1. Transforming Stroke Care in
London:
The story so far
Tony Rudd
Clinical Director for Stroke in London

2. 2 2
In 2004 the Sentinel Stroke Audit showed that
stroke services in London were poor…
Physiotherapist
assessment within
72 hours of admission
%
646561
63
96
73
53
87
75
68
32
64
29
43
70
57
4943
87
68
94
75
91
26
90
82
75
100100
84
6970
57
7776
59
28
8683
38
77
90
52
7481
64
45
9191
75
100
70
34
65
89
100
93
70
95
79Emergency brain scan
within 24 hours of
stroke
%
90%
90%
Patients treated in a
Stroke Unit
%
0035
8
1518
20
30353845454550555859606466
72
82848585
9395
100100
90%
Case for change

3. 3
More strokes occurred in outer London but most providers were in
inner London
GAPS
GAPS
GAPS
OVERLAPS
The more intense the red the greater number of providers available
to provide service to the area.

4. Story so far
4
The development of the strategy was subject to wide engagement with
the model of care agreed by clinicians and user groups
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
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
30 min
LAS journey* After 72 hours
Discharge from
acute phase
Community
Rehabilitation
Services
*This was the gold standard maximum journey time agreed for any Londoner travelling by ambulance to a HASU
New acute model of care

5. Prophets of doom predictions
• It would not be possible to implement major system
reorganisation in London for a condition as complex as stroke
• Staffing requirements would not be achievable
• Patients would not accept being taken to a hospital that is not
local to them
• It would not be possible to transport people within 30 minutes
to a HASU
• Repatriation would fail and HASUs would quickly become full
• Trusts would fight to retain services
• Even if acute services work it would fail because it would be
impossible to change community services
• The new model would be unsustainable

6. 6
Following bidding and evaluation a preferred model
was agreed and consulted on

7. London Stroke Care: How is it
working?
• 1st
February 8 Hyperacute (HASU) stroke units
opened taking all patients who might be
suitable for thrombolysis
• 19th
July all stroke patients taken to one of the
HASUs
• Over 400 additional nurses and 87 additional
therapists recruited to work in stroke care in
London by July 2010

8. Beds – Open vs Planned
HASU Beds
NWL NCL NEL SEL SWL
Open 36 18 24 22 16
Planned 36 18 24 33 20
SU Beds
Open 130 93 114 57 90
Planned 156 93 114 140 92

9. London Stroke Care: How is it
working?
• Between February and July the proportion of
patients admitted directly to a HASU
increased from 33% to 69% . Since July over
90%
• The average journey time from home to a
HASU is 14 minutes. The HASU with the
longest average transfer time was Kings at 17
minutes. The average time from LAS taking
the call to arrival at a HASU is 55 minutes

10. 10
The number of stroke patients taken by London
Ambulance Service to a HASU has been increasing
as implementation progresses
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
O
ct-09
N
ov-09
D
ec-09
Jan-10
Feb-10
M
ar-10
A
pr-10
M
ay-10
Jun-10
Jul-10
A
ug-10
-indicative
Non-HASU
HASU

11. London Stroke Care: How is it
working?
• 587 patients thrombolysed in the 5 months
between Feb 2010 and June 2010 compared
to 174 in the same 5 months in 2009
• The thrombolysis rate for patients brought by
LAS to hospital in London is 14%. If use the
incidence data of 11,000 strokes per year in
London then the thrombolysis rate is 12%.
These rates are higher than any reported for a
large city in the world

12. London Stroke Care: How is it
working?
• Vital signs performance data
– London is performing better than all other SHAs in
England
• % of patients spending more than 90% of their hospital
stay on a stroke unit
– 48.3% in Q1 08/09
– 83.7% in Q1 10/11 (England performance 68.1%)
• % of patients with high risk TIA treated within 24 hours
– 48.6% in Q1 08/09
– 84.9% in Q1 10/11 (England performance 56.2%)

13. London Stroke Care: How is it
working?
• Average length of stay in a HASU is 3 days.
Average length of stay overall has fallen e.g.
24 to 17 days at UCLH
• % of patients discharged home directly from
HASU about 40% (predicted 20%)

14. 14
Performance data shows that London is performing better
than all other SHAs in England
40
45
50
55
60
65
70
75
80
85
90
Q1 Q2 Q3 Q4 Q1
2009/10 2010/11
%achievement
London
England
Target
Thrombolysis rates have increased
since implementation began to a
rate higher than that reported for
any large city elsewhere in the
world
% of patients spending 90% of their time on a
dedicated stroke unit
40
45
50
55
60
65
70
75
80
85
90
Q1 Q2 Q3 Q4 Q1
2009/10 2010/11
%achievement
London
England
Target
% of TIA patients’ treatment initiated within 24
hours
0%
2%
4%
6%
8%
10%
12%
14%
16%
12%
10%
3.5%
Feb – Jul 2009 Feb – Jul 2010AIM

15. 15
Efficiency gains are also beginning to be
seen
0
2
4
6
8
10
12
14
16
18
20
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug
2009/10 2010/11
Average length of stay HASU destination on discharge
• The average length of stay has fallen from
approximately 15 days in 2009/10 to
approximately 11.5 days in 20010/11 YTD
• This represents a potential saving of
approximately [DN - insert figure]
• Approximately 35% of patients are discharged
home from a HASU. The estimate at the
beginning of the project was 20%.
0%
10%
20%
30%
40%
50%
60%
Home Other Stroke Unit RIP (blank)

16. London Stroke Care: How is it
working?
• No significant problems with repatriation to
SUs. Good exchange of patient information.
• Significantly improved quality of care in SUs
• Evidence of constructive collaboration
between hospitals
– SU Consultants joining HASU rotas and
participating in post-take rounds and educational
meetings
• Very positive anecdotal patient feedback

17. 17
Case study
A 73 year old male from Harrow was one of the first patients to be taken to the Northwick
Park Hospital HASU after suffering a stroke at home.
He describes the experience as “miraculous”.
He collapsed at home at 2.30am feeling sick and dizzy with weakness in his legs. His wife
called an ambulance and paramedics took him to Northwick Park Hospital A&E. He was
immediately given a CT scan and subsequently thrombolysis.
The patient recalls “It was very serious…My care at the hospital was superb. My speech was
slurred before I had the injection but afterwards I was word perfect .It was incredible. After
being given the treatment I came round straight away and the next day I woke up and was
almost back to normal, had breakfast and went home. I am now completely back to normal
and go to the gym twice a week.”
The patient was not unfamiliar with stroke. He had one three years previously following a
triple heart bypass and was in hospital following complications for three and a half months.
So the experience this time – in and out of hospital in less than two days – was a revelation
for him.

18. Medical Workforce Initiatives
• 1 month intensive training for consultants on
HASU rota
• 6 month fast track training post CCST
• E learning programme in development
• Simulation centre courses being developed
– Senior doctors and nurses
– Band 5 nurses

19. Areas where issues remain
• Acute stroke patients presenting at non HASU
A&E departments
– Too many
– Some difficulties transferring to HASU
– Concerns by some SUs that inappropriate to
transfer to HASU and not in patients interest to
move
• Out of London patients being brought by
ambulance to non HASU A&E departments

20. Areas where issues remain
• Stroke unit catchment areas
• Interventional neuroradiology service
• Stroke in children

21. Areas where issues remain
• Community services in many areas still
insufficient
– Early supported discharge
– Longer term rehabilitation
– Vocational rehabilitation

22. Areas where issues remain
• Collecting data to prove the model is worth it
– SINAP
– Additional London data items
– Economic evaluation

23. What does the future hold?
• Unlikely enhanced tariff will continue
• GP Commissioning: How will this work for the
London stroke model?
• Andrew Lansley not convinced that the
London model is the right one
• Outcomes framework
– Public data being displayed by London Health
Observatory
– Need to collect real outcome data

24. Next steps
24
• Assessment of stroke outcomes data from all London
units
• Appraisal of new financial arrangements to ensure best
efficiency and value for money
• Improve availability on stroke outcomes data to patients
and the public
• More focus on life after stroke and long term care
•Longer term commissioning strategy...............