• No differences by age, gender, ethnicity,
  disability level or time since stroke
• Significantly different by nation (p0.009)
• Northern Ireland66
• Wales65
• England54
• Scotland49

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Unmet health needs
N reporting problem (weighted ) Need unmet () Need met to some extent ()
Mobility 321 (58.4) 25 43
Falls 265 (43.9) 21 47
Incontinence 217 (37.2) 21 40
Pain 249 (39.5) 15 51
Emotional 244 (38.4) 39 34
Speech 194 (34.3) 28 33
Sight 212 (37.2) 26 39
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Other unmet needs
N reporting problem (weighted ) Need unmet () Need met to some extent ()
Fatigue 301 (51.7) 43 36
Concentration 260 (44.7) 43 41
Memory 260 (42.8) 59 25
Reading 148 (23.2) 34 43
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Changes in social participation

• 52 unable to return to work or reduced hours
• Significantly higher in Black and other ethnic
  groups compared to Whites (p0.006, population
  registers)
• 67 reported loss in leisure activities
• Significantly higher in Black and other ethnic
  groups compared to Whites (p0.012, population
  registers)

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Impact on finances

• 18 of those working at time of stroke reported a
  loss of income since stroke
• 31 reported increased expenses
• 16 (25 population registers) reported need for
  benefits advice

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Family

• 42 reported a negative change in relationship
  with partner
• 26 reported negative changes in family
  relationships

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Groups at higher risk?

• No differences by
• age
• gender
• time since stroke
• Higher unmet need
• disability, including communication disability
• ethnic minority stroke survivors
• people living in poorest areas

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Stroke survivors in London denied recovery says
new report calling for better coordination and
support Stroke survivors across London say
they are being denied the chance to make their
best recovery because of a lack of patchy post
hospital care and confusion between health and
social care services, states a new national
report published today (Tuesday May 1st 2012) by
the Stroke Association.
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Stroke Association Survey Findings

• 85 of stroke survivors say that the impact of
  stroke is not understood
• Six out of ten (59) said that health and social
  care services did not work well together
  resulting in families and carers having to take
  responsibility for coordinating care.
• Almost a third (31) reported services being
  reduced or withdrawn even though their needs had
  stayed the same or had increased.

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Stroke Association Survey Findings

• 38 felt they did not receive enough support from
  NHS services
• Almost a third (31) reported services being
  reduced or withdrawn even though their needs had
  stayed the same or had increased.
• 77 are unable to get out as much since they had
  their stroke.

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Life After Stroke Commissioning Guide
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London stroke strategy where this fits
London stroke strategy (2008)
Public consultation (2008/09)
Rehab commissioning guide (2009)
Life after stroke (2010)
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Principles

• Active citizenship
• Quality of life
• Empowerment

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Scale of need
Sum of stroke and TIA patients in a GP register
in 2008/9

• Prevalence ranges from 1.6 to 0.8 of
  registered GP population
• 88,000 people across London on GP registers have
  had a stroke or TIA

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Diverse needs

• 15 have on-going continence problems
• 25 of nursing home residents have had a stroke
• 33 of stroke survivors report depressive
  symptoms
• 20 silent stroke underlying cognitive
  problems

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Regular review

• Needs change over time
• Recognise variability of needs and aspirations
• National guidance 12 monthly review

Structured social group
Therapist
Social care
Stroke survivor
GP
Stroke navigator
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Information

• Stroke care navigator
• Single point of contact
• Direct role in delivering care
• Coordinate care packages
• Training stroke survivors and carers
• Work across different sectors
• London stroke directory
• www.londonstrokedirectory.org.uk

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Engaging with community life

• Stroke survivors do not get out of the home as
  much as they would like
• Building confidence
• Addressing practical issues
• Community/social groups have benefits beyond
  primary purpose

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Peer support peer-led services
Improve emotional wellbeing
Sense of purpose
Confidence
Peer support
Build capacity
Range of functions
Source of information
Improve functional status
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Carers and families

• Carers have a right to their own needs review
• Training and education should be provided
• Local authority and charitable sector support is
  available

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Conclusions

• Stroke care is better in London as a result of
  the stroke reorganisation
• BUT......
• Still failing to meet longer terms needs of
  people after stroke
• There is no additional money for changing these
  services
• Need to persuade commissioners that these are
  services that are worth investing in for both
  clinical and economic reasons
• Major concerns that government cuts will
  negatively affect the resources available to
  people for longer term support