Mind the gap

NHS
CANCER
NHS Improvement
Stroke

DIAGNOSTICS

HEART

LUNG

STROKE
MIND
THE
GAP
TO

WAYS
ENHANCE
THERAPY
IN

PROVISION
STROKE
REHABILITATION

Acknowledgements
Authors: With additional thanks for their support,
contributions and comments to:
Jill Lockhart, National Improvement Lead,
NHS Improvement - Stroke Professor A Rudd, Stroke Physician, Guy’s and
St Thomas’ Hospital
Ina James, Team Leader Physiotherapist, Stroke
Services, York Hospitals NHS Foundation Trust Professor V Pomeroy, Professor of
Neurorehabilitation, University of East Anglia
Gail Linstead, Stroke Service Improvement
Manager, North of England Cardiovascular National rehabilitation projects 2009-10
Network Therapy Teams from Medway Healthcare and
York NHS Foundation Trust
With considerable thanks to the NHS
Improvement - Stroke Increasing Access to Brighton Paradza, Senior Clinical Specialist
Therapy National Project Teams: Physiotherapist, Cardiothoracic Acute
Services, The James Cook University Hospital
Sheffield Teaching Hospitals NHS Foundation
Trust, Stroke Therapy Service Fiona Lunn, Nurse Consultant Stroke and the
Stroke Team at University Hospital of North
Sheffield Primary Care Trust Speech and Staffordshire NHS Trust
Language Therapy Service into Sheffield
Teaching Hospitals NHS Foundation Trust

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

Newton Abbot Hospital Teign Ward and
Torbay and Southern Devon Care Trust Stroke
Therapy Team and Community Neurology
Service Team, South Devon

NHS Camden - stroke REDs team

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

South Tyneside NHS Foundation Trust
Physiotherapy Stroke Team

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

Chesterfield Royal Hospital NHS Foundation
Trust Acute Stroke Unit Team

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

Contents
4 Foreword
5 Executive summary
6 Introduction
8 National guidelines
10 Who can deliver more rehabilitation?
14 When - a seven day service?
17 How long - getting more out of the whole week?
22 Where can more therapy make a difference?
24 How - bridging the gap?
28 Conclusions
30 References
31 Case studies
32 NHS Camden – stroke REDs
Improving access to 45 minutes of therapy for stroke patients
36 The community stroke team in Blackburn with Darwen,
part of Lancashire Care NHS Foundation Trust
Retrospective evaluation of therapy need and provision
37 Medway Community Healthcare Stroke Rehabilitation Unit,
St Bartholomew’s Hospital, Rochester, Kent
Improving access to 45 minutes of therapy for stroke patients
39 South Tyneside NHS Foundation Trust
Increased stroke physiotherapy provision on stroke wards
40 Sheffield Teaching Hospitals NHS Foundation Trust
Implementing seven day occupational and physiotherapy services for stroke
42 Sheffield Primary Care Trust and Sheffield Teaching Hospitals NHS Foundation Trust
Sheffield stroke unit seven day working pilot for speech and language therapy
43 Chesterfield Royal Hospital NHS Foundation Trust
Developing a seven day physiotherapy service on the acute stroke unit
44 Newton Abbot Hospital stroke unit with Torbay and Southern Devon Care Trust
South Devon Stroke Services: Seven day working and 45 minutes of therapies
46 Guys and St Thomas’ NHS Foundation Trust
Seven day service: Weekend rehabilitation support worker model
48 Stoke-on-Trent: University Hospital of North Staffordshire NHS Trust
49 Stakeholders

3


Foreword
One thing we have learnt from
implementation of the National Stroke
Strategy is that the NHS cannot be a
Monday to Friday service any more for
people who have had a stroke. The
faster you act, the more of the person
you save is the mantra for the medical
emergency response, and increasingly,
we are seeing this is what is needed
for therapy services too.

The NICE Quality Standards for Stroke
gives therapists a standard to work to
for the first time. This report gives you
lots of ideas and methods to get
started to make those standards a
reality. It’s going to require hard work
and soul searching to think carefully
about what you do now and what can
be changed and improved. I urge you
to embrace this as a way to describe
what you do and ensure it is valued by
everyone.

In a stroke team, rehabilitation is
everyone's business. The teams
featured in this report have learnt to
share skills and to make rehabilitation
the basis of the patient’s day.

And that’s the key message. We must
make sure the service works to meet
the needs of the patient, not the
other way around.

Professor Sir Roger Boyle CBE

4


Executive summary
It is accepted that rehabilitation is an
essential part of the management and
treatment for stroke survivors -

“Rehabilitation after
stroke works. Specialist
co-ordinated rehabilitation,
started early after stroke and
provided with sufficient
intensity, reduces mortality
and long-term disability.”
National Stroke Strategy 2007

There is much diversity across the
shape, content and delivery of
rehabilitation and therapy services
across England and this presents a
challenge for both service
improvement and research.
All patients can have a rest day if it is Well organised and structured
This project explored some of the appropriate, but it doesn’t always additional therapy services, delivered
different models adopted by therapy need to be Saturday or Sunday for over more days of the week impact
services to deliver more therapy/ every patient. Seven day therapy positively on patients and therapy
rehabilitation in the context of major services enable equity of access and delivery (frequency and intensity)
change within the NHS nationally and the opportunity for patients to begin across the whole week.
locally. their treatment as early as possible.
They support swifter multidisciplinary This work has, arguably, only
This publication discusses their effect team engagement and speedier scratched the surface of the issue of
on patients, services and organisations, progress, thereby capitalising on other therapy availability, yet hopefully,
provides some useful learning to improvements to the front part of the provides useful ideas and insights.
inform the debate with further detail stroke pathway. Meanwhile, seven day Project teams have shown the benefit
about 45 minutes, process and community stroke services can have of applying systematic service
outcomes and asks further questions more influence on hospital length of improvement analyses to their
for therapy services to consider. stay than weekend therapy inpatient functioning, processes and patient
services. outcomes. To support further
The commonly emerging themes were development, more scientific research
how important it is to understand Access to, and delivery of, 45 minutes in this area is also crucial. It is worth
existing services fully by using therapy, improved when seven day noting that improved and efficient
accurate data and relevant data services were available and following services create an environment in
analysis, that managing human demand and capacity activity analysis which research can be better
dimensions is paramount with making across the pathway. This improvement facilitated and enabled, and an
such huge cultural changes within brought different benefits reflecting effective research culture within
therapy services and the need to the service needs, patient stage of clinical services enhances their ability
continue optimising workforce recovery and their goals. All models to care for their
combinations and work collectively received very positive qualitative patients.
along the pathway is essential to feedback from patients regardless of
delivering effective responsive and who delivered it.
timely services.

5


Introduction
There are many policy drivers for this
project including the National Stroke
Strategy (1), Royal College of
Physicians (RCP) National Clinical
Guidelines for Stroke (2), National
Institute for Clinical Excellence (NICE)
quality standards for stroke (3), and
Care Quality Commission (CQC)
report on stroke services (4).

In addition, the requirement to
improve quality and productivity to
ensure services continue to meet
demand within existing resources
requires all services to review and
maximise the use of their workforce.
Therapy stroke services are facing
increasing pressure as research
suggests that their services deliver
poorer outcomes, yet are better
resourced than some European
counterparts. (14) There is increasing
pressure from commissioners to
demonstrate the added value of
specialist services, in comparison with
generic ones. National standards set out the Project teams also wanted to
expectations; however, services are understand more clearly which
This can be viewed by therapists as a struggling to work out how to patients receive most therapy and why
challenge to their services, or as an implement them. This publication this happens. The projects did not aim
opportunity to examine practice summarises some practical service to examine the questions around ad
objectively and pragmatically, gain a delivery solutions and the ways in hoc or formalised organisation of
fuller understanding of how they can which these “Mind the Gap”. therapy services, whether more
improve patient contact time and therapy improved clinical functional
deliver higher quality rehabilitation Process of the projects outcomes, or the nature of the clinical
across the stroke pathway. This would Aim approaches and modalities used.
enhance the significant changes that The aim of this work was to:
have already taken place in stroke care • Look at the impact of different
and positively embrace the culture models that stroke services are using
change required to deliver a to increase access to therapy and
responsive, flexible, timely and rehabilitation
relevant therapy service for stroke • Understand how to affect delivery
survivors. of national quality standards,
guidelines and aspirations for stroke
services
• See if there were any changes to
treatment intensity or frequency,
length of stay and other outcomes.

6


Methodology This publication builds on the learning • South Devon - A combined team
There were two project streams: from project sites in the national of therapists on the stroke
1. Delivering 45 minutes of rehabilitation projects 2009-10 (25) by rehabilitation unit at Newton Abbot
therapy further work with the nine project Hospital, and community
2. Providing a seven day service. sites involved in delivering seven day neurology service
or 45 minutes of therapy services. It is • The NHS Camden - stroke REDs
There were nine project sites who not presented as scientific research, team
participated in the project from both but service improvement work, with • Community stroke team in
hospital and community measurement and comment Blackburn with Darwen,
environments. accordingly. part of Lancashire Care NHS
Foundation Trust
Each site provided information on: Observations are included from other • South Tyneside NHS Foundation
• Population sites across stroke and wider therapy Trust physiotherapy stroke team
• Numbers of stroke patients services in England, and stroke • Medway Community Healthcare,
referred therapy services in USA, Canada and the staff on the stroke rehabilitation
• Type of service New Zealand. The publication includes unit at St Bartholomew’s Hospital,
• Bed numbers (if applicable) some of the research evidence and Rochester, Kent
• Staffing the results of a consultation with a • Chesterfield Royal Hospital NHS
• Length of stay and/or functional wide range of relevant stakeholders. Foundation Trust acute stroke
outcomes. unit team.
Project teams
Each site also collected data on The organisations taking part in the For ease of reading, teams will be
approximately 30 patients. The projects were as follows: referred to by the emboldened titles
samples were not comparable and are above in the rest of the document.
only a snapshot of each site. Only one • Sheffield therapy team, from the
site managed to collect data before Sheffield Teaching Hospitals NHS
and after a change in service delivery Foundation Trust
took place. The data included some or • Sheffield speech and language
all of the following: therapy, from the Sheffield Primary
Care Trust speech and language
• Admission to treatment service into Sheffield Teaching
• Frequency of treatment (i.e. how Hospitals NHS Foundation Trust
often or on how many days therapy • The stroke unit at St Thomas’
was given) Hospital, Guys and St Thomas’ NHS
• Intensity of treatment (how long the Foundation Trust
treatment session was for)
• Therapist opinion on frequency and
intensity required
• Reason for 45 minutes of therapy
not being received
• Staff, patient and carer satisfaction.

7


National guidelines

NATIONAL STROKE STRATEGY - QUALITY STANDARDS FOR
DEPARTMENT OF HEALTH STROKE - NICE

“People who have had strokes access Quality Standard - 5
high-quality rehabilitation and, with their Patients with stroke are assessed and
carer, receive support from stroke-skilled managed by stroke nursing staff and at
services as soon as possible after they least one member of the specialist
have a stroke, available in hospital, rehabilitation team within 24 hours of
immediately after transfer from hospital admission to hospital, and by all relevant
and for as long as they need it.” (Quality members of the specialist rehabilitation
Marker 10: High quality specialist team within 72 hours, with documented
rehabilitation) multidisciplinary goals agreed within five
days.
“Survival is strongly associated with
processes of care… such as early Quality Standard - 6
mobilisation, early feeding and measures Patients who need ongoing inpatient
to prevent aspiration. Speech and rehabilitation after completion of their
language therapists, physiotherapists, acute diagnosis and treatment are
occupational therapists and dietitians treated in a specialist stroke
have specific contributions to make in rehabilitation unit.
delivering these particular aspects of
care. The probable explanation for Quality Standard - 7
higher survival and lower Patients with stroke are offered a
institutionalisation rates (on stroke units) minimum of 45 minutes of each active
are the significant differences in both therapy that is required, for a minimum
multidisciplinary team working – such as of five days a week, at a level that
early assessment, goal setting and enables the patient to meet their
discharge planning.” (Quality Marker 9: rehabilitation goals for as long as they
Treatment) are continuing to benefit from the
therapy and are able to tolerate it.
“Existing staffing numbers and skill mix
profiles are insufficient to deliver the Quality Standard -10
required input in stroke care pathways. All patients discharged from hospital
Workforce review is therefore needed, who have residual stroke-related
along with a workforce plan that defines problems are followed up within 72
the care pathway, lists the functions at hours by specialist stroke rehabilitation
each stage and the competencies services for assessment and ongoing
required to perform the functions, and management.
then ensures training is put in place to
support staff to acquire the
competencies. “ It recommends that
services “consider new and more flexible
roles (i.e. expanding roles across
professional boundaries)” (Quality
Marker 18: Leadership and skills)

8


NATIONAL CLINICAL GUIDELINE FOR
STROKE, THIRD EDITION – ROYAL
COLLEGE OF PHYSICIANS

A) Patients should undergo as much
therapy appropriate to their needs as
they are willing and able to tolerate
and in the early stages they should
receive a minimum of 45 minutes
daily of each therapy that is required.

B) The team should promote the practice
of skills gained in therapy into the
patient’s daily routine in a consistent
manner and patients should be
enabled and encouraged to practice
that activity as much as possible.

C) Therapy assistants may facilitate
practice but should work under the
guidance of a qualified therapist.

Further assessments can and should be
undertaken later, and this set of
recommendations focuses on those that
are important in the first 48 hours; to
identify major impairments that may not
be obvious but that may have an
influence on early management, guide
prognosis and draw attention to
immediate rehabilitation needs.

“All patients with any impairment at 24
hours should receive a full
multidisciplinary assessment using an
agreed procedure or protocol within five
working days, and this should be
documented in the notes”.

9


Who can deliver more rehabilitation?
Flexibility and creativity about staffing What the stakeholders say
KEY MESSAGES
may be needed to deliver improved The general consensus from the
rehabilitation for stroke patients. This stakeholders is that rehabilitation • A flexible and creative
section describes the different assistants are a cost effective way of approach to rostering can
approaches the projects took, and the ensuring that patients get a robust gain support from a wider
impact. rehabilitation package, and may be pool of appropriate staff to
essential to meeting both 45 minutes keep additional services
What the evidence says and seven day therapy provision. sustainable and enhance
The NICE quality standards define However services need to have clinical skills for therapists
therapy services as physiotherapy, mechanisms in place to ensure that • Weekend services that include
occupational therapy, and speech and these assistants have suitable acute and community staff
language therapy. Individual patients supervision and support to maintain can assist with a smoother
may require treatment from other the competencies required to follow transfer of care experience for
professionals such as clinical professionally developed plans patient and carers
psychologists and dieticians. They are effectively. • Additional rehabilitation
relevant to all environments across the provided by a therapy team
pathway. (3) Royal College of Other time consuming tasks such as has more impact meeting
Physician (RCP) Guidelines state that completing outcome measures, required standards than when
therapy assistants may facilitate the delivering equipment and some it is delivered by suitably
practice but should work under the administrative tasks could be trained nurses
guidance of the qualified therapist. (2) delegated to rehabilitation assistants • Stroke skilled support workers
to free up qualified therapists’ time. can assist therapy services
Practice outside the UK with achieving 45 minute
In the US, state-funded Medicare The stakeholders also suggest that to therapy sessions and seven
requires specifically physiotherapy, achieve both the access to seven day day services and are integral
occupational therapy, and speech and services and 45 minutes of therapy, to achieving the NICE quality
language therapy are delivered, but teams should take a more integrated standards
services such as psychology are not approach to rehabilitation. Therapists • Joint working with nurses has
included. Therapy services can be should increase involvement with the a positive effect on cohesion
supported by rehabilitation patient and the wider team, and and compliance and can be
technicians for administrative who where appropriate should include achieved in addition to direct
support work and are not directly nursing staff and the family in therapeutic clinical contact
involved in the provision of therapy promoting a continuous rehabilitation time
services. Qualified occupational culture. This can also support the
therapy assistants and physical patient towards self-management in
therapy assistants may provide the longer term.
therapy services directly to patients
under the appropriate supervision of
licensed therapists, and families are
very engaged.

10


Project findings The South Tyneside physiotherapy This model enables the service to
The stroke unit at St Thomas’ stroke team provided a weekend meet the NICE quality standards 5 and
Hospital offers an additional service for the stroke unit, by 6, the National Stroke Strategy and
weekend rehabilitation service that is recruiting an additional band 5 the RCP guidelines for physiotherapy.
provided by rehabilitation support physiotherapist and band 4 technical Their admission to assessment time
workers who work as healthcare instructor to work five days improved from 52% within 72 hours
assistants during the week. The comprising three during the week and (2008) to 93%.
content and structure of the weekend two at the weekend. They solved the
programme is selected by the recruitment challenge by including the The South Devon team on the stroke
therapists from an ‘options menu’. post within the existing band 5 rehabilitation unit at Newton Abbot
rotation scheme, and gradually rolled Hospital reallocated existing funding
Whilst the 20 minute sessions the out the changes in contracts with for the band 5 physiotherapy post to
rehabilitation support workers provide each new member of staff. fund three band 3 rehabilitation
do not meet the NICE quality support assistants and four hours of a
standards or RCP guidelines To ensure competence, supervision band 6 occupational therapist or
specifically, they do demonstrate a and support the band 5 therapist can physiotherapist for Saturday. The
proactive multidisciplinary approach to liaise with the on call therapy team at additional rehabilitation support
rehabilitation, and support workforce weekends, and is supported during assistants are rostered from Saturday
flexibility. Patients have a greater the rest of the week from within the to Tuesday, and the qualified staff
number of rehabilitation contacts stroke team. The stroke team act from a rota of stroke skilled therapists
during admission, but not therapy pragmatically and flexibly when there from the team and community
direct contacts. Therapists feel that is a vacant post to provide a six day service.
patients who use this service maintain service from within the existing staff.
better ‘carry over’ for Monday than Their new model demonstrated an
those who do not. Since the inception of the project, improvement in admission to
many more patients have received 45 treatment time, with 100% of
minutes of physiotherapy, and therapy patients being assessed within 72
has been provided at the weekend. hours compared to 80% in 2008. All
appropriate patients were able to
access 45 minute treatment sessions
Percentage of patients seen for 45 minutes of therapy compared to 92% in 2008. Feedback
before and after the changes in South Tyneside from patients and carers was already
very good, but had highlighted a wish
for more therapy opportunities.
Before introduction of Since August 2009 Since August Since Aug 2009
project (week days) (week days) 2009 average daily
(weekends) (seven day) Staff felt that communication
between hospital and community
33.8% 75.6% 68% 68% services, and appreciation of the
transfer process for patients,
improved. It also meant that weekend
staff had a reasonable frequency of
shifts to maintain their work-life
balance, and enabled community
therapists to keep their acute
rehabilitation skills up to date.

11


The benefits for the patients, service In Blackburn with Darwen, the Assistant support staff, backed up by
and carers with the new model community stroke team have competency based education, can
outweighed the disadvantages of the established support links with a pool enable therapy services to improve
loss of a band 5 rotational post on the of rehabilitation support workers and assessment time, and 45 minute
service. intermediate care support staff which therapy sessions, more readily than
enables them to provide 45 minutes healthcare assistants (Blackburn with
In Sheffield Teaching Hospitals NHS of therapy, daily and for as long as Darwen community stroke team).
Foundation Trust the occupational needed to meet NICE quality This is because of their contribution
therapy and physiotherapy services, standards. Their data showed that within the team across seven days.
moved from five to seven day services most of the 45 minute sessions were Healthcare assistants can bring
as part of a major change across delivered by the rehabilitation different benefits, such as a greater
therapy teams. The stroke service assistants with varied support from understanding of the rehabilitation
included an ‘away team’ comprising qualified therapists. process when delivering nursing
therapists from neurosciences, spinal care.(St Thomas’ Hospital).
injuries and neuro-rehabilitation Summary
services and a ‘home team’ All the models demonstrated higher The Sheffield therapy team project
comprising staff from the stroke team. patient and carer satisfaction, but only demonstrated the challenges faced
those that included additional when taking therapy staff with
It was felt that although there were qualified staff were able to impact on common core neurology skills into a
commonalities of clinical skills, the assessment time and the NICE quality different environment and the need to
transposition of staff into a different standards. Traditional concerns around support and manage this carefully. In
geographical location, with unfamiliar using band 5 therapists and sufficient South Devon a creative and inclusive
equipment, protocols, documentation supervision at weekends were avoided approach to rostering meant weekend
and profiles, required considerably by the South Tyneside model and in staff had the reasonable frequency of
more adjustment and settling in time South Devon the loss of the band 5 shifts to maintain a work/life balance
than had been anticipated. With up to was outweighed by the gains. No and enabled community therapists to
28 staff within therapy services model impacted negatively on keep their acute rehabilitation skills up
working on a weekend a robust recruitment, supervision, retention of to date.
support system was required which staff, or length of stay.
included the rostering of a duty
manager for therapy services at
weekends to support staff and deal Sheffield Teaching Hospitals NHS Foundation Trust -
with any staffing problems. Ability to deliver 45 minutes

Before the seven day service, 100
Sheffield OT Sheffield PT
physiotherapy and occupational 90
therapy were able to provide access to 80
45 minutes of therapy for 76% of the
time, on average, for appropriate 70
patients. Post implementation this
Percentage

60
increased to 92% for physiotherapy 50
and 91% for occupational therapy.
NICE quality standards 5 and 6 were 40
achieved. The recommendations of 30
the National Stroke Strategy around
20
vital signs and early access to therapy,
45 minute sessions and delivery of 10
RCP clinical guidelines improved. 0
Pre seven day Post seven day

12


Where teams instigated specific joint
working, there were initial
reservations from some therapy staff
that their skills would be diluted.
However, it was found to have
positive effects not only on the
patients and nursing staff directly, but
on compliance with therapy
timetabling, as therapists still had time
to undertake their specific and highly
complex therapy work. Joint working
may improve communication; by
working in tandem, information is
passed on and there is less time
wasted. In addition, there is greater
consistency with handling and moving
patients, an area often highlighted as
a concern by patients.

13


When - a seven day service?
This section looks at the frequency of Practice outside the UK
KEY MESSAGES
rehabilitation required to meet NICE In the US, state funded Medicare
quality standard 7 to offer therapy services adopt the ‘three hour rule’ - • Weekend therapy services
input ‘for a minimum of five days a three hours a day of physiotherapy, impact on service delivery
week’; and the potential alternatives occupational therapy and speech and across the whole week
for delivery of additional services. language therapy five to six days a positively
week. The staffing ratio is 7:1 patient: • Seven day services can have
What the evidence says therapist each day, supplemented greater impact than six day
Studies in US rehabilitation centres with administrative rehabilitation services
found that factors such as function at technicians. • Additional days of therapy
admission, length of stay and intensity services have a positive effect
of therapy collectively contributed to In addition to this there are one to on admission to treatment
greater functional gains, but length of two hours daily of occupational times and 45 minutes of
stay and intensity of therapy alone did therapy or physiotherapy group therapy
not always [Chen et al] (20) sessions and weekly speech and • Seven day therapy services
cognitive group therapy sessions. enable patients to begin their
A single study found moderate treatment as early as possible
evidence that the same therapies In Canada, the requirement is for a • Seven day community stroke
delivered more intensively, over a minimum of one hour of direct services can influence hospital
shorter period of time, resulted in therapy for each relevant core therapy, length of stay and vital signs
faster recovery and earlier discharge for a minimum of five days a week positively and more
from hospital [Teasell et al] (5). based on individual need and significantly than single
tolerance. (10) therapy weekend inpatient
A trial conducted in Japan compared services
outcomes for stroke patients admitted What the stakeholders say • Patients and carers welcome
to a conventional stroke rehabilitation Access to therapy, and therapy additional rehabilitation
programme five days per week and assessments, should be consistent and opportunities at weekends
patients admitted to a programme continuous within rehabilitation
seven days per week. The intensity settings across seven days. In turn,
and frequency of treatment varied patients are more likely to respond
between the programmes and better to therapy, avoiding a loss of
patients were encouraged to remain momentum over a weekend and
active outside of the structured therapists could have more capacity to
sessions. Additional weekend therapy offer 45 minutes of therapy. Some
resulted in significant improvements in stakeholders felt that patients need to
FIM1 scores as well as a reduction in have a day of rest and reflection, and
length of stay. [Sonoda et al] (21] they agreed that patients risk losing
[Teasell] (5). out if this happens on a week day and
no weekend service is available.

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

14


Project findings Qualitative data indicated that all In Chesterfield Royal Hospital, the
In South Devon, the additional speech and language therapists seven day physiotherapy service on
service over the weekend enabled involved in the pilot felt that they had the acute stroke unit found that
patients to have an increase in impacted positively on patients by although they did not reduce length
number of sessions. This also having this service, and 50% felt of stay significantly, there was a
impacted positively on the team’s happy to be working at a weekend. gradual process of setting discharges
ability to deliver 45 minute sessions. The team noted that there seemed to for earlier in the week than before.
Patients’ length of stay was already be more clinical need for dysphagia They commented on an improved feel
improving and could not solely be assessment than dysphasia treatment. to Mondays due to the reduced
attributed to the additional weekend pressure to catch up with the backlog
service. In the Sheffield therapy team, funds from the weekend.
were provided for seven day working
For the South Tyneside team, the across orthopaedics, stroke, ‘front of Blackburn with Darwen community
seven day physiotherapy service door’ and respiratory services. The stroke team and NHS Camden -
assessed all patients within 24 hours additional service for stroke comprised stroke REDs community stroke
and delivered 45 minute sessions an occupational therapist, a teams both operate through a
where appropriate, although length of physiotherapist and two assistants multidisciplinary ‘in reach’ model and
stay was not significantly altered. The who took their time back from provide occupational therapy,
team agreed that to do that a similar existing services in the week. physiotherapy, speech and language
service from occupational therapy therapy five days a week and
would be needed. At the weekend patients were ‘enabling care’ (rehabilitation support
prioritised according to four criteria: through suitably trained social care
The Sheffield speech and language staff) seven days a week. They meet
therapy team piloted Saturday 1. To facilitate discharge NICE quality standards 7 and 10, the
morning working over three months 2. Eligibility for existing ESD RCP guidelines and quality marker 10
on the acute stoke unit. The service 3. New patients (rehabilitation) quality marker 12
was provided by band 6 and 7 speech 4. Other rehabilitation patients (transfer of care and health and social
and language therapists, from a roster care joint working) and quality marker
of paid volunteers. In the pilot they The team noted that the effect of 19 (workforce) of the National Stroke
found, from a small sample size, that seven day working within stroke Strategy. NHS Camden - stroke
80% of patients referred to speech seemed to be stronger for facilitating REDs data showed a significant
and language therapy were seen discharge. Their data showed a contribution to reducing length of
within 24 hours, 25% of patients positive impact on admission to stay in the acute hospital, now down
required daily speech and language assessment times from 62 hrs to 10 days, and demonstrated to local
therapy at some point in their stay, (occupational therapy) and 47.4 hours organisations the contribution of
but not consistently across their whole (physiotherapy) pre change, to 25.6 comprehensive and responsive
inpatient spell, and more than 50% hours for occupational therapy and community stroke services to
required 45 minutes on some days. 30.4 hours for physiotherapy post resolution of acute challenges.
change.

15


Summary through whole pathway change,
The project teams reported that the when all services operate across seven
biggest impact of a seven day service days. Single professional changes, in
was on admission to treatment time one part of the pathway only, are
and the ability to provide an equitable unlikely to have a significant impact
service. Once this had occurred, they on length of stay or cost benefits for
found that the whole working week an organisation. (South Tyneside).
began to change too, and therapists However, they do have a positive
could offer more contact time. effect on satisfaction levels, speedier
access to assessment and frequency
Services across seven days moved and intensity of sessions for those
closer to achieving the NICE quality patients who can tolerate it.
standard than six day services.
Findings of teams from Medway Patients also value opportunities for
Community Healthcare and York more therapy across the pathway.
Hospital NHS Foundation Trust in the Therapy services may consider
national projects 2009 - 2010 who developing seven day services as a first
delivered a six day therapy service step towards achieving 45 minute
improved admission to treatment therapy sessions, because of its impact
time, but could not achieve 100% on intensity as well as frequency.
(25). Seven day services in South
Tyneside and Chesterfield Royal However, any opportunity to enhance
Hospital achieved this standard. This rehabilitation, by weekend sessions
is likely to be due to a removal of the from suitably trained healthcare
weekend backlog of outstanding assistants (St Thomas’ Hospital) or,
assessments on Mondays, freeing up by joint working (Medway
more time each day to allocate for Community Healthcare and South
direct treatment and the effect of a Devon) or by having an additional
seven day presence on presence (Sheffield speech and
communication between the language therapy) can bring benefit;
multidisciplinary team, and with either for multidisciplinary team
patients and carers. Models that used cohesion, mutual support, and
existing therapy staff differently or education or simply improving
over more hours in the week found communication and reducing the
more opportunities to deliver a greater need for additional documentation.
proportion of 45 minute sessions and
for joint working than in five days.

The findings of the projects show
that, once established, the culture
of a seven day service facilitates
more timely decision making.
(Chesterfield Royal Hospital) It has
the potential to shorten length of stay

16


How long - getting more out
of the whole week?
This section deals with the intensity of For example, one survey observed that What the stakeholders say
a patient’s therapy, meeting the NICE a significant treatment effect was Stakeholders indicated that therapy
quality standard of 45 minutes. achieved among studies which should be available to patients as early
provided a mean of 8.8 hours of as possible once they are medically
What the evidence says therapy per week for 11.2 weeks stable, and commented that
There is evidence to show that higher compared to trials that only provided psychology should be included
intensities of treatment can impact approximately two hours per week for because if problems are left
significantly on outcomes, activities 22.9 weeks. [Bhogal et al] (24). One unattended, they can become worse
for daily living and reduce study that looked into the benefits of over time. Some suggested that if in
impairments. [Langhorne et al] (7) aphasia therapy reported problems the early stages some patients are
[Kwakkel et al] (11) Patients may not with patients’ tolerance of intensive unable to tolerate a single 45 minutes
benefit equally, which makes specific therapy. However, patients who session, services can deliver multiple
guidance about intensity of received an average of 1.6 hours of shorter sessions over the course of
rehabilitation therapy harder to therapy per week had significantly one day.
provide. [Duncan et al] (9). higher scores than those who received
Many therapists express concern only 0.57 hours of therapy. [Bakheit et If two therapy staff are involved in a
about how many patients can tolerate al] (23). joint session and are working on
45 minutes of therapy. However, different aspects of therapy, and the
physiotherapists have been shown to Practice outside the UK session is goal directed, then this can
overestimate the duration of therapy, Canadian guidelines state that be counted as two sessions.
and that intensity of treatment is also “Patients should receive the intensity
dependent on the ability and the and duration of clinically relevant Stakeholders don’t yet agree what
willingness on the part of the patient. therapy defined in their individualised constitutes 45 minutes of ‘contact’
[Teasell et al] (5). rehabilitation plan and appropriate to time. For the first time therapists have
their needs and tolerance levels.” been given a treatment time
Greater benefit may be achieved if (intensity) guide of 45 minutes but
high-intensity therapies are provided In the US, a patient must be able to need to maintain a level of flexibility
in the early stages of rehabilitation. safely tolerate the level of within this to accommodate patient
[Teasell et al] (5). rehabilitation therapy programme individual needs. Some therapeutic
provided in an inpatient rehabilitation interventions, such as psychology, may
There is not conclusive evidence that unit. The intensity of therapy provided not fit well with a rigid time frame.
more intensive speech and language must further the patient’s progress in Some academic stakeholders
therapy is better than less intensive meeting goals, rather than setting the commented that services should be
therapy, although for patients who patient back by overtaxing them. offering ‘up to’ 45 minutes. However,
can tolerate it, more intensive therapy Publicly funded stroke rehabilitation other front line stakeholders felt that
appears to result in improved facilities do not receive payment anything less than 45 minutes might
outcomes. [Teasell et al] (5). On unless they provide at least three be limiting and therefore less
average, positive studies provided a hours a day of therapy, 55 minutes of effective. This may be due to the
total of 98.4 hours of therapy while one-on-one therapy sessions with differences in definition of what
negative studies provided a total of physiotherapy, occupational therapy counts towards ’45 minutes of
43.6 hours of therapy. and speech and language therapy. If therapy’ and the debate around
the patient is unable to tolerate this, direct/non-direct therapy.
then it should be given in two 30
minute sessions. (6)

17


Some people have started to refer to therapy, yet the same patient group
KEY MESSAGES
the amount of time a patient has for had least success as recorded by the
• Patients do not all benefit therapy as the ‘dose’, to start to goal attainment scale. They
equally from access to 45 formalise the requirement for a set recommend that therapy services
minute therapy sessions amount of therapy time to be should adopt a menu of outcomes, to
• In the community, patients available per patient, per day. inform service development.
with more severe disability
improved most with access to Stakeholders felt that access to both Using the NICE clinical standard of 45
45 minute therapy sessions 45 minutes of each therapy and seven minutes of therapy per day, five days a
• Patients’ need for, and day services should reduce length of week, each patient should get 990
tolerance of, 45 minutes can stay through faster completion of minutes of therapy over the six weeks
fluctuate, so services need assessments, more time for discharge they are with the team. The team
to be sufficiently flexible and planning, faster improvements in found 17.5% of patients achieved the
responsive to meet this mobility, activities of daily living, and required amount of therapy from
• Joint working with nurses has patients managing at home more physiotherapy, 21.5% from
a positive effect on cohesion quickly. occupational therapy and 11.1% from
and compliance and can be speech and language therapy. Those
achieved in addition to direct Project findings patients who received 990 minutes of
therapeutic clinical contact NHS Camden - stroke REDs agreed occupational therapy and
time local definitions and clarified contact physiotherapy had an average
• Multiple 45 minute episodes and non contact activities for their increase in their Barthel scores of 6.4
by individual disciplines during service and the team reviewed data points, compared to an average
a day may be difficult for a for 91 patients across six weeks of increase of 3.4 points by those who
patient to manage; combined, rehabilitation, comparing the intensity didn’t and an average increase in their
goal orientated visits work of therapy received using valid clinical Nottingham Extended Activities of
• Staff may need to collect data outcome measures. The data showed Daily Living (NEADL) scores of 12
to challenge their own that patients with lowest Barthel points, compared to 10 points for
assumptions about why scores had the greatest need of, and those who didn't.
services are not being benefited most, from access to
provided, to be sure it is
because patients cannot
tolerate it, and not because of NHS Camden - stroke REDs -
the ability of the service to 45 minutes - impact on Barthel score points gained
provide it
• Services that operated over 35
Met Not met
seven days had more success
30
in meeting the 45 minute
guideline 25
Percentage

20

15

10

5

0
0-2 2-4 4-6 6-8 8-10 10-12 12-14 14+

18


There is a significant difference with
the Barthel outcome measures, when NHS Camden - stroke REDs- Reasons for not receiving 45 minutes of therapy
compared with the sample of patients
Declined daily therapy
who get least therapy in terms of time Clinically not required
(intensity) and number of visits No SLT required
(frequency). At the start of No occupational therapy required
intervention the Barthel for this group No physiotherapy required
No staff capacity
with most amount of therapy is lower.
Patient unavailable
This suggests that people, who Patient fatigued
received the most therapy in terms of Patient refused
intensity, were functioning at a lower Patient poorly

level, based on the Barthel (average 0% 10% 20% 30% 40% 50% 60%
score of 11.8)

Regarding progress and change in the
Barthel scores, this group of patients
made significantly larger gains ‘Continuing to benefit’ and ‘able to tolerate’ should be
(average of 6.3) when compared to
those who received the least amount defined jointly by both patient/carer and MDT.
of therapy.

The team make joint decisions with ‘Therapy time’ is anything related to person focussed
the patient about what level of rehabilitation facilitated by a specialist stroke practitioner
intensity is appropriate for them. They and evaluated using clinical outcome measures.
collected data to determine the
reasons why 45 minutes of therapy NHS Camden - stroke REDs
was or was not achieved for each
patient. Thirty percent of patients
reported fatigue as a major factor
affecting ability to participate in an 3. Non-manageable at home – ranging from 14 – 49 days of 45
intensive therapy programme at residential intermediate care bed minutes of therapy, two to three times
home. For many patients there were with CST therapist support each day, over seven days. Patients on
multiple reasons why 45 minutes of 4. Residential/nursing care – CST core pathway one with mild and minimal
therapy was not achieved. team visit on discharge to check disability required much less intensive
correct patient management. therapy. People in care homes may
Blackburn with Darwen community need 45 minute sessions of therapy
stroke team focuses on meeting They defined therapy for their service each day to improve a particular task.
patient need rather than just early locally, and analysed a database of 20
discharge for people in both hospital patients to determine which patients On the whole, there were more 45
and community through four needed or benefited from 45 minute minutes of therapy contacts from
pathways of support. sessions, and from which therapies, rehabilitation assistants with varied
and examined the range from each input from therapists. Patients with
1. High functioning – home with core therapy and the service. moderate to total dependency
team support only (Barthel) received most input from
2. Lower functioning but manageable They found that not all patients support workers and intermediate
at home – home with community needed 45 minutes of therapy each care support staff, enabling the
stroke team (CST)therapists and day, and that the need varied greatly. community stroke team to provide 45
domiciliary rehab team support Patients with moderate to severe minutes of therapy daily for as long as
levels of disability (pathways two to needed.
four) needed a level of support

19


Local definition of therapy

Any assessment or treatment provided by the qualified
therapist from the community stroke team (CST)
including physiotherapy, occupational therapy or speech
and language therapy.
Any therapy intervention which is part of the programme
set by CST qualified staff and carried out by our
rehabilitation support workers, on one of our pathways.
Blackburn with Darwen community stroke team

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

Average Range Average days 45 Range Average other Range
length of stay minutes therapy 45 minutes days
in service from core stroke from support
team service

Pathway 1 131 22 - 265 50 1 -149
Pathway 2 175 110-243 68 52-97 43 40 -49
Pathway 3 141 84 -195 42 41-69 29 14 -42
Pathway 4 220 43 - 574 86 9-225 38 38

The Sheffield speech and language The South Devon team, as part of a against the percentage that received
therapy team initially questioned demand and capacity exercise, 45 minutes per therapy group across
whether 45 minutes would be right showed that they had only small all project teams.
for each patient and whether their numbers of patients who could
service needed to be more flexible to tolerate 45 minutes of each active Those who were assessed as needing
deliver it. The project enabled them to therapy for five days a week and that 45 minutes of therapy, tended to get
identify that 25% of patients required they had a surprising number of it when the services were increased.
daily speech and language therapy refusals due to fatigue. Within the therapies, speech and
intervention and over 50% needed 45 language therapy is suggested as the
minutes on certain days. The pilot was The issue of judging whether a patient area where it is hardest to meet
not long enough to demonstrate continues to benefit and/or is able to assessed need.
whether daily availability of speech tolerate remains a subjective
and language therapy could impact assessment on the part of the
on adverse effects for patients, e.g. therapists. The scatter plot, taken
incidence of aspiration pneumonia, from data from the projects, shows
but staff found that being available on the percentage of patients thought to
a Saturday had a positive effect on benefit from or tolerate 45 minutes
patients.

20


Seven day working enabled the work
Numbers of patients who could tolerate 45 minutes of therapy to be more equitably spread across a
week, which meant there were more
100
opportunities to achieve 45 minute
% 45 minutes delivered

therapy sessions (Chesterfield Royal
80 Hospital, South Tyneside, and
South Devon).
60
Some of the teams’ initial
40 preoccupation with attempting to
define the detail around 45 minutes
20 issues translated into attention to
methods of changing the shape of
0 their service, and the ways in which
0 20 40 60 80 100 they worked, so that they could
% assessed as needing 45 minutes of therapy deliver:

SLT OT PT • More hands on treatment each day
• A flexible response to patient need
• More opportunities for therapy in a
variety of forms.
Summary In the community, patients with more
The project teams’ findings mirrored severe disability improved most with Focussing more on improving service
international guidance around access to 45 minute therapy sessions. delivery may better enable therapy
tolerance and therapy. NHS Camden services to provide a service that
- stroke REDs and Blackburn with Where therapy services collected data meets national guidelines and be able
Darwen community stroke team data for when a 45 minute treatment to offer the right therapy at the right
allowed detailed analysis of allocation session occurred, and if not, why not, time, for the right reasons to the right
and uptake of the 45 minute sessions. it offered them valuable insight into patients as and when they can
It supported the research findings that their reasoning processes and fixed tolerate it and need it.
one size does not fit all and of the assumptions that may be derived from
complexities created by organisations practice or working to prioritisation The project findings demonstrated
and priorities. protocols. Some teams at each stage that ‘therapy’ relates to allied health
of rehabilitation reported that more professions, including assistants, but
Their pragmatic approach based patients could tolerate 45 minutes if that any opportunity to enhance
on thorough assessment, good it was available and the data showed rehabilitation, either by weekend
multidisciplinary team communication, that where it was not possible to sessions from suitably trained
shared skills and competencies, deliver it, it was often due to the healthcare assistants (St Thomas’
involving the patient and carers and service organisation. This suggests Hospital), by joint working (Medway
SMART (Specific, Measurable, that services might learn from Community Healthcare and South
Attainable, Relevant and Timely) undertaking demand and capacity Devon) or by having an additional
multidisciplinary team goals enabled exercises and reviewing their practice presence (Sheffield speech and
them to avoid unnecessary and processes, before making language therapy) can bring
45 minute sessions without changes in staffing, or requesting benefit.
compromising outcome and additional resources, endorsed by the
preventing fatigue for people at findings of Medway Community
home. This information is also Healthcare.
valuable to inform the commissioning
services, and developing resources.

21


Where can more therapy make a difference?
Projects were drawn from across the Project findings
KEY MESSAGES
stroke pathway and demonstrated The Chesterfield Royal Hospital
that seven day services had a benefit team provided a seven day • Patients can benefit from
in all settings. physiotherapy service on an acute access to seven day therapy
stroke unit. Data showed services in all settings across
What the evidence says improvements in NICE quality the pathway
The Collaborative Evaluation in Stroke standards 5 and 6 and the RCP • The benefits and opportunities
across Europe (CERISE) studies guidelines for physiotherapy from seven day therapy
conclude that whilst there is evidence assessment times. There was no services vary along the
for the positive effect of intensive significant effect on length of stay, but pathway, reflecting the
task-specific exercise on the functional some individual reductions, which different needs of the patient
recovery of stroke patients, stroke suggested planning discharges earlier • Individual requirements for 45
rehabilitation units in the UK are not in the week was having an effect. minutes of therapy can vary
organised to optimise the amount of during the course of their
therapy given to patients. Included The South Tyneside, Medway, journey along the pathway,
within this are aspects of environment South Devon and Sheffield therapy not just depending on their
and culture, organisational priorities, teams delivered their additional medical status, but also on
different healthcare systems with their service on a stroke rehabilitation unit. their goals
different barriers and incentives to The South Tyneside unit is now able • Therapy support workers can
change, case mix and admission to achieve the NICE quality standards assist with successful delivery
criteria. [Putman et al] (13,15) 5, 6 and 7 and RCP guidelines for of 45 minutes and a seven day
physiotherapy and have identified that service at all stages
However, it may also be worth noting the next stage is to develop the
that although in international occupational therapy service. In South
comparisons, UK stroke units had the Devon and Medway Community
lowest therapy contact time and best Healthcare, the teams are working to The Blackburn with Darwen and
staffing, they also had rehabilitation identify how to improve the service NHS Camden - stroke REDs
units with the least exclusion criteria further to be able to offer additional community teams both have robust
and decisions about therapy for opportunities for therapy, by data collection systems. This supports
patients were more often made by reviewing their use of non contact extensive analysis which enables them
clinicians. time, and developing sustainable to identify the effect of 45 minutes of
group work. therapy on clinical and service
What the stakeholders say outcomes. This has resulted in
Stakeholders felt that seven day The Sheffield therapy team reflected improved multidisciplinary team goal
services should be available across the on the experience and their data and setting, predicting outcomes and
pathway from hyperacute to early identified some questions for further devising effective packages of
supported discharge teams in the discussion locally about organisation intervention on an individual basis,
community, where patients continue and distribution of therapy resources maximising the use of their skill mix.
to benefit. along the stroke pathway. They are both able to demonstrate a
positive financial impact on the acute
Patient feedback in the Sheffield service through reducing length of
speech and language therapy stay, and for social care by reducing
project indicated that during the acute final packages of care. Blackburn
stage of the pathway they want to with Darwen community stroke
receive a seven day service, but are team (2010) reduced final packages
less keen when they are back at home of care per week by 240 hours of
as they welcome a break at care/week, equating to £93,600
weekends. savings per year.

22


Summary In the community, therapists were
The project teams crossed the able to look at resolving the challenge
pathway from hyperacute stroke unit of overloading the patients with
to community teams, and in all cases excessive visits through developing
they made a difference. shared competencies and multiskilled
staff delivering goal orientated
However, in each setting, additional sessions (NHS Camden - stroke
services bought other, slightly REDs and Blackburn with Darwen
different gains too, reflecting the community stroke team).
stage of recovery and different needs
of the patients from each Feedback from carers, and other staff
environment. was positive regardless of location.

In South Devon and Medway Seven day therapy services have a
Community Healthcare, the teams value in all settings across the
had developed joint working with pathway; specifically to deliver equity
nursing staff and were considering of access to assessment and, where
group work. This is probably more these exist, the project teams found a
viable and sustainable on a stroke positive effect on direct contact time
rehabilitation unit than in an acute and 45 minutes of therapy.
stroke unit where the focus was more
on developing an equitable service
across the week, and facilitating
speedier and smoother transfer on
(Chesterfield Royal Hospital, South
Tyneside and Sheffield therapy).

23


How - bridging the gap?
”The gap”- themes from the
research
Collaborative Evaluation in Stroke
across Europe (CERISE) studies have
shown that stroke patients in the UK
spend much less time engaged in
therapy than in European
rehabilitation units. Findings for the
UK suggest one hour a day, compared
with three in Switzerland. In all
centres, physiotherapy comprised
nearly 40% of therapeutic time, but
occupational therapy comprised 20%
- 30%, except in the UK unit where it
was 11.6%. In the UK, 35% of
therapy time consisted of nursing
care. After correction for case-mix,
overall therapy time in the UK unit
was significantly less than the other
countries, and the differences in
therapy time were not attributable to
differences in staffing. [De Witt] (14)
(16) (17)

In a more recent study, therapy some significant difference in content. However, stakeholders and some
staffing levels were comparable with They refer to the ‘black box’ of therapy services reported challenges
existing literature, yet there was wide challenges around understanding and embedding group work within stroke
unexplained variation in contact time measuring what therapists do; such as unit routines for various reasons,
with the patient. Seventy five percent lack of reporting the detailed including lack of time, staff availability
of patients received less than an hour characteristics of the interventions, to transport patients and difficulty
of therapy, and 25% less than half an the complexity and diversity of gaining sustained nursing support.
hour of any therapy each day. The interventions and the potential range
lowest levels of therapy input were of different approaches used, along Develop a seven day
from speech and language therapists, with the practice adopted by rehabilitation culture
with only 25% of patients having any therapists of reliance on clinical Project teams in the community
contact with a therapist, and a experience rather than on theoretical (NHS Camden - stroke REDs and
median contact time of 30 minutes. frameworks, and the overlap and Blackburn with Darwen community
[Rudd et al] (19) blurring associated with joint working. stroke team) and on stroke
[De Witt] (12) rehabilitation units (South Devon
Part of the CERISE study explored the and Medway Community
relationship between the content of One possibility for increasing contact Healthcare) have undertaken work
therapy and the level of patient motor time is through group work. Recent specifically to develop their
impairment, expecting the content of studies have also shown that the rehabilitation culture.
therapy to differ in patients with efficiency of limited therapeutic
different levels of motor impairment. resources can be increased by using
They found significant differences in circuit training programmes in which a
duration of physiotherapy and group of patients is allowed to
occupational therapy sessions and practice at different workstations at
the same time, under the supervision
of a therapist. [Kwakkel et al] (8)

24


Understand the data
KEY MESSAGES
Both Blackburn with Darwen and
• Develop a rehabilitation culture in your team NHS Camden - stroke REDs
• Visit a successful site prior to making change to improve understanding community stroke teams have
and support for the process locally established comprehensive databases
• Consider a single management system for nursing and therapy which which enabled them to thoroughly
can improve line management consistency, provide better coordination understand their services and
and enhance stroke specialist clinical governance outcomes, especially around access to
• Involve and include staff and establish good communication processes and delivery of 45 minute therapy
• Be prepared for staff objections and manage these through good sessions. Their systems work
communication processes alongside, and in addition to, local
• Understand the team’s true demand and real capacity to improve databases which have limited ability to
understanding, planning and control of the work, enabling more provide useful qualitative and
therapy time to be offered. quantative information about therapy
services. The initial additional effort
required for data entry is outweighed
by the benefits derived from
The Medway Community The stroke service in the United comprehensive analysis of a person’s
Healthcare team felt that the therapy Hospital of North Staffordshire progress through a pathway or
culture should form the basis of the (UHNS) redesigned their services service.
patient’s day. One way of achieving along the lines of the Trondheim
this was by partnering members of model in Norway following a visit to Manage the human dimensions
the nursing and therapy staff during the unit. (26) They have a The Sheffield therapy project team
morning washing and dressing, and at rehabilitation ward with joint working was part of a bigger initiative
lunchtimes. This integrated approach between nurses and therapists, with delivering a seven day therapy service
also meant moving the therapy team joint ward rounds and assessments. across five clinical domains, with 26
to a base on the stroke rehabilitation All the patient activities have a staff to cover the weekend stroke
unit alongside the nursing staff. rehabilitation focus and treatment is service. It involved a major
goal orientated rather than process consultation process including
Project teams in South Devon, orientated. Some tasks remain nursing meetings with stewards and human
Medway Community Healthcare tasks, and the therapists contribute resources staff to ensure clarity and
and Sheffield therapy services towards these. equitable decision making.
changed the start time for therapists Communication systems were put in
to enable them to work more To achieve this they reviewed therapist place, including a reference group
inclusively with nursing staff, and and nursing roles on the unit to with a collection of staff across all
more effectively support the patients’ promote blurring of boundaries, grades and all areas, which proved to
routine, fostering the rehabilitation focusing on the needs of the patient be a good barometer for staff
culture. with family participation. Therapists experience and gave the manager
now work solely on the stroke unit opportunities for regular and direct
Whilst not part of the original NHS and are managed by the stroke unit contact.
Improvement - Stroke project, the manager. They have introduced new
team from the stroke service in Stoke- roles that do not have profession
on-Trent undertook their own change related titles, but are focused on
programme, addressing many of the rehabilitation. All staff work shifts,
areas of interest to those looking to nurses 24 hours and therapists seven
enhance access to therapy. days, with band 2 staff alternating
therapy and nursing rotas.

25


Staff fed back comments during the
Challenges and solutions in Sheffield
process that were reviewed
Teaching Hospitals NHS Foundation Trust
immediately. Actions were planned
and communicated to the teams
Moving and handling: non stroke-skilled staff need time to develop
through the team leads, then
confidence and familiarity with the handing procedures, protocols and
published so that everybody was
issues for stroke.
aware of the responses made. Training
and in-service training sessions were Data collection and paperwork: simplify administration and
provided as issues and concerns were measurement. Be clear about data collection systems and how the service
raised. will be evaluated.

The short time frame for Variation in assistants’ skills: capitalise on the enthusiasm and good
implementation prevented the delivery will of those working most frequently in the service, and be prepared to
of the thorough training plan that had support peripatetic and part-time staff.
been envisaged, but orientations were
Time and rosters for staff: establish a consistent start-time for
provided, including tours of the unit,
occupational therapy to better support nursing staff, enabling longer term
clinical information and opportunities
flexibility and consistency across all staff. Do this in stages, over the
to ask questions and for shadowing.
longer term.
A duty manager worked each Staff engagement: Proper consultation is essential. It is particularly
weekend to support the 26 staff important to focus on the benefits for the patients.
across two sites. This enabled staff to
have on the spot support, and
showed a management commitment
to weekend working. Some duty St Thomas’ Hospital team needed to Analyse your workforce and
managers also contributed to the ensure that the rehabilitation support design for the future
clinical workload at the weekend. This workers could be supported with the The NHS Camden - stroke REDs
was a valuable learning experience to complexities of a dual role at service carried out a demand and
help understand and manage the weekends, and recognised their capacity exercise to develop a realistic
process of change and support staff perceptions of split loyalties as part of and appropriate business case for an
but did have cost implications. both the rehabilitation and nursing early supported discharge service,
Possible alternatives are to provide an staff. Initially all staff were trained, but which suggested a ratio of patient
on-call phone support, or to allocate with turnover and staff migration, a contact and non-contact time of
the responsibility of a site lead to a gap emerged. This was managed by 50:50. By using this ratio, supported
band 7 or band 6 member of staff taking a shared responsibility by other crucial data, they could
working at the weekend. approach within the multidisciplinary accurately identify the correct skill mix
team, through incorporating the of staff and the model required.
rehabilitation skills into the
competency documents for all nursing Medway Community Healthcare
and health care assistant staff. They undertook a demand and capacity
gained the sign up to the concept exercise on the stroke rehabilitation
from the team, adopting a different unit. Challenges they faced were
uniform for rehabilitation support getting the staff to appreciate the
workers at weekends and devolving concept of ‘true demand’, and
responsibility to the band 6 nurse for understanding that the basic premise
supervision and support for the behind the data collection was that all
rehabilitation support workers during patients should get 45 minutes of
their shifts. each therapy daily. By carrying out the
exercise the team were able to

26


re-examine their service objectively
and find time within the schedule to
allow the occupational therapist to
run a weekly carer clinic. They were
also able to introduce therapy
timetables on the ward with improved
compliance and support from the
nursing staff. The insights they gained
from the exercise were so useful that
it has been rolled out across their
entire stroke pathway.

The South Devon team completed a
demand and capacity exercise and as
a result implemented group sessions
in the gym three times a week,
timetabled to coincide with maximum
staff availability. They have allocated a
senior member of staff on each day
with dedicated time to update ‘the
big pieces of paperwork’, including
discharge summaries, overview
assessments and the continuing
healthcare screens. The remaining
staff can continue with the clinical
work, confident that the paperwork is
under control.

27

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