business case proforma · the business case was presented to the finance committee on tuesday 27th...

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Atta

Decision Making Business Case

Appendix Ki

FINANCE COMMITTEE November 2018 / TRUST BOARD – December 2018

Subject: Stroke Business Case

Author: Rachel Otley Head of Planning & Partnerships, Giles Brown Head of Financial Planning and Sue Braysher Director of System Transformation

Presented by: Sue Braysher, Director of System Transformation

Purpose of paper: Business Case for the establishment of a combined Hyper Acute and Acute Stroke Unit at Darent Valley Hospital, one of three units in Kent and Medway

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Key points for the Trust Board:

This Business Case is focused on the impact on Dartford and Gravesham NHS Trust only; the Decision Making Business Case (DMBC) is included at Appendix A and presents the case for improving stroke services across Kent and Medway. The Business Case assumes a March 2020 opening of the new service at DVH, aligned with the opening of the new unit at Maidstone Hospital. The new unit at Ashford will open a year later in 2021.

The STP wide template has been used for this business case. Assumptions included are aligned across the STP. Any DGT specific assumptions are highlighted as such (e.g. ward design).

The Business Case was presented to the Finance Committee on Tuesday 27th November. Changes have subsequently been made to the Business Case taking the advice of the Finance Committee and further work with the STP Stroke Programme. Changes have been made to the workforce model & therefore financials to reflect the following:

o The STP has revised its guidance on the ratio of Therapists to Therapy Assistants in a letter to the Trust (received since the previous version of the Business Case was submitted to the Finance Committee). We had included this as 1:2 but have revised this to 1:4 as requested (saving £95K in this updated version of the Business Case)

o The Clinical Psychologist has been signed off by the STP as a B7 as we had requested (saving £16K in this updated version of the Business Case)

o The 2 Registrars have been removed as per the STP advice. We have reached an agreement whereby we will continue to develop our existing Registrar (and the career path to Consultant) & probably supplement with an additional Registrar in the transition to full Consultant complement, which may indeed take 4-5 years to achieve (saving £137K in this updated version of the Business Case).

o Additional savings of £14K on Medical Secretaries to reflect new ways of working over time

o Reducing Pharmacy support to that advised by the STP (giving a further saving of £20K).

o The STP has agreed that the ward housekeeper and additional A&E Nurse to support the additional RESUS bay are taken below the direct cost line and are instead charged against the allowance for support services (saving £30K in this updated version of the Business Case)

o The only variation to the STP model relates to our current Clinical Nurse Specialist roles which we wish to retain. A B7 & B8a will be funded through the B4 allocation; we believe it is vital to keep these skilled and highly valued staff available to the new service in the short and medium term, hopefully providing opportunities for career development and progression across our nursing establishment. The STP is aware and supports a pragmatic approach living within the cost envelope available.

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This final version is now £19K within the overall STP financial envelope and is therefore aligned to the DMBC in affordability terms as well as workforce structure and the single clinical pathway.

This final version has now been shared with the STP Stroke Programme and NHSI in order that NHSI can give assurance on alignment with the full CCG led Decision Making Business Case (DMBC) which the Joint Committee of CCGs will review in January and use to make their final decision on the HAU / ASU sites across Kent & Medway.

The Joint Clinical Commissioning Committee is meeting on the 10 January to approve the DMBC and make the final decision on the stroke configuration. At this stage, DVH remains a preferred site alongside Maidstone and William Harvey Hospitals. The configuration proposed will effectively mean that the majority of activity currently at Tunbridge Wells and PRUH, Farnborough will come to DVH, whilst the majority of activity currently at Medway will go to Maidstone.

There could be a Judicial Review once the formal decision is made.

The financial cost of this business case has increased since the Pre Consultation Business Case stage as the workforce requirements for the entire stroke service (rather than ward establishment alone) has now been considered; the estates requirements have been further refined relating to ward refurbishment and work in the Emergency Department regarding resuscitation bays.

Additional funding and indirect costs have been amended since the

Finance Committee to ensure consistency with the ‘as is’ assumptions and the latest STP modelling.

The Trust is proposing to lease a modular unit for 3 years at the east end of the DVH site (for which we will need to seek planning permission). This will accommodate patients that are displaced from Ebony ward as a result of the expansion of the Stroke ward, pending Local Care delivery providing alternative out of hospital pathways. Any delay in enabling specific pathways to be delivered in a non acute setting could require an extension to the lease period.

The Trust will review its overall bed requirement and need for the modular ward as winter progresses.

The current working draft Quality Impact Assessment is included as Appendix C. It is a working draft under the guidance of the Medical Director and Director of Nursing, both of whom require further detail before final sign off. More work needs to be completed on our internal implementation planning and transition to the new stroke service and the development of the new Regional (K&M wide) stroke service. It is critical that we develop appropriate governance covering the transition to full implementation whilst improving our SSNAP performance, since both workforce and patient numbers will significantly increase over a relatively short period. The Risk Register will be updated on a monthly basis.

The Trust Business Case also sets out the proposal for investment in CaptureStroke, software that will allow the live and mobile monitoring of performance against standards and rapid submission of data to SSNAP. This will release clinical time currently spent inputting and uploading data. This will improve the Trusts’ audit compliance which is amongst the worst in the country. A summary case is available at Appendix B.

The financial impact of DVH becoming a HASU / ASU stroke unit is a

£1.9m loss by 2023/24 compared to £0.9m As Is or £1.8m Do Minimum. Between go live and 2022/23 additional spend is incurred relating to the modular lease costs (£0.9m a year) and agency premia (£0.8m in 20/21 falling to £0.2m in 22/23).

Since a definitive diagnosis as to whether a patient has had a stroke or TIA cannot be made until a hospital assessment has been undertaken,

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DVH will see some additional patents with a suspected stroke which will turn out not to be the case. The financial impact of this activity has not been reflected in the STP Business Case but it is assessed in the Trust case with an incremental impact of £0.25m before any additional income is received.

The Trust’s Business Case is currently based on the following caveats:

o The Rehabilitation pathway is critical to the achievement of improved health outcomes for stroke patients, a reduced acute length of stay, improved efficiency of the unit and attainment of improved SSNAP ratings. A pathway has been proposed but engagement with all key providers is yet to commence. The pathway will need to be commissioned and up and running in advance of the service going live at DVH. A social worker originally included in the Trust’s proposed workforce structure has been removed as we have been assured that it will be instead included in the Rehabilitation Business Case. The post remains important to ensure effective discharge from the HASU / ASU.

o A local top-up to tariff or a local tariff would improve the financial viability of the service. This will need to be agreed with commissioners once the impact of the tariff for 2019/20 has been assessed. The finances included in this business case are based on 2018/19 published Best Practice tariff HRG4+ (based on significantly improved SSNAP performance). The structure of the new 19/20 tariff system has been changed significantly so the impact will be reassessed following publication of the tariff in early 2019. The Kent & Medway (K&M) Stroke Programme lead has given assurance that there will be a K&M wide commissioner & provider review of tariff income versus cost to providers and serious discussion to determine whether a top up or local tariff is appropriate and at what stage.

o The workforce set out in the business case is that which is required to deliver the high performing high quality service promised from the Consultation, however it is recognised that recruiting to this will be challenging and therefore transitional or alternative ways of working will need to be considered during the implementation period.

o The bed numbers have been calculated throughout the development of the PCBC and DMBC based on no growth. The South East Coast Clinical Senate have recently (October 18) recommended that growth of 30-44% is considered. The bed impact of this for DGT would be 10-15 additional beds (44-49 beds in total). This could be achieved by expanding into Ebony ward and maintaining the modular unit until the Local Care developments deliver a sufficient reduction in acute bed demand. Work with the K&M Directors of Public Health is ongoing to assess the impact of prevention schemes to consider if the no growth assumption should be amended. If the impact is deemed to be significant this would lead to a remodelling of the bed base needed which would inevitably delay the progression of the DMBC and associated Trust Business Cases.

o The current telemedicine system is reliant on a KMPT hosted server which will cease in December 2018. A new solution such as Skype for Business is required. This must be in place as soon as possible to maintain a safe cross-county consultant on- call. This has been raised within the STP but to date has not been prioritised by the other trusts. Investment required is not at this stage included in this Business Case.

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Although the capital costs included in this business case have remained as per the modelling to select the preferred site, The Hospital Company will need to support the Trust to make sure that Serco do not seek to increase costs unjustifiably. Discussions with The Hospital Company and Serco are ongoing to obtain costings for the submitted designs and necessary works. The production of OB capital forms with appropriate contingency & optimum bias are required by January 2019. A mitigation strategy is being worked up to ensure we can meet this deadline. Until the final prices are received a level of risk will remain on the capital estimates being used.

Consideration of public and patient involvement and communication:

The K&M wide programme has patient and public engagement at its heart and has an agreed communications plan to ensure that our local populations are kept up to date with progress.

Recommendations: The Trust Board will be asked to approve this business case noting the caveats highlighted above.

The Finance Committee and Trust Board should further review progress, particularly on the impact of the 2019/20 tariff, at future meetings over the implementation period, providing the Trust is confirmed by the JCCC at the meeting in January 2019 as the site for a HASU / ASU stroke unit.

Links to Board priorities, Board Assurance Framework, Trust Risk Register

Organisational Priorities

• Provide high quality, safe patient services • Deliver financial sustainability and efficiency • Strengthen operational efficiency and effectiveness • Promote excellent education and personal development • Proactive partner engagement

CQC Reference • Safe • Effective • Caring • Responsive • Well-led

Board Assurance Framework/ Trust Risk Register

Committee/ Meetings at which this paper has been discussed/ approved Date

Finance Committee Nov 18

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STP Business Case

Stroke Services in Kent and Medway Developing a combine Hyper Acute and Acute Stroke Unit at Darent Valley Hospital

Draft version 0.3.5 30 November 2018

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Contents Contents ........................................................................................................................................................... 6 Table of Figures ................................................................................................................................................ 6 Document Information ....................................................................................................................................... 7 Executive Summary .......................................................................................................................................... 9 1. Introduction .............................................................................................................................................. 14 2. Vision ....................................................................................................................................................... 15

2.1. Ambition for Stroke Services in Kent and Medway ............................................................................. 15 2.2. DGT’s Organisational Mission, Vision, Objectives and Clinical Strategy............................................. 15

3. Scope / Context ........................................................................................................................................ 18 1.1. Background to Stroke Services .......................................................................................................... 18 3.1. Current Activity .................................................................................................................................. 19 3.2. Key Issues with Current Stroke Service Provision .............................................................................. 20 3.3. Case for Change ................................................................................................................................ 20 3.4. DGT Existing Stroke Service .............................................................................................................. 21

4. Options ..................................................................................................................................................... 26 4.1. Introduction ........................................................................................................................................ 26 4.2. Requirements of the Preferred Option: DVH, Maidstone, William Harvey ........................................... 26 4.3. STP Critical Path ............................................................................................................................... 32 4.4. Disinvestment Case ........................................................................................................................... 33

5. Delivery Plan ............................................................................................................................................. 37 5.1. Overview of requirements at DVH ...................................................................................................... 37 5.2. Activity at DVH ................................................................................................................................... 38 5.3. Impact on Workforce .......................................................................................................................... 39 5.4. Impact on Estates .............................................................................................................................. 44

5.5. Impact on Radiology .......................................................................................................................... 46 5.6. Impact on Other Services / Areas ...................................................................................................... 48 5.7. IM&T Requirements ........................................................................................................................... 48 5.8. Implementation Plan .......................................................................................................................... 49

6. Benefits / Dis-benefits ............................................................................................................................... 52 6.1. DGT Benefits During Implementation Period ...................................................................................... 52 6.2. STP Benefits Post Go-Live ................................................................................................................ 55 6.3. DGT Specific Benefits Post Go-Live................................................................................................... 57

7. Activity ...................................................................................................................................................... 58 7.1. Inpatient Activity ................................................................................................................................. 58 7.2. Outpatient Activity .............................................................................................................................. 59

8. Financials ................................................................................................................................................. 61 9. Risks ......................................................................................................................................................... 65 10. Governance Structure ........................................................................................................................... 67

10.1. Pre-Implementation Phase ............................................................................................................. 67 10.2. Implementation Phase and Beyond Go-Live ................................................................................... 68

Appendix B: Proposal for Investment in CaptureStroke .................................................................................... 71 Glossary of Terms ............................................................................................................................................ 75

Table of Figures Figure 0-1: Stroke Pathway ............................................................................................................................... 9 Figure 0-2: Financial Impact of the HASU/ASU ............................................................................................... 12 Figure 2-1: Summary of Organisational Mission, Vision and Objectives .......................................................... 15 Figure 2-2: Summary of Clinical Strategy ........................................................................................................ 16 Figure 3-1: Trust Locations in Kent and Medway and Surrounds .................................................................... 18 Figure 3-2: Stroke and Atrial Fibrillation Prevalence ........................................................................................ 19 Figure 3-3: Kent and Medway Historic Stroke Activity by Site .......................................................................... 20 Figure 3-4: Current Achievement of Recommendations / Targets by Trust ...................................................... 20 Figure 3-5: Current DVH Stroke Ward Footprint .............................................................................................. 21 Figure 3-6: PRUH Activity ............................................................................................................................... 22

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Figure 3-7: Baseline Workforce WTEs .............................................................................................................23 Figure 3-8: DVH Baseline Financial Position for Stroke Services (2017/18) .....................................................24 Figure 3-9: SSNAP Performance April 2017-June 2018 ...................................................................................24 Figure 4-1: Number of strokes and beds required at each hospital in the preferred option ...............................27 Figure 4-2: Population flows to HASU/ASU ......................................................................................................27 Figure 4-3: Proposed Kent and Medway Stroke Pathway.................................................................................27 Figure 4-4: Future Care Model for K&M STP ....................................................................................................28 Figure 4-5: TIA Pathway ..................................................................................................................................29 Figure 4-6: Critical Co-Dependencies and Building Blocks ...............................................................................30 Figure 4-7: Rehabilitation Pathway ...................................................................................................................32 Figure 4-8: Critical Path ...................................................................................................................................33 Figure 4-9: Two phased go-live population modelling .......................................................................................33 Figure 4-10: Financial Impact of Disinvestment ................................................................................................35 Figure 4-11: Disinvestment Case Benefits and Risks .......................................................................................35 Figure 5-1: Stroke Pathway ..............................................................................................................................37 Figure 5-2: Number of Strokes, TIAs and Mimics as well as A&E attendances ................................................38 Figure 5-3: WTEs by Staff Group .....................................................................................................................39 Figure 5-4: Stroke Team Pay Costs by Staff Group ..........................................................................................40 Figure 5-5: Comparison STP to latest DGT staffing structure ...........................................................................40 Figure 5-6: Stroke Team Structure ...................................................................................................................41 Figure 5-7: Minimum staffing requirements for Day 1 .......................................................................................42 Figure 5-8: Modular unit workforce requirements .............................................................................................43 Figure 5-9: Proposed Ward Configuration ........................................................................................................44 Figure 5-10: Proposed A&E Resuscitation Configuration .................................................................................46 Figure 5-11: Radiology Activity Assumptions....................................................................................................47 Figure 5-12: Summary Implementation Plan ....................................................................................................49

Figure 5-13: Milestone Plan .............................................................................................................................51 Figure 6-1: SSNAP KPIs ..................................................................................................................................53 Figure 6-2: Benefit Inputs Outputs and Outcomes ............................................................................................55 Figure 6-3: A selection of Key Performance Indicators .....................................................................................56 Figure 6-4: Benefits Reporting Mechanism ......................................................................................................56 Figure 7-1: Strokes, TIAs and Mimic Activity at HASU/ASUs ...........................................................................58 Figure 7-2: Activity for A&E and non-strokes ....................................................................................................59 Figure 8-1: Financial Summary ........................................................................................................................61 Figure 8-2: Revenue Implications .....................................................................................................................61 Figure 8-3: Capital Cost Implications ................................................................................................................62

Figure 8-4: Workforce Cost Implications ...........................................................................................................62 Figure 8-5: Analysis of income and expenditure ...............................................................................................63 Figure 9-1: Risk Scoring Matrix ........................................................................................................................65 Figure 9-2: DGT Identified Risks ......................................................................................................................65 Figure 10-1 - Weekly Team Meeting Membership: Core Team ........................................................................67 Figure 10-2 - Weekly Team Meeting Membership: Subject Matter Experts ......................................................68 Figure 10-3 – Stroke Project Board Membership ..............................................................................................69 Figure 10-4: Impact Analysis on Stroke Resources ..........................................................................................69 Figure 0-1: Trust SSNAP Audit Performance ...................................................................................................71 Figure 0-2: CaptureStroke Costs ......................................................................................................................72 Figure 0-3 Do Nothing: Benefits and Risks .......................................................................................................73 Figure 0-4 Invest in CaptureStroke: Benefits and Risks ....................................................................................73 Figure 0-5: Wait for an STP decision: Benefits and Risks .................................................................................74

Document Information

Document Owner Director of System Transformation

Document Organisation Dartford and Gravesham NHS Trust

Document Status Draft version 1

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Document Date Committee Comments

PCBC STP Finance Directors Group

PCBC Stroke Operational planning Group

PCBC Stroke Programme Board

PCBC Dec 17 NHSI and NHSE Assurance Joint Committee of CCGs

PCBC Jan 18 Joint Committee of CCGs

Financial Model TBC STP Finance and activity Modelling (FAM) Group

Sign off model

Finance Update 7/9/18 STP Finance Directors Group Sign off model

DMBC Stroke Operational planning Group

DMBC Stroke Programme Board

DMBC NHSI and NHSE Assurance

DMBC Joint Committee of CCGs

Revision History – Trust

Version Number

Revision Date

Previous Revision

Date

Summary of Changes

Changes Marked

0.1 25 October SRO review and feedback from Trust Board on governance arrangements included

Accepted

0.2 November Included additional content including drafting of executive summary

0.3 November SRO and team review. Workforce and finances updated

Accepted

0.4 November Finance Committee amendments

Accepted

0.5 November Refresh of financials and workforce

Approvals – Trust

Version Number

Date of Issue

Approving Body

0.3.3 23 Nov Finance Committee

1 30 Nov Trust Board

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Executive Summary The Kent and Medway Sustainability and Transformation Partnership (STP) have been undertaking a review of urgent stroke services led by local doctors and other clinicians over the past four years. The aim is to re-organise services so that specialist stroke staff can more consistently deliver high quality care around the clock, and in so doing reduce deaths and long-term disability from stroke for local people. Currently stroke services do not consistently meet best- practice standards across the whole of Kent and Medway. Following a public consultation the Joint Clinical Commissioning Committee unanimously agreed to pursue the preferred option of three hyper acute stroke units, co- located with acute stroke units, at Darent Valley Hospital in Dartford, Maidstone Hospital and William Harvey Hospital in Ashford.

The STP has now developed a Decision Making Business Case (DMBC, available at Appendix A) to set out the model of care, workforce requirements, estate proposals and financial impact of the preferred option. This will be considered for approval by the Joint Clinical Commissioning Committee in January 2019. The DMBC sits alongside the Trust Business Case which focuses in more detail on the impact of developing a combined hyper acute and acute stroke unit at Darent Valley Hospital (DVH) and also considers, at a high level, the implications of disinvesting in stroke services (see section 4.4, Disinvestment Case). Once approved NHS England will request the Department of Health to release the capital supporting implementation.

There will be a two phased go-live, with Darent Valley and Maidstone Hospitals going live in March 2020 and William Harvey Hospital in early 2021 as more significant estates work is required at William Harvey to expand the stroke service. This two phased go-live will not result in additional changes of flow for patients that will be coming to DVH.

The ambition is to deliver clinical sustainable, high quality stroke services that are accessible to Kent and Medway residents 24 hours a day, seven days a week. The aims and benefits associated with the stroke service are fully aligned with each of the three elements of DGTs Clinical Strategy as well as the Trust’s mission, vision and objectives. Becoming a HASU/ASU will improve core stroke service, create a specialist unit and improve pathways with the community rehabilitation services.

An overview of the inpatient stroke pathway is illustrated in Figure 0-1. Further detail of the stroke service and overall requirements are available in the DMBC and section 4.2 (requirements of the preferred option) of this business case. Figure 0-1: Stroke Pathway

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The proposal of three combined HASU/ASUs at DVH, Maidstone and William Harvey Hospitals means that patients from the Medway Towns (c.110 patients a year), from Dartford Gravesham and Swanley (c.400 patients a year), Sevenoaks (c.90 patients a year), as well as Bexley (c200 patients a year) will come to the Emergency Department at Darent Valley. This is a doubling of confirmed stroke activity for DVH. In addition to the confirmed strokes (c.800 per year) it is expected that there will be c.80 TIAs and c.200 stroke mimics as well as 1,000 patients that attend the Emergency Department as a ‘query stroke’. To manage this activity the Trust will need to invest in the workforce and estate to deliver this service and achieve the intended benefits.

The benefits of the HASU / ASU model are nationally well evidenced, with London saving an extra 96 lives between 2008-12 compared to other stroke services in the UK. The Royal College of Physicians operate Sentinel Stroke National Audit Programme (SSNAP) to compare the performance of stroke units across the country against a set of key standards that are shown to reduce disability and improve health outcomes for patients that experience a stroke. The SSNAP tool then grades services based on their performance from A to E, where A is the best performing and E the worst performing. DGT is currently rated a D (for further information on the benefits, see section 6; and for information on the current service at DGT see section 3.4, DGT Existing Stroke Service).

To achieve an A rating and deliver improved quality of care the Trust will provide the right people at the right time and in the right place.

Right people A highly skilled truly multi-disciplinary workforce is critical to the outcomes for stroke patients. The core team is comprised of medical, nursing and therapy staff and strongly supported by radiology, pharmacy, cardiology, neurology, neuro psychology and pathology, see section 5.3 (Impact on Workforce) for more information.

The team will have a clinical lead and a stroke lead practitioner to head up the service, providing a strong focus on quality, performance, education and governance. They will be supported by a core team of:

Consultants – undertake clinical activities including stroke clinic, TIA clinic, MDMs, ward rounds, assess/thrombolyse in A&E, on-call providing a 7 day service;

Registrars – management of patients on ward, assessment of patients in A&E, on call, support stroke/TIA clinics;

Training Doctors – take patient history, bloods, accompany consultant on ward round, request tests, discharge planning, cannulas, catheters etc., maintain patient notes, death certificates;

Ward Sister/Manager – ensure high quality care is delivered on the ward, line management of nursing team on ward, clinical professional and managerial leadership on the ward;

Stroke Clinical Nurse Specialists – providing physical nursing care to complex patients, psychological care for patients, patient and nurse education, follow up of all stroke & TIAs for holistic assessment, referrals to other organisations, quality improvement;

Stroke Assessor Nurses (new role to DGT) – assess all patients in A&E that arrive query stroke, ensure timely CT scan, thrombolyse (if appropriate) within one hour of the patient calling the ambulance, transfer to HASU if stroke patient or alternative ward/care setting if not;

Qualified and unqualified nurses on the HASU and ASU – to provide nursing care to all patients; Clinic nurses – take bloods, undertake tests, support patients during their outpatient care and obtain results for

clinical decision making;

Physiotherapists, Occupational Therapists, Dieticians, Speech and Language Therapists – to each provide 45 minutes of therapy input per day to each patient across 7 days;

Clinical Neuro-Psychologist – undertake psychological assessment and psychological care of the patients;

Pathway co-ordinator – bed management role for the service supporting early access to stroke unit, ring fencing of stroke bed and timely transfer to appropriate pathway, ensuring patients have 90% of their stay on the stroke ward and supporting discharges.

The ward team will be supported by an experienced pharmacist to undertake clinical assessment of patients and a pharmacy technician, ward clerks, housekeeper and medical secretaries.

The ongoing use of telemedicine for on-call will maximise clinical resource across Kent and Medway and allow standards to be achieved out of hours.

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Right Time Time is critical for stroke patients. Many of the SSNAP standards are time focused (based on Time is Brain campaign) such as assessment by a stroke Consultant within 24 hours; assessment by a stroke nurse within 24 hours; and a swallow assessment within four hours. To achieve these standards the multi-disciplinary team must work effectively together. For example, to achieve the standard of thrombolysing a patient within one hour the ambulance team will contact the HASU/ASU Emergency Department to alert the team of a possible stroke patient arriving; the stroke assessor nurse based in A&E will contact the stroke team; the stroke assessor nurse will assess the patient and arrange a CT head scan with support of the radiology team; the radiologist will provide immediate interpretation of a scan and the stroke nurse assessor and stroke medical team can then thrombolyse the patient. This is an important standard as evidence suggests that each minute, 1.9 million neurons, 14 billion synapses, and 12 km of myelinated fibers are destroyed.1

Sufficient capacity in resuscitation in A&E is required. Given the volume of activity expected, this business case includes one additional resuscitation bay.

Urgent access to radiology, primarily CT Head and MRI Head, will require dedicated slots each day as well as sufficient time of a neuro-radiologist to report on these scans. Additional radiology workforce and outsourcing costs for displaced activity has therefore been included in this business case (see sections 5.3 Impact on Workforce, and 5.5 Impact on Radiology).

As many of the standards are time critical, real time data will support the team to monitor the achievement of standards for patients. This business case therefore includes the introduction of CaptureStroke to record the care patients receive, monitor live performance and submit data to SSNAP at a cost of c.£32k p.a.. This will reduce reliance on clinical staff uploading data and improve the Trust performance for audit compliance which is amongst the worst in the country. This will improve case ascertainment and audit compliance where by SSNAP penalises trusts for poor compliance. Capture stroke will allow real time data collection for real time service improvement. See section 5.7 (IM&T Requirements) and Appendix B for more information.

Right Place The Hyper Acute Stroke Unit will be much like a High Dependency Unit, stroke patients will be directly admitted to a HASU bed for up to 72 hours before being transferred to an Acute Stroke Unit bed. The establishment of a HASU will mean that patients do not usually require support from Intensive Care Unit and therefore no additional ICU capacity is required as a result of the expansion of stroke services. The Trust will require 10 HASU beds and 24 ASU beds to accommodate the stroke, TIA (sometimes known as a mini stroke) and stroke mimics (see section 5.4, Impact on Estates, for further information).

The current stroke ward is Spruce on level 2 West. This has a total of 23 beds with a further 3 escalation beds when required. On average five of the beds on Spruce are used for general medical patients.

The proposed inpatient bed solution is:

Use Spruce as the Stroke ward

Expand into the three side rooms, one four bedded bay and one six bedded bay from the adjoining ward Ebony

Extend into the therapy unit Empress to provide sufficient storage on the unit for the equipment required to mobilise patients in the HASU in particular

Introduce a modular unit adjacent to the Jade Unit to create sufficient capacity in the hospital to accommodate the displaced activity until Local Care delivers the required reductions in bed numbers to allow the unit to be decommissioned (estimated to be three years)

Financial Impact Stroke tariff includes best practice tariffs which can be achieved when certain standards are met. However, it is nationally recognised that the tariff is insufficient to cover the costs of delivering a service that meets all of the clinical and workforce standards. A discussion regarding a top-up to tariff with commissioners commenced in mid November

1 Time is Brain, https://www.safestroke.eu/2017/03/17/time-brain-think-fast-prevent-stroke-strokeeurope/

https://www.safestroke.eu/2017/03/17/time-brain-think-fast-prevent-stroke-strokeeurope/

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and will continue once the impact of the revised tariff for 2019/20 on stroke has been assessed, this is likely to be quarter one 19/20.

The table below summarises the income and expenditure (pay and non-pay) as well as the capital charges for delivering the HASU / ASU at DVH once a ‘steady state’ has been reached (2023/24). This shows that the service will be loss making.

Figure 0-2: Financial Impact of the HASU/ASU

£000s

Income (including best practice tariff) 5,696

Expenditure

Pay 6,056

Non-Pay 1,456

Capital charges 44

Surplus / (Deficit) (1,860)

Delivering the project The Trust will have robust project governance and sufficient project resource for the duration of the implementation period, through to the achievement of HASU/ASU status which will be externally assessed by the South East Coast Clinical Senate, aiming for September 2020. Appropriately resourcing the project and strong leadership is paramount to delivering the implementation plan, building a high performing team successful and ultimately delivering an A rated HASU / ASU service. A dedicated project manager and lead stroke practitioner should be appointed immediately following the decision by the Joint Clinical Commissioning Committee.

Disinvestment Case Whilst significant investment would not need to be made in stroke should the Trust disinvest in the service, there are many risks associated with not providing stroke activity. In particular, the ability to recruit to neurology, cardiology, therapy, radiology and emergency department may be impacted, see section 4.4 Disinvestment Case for further information.

Caveats This Business Case is currently written with the following caveats and more assurance will be required by the Trust Board on some of the issues listed as work progresses:

a) The Rehabilitation pathway is critical to the achievement of improve health outcomes for stroke patients, a reduced acute length of stay, improved efficiency of the unit and attainment of improved SSNAP ratings. A pathway has been proposed but engagement with all key providers is yet to commence. The pathway will need to be commissioned and running in advance of the service going live at DVH. A social worker originally included in the Trust’s proposed workforce structure has been removed as we have been assured that it will be instead included in the Rehabilitation Business Case. The post remains important to ensure effective discharge from the HASU / ASU.

b) A local top-up to tariff or a local tariff would improve the financial viability of the service. This will need to be agreed with commissioners once the impact of the tariff for 2019/20 has been assessed. The finances included in this business case are based on 2018/19 published Best Practice tariff HRG4+ (based on significantly improved SSNAP performance). The structure of the new 19/20 tariff system has been changed significantly so the impact will be reassessed following publication of the tariff in early 2019. The Kent & Medway (K&M) Stroke Programme lead has given assurance that there will be a K&M wide commissioner & provider review of tariff income versus cost to providers and serious discussion to determine whether a top up or local tariff is appropriate.

c) The workforce set out in the business case is that which is required to deliver the high performing high quality service promised from the Consultation, however it is recognised that recruiting to this will be challenging and therefore transitional or alternative ways of working will need to be considered during the implementation period.

d) The STP Stroke Programme has based its workforce models included in the DMBC on the South East Coast Clinical Senate (SECS) Guidelines. The related funding has been calculated and is shown under the STP workforce model. The Trust has completed an in-depth review of these workforce structures and a few differences remain resulting in a net 4.85 Wtes higher than the STP model , 4.65 Wte relates to TIA

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triages nurses due to the impact of Bexley patients switching to DVH from the Princess Royal University Hospital (PRUH) in Orpington.

e) Overall the Trust workforce model currently is marginally below the STP costed model. f) The bed numbers have been calculated throughout the development of the PCBC and DMBC based on

no growth. The South East Coast Clinical Senate have recently (October 18) recommended that growth of 30-44% is considered. The bed impact of this for DGT would be 10-15 additional beds (44-49 beds in total). This could be achieved by expanding into Ebony ward and maintaining the modular unit until the Local Care developments deliver a sufficient reduction in acute bed demand. Work with the K&M Directors of Public Health is ongoing to assess the impact of prevention schemes to consider if the no growth assumption should be amended. If the impact is deemed to be significant this would lead to a remodelling of the bed base needed which would inevitably delay the progression of the DMBC and associated Trust Business Cases.

g) The current telemedicine system is reliant on a KMPT hosted server which will cease in December 2018. A new solution such as Skype for Business is required. This must be in place as soon as possible to maintain a safe cross-county consultant on-call. This has been raised within the STP but to date has not been prioritised by the other trusts. Investment required is not at this stage included in this Business Case.

h) Although the capital costs included in this business case have remained as per the modelling to select the preferred site, The Hospital Company will need to support the Trust to make sure that Serco do not seek to increase costs unjustifiably. Discussions with The Hospital Company and Serco are ongoing to obtain costings for the submitted designs and necessary works. The production of OB capital forms with appropriate contingency and optimum bias are required by January 2019. A mitigation strategy is being worked up to ensure we can meet this deadline. Until the final prices are received a level of risk will remain on the capital estimates being used.

i) The Trust Board is receiving the draft DMBC sent to the Clinical Senate (October 2018) and therefore continues to have drafting notes, does not contain finances, and does not reflect amendments following the Clinical Senate review. The final draft will incorporate the finances included in each of the Trusts’ business cases and will be shared with the Joint Clinical Commissioning Committee for their approval in January.

Recommendation The Trust Board are asked to approve this business case to expand the stroke service into a combined hyper acute stroke unit and acute stroke unit, one of three in Kent and Medway, subject to the caveats listed above. Although this will add some financial pressure to the Trust, the success of the unit will be a huge reputational benefit to the Trust, potentially enable further service developments in future years such as trauma services, and most importantly improve the lives of stroke patients in Kent and Medway.

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Stroke services across Kent and Medway do not currently meet national standards. There is vast opportunity to improve patient care. As such a review of stroke services has been undertaken and a new service model has been developed.

Darent Valley Hospital has been identified as one of three combined Hyper Acute and Acute Stroke Units for Kent and Medway alongside Maidstone General Hospital and William Harvey Hospital in Ashford.

The ambition is to significantly improve health outcomes for those in Kent and Medway that access the stroke services.

Medway NHS Foundation Trust will no longer provide stroke services, patients from Medway Towns will be cared for at either Maidstone or Darent Valley Hospitals. Stroke patients currently seen at Tunbridge Wells will be cared for predominantly at Darent Valley, an element at Maidstone and a small number at Eastbourne.

The Trust plans to expand the service at Darent Valley by March 2020.

This business case sits alongside the STP’s Decision Making Business Case and also presents a summary disinvestment case for Board consideration should the Decision Making Business Case not be supported by the Joint Clinical Commissioning Committee in January 2019.

1. Introduction

Kent and Medway Sustainability and Transformation Partnership (STP) has been working to develop plans to transform health and social care across Kent and Medway to meet the changing needs of local people, in line with evidence-based best practice and taking due account of the financial constraints across the area. A major part of the STP programme has been the review of hospital-based stroke services. This review has been undertaken in light of the way stroke services are currently set up across Kent and Medway has resulted in local hospitals, including DVH, not consistently meeting the national standards for clinical quality, not treating the number of recommended strokes per year in order for specialist stroke staff to maintain their skills or achieving the minimum recommended staffing levels.

The Stroke Review has been a five-step process which started in December 2014 with planned implementation from January 2019. The five steps of the process are:

• Confirm case for change and vision (December 2014 to December 2016): including establishing the Stroke

Review, publishing the case for change and undertaking significant pre-consultation stakeholder engagement.

• Development of clinical model and options (January 2017 to February 2018): including agreeing the clinical

model, identifying options for consultation, developing this PCBC and continued stakeholder engagement.

• Consultation (February 2018 to April 2018): public consultation including extensive stakeholder engagement

across the affected population.

• Decision-making (April 2018 to January 2019): consideration of the feedback from consultation and decision-

making on the recommended option to implement following engagement and consultation.

• Transition to implementation (planned January 2019 onwards): implementation of the agreed option.

The Pre Consultation Business Case (PCBC) formed the basis of the public consultation. This included the rationale for a three site combined Hyper Acute and Acute Stroke Unit (HASU / ASU) and presented five options, three of which included Darent Valley Hospital. Following the consultation, the Joint Clinical Commissioning Committee (JCCC) unanimously agreed on the preferred option, namely: Darent Valley, Maidstone General and William Harvey hospitals develop combined Hyper Acute and Acute Stroke Units.

A Decision Making Business Case (DMBC) sits alongside this Trust specific business case and presents the case for the Kent and Medway preferred option (a draft of the DMBC is available at Appendix A). This is to be considered by the JCCC in January respectively. Should the DMBC be approved, the Trust will be required to deliver the implementation plan (summary is available at section 4 and a detailed live implementation plan is available on request).

This Business Case sets out the implications for Dartford and Gravesham NHS Trust (DGT) in developing a HASU/ASU at Darent Valley Hospital (DVH) as well as the summary disinvestment case.

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The ambition is to deliver clinical sustainable, high quality stroke services that are accessible to Kent and Medway residents 24 hours a day, seven days a week. The aims and benefits associated with the stroke service are fully aligned with each of the three elements of DGTs Clinical Strategy as well as the Trust’s mission, vision and objectives. Becoming a HASU/ASU will improve core stroke service, create a specialist unit and improve pathways with the community rehabilitation services.

2. Vision

2.1. Ambition for Stroke Services in Kent and Medway The Decision Making Business Case (DMBC) articulates the ambition for stroke services across Kent and Medway in the context of the vision of the STP. The Draft DMBC is available at Appendix A.

The DMBC states that for hospital stroke services, our ambition is to deliver clinically sustainable, high quality stroke services that are accessible to Kent and Medway residents 24 hours a day, seven days a week. The new model of care will:

1. Fulfil the best practice recommendations as set out in the National Stroke Strategy; 2. Deliver improved quality of care, patient experience and patient outcomes; and 3. Support the sustainability of Kent and Medway stroke services by consolidating hospital stroke care, as

required.

It will deliver a number of benefits for patients, see section 6, including:

more people will survive a stroke

improved quality of life and independence for people who have had a stroke greater number of people being able to return home rather than go into residential or nursing care after a

stroke

reduced length of stay in hospital after a stroke

better access to high quality services and expertise

In addition, the proposed changes will:

develop hyper acute stroke units to which patients can be directly admitted within a maximum of four hours of arriving at hospital

increase the number of stroke patients seen at each unit to meet national quality guidelines on minimum throughput

increase access to specialist staff and equipment all day every day ensure eligible patients receive thrombolysis within 120 minutes of calling an ambulance with a suspected

stroke

enable the vast majority of patients to access brain imaging within one hour of admission to hospital

deliver assessment by a multi-disciplinary team for 7 days a week in all units

support hospitals to achieve an overall A grade for SSNAP performance2

Ultimately the ambition is to reduce the number of people who have a stroke, provide the best possible care to those who do, reduce the number of deaths from a stroke, and improve life after stroke and long term disability as stroke is the leading cause of disability in the UK.

2.2. DGT’s Organisational Mission, Vision, Objectives and Clinical Strategy The development of a combined HASU/ASU is one of the Trust objectives for 2018/19. The Trust mission, vision and objectives for 2018/19 are shown in Figure 2-1.

Figure 2-1: Summary of Organisational Mission, Vision and Objectives

2 SSNAP – Sentinel Stroke National Audit Programme: https://www.strokeaudit.org/

https://www.strokeaudit.org/

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The key tenets of the Trust’s 20:20 Five Year Clinical Strategy is shown in summary at Figure 2-2.

Figure 2-2: Summary of Clinical Strategy

DGT’s strength is in its high quality core services provided to local people. These core services include A&E, General surgery, urology, orthopaedics, general medicine, elderly medicine, paediatrics, gynaecology and maternity. It is a core objective of the Clinical Strategy to improve and grow these core services to ensure they remain as a central focus of the Trust’s service provision, and will specifically focus on the following areas:

• constantly improving patient safety

• high quality patient experience

• expanding seven day services

• ensuring the right staffing levels and right leadership

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• providing responsive care

The second element of the 20:20 Clinical Strategy is the consolidation of existing specialist services and the development of other specialisms, in partnership with other top national organisations where appropriate, and building on existing links with tertiary care providers.

The third aspect of the strategy is to work with local partners to support out of hospital care – hospital without walls – with the aim of providing integrated care closer to people’s homes through the use of technology, community teams etc., which will provide a better patient experience, improved efficiency of resources, and reduce attendance at hospital. In addition, the service will contribute to Public Health and CCG campaigns aimed at improving the health and wellbeing of the population, reducing the risk of strokes.

The development of a HASU/ASU at DVH is consistent with each element of the clinical strategy:

Transforming core services – stroke is a core service offered by the Trust. However, the service is currently not meeting the standards our patients should expect. This is primarily due to the inability to recruit to the service and the relatively small size of the service itself. Transforming and strengthening this service by establishing a HASU/ASU with sufficient patient numbers will attract the right team and will include introducing new pathways that will improve patient outcomes.

Local specialist services – hyper acute stroke units offer a high dependency unit level of care which are more resource intensive but deliver significant patient benefits (see section 6). These units are being developed across the country and require a minimum volume of strokes to be effective and efficient. Centralising this specialist resource at DVH aligns with our strategy to develop local specialist services.

Hospital without walls – the stroke clinical network will play a key role in overseeing the development and ongoing performance of the stroke service in Kent and Medway. Pathways for patients with a stroke will be the same at each of the three HASU/ASUs to ensure all patients receive the same high level of care. This requires close working with the other three HASU/ASUs. Rehabilitation in the community setting is a vital part of the stroke pathway, the Trust will liaise with community providers in Bexley, Dartford, Gravesham, Swanley and the Medway Towns to discharge patients to the most appropriate setting of care for their individual needs.

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Stroke care across Kent and Medway does not compare well nationally. The DGT service currently sees a below optimal number of patients (400 p.a.), has not been invested in since 2008 and has been subject to a service review for a number of years, these factors mean that recruitment has been a significant challenge. As such the service is underperforming and is currently rated by Sentinel Stroke National Audit Programme (SSNAP) as ‘D’ on a scale of A-E (where A is high performing). In addition, the service is not adequately compensated through the national tariff. The stroke ward is Spruce, based on Level 2 West, which has 23 beds, 18 of which are typically used for stroke patients with the remaining 5 for general medical patients.

3. Scope / Context

1.1.Background to Stroke Services A stroke is the brain equivalent of a heart attack. The blood supply to part of the brain is interrupted by either a blood clot or a bleed, and surrounding brain tissue is damaged or dies. There are two main types of stroke, ischaemic or haemorrhagic stroke. Ischaemic strokes are the most common form of stroke, caused by a clot blocking or narrowing an artery carrying blood to the brain, whilst haemorrhagic strokes are more likely to be fatal. Some patients may suffer from a Transient Ischaemic Attack (TIA), a temporary stroke that occurs when the blood supply to part of the brain is cut off for a short time only. This results in short term symptoms which normally resolve within 24 hours. This is often a warning that the patient may be at risk of a more serious stroke occurring. A haemorrhagic stroke is where a blood vessel bursts or leaks and blood spills into or around the brain and creates swelling and pressure, damaging cells and tissue in the brain. This is more likely to have a poor outcome and even death. The likelihood of suffering a stroke increases with age and smoking, amongst other factors.

Stroke is a major health problem in the UK. It is a preventable and treatable disease which, nevertheless, is the third biggest cause of death in the UK and the largest single cause of severe disability. Each year in England, approximately 110,000 people have a first or recurrent stroke which costs the NHS over £2.8 billion. South Asians (Indians, Pakistanis and Bangladeshis) have a higher risk of stroke than the rest of the population. Stroke mortality rates in the UK have been falling steadily since the late 1960s. The development of stroke units and the further reorganisation of services following the advent of thrombolysis (the use of drugs to reduce clots), have resulted in further significant improvements in mortality and morbidity from stroke.

Patients with any type of stroke should receive their care on a specialist stroke unit. Initially this will be on a hyper acute stroke unit and then after 72 hours it will be on an acute stroke unit; some hospitals have combined units. Hyper acute stroke units enable patients to have rapid access to the right skills and equipment and be treated 24/7 on a dedicated stroke unit, staffed by specialist teams. Following a stroke, a patient is taken directly to a hyper acute stroke unit where they will receive expert care, including immediate assessment, access to a CT scan and clot-busting drugs (if appropriate) within 30 minutes of arrival at the hospital. Acute stroke units (ASUs) are for subsequent (after 72 hours) hospital care. These units offer ongoing specialist care with 7-day therapies services (physiotherapy, occupational therapy, speech and language therapy, dietetics input) and effective multi-disciplinary team (MDT) working.

Stroke services have been reconfigured across the country and consolidating services to provide rapid access to specialist staff, equipment and imaging has been demonstrated to improve quality and outcomes for patients. For example, in London, the reconfiguration of urgent stroke services in 2010 led to an increase in thrombolysis rates from 12% in Feb-July 2010 to 18% in Jan-July 2012 and saved almost 100 lives per year.

Figure 3-1 illustrates the geographical location of the existing hospital sites in Kent and Medway, and surrounding areas, providing hospital stroke services. It is noted that stroke services are currently withdrawn from Kent and Canterbury Hospital on safety grounds.

Figure 3-1: Trust Locations in Kent and Medway and Surrounds

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There are four Trusts providing hospital stroke services across seven sites:

• Dartford and Gravesham NHS Trust (Darent Valley Hospital site);

• East Kent Hospitals University NHS Foundation Trust (William Harvey Hospital in Ashford and Queen

Elizabeth, the Queen Mother Hospital in Margate);

• Medway NHS Foundation Trust (Medway Hospital in Gillingham); and

• Maidstone and Tunbridge Wells NHS Trust (Maidstone General Hospital in Maidstone and Tunbridge Wells

Hospital in Tunbridge Wells).

There are 134 beds for stroke patients (note this total excludes the beds at Kent & Canterbury Hospital which are not currently being used for stroke services), of which 23 ASU beds are provided at DVH (although only 18 are typically used for stroke patients). This total includes 10 HASU / ASU beds at PRUH, a figure modelled on K&M activity seen at the PRUH.

Currently all DVH patients requiring thrombectomies are transferred into the South East network and have this procedure carried out at King’s College Hospital or St George’s Hospital.

3.1. Current Activity The total Kent and Medway population is c. 1.8m. On average the prevalence for stroke is 1.7% and 2% for atrial fibrillation for this population (source: CCG Stroke Profiles – Public Health England 2014). This masks variances across the footprint, as shown at Figure 4-2, due to different demographic profiles. Figure 3-2: Stroke and Atrial Fibrillation Prevalence

K&M Average National

Stroke prevalence (%) 1.67 1.7

Atrial Fibrillation prevalence (%) 1.99 1.7

% population over 65 years 18.49 17.7

% of population in most deprived quintile 14.10 20.1

This shows that Kent and Medway is currently marginally under the England average for stroke and slightly above average for atrial fibrillation prevalence. This is a marker of activity at 2014; public health analysis identifies that, based on the current preventative measures and pattern of stroke incidence locally and nationally, this figure will not change significantly over the next 10 years, including projected population growth across Kent and Medway.

Figure 3-3 shows the overall a relatively static historic picture of stroke activity by Kent and Medway hospital site.

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Figure 3-3: Kent and Medway Historic Stroke Activity by Site

It is noted that c. 70 patients per year admitted to DVH are from Bexley CCG i.e. outside of the Kent and Medway STP area.

3.2. Key Issues with Current Stroke Service Provision The achievement of key national recommendations / targets, by Trust, (source: 4/2015 – 3/2016 SSNAP) is summarised at Figure 3-4.

Figure 3-4: Current Achievement of Recommendations / Targets by Trust

The summary at Figure 3-4 shows that few targets are currently being met throughout the whole STP area. DGT’s SSNAP performance was rated ‘D’ during the assessment period.

A weekly operational stroke meeting has been in place since April 2018 in order to review progress against these national standards and improve performance and the delivery of care.

3.3. Case for Change There are currently no specialist acute stroke units in Kent and Medway. Stroke services in Kent and Medway do not consistently meet the national standards for clinical quality. Six out of seven local units treat fewer patients than recommended, there are a lack of specialist staff available 24 hours a day, seven days a week and many patients do not receive the most appropriate diagnostics and treatment within recommended time limits. The evidence shows that non-

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compliance with standards for clinical quality results in disability, poor quality of life and death. The case for change is overwhelming and services need to change as quickly as possible.

The case for change was developed by clinicians with involvement from representatives of patient groups and the public, provider organisations and health and social care managers. The key elements of the case for change are set out below. The stroke case for change is available as part of the DMBC, Appendix A.

3.4. DGT Existing Stroke Service Key facts about the Stroke service:

• C.400 strokes in 17/18

• Led by Dr Aghoram – Stroke and Elderly Care Consultant

• Spruce ward on level 2 is for stroke patients, 23 beds available, typically 18 are used for stroke patients

• Aim to have one ring-fenced bed for stroke patients on the ward

• Service links closely with Therapies, Radiology, Cardiology and Neurology

• Stroke performance is nationally compared using SSNAP which gives ratings three times a year. April – June

2018 performance is rated D (A-E, where E is worst) this is an improvement from the previous E rating. Aim

is to achieve D/C by March 2019 with improvements in CT access, recruitment of doctors and bed

management

• Performance cannot improve beyond a low C without significant investment in workforce

• Stroke patients do not consistently receive all of their stroke care on the stroke ward due to bed pressures

in the hospital

• Recruitment is a key issue, under establishment for all staff groups. This has been a challenge due to the

pending outcome of the K&M service review. Establishment is still below clinical standard requirements

• Tariff received does not sufficiently compensate for the costs incurred

3.4.1. Estates Overview

DGT provides inpatient stroke services on Spruce Ward, Level 2, DVH (Figure 3-5). The ward has 23 beds and (at times) 3 escalation beds. Spruce Ward is situated between Ebony Ward (geriatric medicine) with 28 beds and (at times) 3 escalation beds, and has adjacencies to Empress Unit for therapies. The current ward is situated above the Philip Farrant centre.

Figure 3-5: Current DVH Stroke Ward Footprint

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3.4.2. DVH Stroke Activity

The vast majority of stroke activity (84%) is commissioned by DGS CCG and 10% from Bexley CCG. The Trust currently receives very little activity from other Kent and Medway commissioners.

DGT currently achieves an ALOS of 14 days for stroke patients.

Currently many patients for whom DVH is the closest hospital (Carnall Farrar assessment) are being transported to Princess Royal University Hospital (PRUH) in Orpington by the London Ambulance Service (LAS) in the event of a suspected stroke, due to the presence of a high quality HASU at PRUH but not at DVH. Figure 3-6 provides a summary of the PRUH activity, showing more activity is diverted to PRUH than DVH, albeit DVH is closer.

Figure 3-6: PRUH Activity

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3.4.3. Workforce

The Trusts across Kent and Medway have been unable to recruit sufficient staff to meet the clinical standards for Stroke services. This is one of the key factors driving this review. For example, across Kent and Medway there is a shortfall of at least 34 consultants (based on clinical standards and those in post in April 2018). London moved to a centralised HASU model in 2008.

The current workforce providing stroke services at DVH is below establishment and below the minimum clinical standards for stroke unit for each of the clinical groups.

Figure 3-7: Baseline Workforce WTEs

Staff Group In post 30 April 2018 (WTE)

Required for HASU / ASU (WTE)

Gap in WTE

Consultant 1.00 7.10 6.10

Non-consultant grade medical

6.00 8.00 2.00

Nurses (registered and unregistered)

32.80 71.19 38.39

Scientific, Therapeutic & Technical

9.30 28.55 19.25

Stroke lead nurse, specialist nurses & non clinical

3.5 11.32 7.82

TOTAL 52.6 126.16 73.56

The following points are of note:

In post WTEs excludes current use of temporary staff to cover vacancies

Additional staff to ensure appropriate HASU / ASU workforce comprises both increased patient numbers and creation of roles the Trust currently does not have (e.g. Assessor nurses in ED and Stroke lead nurse)

Non-clinical staff includes 1 WTE housekeeper provided through our PFI provider Non-consultant grade medical posts relate to deanery funded training roles (increase on current posts are

subject to STP led engagement with the Deanery) and registrars. Only training roles are in the future HASU / ASU model.

The Trust registrar currently employed in Stroke will be used in the short to medium term to cover expected vacancies in the consultant establishment and a further one may need to be employed.

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Roles for the HASU / ASU model aligns with the STP defined model, but there are some differences in Wte requirements – this is explained in section 5.3.

The Trust currently has two Clinical Nurse Specialists (CNSs) and these will be used to deliver the future workforce model.

Additional radiology staff of 3.52 WTE to support HASU/ASU are excluded from 126.16 as will be added to Imaging staffing in totality to support delivery of stroke. Also an anticipated extra 0.6 Wte nurse for the Emergency Department to support the resuscitation area is extra as relates to support function rather than core stroke workforce.

3.4.4. DVH Stroke Services Financial Position

The baseline financial position for DVH (as at 2017/18) is shown at Figure 3-8.

Figure 3-8: DVH Baseline Financial Position for Stroke Services (2017/18)

2017/18

Income £2,373,000

Workforce Costs £2,540,000

Estimated service on-costs (30%) £755,000

Total (£922,000)

The current stroke service is currently loss-making when income is compared to cost in service line reporting. A HASU / ASU (adequately staffed) would allow more standards to be met and therefore enable attainment of the best practice tariff, but this would still be unlikely to cover the cost base. The ambition for Kent and Medway providers is to agree a local top-up to tariff with commissioners in line with other stroke services across the country including London and Manchester.

If a HASU/ASU model was not to be implemented a ‘do minimum’ would be the provision of a seven day service (recognising recruitment issues); this would have the effect of increasing workforce costs and associated support. The loss would then increase to £1.8m a year.

3.4.5. DVH Stroke Services External Review: May 2017

The National Clinical Director of Stroke and the Royal College of Physicians Peer Review Team undertook a review of the stroke services at DGT in May 2017. The aim of the review was to appraise performance in light of the Sentinel Stroke National Audit Programme (SSNAP) data from the Trust and consider the long term sustainability and viability of hyper acute stroke care at the Trust.

Areas where progress had been made in the preceding year were noted, including increased rates of thrombolysis for patients within one hour of hospital arrival which are in line with targets, audit compliance and case ascertainment are good, and goal are set within 5 days for 97% of patients, which is a significant improvement.

Areas were also identified for improvement. SSNAP data shows that DGT has consistently scored ‘D’ and ‘E’ scores (against a target of ‘A’) for key indicators in the preceding 12 months. The table below shows the performance of the Trust against the patient-centred SSNAP domains for the past four SSNAP reports.

Figure 3-9: SSNAP Performance April 2017-June 2018

Apr-July

2017

Aug – Nov 2017

Dec 17 – Mar 2018

Apr – Jun

2018

SSNAP level D D E D

1) Scanning A A B B

2) Stroke unit E E E E

3) Thrombolysis B D D D

4) Specialist Assessments D D E D

5) Occupational therapy D C D A

6) Physiotherapy C C B B 7) Speech and Language therapy E E E E

8) MDT working D D E E

9) Standards by discharge B D D D

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Apr-July

2017

Aug – Nov 2017

Dec 17 – Mar 2018

Apr – Jun

2018 10) Discharge processes C D D D

There were several recommendations from the external review of May 2017. These recommendations should be delivered for as long as DGT continues to provide stroke services. Recommendations included:

• The hospital should invest time and planning now to improve stroke services. The STP stroke review

process has been seen to slow down progress of service improvements by DGT, which is seen as important

for patient confidence and staff retention. Stroke service leadership arrangements should be reviewed to

ensure sufficient management support and time for clinical leadership.

• The hospital should redesign acute stroke pathway in order to provider hyper-acute stroke care and

improved bed management to ensure patients are admitted to a stroke unit bed.

• Direct admission to a stroke unit bed. Reorganisation of the stroke unit beds to ring-fence 2-4 beds for

hyper-acute stroke care.

• Remove the 2 tier service between thrombolysed and non-thrombolysed patients in order to provide a

consistent stroke service.

• The hospital should work to improve patient flow.

• Increased co-ordination with social services to ensure best use of clinical time and improve the efficiency of

the patient pathway. Use ‘discharge to assess’ policies, where appropriate.

• Early supported discharge team. The ESD team is remote from the stroke unit and a high level of patients

are not discharged home with ESD but transferred for inpatient rehabilitation. This is less efficient, and

more costly.

• Review therapy provision and structures.

• Staffing levels should be reviewed in line with national guidance.

• The current stroke therapy team (Occupational Therapy, Physiotherapy and Speech & Language Therapy) is

not a dedicated team, and has resulted in stroke patients not receiving the level of therapies in accordance

with national guidelines.

• Staff where possible should be ring-fenced for stroke patient.

3.4.6. Improvement Trajectory against SSNAP

Since April 2018 the team has held weekly meetings to review performance which has resulted in the re-introduction of the ring-fenced bed. A clear trajectory has been established which the team are responsible for achieving:

• June 2018 – low score D (towards E) Achieved.

• September 2018 – high score D (towards C) Results awaited.

• March 2019 – low score C

• September 2019 – high score C

• December 2019 – low score B

• March 2020 – high score B

These improvements can only be achieved if there is continuous organisational focus and staff are recruited in order to deliver the improved services required including recruiting to establishment and appropriate capacity in community rehabilitation provision.

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Attachment X:XX

4. Options

The stroke review consulted on five options for the location of three combined hyper acute and acute stroke units. The public and Joint Clinical Commissioning Committee supported the option for Darent Valley, Maidstone General and William Harvey hospitals to develop this service. This results in doubling the number of confirmed strokes coming to Darent Valley, increasing the bed numbers (assuming no growth) to 34 beds.

The new service model requires dedicated hyper acute beds and acute stroke beds in the hospital as well as a range of rehabilitation services in the community. The pathway for both strokes and TIAs has been developed on the basis of a 7 day service.

The service will go live in two phases with Darent Valley and Maidstone going live in March 2020 followed by William Harvey in early 2021.

The DMBC will be considered by the Joint Clinical Commissioning Committee in January 2019. If the preferred option is not accepted and an option excluding Darent Valley is proposed, the Trust will be required to develop a more considered disinvestment case. Disinvestment of stroke would impact on recruitment and retention for therapies, neurology, radiology and emergency department. Stranded costs would result mainly in non-direct patient areas including PFI and corporate support, activity would need to be replaced appropriately in line with commissioning intentions. Activity reduction is unlikely to reduce staffing or capacity requirements in A&E, radiology or neurology. Disinvestment in stroke would have a very small financial benefit for stroke services directly but would financially and clinically impact A&E, radiology, neurology and therapies.

4.1. Introduction The public consultation for the improvement of urgent stroke services in Kent and Medway took place from February until April 2018. The consultation asked the public for their views on the establishment of hyper acute stroke units; whether three is the right number and the five potential options for their location.

• Option A: Darent Valley Hospital, Medway Maritime Hospital, William Harvey Hospital

• Option B: Darent Valley Hospital, Maidstone General Hospital, William Harvey Hospital

• Option C: Maidstone Hospital, Medway Maritime Hospital, William Harvey Hospital

• Option D: Tunbridge Wells Hospital, Medway Maritime Hospital, William Harvey Hospital

• Option E: Darent Valley Hospital, Tunbridge Wells Hospital, William Harvey Hospital

The consultation shared the assessment to date of the five options against four domains: quality of care, travel times, investment and workforce, and implementing the options. Following the end of the consultation each of the hospital Trusts were asked to present to a panel on the deliverability of a HASU/ASU at the hospital site. Subsequently the Clinical Commissioning Groups in Kent and Medway met as a joint committee to discuss the outcomes and unanimously agreed a preferred option, Option B: Darent Valley Hospital, Maidstone General Hospital, William Harvey Hospital.

The DMBC requires approval from provider Trust Boards, NHS England and the JCCC. This business case focuses on the options available to DGT at this stage in the process which are: deliver the preferred option B or disinvest in stroke services.

4.2. Requirements of the Preferred Option: DVH, Maidstone, William Harvey

4.2.1. Overview of activity and bed requirements

Figure 4-1 shows the number of strokes and bed requirements for each of the HASU ASU units in Kent and Medway as well as the PRUH and Eastbourne Hospital which will see a change in the number of Kent and Medway strokes they receive. Activity from Bexley CCG postcodes which are closer to DVH than to PRUH will come to DVH rather than PRUH (London Ambulance Service have stated that were DVH to offer a high quality HASU service, they would take patients to DVH if this was closer than London HASU sites).

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Figure 4-1: Number of strokes and beds required at each hospital in the preferred option

Site Number of Strokes

HASU Beds

ASU Beds Total Beds Current Beds

Darent Valley Hospital 807 10 24 34 23

Maidstone General Hospital

865 10 26 36 12

William Harvey Hospital 1,199 14 37 51 24

Eastbourne Hospital 17 1 2 3 0

PRU Hospital 54 1 2 3 10

Other outflows 72 0 1 1 0

The map at Figure 4-2 shows how the populations will flow to each of the future HASU / ASU sites.

Figure 4-2: Population flows to HASU/ASU

4.2.2. Proposed Service Model and Requirements

Implementation of the agreed service model will result in all stroke activity taking place at a combined HASU / ASU unit only. This will mean that the Ambulance service will take any patient that they suspect may have had a stroke to the HASU site – for every stroke / TIA / mimic patient there is expected to be one inappropriate A&E attendance at the HASU site. Patients confirmed not to have had a stroke in A&E will be: discharged; admitted to DVH if the estimated length of stay is less than 48 hours; or, repatriated to the patient’s local hospital if admission is required and likely to be more than 48 hours length of stay.

A confirmed stroke / TIA or suspected stroke (mimic) will be admitted to a HASU bed for 72 hours, at this point the patient will then transfer to an ASU bed. Following the acute stay, the patient will receive rehabilitation (at home or inpatient) local to their home and may be required to attend a follow up outpatient appointment at the HASU / ASU site following discharge.

Figure 4-3 summarises the high level proposed stroke pathway, the Trust is focused on delivering Stage 2, the acute stage which is set out in more detail in Figure 3-8.

Figure 4-3: Proposed Kent and Medway Stroke Pathway

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Figure 4-4: Future Care Model for K&M STP

The key requirements of ‘good’ hyper acute and acute stroke units that delivers the best outcomes for patient are:

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• Access 24 hours, seven days a week

• Rapid and accurate diagnosis

• Clinical expertise

• Access to imaging and good interpretation

• Direct admission to a specialist stroke unit

• Immediate access to treatment

• Specialist centres with sufficient numbers of patients and expert staff

• High quality information and support for patients and carers

• Inpatient care through a specialist unit with co-ordinated assessment and plans for discharge to continued

rehabilitation

• The service measures what it does, publishes data and constantly looks for improvements.

In order to meet these requirements, Kent and Medway hyper acute and acute stroke units will adhere to the following national recommendations for hyper acute and acute stroke units:

• Be a seven-day dedicated specialist unit with more than 500 confirmed stroke admissions

• Achieve rapid assessment and imagery; imaging within one hour and call to needle (thrombolysis) times of

two hours

• Have patients admitted directly onto a specialist stroke unit within four hours

• Have patients stay in the stroke unit for at least 90% of the inpatient episode

• Assess patients by specialist stroke consultant and stroke trained nurse and therapist within 24 hours

• Have seven-day stroke consultant cover

• Have seven-day stroke trained nurse and therapist cover.

In addition, the South East Strategic Clinical Network Stroke and TIA Service and Quality Core Standards 2016 set out that the care of people with suspected stroke should aim to minimise time from call to needle to a recommended standard of within 120 minutes. This requires:

• Call to (hospital) door time as soon as possible < 60 minutes

• Door to needle time for those appropriate for in licence use of IV thrombolysis as soon as possible <60 mins.

The Trusts will need to provide 7 day services for consultant cover, TIA clinics, diagnostics and therapies. Successful stroke units are built around a stroke-skilled multi- disciplinary team that can meet the needs of individuals. A good stroke unit is considered to significantly improve patient outcomes. For further information and references for the standards above see the DMBC.

4.2.3. TIA Pathway

The Clinical Reference Group has developed an agreed TIA pathway based on National Institute for Clinical Excellence (NICE) guidance. The triage service will be located at the HASU/ASUs for all GPs in Kent and Medway to refer to. All ‘high risk’, ‘probable’ and ‘possible’ TIAs will be seen at the HASU ASU site whilst ‘unlikely’ and ‘other neuro/speciality’ will be seen at their local hospital, which for some patients will not be a HASU/ASU site. This will require the HASU/ASU staff running clinics from the non-HASU/ASU sites: Medway, Pembury, Kent & Canterbury and Queen Elizabeth Queen Mother hospitals. In order to deliver this TIA pathway, the TIA clinics will need to operate a 7 day and extended day service.

Figure 4-5: TIA Pathway

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Those patients with a TIA will be admitted to a HASU bed for one day and will be discharged from the HASU (i.e. will not require an ASU bed).

4.2.4. HASU / ASU Co-Dependencies

The STP has identified critical co-dependencies and building blocks necessary for a site to provide HASU / ASU services, and these are detailed at Figure 4-6.

Figure 4-6: Critical Co-Dependencies and Building Blocks

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Other key dependencies and enablers include: • Rehabilitation services including community beds, residential / nursing care homes;

• Early supported discharge services;

• Ambulance services;

• Patient transport services;

• Social services;

• IT;

• Communications;

• Workforce; and

• Public transport.

4.2.5. HASU / ASU Workforce Requirements

There are separate clinical standards for workforce to provide hyper acute and acute stroke care. Listed below are the minimum workforce standards for both the HASU and ASU. These staffing standards allow for non-clinical patient time (attending MDTs, writing patient notes, organising referrals etc.) and time for training, development, annual leave or sickness, further workforce information is available at section 5. None of the units in Kent and Medway currently meet the staffing standards.

The clinical standards for the HASU include:

• 24/7 consultant availability with a minimum 6 trained thrombolysis physicians on rota and consultant-led

ward round 7 days a week;

• 6 BASP thrombolysis trained physicians on a rota 24/7

• 2.9 WTE nurses per bed to comply with 80:20 trained vs untrained skill mix

• 0.73 WTE physiotherapist per 5 beds (respiratory and neuro)

• 0.68 WTE occupational therapist per 5 beds

• 0.34 WTE speech and language therapist per 5 beds

• 0.2 WTE clinical psychologist/neuropsychologist per 5 beds

• 0.15 WTE dietician per 5 beds

• Access to social worker (this is assumed to be through the rehabilitation provider)

The clinical standards for the ASU include: • 1.35 WTE nurses per bed (65:35 trained to untrained skill mix)

• 0.84 WTE physiotherapist per 5 beds

• 0.81 WTE occupational therapist per 5 beds

• 0.40 WTE speech and language therapist per 5 beds

• 0.2 WTE clinical psychologist/neuropsychologist per 5 beds

• 0.15 WTE dietician per 5 beds

• Social workers (to be employed through the rehabilitation provider)

• Access is available to a range of additional professionals, including those in:

o Oral health

o Orthotics

o Pharmacy

The NHS South East Clinical Networks Stroke Service Specification clinical standards also set a minimum standard for Consultant staff for each unit to provide a 1:6 rota. The standards above for therapists are for five days, these standards have been extended across 7 days as per SSNAP.

4.2.6. Rehabilitation

Rehabilitation requirements for stroke patients vary significantly. Following hospital admission patients will be discharged to the most appropriate care setting: home with rehabilitation support at home; inpatient rehabilitation; or, nursing/residential home with rehabilitation support. The proposed rehabilitation pathway is presented in Figure 4-7. This has been developed by the STP. A key next step for the STP is to bring together the rehabilitation providers across

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Kent and Medway (including Bexley) to agree this pathway and develop an implementation plan that allows this to be commissioned and in place by the time the HASU/ASU services go live.

Figure 4-7: Rehabilitation Pathway

Existing rehabilitation services vary across Kent and Medway. DVH patients that require on-going therapy input as an inpatient are discharged to the Sapphire Unit operated by Virgin at Gravesend Community Hospital. This unit does not offer 7 day therapy input and has a high threshold for accepting referrals which limits the type of patient that it is able to care for. At a minimum these would need to be revised and capacity increased for the service to reduce length of stay and better allow the Trust to meet the 90% stay on the stroke unit SSNAP requirement.

4.3. STP Critical Path The provisional critical path is shown in figure 4-8. Once the DMBC and individual Trust business cases / disinvestment cases have been approved, the implementation plans can begin to be delivered. However unresolved issues, including a locally agreed tariff, transition funding and the rehabilitation provision, may impact the willingness of the acute trusts to proceed with implementation until progress is seen in these areas.

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Figure 4-8: Critical Path

This critical path assumes a two phased go-live with Maidstone and Darent Valley Hospitals at sufficient capacity to accommodate the additional demand in March 2020 and William Harvey in January 2021. The flows of patients in 2020 (Phase 1) and from 2021 onwards (Phase 2) are shown in Figure 4-9.

Figure 4-9: Two phased go-live population modelling

Following the opening of the additional capacity, the HASU/ASU unit will undergo an accreditation process in order to confirm its Hyper Acute Stroke Unit status. Therefore the benefits of the HASU/ASU may only be delivered in part from March 2020 and in full near/following accreditation. For the purposes of the benefits realisation modelling it has been assumed that it will take six months for the unit to become accredited. Accreditation is heavily reliant on workforce and rehabilitation capacity to allow for the HASU / ASU to function effectively. The Trust has little ability to influence the progress of the development of the required rehabilitation services but is able to begin recruiting early, should the transition costs allow. Further details of the anticipated benefits can be found in section 6 of this business case and in the DMBC.

4.4. Disinvestment Case The DGT Trust Board, and the JCCC have the option to not support the Preferred Option presented in the DMBC and summarised in section 4.2. The option to disinvest in stroke services is therefore summarised below.

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The South East Clinical Senate has considered the implications of not becoming a stroke unit, emphasising the importance of the stroke network3. This recommends the following:

• Whilst there is no requirement for the maintenance of specialist stroke clinicians to be based at the non-

stroke hospital, core diagnostic skills should remain to support the confirmation of patients arriving in A&E

or on a ward who have a stroke;

• The hospital must remain part of the stroke network for at least an agreed transition or embedding period;

• Pathways to transfer patients to the HASU / ASU and repatriate non-stroke patients must be robust and

unnecessary transfers of care avoided wherever possible to reduce handovers, disruption in continuity of

care which may impact on clinical risk, recovery and length of stay;

• The move of the stroke service should not de-stabilise remaining services (e.g. elderly care and the

therapies), risks are to be well mitigated;

• Neurology or geriatric assessment of those who have previously had a stroke but are inpatients for another

acute diagnosis will be required to identify whether transfer to the HASU / ASU is required;

• A stroke champion from each of the medical, nursing and therapies workforce should be identified to

maintain the professional links and liaison between the hospital and stroke centre and network; and

• The maintenance of clinical skills within the therapies workforce for stroke patient management is

important for supporting patients who are considered unsuitable for transfer to the HASU / ASU hospital.

Rotation of staff through the HASU / ASU hospital can ensure maintenance of the necessary skills.

The following areas will be further appraised, in the event that DGT is determined not to become a HASU / ASU: • Recruitment to the following areas is likely to be negatively impacted: neurology, radiology (particularly

Interventional Radiology), A&E and therapies will need to be considered.

• Activity reduction in A&E, radiology, neurology, cardiology and therapies will be unlikely to result in lower

capacity or staff requirements. Each of these areas has staff vacancies so time released from stroke will be

refocused on other areas.

• Released capacity in CT and MRI will be used to reduce outsourcing of activity and improve wait times for

these diagnostics.

• It is currently assumed that there will be no non-recurrent staffing costs. Existing staff associated with the

stroke service at DVH are expected to either leave to take positions at a HASU / ASU or be redeployed

elsewhere in DGT.

• Stranded costs will be incurred as a result of having to continue to pay PFI costs for Spruce ward, until such

time as agreement can be reached with the CCG regarding future alternative activity and use. Furthermore

other indirect corporate and support costs partially funded by Stroke income currently will remain without

another funding stream in the short term.

The impact on these areas has been explored in more detail by Medway NHS Foundation Trust as Medway Maritime Hospital is not within the preferred option. This is included in the DMBC. Should DVH be required to disinvest in stroke services, the Trust will develop plans building on learning from other providers that have disinvested including Guy’s and St Thomas’ NHS Foundation Trust.

4.4.1. Workforce Implications

There are few staff at DVH that are dedicated to stroke care – the majority also work in other specialties. However the existing stroke service team produce, comparatively with other providers in Kent and Medway, good patient outcomes. For example, DGT has the best standard mortality rate for stroke out of all Kent and Medway providers.

All staff (working more than 50% of their time on stroke) will be offered the ability to transfer to the stroke unit of their choice and supported to move if they wish to do so. All those that do not wish to move could be absorbed into the vacancies at DVH in other specialities. This requires further detailed TUPE consideration. A STP-wide workforce plan is required for stroke so as to not de-stabilise one service over another prior to go live.

3http://www.secsenate.nhs.uk/files/3814/5503/1676/Hospitals_without_acute_stroke_units_-

_implications_and_recommendations._South_East_Clinical_Senate_Jan_2016.pdf

http://www.secsenate.nhs.uk/files/3814/5503/1676/Hospitals_without_acute_stroke_units_-_implications_and_recommendations._South_East_Clinical_Senate_Jan_2016.pdf

http://www.secsenate.nhs.uk/files/3814/5503/1676/Hospitals_without_acute_stroke_units_-_implications_and_recommendations._South_East_Clinical_Senate_Jan_2016.pdf

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4.4.2. Estate Implications

Depending on the outpatient model of care, the reduction in clinics at DVH would release 13 clinic room slots per week in Evergreen. This may allow for a new use of Evergreen or mitigate the need to expand outpatients in future.

Stroke currently occupies 18 beds on Spruce ward. No longer providing stroke care would release this capacity to expand an existing service (either as part of the Trust or STP strategy) or to accommodate the growth / reduce occupancy, albeit this would need agreement with commissioners. Until that time, the cost of Spruce ward would be a stranded cost to DGT.

4.4.3. Financial Implications

The Trust would require discussions with commissioners before assuming that the income for stroke services could be replaced. Figure 4-10 shows the potential incremental change to the Trust finances on the following basis:

• Income – disinvestment lose 100% income

• Pay – disinvestment direct staffing either move to ASU/HASU units or be redeployed

• Service support costs – disinvestment assume these are stranded costs

• Capital charges – Spruce ward related element still be chargeable (including PFI unitary payment) to Trust

and thus a stranded cost until alternative use for the space could be found.

It is worth noting the following assumptions:

• Elements of current income and spend relating to stroke that excluded from DMBC that would impact

favourably on HASU/ASU hospital (as expect positive contribution) and adversely on disinvestment (income

loss not offset by cost reduction). Examples:

o A&E as the ambulances convey any patient that is query stroke straight to the HASU/ASU A&E

o Outpatients, some outpatient activity will only take place at the HASU/ASU however, wherever possible

this will remain at the local hospital

• Cost behaviour in support services assumed to be linear with workforce increase

• Direct Non pay costs excluded as deemed to fall below materiality threshold

Figure 4-10: Financial Impact of Disinvestment

2017/18

Income £2,373,000

Workforce Costs £2,540,000

Estimated service on-costs (30%) £755,000

Total (£922,000)

As Stroke is a loss making service, disinvesting from stroke services would financial benefit the Trust. However this does not factor in the cost of mothballing the stroke beds and other associated stranded costs.

The Trust should also consider the avoided costs. If compared to the income and expenditure for the combined HASU/ASU then the avoided costs would be significant. See section 8 for more detail.

4.4.4. Disinvestment Case Benefits and Risks

Figure 4-11 summarises the benefits and risks associated with the disinvestment of stroke services for DGT.

Figure 4-11: Disinvestment Case Benefits and Risks

Benefits Risks

No ongoing requirement for dedicated stroke personnel, which is in scare supply in K&M

Released capacity at DVH could be used by other services, potentially meaning that the internal bed programme does not need to develop as many new beds as currently estimated (subject to commissioner agreement and whether future ned capacity is required

Temporary investment in workforce is likely to be required from April 2018 irrespective of option chosen

Loss of HASU/ASU could significantly impact on DGT’s ability to obtain major trauma unit status

Loss of stroke care at DVH may impact on attractiveness of posts in other specialities such as therapies, neurology and radiology (particularly

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Benefits Risks

in the acute or other healthcare setting) Stroke staff are all multi-skilled and in high demand

occupations, so DGT highly likely to wish to retain their skills, even without a stroke service

Stroke service is currently loss-making for DGT; disinvestment from this service will have a positive impact (this does not however take into account the impact on allied clinical services)

interventional radiology) For neurology, it may mean neuro-centres are created

at HASU sites in K&M

The delay in getting to consultation and time required to develop the stroke centres may result in staff leaving the service for other roles, further destabilising the service

Emergency measures / closure may need to be considered if service becomes unsustainable or unsafe through loss of experienced stroke staff

Stranded costs will be incurred (extent of which to be calculated)

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Attachment X:XX

5. Delivery Plan

A doubling of the number of strokes per year (to 800 strokes) will also see an increase in demand for A&E as such the Trust will require one additional resuscitation bay to manage this activity. Additional demand for CT and MRI will be managed by doing more activity at Queen Mary’s and outsourcing more MRI however an additional ultrasound machine will be needed as well as an additional neuro-radiologist.

A total of 34 beds (10 HASU and 24 ASU) will be needed; this will be achieved by expanding Spruce into the adjoining ward Ebony. The displaced beds will be re-provided in a modular ward located next to the Jade Unit. The most appropriate patients for this modular unit will be confirmed by the Emergency Care and Adult Medicine directorate during the Implementation Period. Given the location this may be patients that are medically fit for discharge. The aim is to decommission the modular unit when local care delivers the required reduction in demand for acute beds. The modular unit will be rented at an annual revenue cost of £905k and the reconfiguration of A&E and Spruce/Ebony along with woks associated with the modular unit will require £556k capital.

There will need to be an additional 5 consultants (bringing the total to 7) to meet the clinical standards. Overall an additional 79 whole time equivalents will be required to staff the stroke service based on current staff in post. This will be challenging to recruit to so this chapter sets out a minimum staffing level required to run the unit, recognising the unit will not meet all of the clinical standards. The ambition is to improve the SSNAP rating from a D to a C by March 2019 and a B by March 2020. This will require an investment in workforce during the implementation period.

The stroke service across the county will continue to rely on telemedicine; the equipment for this is due for replacement and is included in lifecycle costs in 18/19. In addition, Stroke Capture will also be introduced to collate live data to monitor SSNAP performance and patients’ progress along a pathway in live time. This will cost £[77]k in year one and reduce to £32k for each subsequent year.

An Implementation Plan has been developed which sets out actions required in the following categories: clinical, estates, finance, workforce, contracts, communications and project management office. Priority actions following approval of the business case include recruiting a dedicated project manager, recruiting a stroke lead practitioner and introducing Stroke Capture.

The Trust has developed and is maintaining a live implementation plan which sets out the actions required to deliver the combined HASU/ASU at Darent Valley Hospital for a go-live at the end of March 2020. The summary plan is set out in section 5.5. This section first explores the requirements for the HASU/ASU at DVH, anticipated activity, proposed workforce structure and estate solution.

5.1. Overview of requirements at DVH The HASU / ASU at DVH in the preferred option include:

• c.800 strokes per annum, over double the current volume seen

• 34 beds – 10 HASU and 24 ASU

• 1 resuscitation bay

• Workforce that at least meets the basic clinical standards of professional to bed ratios including seven

consultants

• Additional radiology workforce, extra CT sessions at QMH and outsourcing of further MRI activity

• Modular unit for displaced medical patients and additional general medical admissions

Figure 5-1 shows the stroke pathway highlighting radiology and therapy roles.

Figure 5-1: Stroke Pathway

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This chapter will consider the impact of each aspect of this pathway on DVH including the expected activity; workforce, estates, A&E, radiology, outpatient and pharmacy requirements; and the proposal for a modular unit.

5.2. Activity at DVH Figure 5-2 shows the anticipated stroke activity at DVH from March 2020 per year and per day as well as the assumptions used for this activity.

Figure 5-2: Number of Strokes, TIAs and Mimics as well as A&E attendances

Activity Type Volume per year

Volume per day

Assumption

A&E Attendees, query stroke

2,179 6 For every confirmed stroke, TIA or Mimic one non-stroke/TIA/mimic is bought to A&E for assessment

Confirmed Stroke 807 2 The stroke activity numbers have been modelled by Carnall Farrar as part of the STP work using postcode mapping of current stroke activity

TIAs for admission 81 0.2 Activity volumes for TIAs and Mimics have been estimated based on uplifts agreed by the CRG – TIA: 10% uplift on stroke numbers and Mimics: 25% uplift on stroke numbers

Mimic for admission 202 0.6

Non-stroke requiring 48hr admission

545 1.5 For every two strokes/TIAs/Mimics admitted it has been assumed that one non-stroke will be admitted for up to 48hours

Non-stroke requiring repatriation / discharge from A&E

545 1.5 Those not requiring admission will be discharged

TIAs for triage (4 per 1,000 population)

2,692 7 TIA prevalence is 4 per 1000 population. These TIAs will require triage, see TIA pathway in section 4.4

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5.3. Impact on Workforce The workforce requirements have been modelled using agreed standards to provide a 7 day service including two daily consultant led ward rounds, seven day therapy and seven day access to radiology. Whilst the STP has only progressed the workforce modelling to this point, the Trust has developed a detailed structure for the workforce required to deliver the stroke service. This includes a Stroke Lead Practitioner, Stroke Assessor Nurses, Training grade doctors, Radiologists, Radiographers, A&E Nurses, Ward Clerk, Pharmacy, Housekeeping, Medical Secretaries and Social Care. There is a national shortage of workforce so the ability to achieve the required standards is a key risk.

A summary of the stroke workforce required by staff group is set out in Figure 5-3. This is an increase of 77.68 actual WTEs4 and £2.9m pay costs. Figure 5-4 shows the proposed Stroke Team pay costs and Figure 5-5 shows the Staff Team structure.

Figure 5-3: WTEs by Staff Group

Staff Group

Total WTEs Required

Current WTEs in post

Current WTE establishment

Gap from current in post to total required

Total WTEs required Following Finance Committee

Medical (consultants and registrars)

7.10

2.00

3.00

5.10

7.10 removed 2 registrar posts

as per STP model

Nursing

77.74

32.80

39.75

44.94

77.74 removed 2 CNS and 1

admin pathway coordinator to

create 5 band 4 stroke

coordinator/ specialist nurses

as per STP model

Therapy

26.19

8.10

8.10

18.09

26.19 Reduced ratio of

trained to untrained from

2:1 to 4:1

Pharmacy 1.00 1.00 1.00 0.00

Psychology (KMPT) 1.36 0.20 0.20 1.16

Admin & Clerical 3.77 2.50 2.50 1.27

Total 117.16 46.60 54.55 70.56

Training Doctors 8.00 5.00 5.00 3.00

Housekeeper (through PFI provider)

1.00

1.00

1.00

0

Radiology support 3.52 0.00 0.00 3.52

ED nurse 0.60 0.00 0.00 0.60

Revised Total 130.28 52.60 60.55 77.68

4 Gap against establishment is 77.68 WTEs

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The initial total in the table above aligns to the STP staffing model, the variances between this and the current DGT proposed core workforce is shown in figure 5.5.

Figure 5-4: Stroke Team Pay Costs by Staff Group

Staff Group New service £000s

Medical (consultants and registrars)

886

Nursing 3,171

Therapy 1,101

Pharmacy 55

Psychology (KMPT) 73

Admin & Clerical 129

Total 5,416

Training Doctors 351

Housekeeper (through PFI provider)

22

ED resus nurse 30

Radiology support 259

Revised Total 6,078

Figure 5-5: Comparison STP to latest DGT staffing structure

Role Band STP

Model WTE

STP Model £000s

DGT Model WTE

DGT Model £000s

Variance WTE

Variance £000s

Consultant 7.10 886 7.10 886 0 0

Registered Nursing Ward 5/6 44.26 2,177 44.75 2,015 0.49 (162)

Unregistered nursing Ward 3 17.14 525 15.79 484 (1.35) (41)

Physiotherapist 6 7.69 353 7.18 329 (0.51) (23)

Occupational Therapist 6 7.35 337 7.18 329 (0.17) (8)

Speech & Language Therapist 6 3.64 167 4.31 198 0.67 31

Dietitian 6 1.43 65 1.79 82 0.36 17

Therapy Assistant 3 5.03 138 5.73 163 0.70 25

Clinical Psychologist 7 1.36 61 1.36 73 0.00 12

Ward based pharmacist 7 1.00 55 1.00 55 0.00 0

Lead Stroke Practitioner 8b 1.00 71 1.00 70 0.00 (2)

Stroke Co-ordinators / Specialist nurses

4 5.00 159 5.00 139 0.00 (19)

Nurse assessors 5 5.55 273 5.55 259 0.00 (14)

Nurse (outpatient clinics) 5 3.77 146 3.77 146

HCA (outpatient clinics) 3 1.00 27 1.88 58 0.88 30

Admin assistant 3 1.00 27 1.00 24 0.00 (4)

Ward manager 7 1.00 55 1.00 49 0.00 (6)

Admin support 4 1.77 56 1.77 56 0.00 0

TOTAL 112.31 5,434 117.16 5,416 4.85 (19)

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The above table demonstrates that against the STP model the Trust is currently 4.85 WTEs higher and £19k lower. Key points of note regarding differences:

Registered nurses on the ward favourable financial variance as STP model assumed all band 6 whereas roster has a mix and 5s and 6s.

Trust has included 3.77 registered nurses for TIA/Stroke outpatient clinics in recognition of the significant growth expected from Bexley where patients currently are treated at the HASU at the PRUH.

The following points are of note in terms of changes the Trust will need to undertake in moving to the new structure:

Existing 1 Wte registrar and potentially a second post will be needed in the short to medium term to cover vacancies in the consultant establishment until all substantive appointments can be made.

The band four stroke co-ordinators are new roles

Senior nursing roles – current band 8a and band 7 CNSs (2 Wtes) will be utilised as part of the future senior nursing team.

Currently the Trust does not employ any Nurse Assessors in ED and are essential in ensuring that timely and appropriate thrombolysing is undertaken.

The Trust will work through the implications of changing from a current medical secretary model to the admin support roles set out by the STP.

Figure 5-6: Stroke Team Structure

In addition, the Trust will require 0.6 WTE nurses in A&E for the additional resuscitation bay and 3.52 WTEs for Radiology to create the additional capacity, attend MDT meetings, report on scans and extend to 7 day service for both CT and MRI.

The Trust has proposed the following new roles for the stroke service: • Lead Stroke Practitioner – to oversee the quality, performance and management of the service

• Pathway co-ordinator – to manage the admissions and discharges from the stroke unit

• Stroke assessor nurse – to review and manage all patients in A&E that are query stroke; to thrombolyse patients

in A&E (24/7 service). These roles are already in place at Maidstone and William Harvey Hospitals

• Stroke Pharmacist – to manage the drug requirements of stroke patients on the unit

Each of these roles will contribute to the achievement of SSNAP standards, reduce the length of stay, and realisation of the benefits (see section 6).

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Given the difficulty in recruiting to the posts required, the Trust has identified the workforce that would need to be in post for a safe Day 1. The unit may be required to operate with this level of workforce for a period of time whilst recruitment to the vacancies continues. This will mean that in some areas the service will not meet the clinical standards, the table below highlights where this is the case.

Figure 5-7: Minimum staffing requirements for Day 1

Category of Staff

Role

Minimum WTEs required for Day 1

Total WTEs required for best possible service

Comments

Admin & Clerical

Lead stroke practitioner

1

1 Recruit during implementation period to lead the development of the unit

Medical Lead Stroke Consultant

1 1

Medical Consultant 4 6.1 Minimum of 4 required

Medical Registrars 2 0 Minimum of 2 required to support expected consultant vacancies.

Medical Junior doctors/ physician associates

8 8 Anticipate funding and allocation from Health Education England

Therapy Therapists (trained) 14.62 20.46 Minimum for Day 1 to deliver 5 day service only, SSNAP requires 7 days

Therapy Therapy assistants 4.09 5.73 Minimum for Day 1 to deliver 5 day service only, SSNAP requires 7 days

Nursing HASU qualified 10.53 23.69 1 to 6 ratio for day and night. Will not meet stroke guidelines

Nursing HASU unqualified 7.9 5.26 1 to 6 ratio for day and night. Will not meet stroke guidelines

Nursing

ASU qualified

13.4

21.06 1 to 8 day time ratio, 1 to 10 night time ratio. Will not meet stroke guidelines

Nursing

ASU unqualified

10.53

10.53

1 to 10 day time ratio, 1 to 12 night time ratio. Will not meet stroke guidelines

Nursing Clinic Staff 3 5.65

Nursing Ward Manager 1 1

Nursing Stroke Assessors 2.87 5.55 7am-7pm service only

Nursing ED Nurse for Resus Bay

0.6 0.6 1 nurse to 2 resus bays, additional bay will require staffing

Admin & Clerical

Medical Secretaries

1.5

2.5

Not used typical 0.5 per consultant as assumed new ways of working will reduce number required. Minimum needed will reduce as will not recruit full number of consultants

Admin Clerical

& Stroke – co- ordinators / Pathway coordinator

3

5

Admin Clerical

& Ward Clerk 1 1

Admin Clerical

& Housekeeper 1 1

Other Neuro Clinical Psychologist

1.36 1.36 Minimum for Day 1 to deliver 5 day service only, SSNAP requires 7 days

Clinical Support Pharmacy 1.0 1.0

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Category of Staff

Role

Minimum WTEs required for Day 1

Total WTEs required for best possible service

Comments

Clinical Support Radiology 3.52 3.52 Incremental to current WTEs

Total for stroke service 96.92 130.28

Modular Unit

Modular Unit – Medical

Junior Doctors

TBC

TBC Number of junior doctors will depend on the clinical model for the unit

Modular Unit – Nursing

Ward Manager 1 1


Qualified Nurses 13.4 13.4 1 to 8 day time ratio, 1 to 10 night time ratio.


Healthcare Assistants 10.53 10.53 1 to 10 day time ratio, 1 to 12 night time ratio.

Modular Unit – Admin & Clerical

Ward Clerk

1.22

1.22

Modular Unit – Admin & Clerical

Housekeeper

1

1

Total for modular workforce 27.15 27.15

Total for all workforce 124.07 157.43

The total WTEs for stroke service of 130.28 is 13.12 above the 117.16 described in Figure 5.5 aligned to the STP model due to the following roles:

Junior Doctors as assumed HEE funding 8.00

Housekeeper as captured in support services 1.00

ED resus nurse as captured in support services 0.60

Radiology increase as part of support services 3.52

A detailed recruitment plan will be developed with support from the Trust and STP HR teams and sit alongside the implementation plan. The lead stroke practitioner will own this and be responsible for ensuring the service is established on a timely basis bearing in mind the launch in March 2020. Each role will have an agreed lead in time to allow for sufficient induction to the Trust and unit, this may require over-recruiting to Spruce for a short and agreed period of time.

For the modular unit (for the displaced activity), the Trust will need to recruit additional nursing staff for the ward including a ward manager, housekeeper (through SERCO), a ward clerk, healthcare assistants and nurses. Figure 5-7 shows the workforce requirement for the 18 bedded modular unit as both total and incremental whole time equivalents. The incremental pay cost is £253k (see Section 8, Financials further information).

Figure 5-8: Modular unit workforce requirements

Staff Group

WTEs Required WTEs Transferring from Ebony

Establishment WTEs Transferring from Ebony

Gap in Actual WTEs

Housekeeper 1.0 0 0 1.00 Ward clerk 1.22 0 0 1.22 Healthcare Assistant 10.53 7.6 9.63 2.93 Registered Nurse 10.77 5.4 7.74 5.37 Ward Manager 1 0 0 1.00

Total 23.52 13.01 17.37 10.52

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There is also an organisational development aspect of the workforce implementation plan to ensure that the Trust both recruits and on-boards new members of staff. There will need to be a culture change within the unit to improve performance, governance and the operational running of the unit to HASU / ASU standard. There will be leadership training and team building opportunities for the team drawing on the resources within the Alliance with Guy’s and St Thomas’ NHS Foundation Trust as well as those offered by the Kent and Medway STP. In addition, a talent management and development pathway for all roles will be devised to improve retention of staff and offer greater career progression and diversification (for example rotations across nursing and therapy for healthcare assistants).

5.4. Impact on Estates The current stroke footprint at DVH is described at Section 2.2. The proposed estates solution at DVH has been identified on the following basis:

• Spruce (current stroke ward) has 23 beds and three escalation beds. Ebony (adjoining ward) has 28 beds

and three escalation beds;

• Escalation beds are not suitable for stroke patients unless they are awaiting discharge as hoists need to be

used, access from both sides of the bed is required and call systems are needed;

• Retain ease of access from A&E and to radiology and the therapy unit (adjacent to Empress);

• No other possible strategic service moves have been taken into consideration;

• Bed modelling undertaken by Carnall Farrar as at September 2018 has been used;

• 80% occupancy level is required for both HASU and ASU beds;

• HASU beds will need to be exempt from the single sex accommodation requirements; and

• Spruce is currently operating at over 100% occupancy and includes stroke and other medical patients. The

estates options include decant space for the displaced activity from Spruce.

The proposed estate solution includes: • Changes to A&E to create one additional resuscitation bay;

• Developing Spruce into a combined HASU and ASU:

o Use all 23 beds on Spruce;

o Acquire from Ebony: four bedded bay, six bedded bay, two side rooms, one bathroom;

o Remove the six escalation beds from both Spruce and Ebony;

o Five side rooms, three with en-suites;

o On ward therapy space;

o On ward room for MDTs / out of hours TIA assessment / family room;

o Assisted bathroom;

o Shared facilities with Ebony – one clean utility and drug room, kitchen and staff room;

o Dedicated junior doctor space;

o Maintain 16 beds on Ebony for medical patients;

o Developing a modular unit for 18 beds to mitigate the reduction in medical beds available due to stroke

expansion; and

o Converting two therapy offices into an office for the ward managers and a store (offices to be re-

provided within the Empress unit)

• A leased modular unit for 185 beds will need to be sought for the displaced activity. This is made up of:

o 3 beds on Spruce currently used by medical patients

o 12 beds that stroke will require from Ebony (including two single rooms that will be repurposed)

o 3.2 additional medical beds required to manage the non-elective tail admissions whilst waiting for

discharge or transfer to another hospital

• 16 remaining beds on Ebony ward could continue to be used for neurology / geriatric patients.

Figure 5-9 sets out the proposed ward configuration for Spruce as the combined HASU and ASU.

Figure 5-9: Proposed Ward Configuration

5 To be confirmed

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5.4.1. Estates Impact on A&E – Resuscitation Bays

The acute stroke pathway begins in A&E majors and therefore additional resuscitation capacity is required. It is assumed that for every stroke / TIA / mimic patient that attends, an additional one patient that is query stroke in the ambulance is not. These patients will be assessed in majors too. On the basis that four patients could be seen per day in a single resuscitation bay, an additional resuscitation bay is required and as such capacity for one bay has been identified. Figure 5-10 shows the changes required to Majors B and Resuscitation within A&E to accommodate the additional resuscitation bay.

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Figure 5-10: Proposed A&E Resuscitation Configuration

5.4.2. Estates Impact on Radiology - CT Scanner / MRI / Carotid Doppler

Radiology activity is driven by stroke activity volume, at this time there is no estate impact envisaged for CT, MRI or Carotid Doppler.

5.4.3. Estate cost assumptions

Costing assumptions for the estate proposal (see section 8, financials): • Leasing costs for a modular unit for 18 beds (£905k p.a.); element of capital cost associated with connecting

services

• Capital refurbishment costs for conversion of existing ward design into HASU/ASU requirements

• Capital costs for the redesign of the smaller Ebony

• Capital costs for creating a junior doctor room outside of Ebony at the end of the corridor on level 3

• No additional rental charges at Queen Mary’s Hospital for additional CT sessions

5.5. Impact on Radiology The additional activity assumed for Radiology is summarised in Figure 5-11.

The additional CT demand will require appropriate activity to be moved from DVH to Queen Mary’s Hospital, Sidcup. DGT are the current provider of this service at QMH and there are two sessions currently unstaffed that could be used. One CT scanner has been replaced at DVH improving the reliability of the CT service.

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MRI capacity is an issue at DVH so to create sufficient capacity at DVH for stroke demand more activity will need to be outsourced.

Carotid Doppler capacity is limited as is ultrasound more broadly. There will be approximately 50 additional ultrasound requests based on current referrals for inpatient ultrasound for stroke patients. These scans may not be due to their stroke condition but are requested to help diagnose any other conditions the patient may have that may impact what type of care the patient requires. It is envisaged this will be managed within the existing equipment available.

The assumptions driving the Radiology activity are based on recommendations from the DVH Stroke Lead Consultant, in some instances this differs to the assumptions made by the STP as the Trust has gone into more detail. It is proposed by the STP that these discrepancies are discussed as part of the Implementation period; however there is a cost impact and therefore the Trust has included its assumptions in this business case. The table below compares the Trust assumptions with the STPs, activity volumes shown are in total and therefore include the current DGT activity. NB: Carotid Doppler is a five day service whereas CT and MRI are required to be 7 day services, activity modelling has been undertaken on this basis.

Figure 5-11: Radiology Activity Assumptions

Activity Type STP Assumption STP Volume DGT Assumption DGT Volume

CT Head p.a. (per day)

100% confirmed strokes require one CT Head

100% confirmed TIAs require CT Head

50% of TIAs seen in clinic require CT Head

1628 (4.5)

100% of A&E attendees with stroke symptoms require 1 CT head to confirm if it is a stroke

50% of TIAs seen in clinic require CT Head

25% of strokes require 2nd CT Head (post thrombolysis)

100% of non-strokes that require 48hr stay at DVH require CT Head

3666 (10)

CT Angiogram p.a. (per day)

50% of strokes require CTA

404 (1.1)

70% of A&E attendees with stroke symptoms require a CTA

25% of likely TIAs seen in clinic will have a CTA

100% of non-strokes that require 48hr stay at DVH require CTA

1677 (4.6)

Total CT p.a (per day) 2031 (5.6) 5343 (14.6)

MRI Head p.a. (per day)

50% confirmed strokes 50% patients seen in TIA

clinic

1144 (3)

50% confirmed strokes 50% patients seen in TIA

clinic 90% confirmed mimics

1325 (4)

Carotid Doppler p.a. (per day)

Not considered

-

100% likely TIAs in clinic will have a CD

45% of admitted TIAs, Mimics & mild strokes require a CD

25% of non-strokes that require 48hr stay at DVH require CD

1864 (7)

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5.6. Impact on Other Services / Areas The impact on Pathology and Pharmacy is considered to be minimal for the following reasons and is therefore not included in the above comparison of options:

• Although additional pathology will be required per patient, the pathology service currently has available

capacity and is therefore likely to absorb this;

• The main drug provided is Alteplase which is readily available in A&E so would not impact on the Pharmacy

department. Alteplase delivery receives its own best practice tariff so the cost will be recuperated.

See section 7.2 for further information on outpatients. Additional outpatient capacity in Evergreen will be required as well as at MFT to ensure outpatient care is provided as locally as possible. Evergreen has sufficient additional capacity to be able to accommodate this but will require additional staffing to support the efficient running of the clinics.

The TIA pathway illustrates that 30% of those triaged by the TIA triage service will be seen in Neurology or another specialty clinic (most likely to be Cardiology or Care of the Elderly). Discussions have taken place with Neurology and Cardiology about the impact on their services. The additional stroke activity will result in an increase in cardiac tests requested as outpatients. The cardiac team are under establishment and will continue to aim to recruit to be better able to meet this demand. Neurology similarly will see an increase in outpatient appointments (see 7.2.3).

5.7. IM&T Requirements The Stroke service currently uses telemedicine to allow for off-site consultant review of patients. This is particularly important out of hours. The system used by all Trusts in Kent and Medway, however the host of the service has given notice and is due to stop providing the service in 2018/19. The Trust has therefore requested that the STP facilitate the procurement of a new solution that can be implemented immediately. This will require new monitors for A&E and Spruce, but will be sourced from Trust capital as required irrespective of extra stroke activity; cost to be determined.

All stroke units are required to submit data to SSNAP which provides quarterly reports, meaning the Trust is only able to monitor its performance against SSNAP standards on a quarterly basis. There are software packages available that pull data from Patient Administration Systems (PAS), A&E systems and Radiology systems to record and show live performance. The software also allows a report to be pulled and submitted directly to SSNAP reducing the need for clinicians (or a new administrator post) to spend time entering every patient’s data individually. One such software is CaptureStroke which has given a cost of £32k p.a. (year one would be higher to include training and Trust costs to develop interfaces with the required systems). However, a Kent and Medway wide solution should be developed and agreed and the STP have requested that this be considered during the Implementation Phase. The Trust wishes to proceed with a free three month trial following the approval of this business case and will need to decide whether to proceed during this period. The costs for this system have been included in the financials for this business case and the DMBC as it is widely recognised that a solution is needed.

A summary and the aims of CaptureStroke are set out below; a more detailed proposal is available at Appendix B. Summary:

CaptureStroke is the market leading performance improvement system for the stroke care pathway, featuring intelligent data collection and assurance monitoring functionality.

CaptureStroke has been developed over several years through collaboration by Silverlink Software Limited (“Silverlink”) with clinical stroke teams across the country. Designed to support multiple audits, SSNAP, SITS, Vital Signs etc.

The system is intuitive, easy to use and understand, and is perfectly suited to multi-disciplinary use. This paperless solution empowers clinicians with real-time performance and key care intervention notifications,

which assist in meeting care targets, whilst providing configurable reporting and data presentation capabilities.

The system can be fully integrated to a Trusts’ existing systems such as their PAS or electronic patient record (EPR) which reduces duplication of effort around the ever growing volume of stroke audit data that is required to be collected.

The system delivers real time insights into care performance to clinical teams caring for stroke patients, service leads and the Trust’s informatics team.

Aims:

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To optimise the treatment and care of stroke patients throughout the Trust (included those within dedicated ward space and stroke outliers) by the implementation of a single specialised data capture and activity record system

To facilitate real-time data capture, including critical care interventions and observations, and relate them to Best Practice Tariff and SSNAP audit

Enable care performance monitoring and trend analysis through use of real-time dashboards and regular reporting

To provide a method of quick and streamlined submission of SSNAP audit data to the Royal College of Physicians

Improving data quality by using the system which automatically highlights to users any data conflicts or inconsistencies, based upon the SSNAP dataset and audit rules, as data is inputted

Reducing the need to review inconsistencies when the SSNAP upload is made To reduce the time spent on data collection and reporting, to minimise the use of paper and to digitalise data

collection

5.8. Implementation Plan The Trust has developed a live Implementation Plan for a go live date of March 2020. This will be owned by the Lead Stroke Practitioner who will be supported by a project manager. Figure 5-12 sets out the summary of the plan and Figure 5-13 the milestone plan. Each of the following areas has specific project plans that collectively form the Implementation Plan: capital and finance, estates, workforce, clinical pathways, IM&T and information governance, operational, communications and project management office. A key part of this plan is a detailed recruitment plan which will be developed following business case approval. This will include identifying the roles and number of WTEs that need to be in place in advance of day 1 to ensure they are fully trained and familiar with the ways of working. Transitional funding will be requested for a period of double running.

Figure 5-12: Summary Implementation Plan

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Figure 5-13: Milestone Plan

Oct

-18

No

v-1

8

De

c-1

8

Jan

-19

Feb

-19

Mar

-19

Ap

r-1

9

May

-19

Jun

-19

Jul-

19

Au

g-1

9

Sep

-19

Oct

-19

No

v-1

9

De

c-1

9

Jan

-20

Feb

-20

Capital funding released

DMBC approval

Trust Business Case approval

Local tariff agreed

Planning permission received

Commence building works

Commence recruitment

All pathways, protocols and

transfers of patients agreed by

CRG

Relevant Trust pathways, policies

and protocols updated

HASU / ASU commissioned from

2020/21, contract signed

All stroke related contracts signed

IG agreements in place

Transport arrangements agreed &

contracts signed

Commence staff, public and

patient engagement

Estates works completed

Operational readiness assessment

including infection control sign off

Go live

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The main benefit of the HASU ASU model experienced elsewhere in the country is improvement in the number of lives saved both in hospital and six months after discharge.

The benefits include improvements to patient outcomes and patient experience, as well as improved experiences for staff through advanced patient care, improved ways of working and opportunities to enhance skills. A series of KPIs have been developed across Kent and Medway.

The Trust has ambitions for the implementation period too. The aim is to achieve a SSNAP rating of low C by March 2019 and improve on this to become a B rating by March 2020. This will be achievable with the introduction of Stroke Capture (live time data collection tool), an increase in workforce and greater reliability of CT due to the recent replacement of one of the scanners.

6. Benefits / Dis-benefits

6.1. DGT Benefits During Implementation Period The Trust will be investing in the team significantly during the implementation period up to go-live in March 2020. During this period the Trust will also be seeking assurance from the stroke leadership team that they have the capacity and capabilities needed to deliver the expansion and that improvements are being made.

In particular the Stroke Project Board (part of the internal governance within DGT) will receive updates on performance against SSNAP as well as other key metrics that can be monitored. This section sets out the critical success factors for the implementation period and the key performance indicators that will also be monitored.

6.1.1. Critical success factors during implementation

DGT is committed to improving the stroke service and being ready to go-live by the end of March 2020 to do so the Trust must achieve the following critical success factors:

1. Recruit a project manager and HR support for recruitment drive and lead implementation of recruitment plan 2. Recruit a senior stroke practitioner to lead the development of the stroke unit 3. Recruit sufficient numbers of staff to safely run the HASU and ASU as well as improve SSNAP performance (see

minimum workforce requirements in section 5.3) 4. Introduce CaptureStroke

5. Replacement of the telemedicine service 6. Open the modular unit 7. Move the current patients from Ebony to allow works to take place on Ebony and Spruce 8. Complete the works on Spruce and Ebony 9. Continue to engage with the STP and across the stroke network to agree the detail of the clinical delivery of the

service including policies and procedures, rehabilitation services and location of outpatient services and flow of patients between DVH and Medway

10. Rehabilitation capacity (inpatient and in the community) to have expanded 11. Prevention programmes commenced including increased atrial fibrillation detection and monitoring in primary

care

12. Effective communications programme – across the STP and internally 13. SSNAP improvement plan trajectory achieved each quarter and strong performance against key metrics listed in

6.1.

6.1.2. Key performance indicators

Listed below are a set of provisional metrics that will be reviewed in addition to monitoring SSNAP performance:

Quality:

o Friends and Family Test o Infections (particularly pneumonia) o 7 day discharges o 12 hourly review in accordance with care plan o Complaints

Patient Safety

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o Pressure sores, deep vein thrombosis and pulmonary embolism o Falls

Well Led o Induction o Appraisals o Staff satisfaction via staff survey o Turnover o Recruitment o Sickness rates o Up to date mandatory training

Team Development o Appointment of lead stroke practitioner (in post 12 months before go-live or earlier if possible) o Appointment of project manager (in post until unit achieves HASU/ASU status or at least three months

post go-live)

o Recruitment against Recruitment Plan o Team building and organisational development support including leadership training for lead

consultant, lead stroke practitioner, senior nurses and senior therapists

DGT currently has a SSNAP rating of D and is amongst the worst performing nationally for audit standards. As such, the Trust will invest in CaptureStroke as an online tool to support the data collection reducing the need for clinical nurse specialists to be using their time to input and upload the SSNAP data. The aim is for the data input to become live. This will rapidly improve the performance against the audit elements of SSNAP which contribute to the overall rating. CaptureStroke also allows the Trust to monitor performance against the overall SSNAP rating live rather than waiting for a quarterly report. The Trust aims to improve to a C rating by March 2019 and a B rating by March 2020.

The SSNAP KPIs are set out in the figure below. Those in Green show where the Trust already achieves national average performance; the remaining KPIs will continue to be areas of focus with those in bold of primary focus pre- implementation:

Figure 6-1: SSNAP KPIs

1. Scanning 2. Stroke Unit

1.1 Percentage of patients scanned within 1 hour of clock start

1.2 Percentage of patients scanned within 12 hours of clock start

1.3 Median time between clock start and scan

2.1 Percentage of patients directly admitted to a stroke unit within 4 hours of clock start

2.2 Median time between clock start and arrival on stroke unit

2.3 Percentage of patients who spent at least 90% of their stay on stroke unit

3. Thrombolysis 4. Specialist Assessments

3.1 Percentage of all stroke patients given thrombolysis (all stroke types)

3.2 Percentage of eligible patients (according to the RCP guideline minimum threshold) given thrombolysis

3.3 Percentage of patients who were thrombolysed within 1 hour of clock start

3.4 Percentage of applicable patients directly admitted to a stroke unit within 4 hours of clock start AND who either receive thrombolysis or have a pre-specified justifiable reason ('no but') for why it could not be given

3.5 Median time between clock start and thrombolysis

4.1 Percentage of patients assessed by a stroke specialist consultant physician within 24h of clock start

4.2 Median time between clock start and being assessed by stroke consultant

4.3 Percentage of patients who were assessed by a nurse trained in stroke management within 24h of clock start

4.4 Median time between clock start and being assessed by stroke nurse

4.5 Percentage of applicable patients who were given a swallow screen within 4hr of clock start

4.6 Percentage of applicable patients who were given a formal swallow assessment within 72h of clock start

5. Occupational Therapy 6. Physiotherapy

5.1 Percentage of patients reported as requiring occupational therapy

5.2 Median number of minutes per day on which occupational therapy is received

5.3 Median % of days as an inpatient on which

6.1 Percentage of patients reported as requiring physiotherapy

6.2 Median number of minutes per day on which physiotherapy is received

6.3 Median % of days as an inpatient on which

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occupational therapy is received 5.4 Compliance (%) against the therapy target of an

average of 25.7 minutes of occupational therapy across all patients (Target = 45 minutes x (5/7) x 0.8 which is 45 minutes of occupational therapy x 5 out of 7 days per week x 80% of patients)

physiotherapy is received 6.4 Compliance (%) against the therapy target of an

average of 27.1 minutes of physiotherapy across all patients (Target = 45 minutes x (5/7) x 0.85 which is 45 minutes of physiotherapy x 5 out of 7 days per week x 85% of patients)

7. Speech & Language Therapy 8. Multi-disciplinary Team Working

7.1 Percentage of patients reported as requiring speech and language therapy

7.2 Median number of minutes per day on which speech and language therapy is received

7.3 Median % of days as an inpatient on which speech and language therapy is received

7.4 Compliance (%) against the therapy target of an average of 16.1 minutes of speech and language therapy across all patients (Target = 45 minutes x (5/7) x 0.5 which is 45 minutes of speech and language therapy x 5 out of 7 days per week x 50% of patients)

8.1 Percentage of applicable patients who were assessed by an occupational therapist within 72h of clock start

8.2 Median time between clock start and being assessed by occupational therapist

8.3 Percentage of applicable patients who were assessed by a physiotherapist within 72h of clock start

8.4 Median time between clock start and being assessed by physiotherapist

8.5 Percentage of applicable patients who were assessed by a speech and language therapist within 72h of clock start

8.6 Median time between clock start and being assessed by speech and language therapist

8.7 Percentage of applicable patients who have rehabilitation goals agreed within 5 days of clock start

8.8 Percentage of applicable patients who are assessed by a nurse within 24h AND at least one therapist within 24h AND all relevant therapists within 72h AND have rehab goals agreed within 5 days

9. Standards by discharge 10. Discharge processes

9.1 Percentage of applicable patients screened for nutrition and seen by a dietitian by discharge (excluding patients on palliative care)

9.2 Percentage of applicable patients who have a continence plan drawn up within 3 weeks of clock start

9.3 Percentage of applicable patients who have mood and cognition screening by discharge

10.1 Percentage of applicable patients receiving a joint health and social care plan on discharge

10.2 Percentage of patients treated by a stroke skilled Early Supported Discharge team

10.3 Percentage of applicable patients in atrial fibrillation on discharge who are discharged on anticoagulants or with a plan to start anticoagulation

10.4 Percentage of those patients who are discharged alive who are given a named person to contact after discharge

In order to improve performance against these KPIs the Trust has:

Introduced a ring-fenced bed on Spruce ward

Replaced the second CT scanner, improving reliability and access to CT

Increased admin support for SSNAP audit

During the implementation period, the Trust will:

Continue to work with Virgin, providers of the Sapphire unit to improve flow of eligible patients from Spruce ward to inpatient rehabilitation

Recruit an additional consultant which will improve ability to assess new patients

Recruit additional therapists allowing for the full 45 minutes of therapy time to be given to each patient, improve 24 hour assessment by a therapist and the number of days a patient receives therapy input during their inpatient stay. Recruitment to commence in time for therapists to be in by January 2020

Recruit nurses towards establishment to improve level of care on the ward and reduce use of bank/agency

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6.2. STP Benefits Post Go-Live The benefits have been developed by clinicians in line with the clinical standards that underpin the proposals for clinical change and will be further discussed with patient representatives. The STP identified benefits inputs, outputs and outcomes are presented in Figure 6-2.

Figure 6-2: Benefit Inputs Outputs and Outcomes

The Trust will be required to collect data monitor internally and to submit to the commissioners to allow them to monitor performance across Kent and Medway. The Trust will continue to submit returns to SSNAP. A key benefit of the investment in the stroke service for DGT’s patients will be an improved SSNAP rating, the ambition being an A rating by the end of 2020/21.

The key performance indicators that will be used to monitor the realisation of the benefits are under development. The latest version will be available in the DMBC and a final agreed during the implementation phase. Figure 6-3 shows a selection of the key performance indicators that have been developed to date.

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Figure 6-3: A selection of Key Performance Indicators

The following principles have been applied in the development of the indicators:

1) Meaningful and transparent – The indicators should be able to be understood by all organisations involved and the public, to enable:

a. Kent and Medway providers to demonstrate that the anticipated benefits are being realised b. Commissioners to monitor whether commissioned services are delivering against the planned

outcomes 2) Pragmatic in number – The indicator set should be sufficiently long to provide coverage, but not so long

that monitoring does not take place due to the burden 3) Focus on patients – The primary focus should be on patient outcomes and patient experience 4) Minimise additional burden – Performance indicators should be based on existing measures and data

collection systems e.g. SUS, and should not create an additional data burden 5) Embed in business as usual – Measurement of the performance indicators should become part of the

commissioning cycle and ‘business as usual’ arrangements.

The benefits reporting mechanism is presented in Figure 6-4.

Figure 6-4: Benefits Reporting Mechanism

6.2.1. Critical success factors post go-live

However, the realisation of these benefits is reliant on the following critical success factors:

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1. Ability to recruit according to the recruitment plan 2. Rehabilitation service to be sufficiently resourced in the community and fully operational 3. Local care plans to deliver the bed reductions anticipated, allowing the modular unit to be decommissioned

after three years (or sooner if possible) 4. Prevention programmes to ensure that the populations health is improving and stroke risk factors decline in

line with growth assumptions in DMBC including increased arterial fibrillation detection and management in primary care

5. Patient flows aligning with the modelling with variances being investigated and lessons learned 6. Pathways across the HASU/ASU and non-HASU/ASU sites for repatriation of non-stroke patients and for

outpatient appointments 7. TIA service to have a rapid access clinic for neurology to refer patients into 8. Sufficient capacity remaining at St Thomas’s and St Georges’ hospitals for patients that are referred to these

hospitals for tests (e.g. bubble echocardiograms and mechanical thrombolysis) 9. Performance of the stroke team in leading the development of the service and against the key metrics including

the quarterly SSNAP improvement plan

6.3. DGT Specific Benefits Post Go-Live In addition to the benefits above, a number of benefits to DGT have been identified:

Significant improvement in Trust’s reputation as a fully functioning district general hospital for our local population

Supports other clinical services and locks in co-dependencies Ongoing attractiveness to workforce specialising in neurology, radiology (particularly interventional radiology),

A&E & therapists (partly as a consequence of improved reputation)

DGT is ideally located to deal with identified HASU / ASU population – geographical location and motorway access

HASU / ASU builds on existing operational strengths at DVH e.g. achievement of cancer standards, A&E 4 hour wait

Helps with planned continued investment / growth in A&E & trauma services at DVH

Sustains provision of neurology on site; in addition, presence of neurology services strengthens the stroke provision as well

Reduces clinical risks associated with the care plan for patients that have a stroke once already admitted to DVH for another purpose

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The Trust will see 807 strokes per year, 81 TIAs and 202 mimics. In addition, for every one admitted stroke/TIA/Mimic the Trust will see one non-stroke in A&E, resulting in 2179 attendances per year. The additional activity will primarily be from Bexley and the Medway Towns.

A total of 10 HASU and 24 ASU beds will be required for stroke patients. A further 3.2 beds will be required for non- stroke patients that were assessed as requiring an acute bed in A&E and inappropriate for immediate transfer to PRUH or MFT.

All stroke patients will require a follow up outpatient appointment, resulting in an additional two clinics per week.

The TIA pathway will triage 2692 patients a year, this will result in 28 TIA patients attending clinic per week (not all of those triaged will require an outpatient TIA clinic appointment; approximately 30% will require a neurology

appointment).

7. Activity

7.1. Inpatient Activity Carnall Farrar has undertaken the activity modelling using postcode analysis on behalf of the STP. The expected activity for DVH is set out in section 5.2. The activity flows to DVH are shown in Figure 4-2 – with activity coming from Bexley, Dartford, Gravesham, Swanley, Sevenoaks and Medway Towns (primarily the Hoo Peninsular).

Activity from Bexley – the London Ambulance service has confirmed that it will take possible strokes to the closest HASU A&E, for much of Bexley this will mean coming to DVH rather than the Princess Royal University Hospital (PRUH). Currently approximately 70 Bexley stroke patients are cared for at DVH a year; this will increase to approximately 200 confirmed strokes per year.

Activity from Medway – the Hoo Peninsular is to the north of Medway and therefore activity from this area is expected to transfer to DVH over Maidstone. This will equate to approximately 110 confirmed strokes per year.

Activity from Sevenoaks – for a proportion of the Sevenoaks population that would currently go to Tunbridge Wells Hospital in Pembury will be bought to DVH. This will equate to approximately 93 confirmed strokes per year.

Activity from Dartford, Gravesham and Swanley – this expected to remain at approximately 400 confirmed strokes per year.

Figure 7-1 shows the number of strokes, TIAs and Mimics that are expected to flow to each of the HASU sites from the current catchment areas of the four acute Trusts in Kent and Medway – DGT, Medway NHS Foundation Trust, Maidstone and Tunbridge Wells NHS Trust and East Kent University Hospitals NHS Foundation Trust. The number of TIAs has been estimated assuming 10% of stroke activity whilst the number of mimics has been estimated assuming 25% of stroke activity.

Figure 7-1: Strokes, TIAs and Mimic Activity at HASU/ASUs

Darent Valley Hospital

Maidstone General Hospital

William Harvey Hospital

Eastbourne PRUH East Surrey

Admitted Strokes 807 896 1239 94 2 18

Admitted TIAs 81 90 124 - - -

Admitted Mimics 202 224 310 - - -

The stroke review is a commissioner led process and the support of commissioners for DVH to become a HASU/ASU has been assumed as the JCCC (which included Bexley Clinical Commissioning Group) have unanimously supported the preferred option proceeding to DMBC stage.

In addition to stroke activity, the HASU/ASU sites will receive patients from the ambulance service or self-presenters at A&E that are “query stroke”. It has been assumed that for every one patient that is admitted for a Stroke, TIA or Mimic, one non-stroke also attends A&E. These non-stroke patients will only be confirmed after observation and diagnostic

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tests and are likely to be diagnosed as having a neurological condition, cardiac condition, require geriatrician care, or are experiencing somatic symptoms. These non-stroke patients will be assessed at DVH by the relevant specialist and a care plan identified. If the patient requires admission for stabilisation or for less than 48 hours then the patient should be admitted to an appropriate non-stroke bed at DVH. If the patient is well enough for transfer and is likely to require more than 48 hour stay in hospital then the patient should be transferred to their local hospital (most likely to be Medway or Pembury). Other patients will be able to be discharged to the most appropriate care setting / GP. Figure 7-2 sets out the volume of this activity.

Figure 7-2: Activity for A&E and non-strokes

Activity Type Activity Volume Assumption for Activity Volume

A&E Attendances

2179

100% of Confirmed Strokes, TIAs and Mimics will attend A&E

100% uplift of confirmed strokes, TIAs and Mimics for non-strokes

Non-strokes for admission at DVH

545

For every two strokes, TIAs or Mimics admitted one non- stroke will be admitted

Beds for non-stroke admissions 3.2 beds Two day length of stay at 92%

occupancy

7.2. Outpatient Activity

7.2.1. Stroke Outpatients

It is assumed that all admitted activity to the stroke ward will be seen in a stroke follow up clinic. Whilst some patients will not be appropriate for an outpatient appointment (due to death or discharged to palliative care) and others require more than one appointment, it has seemed reasonable to assume that all patients will have one appointment. Clinics at DGT have eight appointment slots, two for new patients (patients that the GP refer as concerned the patient has had a stroke but did not result in admission) and six for follow ups. In total, the Trust will need to provide eight clinics per week. A number of these could be provided at Medway Maritime Hospital to provide clinics as locally as possible.

7.2.2. TIA Outpatients

The TIA pathway is set out in section 4.2.3.

The triage service will be located at the HASU/ASUs for all GPs in Kent and Medway to refer to. All ‘high risk’, ‘probable’ and ‘possible’ TIAs will be seen at the HASU ASU site whilst ‘unlikely’ and ‘other neuro/speciality’ will be seen at their local hospital, which for some patients will not be a HASU/ASU site. This will require the HASU/ASU staff running clinics from the non-HASU/ASU sites: Medway, Pembury, Kent & Canterbury and Queen Elizabeth Queen Mother hospitals. In order to deliver this TIA pathway, the TIA clinics will need to operate a 7 day and extended day service.

7.2.3. Other Outpatient Services Impacted

The TIA triage will refer patients into a neurology clinic if appropriate. This will need to be rapid access – appointment within two weeks. There is a business case for an additional 1.5 consultant neurologists, which if approved, would improve ability to meet the outpatient demand.

Stroke patients can be sent for the following cardiac outpatient services:

Syncopy clinics (up to an additional 60 patients p.a. resulting in an additional 7.5 clinics p.a. Cardiology are pursuing a business case for an additional consultant which would accommodate this activity)

Bubble echocardiograms (DGT has limited ability to do these, typically undertaken at St Thomas’s, service could be developed in house but it would be reliant on cardiology recruitment which has not been successful to date)

Transoesophageal echocardiogram (TOE) these tests are typically undertaken at St Thomas’s.

Halter Tapes – cardiology service at DVH

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Whilst Medway patients will be offered these appointments at Medway, the Bexley patients will result in an increase in DGT demand.

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The revenue costs are higher than the possible income (which includes achieving best practice tariff) resulting in an overall cost to the Trust of £1.6m p.a. by 2023/24 (steady state). The capital investment required for the resuscitation area and ward changes will be funded by NHS England and amount to £556,000. A discussion with commissioners regarding a possible top-up to tariff will commence in 2019/20.

8. Financials

Figure 8-1 presents the financial summary of the Stroke HASU / ASU service.

Figure 8-1: Financial Summary

Summary

Revenue Capital

Full year revenue implications (net contribution / cost or net saving) Net cost £1.9m by 2023/24 (steady state)

Capital total £556k

Is this an invest to save scheme? No Is this in the capital plan? No

Is this funded from contingency? No If no, state potential source of funding e.g. NHS England

STP capital bid (in conjunction with other proposed HASU / ASU units) for NHS England funds

If no, state potential source of funding Additional efficiencies

Does this include consultancy expenditure in excess of £50k (inclusive of irrecoverable VAT and other expenses, e.g. expenses)?

No

The revenue implications of the stroke service for the first five years of operation. This illustrates that the service will be an ongoing cost to the Trust, making a negative contribution each year.

Figure 8-2: Revenue Implications

Revenue Implications (Breakdown)

Year 1 (2019/20) £’000

Year 2 (2020/21) £’000

Year 3 (2021/22) £’000

Year 4 (2022/23) £’000

Year 5 ETC £’000

Total

Income 533 5,393 5,696 5,696 5,696 23,016

Exp

end

itu

re Pay 654 6,839 6,456 6,229 6,056 26,234

Non-pay 122 1,488 1,456 1,456 1,456 5,978

Capital charges 10 47 46 45 44 191

Sub-total 786 8,374 7,958 7,730 7,556 32,403

Net contribution (253) (2,981) (2,262) (2,034) (1,860) (9,387)

% contribution -47% -55% -40% -36% -33% -41%

Modular lease costs (226) (905) (905) (679) 0 (2,715)

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Revised Net contribution (479) (3,886) (3,167) (2,713) (1,860)

2019/20 – includes one month impact of costs except for the modular lease which assumes three months costs

Income – includes transition funding covering project management. Assumes that 100% of the available Best Practice Tariff is attained from 2021/22

Non-pay – excludes three years modular unit lease cost of £905k p.a.; 20/21 one off £32k introduction capturestroke IM&T system and ongoing costs or capturestroke included in each year. Includes existing and incremental increase in corporate / overheads

Figure 8-3 shows the capital costs for expanding resuscitation area and making the required changes to the ward.

Figure 8-3: Capital Cost Implications

Capital Implications (Breakdown)

Capital Change Year 1 (2019/20) £’000

Year 2 (2020/21) £’000

Year 3 (2021/22) £’000

Year 4 (2022/23) £’000

Capital 473

Value Added Tax [VAT] 83

Total 556

Commentary including life of asset, estate and information communication technology (ICT) implications:

Assumes 20 year asset life

Includes 20% VAT on works, which as planned to be through PFI provider not be charged

Currently based on cost per square metre pending costing final designs from SERCO

Covers refurbishment ward and provision second emergency department resuscitation bay

Allowance for PFI fees and equipment

Contingency 10%

Optimism bias of 25.88% based on design complexity

The financial cost of the workforce required to deliver a high performing HASU / ASU is shown in Figure 8-4.

Figure 8-4: Workforce Cost Implications

Workforce (Whole Time Equivalent ) Implications (Breakdown)

Workforce Change (full year as at 31 March)

Year 1 (2019/20) £’000

Year 2 (2020/21) £’000

Year 3 (2021/22) £’000

Year 4 (2022/23) £’000

Medical 116 1,394 1,319 1,273

Nursing 300 3,604 3,412 3,292

Professional & Technical (P&T)

140 1,677 1,587 1,531

Administrative & Clerical (A&C)

97 165 137 132

Other

Total 654 6,839 6,456 6,229

Commentary:

A&C includes project management for 19/20 and 20/21; project manager until the end of Q1 20/21

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and HR recruitment support three months in 19/20

Agency premium at this time applies equally across all staff groups on substantive salaries until clarity regarding TUPE and recruitment plans more developed – 13% 19/20 and 20/21, 7% 21/22 and 3% 22/23

A prudent approach has been taken as to proportion of additional post that will be filled substantively by March 2020, a successful recruitment campaign will reduce the agency premium element currently assumed.

Request made to STP from transition funding for cost early recruitment staff before March 2020, this could be £0.7m (based on 12 months or lead stroke nurse and up to three months for other posts). Excluded from 19/20 pay costs currently pending discussion with STP as to funding this.

A full breakdown of the income and expenditure is available at Figure 8-5.

Figure 8-5: Analysis of income and expenditure

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Year 1 Year 2 Year 3 Year 4 Year 5

(2019/20) (2020/21) (2021/22) (2022/23) ETC

£’000 £’000 £’000 £’000 £’000

Income

Clinical

Not achieve full BPT till 21/22.

Per STP model.

419

5,022

5,345

5,345

5,345

Transition funding Project management 85 20 - - -

Deanery funding

Assume all Junior posts funded

by HEE

29

351

351

351

351

Total 533 5,393 5,696 5,696 5,696

Pay

Substantive base

Includes Junior Drs and extra

radiology

505

6,056

6,056

6,056

6,056

Agency premium Per model assumptions 64 763 400 173 -

Fixed term project management

Project manager till Jun 20, 3

months HR

85

20

Total 654 6,839 6,456 6,229 6,056

Existing support costs / overheads Per 'As is' STP model 63 755 755 755 755

Additional Non Pay

Housekeeper Through PFI provider 2 22 22 22 22

Radiology MRI outsourcing, CT out of hours 10 119 119 119 119

Ward MSSE & drugs plus pathology 7 80 80 80 80

Alteplase drug

Administered in ED by assessor

nurses

19

227

227

227

227

Capture stroke IT system. £45k one off in 20/21 4 77 45 45 45

Estates

Increased PFI availability,

equipment maintenance etc

10

121

121

121

121

Total 51 646 614 614 614

Additional Overheads

Capital charges

Proportion Ebony switching to

stroke

3

37

37

37

37

Corporate

Allowance for payroll, HR,

training, CNST etc

4

50

50

50

50

Total 7 87 87 87 87

Transitional

Modular Three years 226 905 905 679

Total 226 905 905 679 -

Revenue impact of capital investment

Capital Charges

Based on £556k capital, 20 year

life

10

47

46

45

44

Other key points of note:

STP model is based on admitted care and TIA clinic activity and thus has not included in income A&E attendances. This will be worked through in terms of the additional income the Trust will obtain and marginal cost required to deliver this as part of implementation.

Transition and implementation cost funding has not been progressed sufficiently to include as funding above PbR in this business case apart from specific project management posts. This would help to reduce the loss to the Trust.

Further iteration of the financials will be developed during implementation.

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There are a number of key risks, primarily resulting in delay of the opening of the service. Risks across the following categories have been considered: estates, operations, workforce, finance, clinical, IM&T and reputation. The DMBC includes a section on risks. The table in this business case therefore focuses on Trust specific risks which have been shared with the STP.

9. Risks

The Project Manager maintains a risk log which is shared with the Stroke team at the weekly team meetings. The risk log will also be shared with the Project Board on a monthly basis.

The Trust has used the STP risk matrix to score the risks in figure 9-2.

Figure 9-1: Risk Scoring Matrix

Figure 9-2: DGT Identified Risks

Risk Description Score Level Owner Mitigation

MCH withdraw services from MFT leaving insufficient workforce at MFT to deliver a safe stroke service resulting in DVH and MGH seeing rapid increase in stroke activity from December 2018

16

High

Stroke Programme

Board

Escalated to commissioners

Inability to agree a local top-up to tariff for stroke care that will allow the HASU/ASUs to no longer be loss making for acute trusts

12

Medium Sue

Braysher

Negotiations with commissioners to commence –in Q1 19/20

External capital funding is yet to be confirmed, risk that NHSEngland do not approve the capital bid / release the funding

8

Medium Sue

Braysher K&M wide mitigation to be agreed

Inability to recruit to agreed minimum level of staffingfor Day 1 resulting in possible quality impacts and high agency costs

16

High Charlotte

Bull

K&M wide recruitment plan, recruitment to commence immediately.

Planning permission is required to deliver the modular unit for displaced medical beds. Risk that Local Authority do not approve and alternative estate solution is required

8

Medium

Laurence Bunnett

Ongoing engagement with Dartford Local Authority Planning Team

Delay caused by external party (Local Authority, The Hospital Company, law firms, Serco) not adhering to planned timetable

16

High Laurence Bunnett

Ongoing engagement with all parties

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Risk Description Score Level Owner Mitigation

CRG unable to agree pathways between HASU/ASU sites and local hospitals for return of non-stroke patients, and local Outpatients and TIA clinics

8

Medium

Dr Aghoram /

Karen Costelloe

Progress updates to STP Programme Board

Inability to agree with other trusts or transport services protocols and price for repatriating patients to local hospital. Risk that the HASU / ASU site will be unable to manage large volumes of non-stroke, out of area patients with existing bed base

12

Medium

Sue Braysher /

Karen Costelloe

Progress updates to STP Programme Board. Requested this be on the Implementation Work plan of the OPG and CRG

Reputational risk if there is a significant delay to the opening of the stroke service

6

Low Sue

Braysher Close monitoring of progress against plan

Insufficient involvement from non-HASU/ASU sites before day 1 resulting in a non-smooth transfer and repatriation protocols not being adhered to

9

Medium

Sue Braysher

Kings, Eastbourne and MFT to be invited to CRG and Operational (OPG) STP meetings

Estate plans yet to be finalised and costed resulting in uncertain final capital cost. Risk that the revised cost is higher than money available

9

Medium Laurence Bunnett

Adjust estates plans to reduce costs wherever possible

Additional costs may be identified by impacted specialties that are linked to stroke activity increase

4

Low Rachel Otley

Early and ongoing discussions with all impacted services

Clinical Senate report recommends increasing the growth assumption from no growth to up to 44% (2015- 2035) in line with Kings research. This will impact on the capacity required for A&E, Radiology, OP Clinics and Beds. This will delay the DMBC and trust business cases by a number of months

9

Medium

Sue Braysher /

Rachel Otley

Rachel Jones (STP SRO) to progress modelling to assess level of prevention required to retain the current no growth assumption

An October draft DMBC only will be available to Finance Committee and Trust Board. The final will be completed in December for Joint Clinical Commissioning Committee review / approval in January 2019. The Trust Board will not receive the DMBC until after its approval. There may be inconsistencies between the DMBC and the Trust Business Case.

16

High

Sue

Braysher

Requested revised drafts of the DMBC and specific information from STP but not forthcoming.

Inability to recruit to agreed 'gold' establishment / required capabilities to achieve all stroke clinical standards resulting in possible quality impacts.

12

Medium Charlotte

Bull Must recruit to at least bronze standard

The current telemedicine system is reliant on a KMPT hosted server which will cease in December 2018. A new solution such as Skype for Business is required. This must be in place as soon as possible to maintain a safe cross-county consultant on-call. This has been raised within the STP but to date has not been prioritised by the other trusts.

20

High

Sue

Braysher

Escalated through STP stroke to IM&T STP lead Susan Acott to prioritise within the IM&T workstream

Rehabilitation pathway is critical to the achievement of improve health outcomes for stroke patients, a reduced acute length of stay, improved efficiency of the unit and attainment of improved SSNAP ratings. A pathway has been proposed but engagement with all key providers is yet to commence. The pathway will need to be commissioned and running in advance of the service going live at DVH for Bexley, Medway, Sevenoaks and Dartford, Gravesham and Swanley populations

16

High

Sue

Braysher

Requesting weekly updates from the Stroke STP lead Rachel Jones at the Stroke Operational Group. Awaiting dates.

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The Trust has established a governance structure for the pre-implementation phase that is well resourced. The Trust has identified governance arrangements for the implementation phase. A lead non-executive director will work alongside the SRO and project manager to support the governance of this program until the unit is running effectively. The Trust will actively engage in all aspects of the STP wide stroke governance arrangements throughout the Implementation Phase which will include workstreams focusing on: clinical, workforce, communications, operations, finance, estates and IM&T.

Weekly Team

Meetings, Chaired by SRO

Fortnightly / Monthly

Updates to Executive Team

& Clinical Directors

Monthly Updates to Trust

Board Sub- Committees

Monthly Updates to Trust Board (Part 1 or

2)

10. Governance Structure

10.1. Pre-Implementation Phase

Meeting frequency

Weekly Meetings The weekly meetings have a set agenda which includes:

Actions

Process update

o Timetable

o Implementation Plan

o Business Case update

o Finance

o Communications

Operational working

o Clinical Pathways (Kent & Medway, SEL)

o Quality & SNAPP

o Workforce

o Estates

o A&E

o Radiology

o Pathology

o Pharmacy

o IM&T

Risks and mitigations

Given the broad remit of the group, the agenda is focused on two to three key items in addition to actions and risks. The membership includes: Figure 10-1 - Weekly Team Meeting Membership: Core Team

Name Role

Sue Braysher SRO and Chair of weekly meeting Director of Strategic Transformation

Dr Prasanna Aghoram Stroke Clinical Lead Caroline Bates Head of Nursing, ECAM Tari Shanganya Stroke Clinical Nurse Specialist

Weekly Stroke Performance

Meeting (SSNAP)

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Weekly Team

Meetings, Chaired by SRO

Monthly Stroke Project Board

Fortnightly / Monthly

Updates to Executive Team

& Clinical Directors

Monthly Updates to

Trust Board Sub- Committees

Monthly Updates to Trust Board (Part 1 or 2)

Name Role

Lisa Miles Spruce Ward Manager Giles Brown Head of Financial Planning Laurence Bunnett Director of Strategic Estates & Capital Karen Costelloe General Manager for Outpatients, Therapies

and Dartford Health Partnerships

Charlotte Bull HR Business Partner, ECAM Sue Daniels Communications Officer Rachel Otley Head of Planning and Partnerships (interim

project manager)

This core team is supported by subject matter experts:

Figure 10-2 - Weekly Team Meeting Membership: Subject Matter Experts

Name SME Area

Felicity Canning Radiology Dr G Tan Neuro-Radiology Emma Bowler Physiotherapy Jo Poulton Occupational Therapy Aimee Barnden Pharmacy Janice Gunn Information Governance Kate Garner Information Neil Perry IM&T General manager for ECAM

A&E and General Medicine

In addition, Steve Wilmshurst, Trust Non-Executive Director will be sitting alongside the SRO and Project Manager to provide advice and guidance and also to offer additional assurance to the Trust Board that the project is progressing as planned.

10.2. Implementation Phase and Beyond Go-Live This governance arrangement is proposed to remain in place for as long as it is required. The aim is that the Trust is assessed to be a HASU/ASU six months after opening (September 2020) and therefore this governance structure is proposed to remain in place until this is achieved as this will demonstrate that the unit is high performing.

10.2.1. Overview

During the implementation phase the Trust will appoint a dedicated project manager to oversee the delivery of the unit. This post will need to remain in place through to the attainment of HASU status.

The weekly meeting will continue during the Implementation Phase with subject matter experts attending as and when required. In addition a DGT Stroke Project Board will be established to monitor progress.

Weekly Stroke Performance

Meeting (SSNAP)

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10.2.2. Project Board

The Project Board will meet monthly and be operationally focused. The proposed membership of this Board is set out in figure 10-3.

Figure 10-3 – Stroke Project Board Membership

Name Role

Sue Braysher SRO and Chair of Project Board Director of Strategic Transformation

Dr Prasanna Aghoram Stroke Clinical Lead Steve Wilmshurst Non-Executive Director (“link NED”) Caroline Bates Head of Nursing, ECAM Giles Brown Head of Financial Planning Laurence Bunnett Director of Strategic Estates & Capital Pam Dhesi Director of Operations Louise Lester Director of HR Charlotte Bull HR Business Partner, ECAM Siobhan Callanan Director of Nursing and Quality Rachel Otley Head of Planning and Partnerships (interim

project manager)

The Terms of Reference for this Board will be developed and shared with the NED and SRO. Membership and the Terms of Reference will be approved by the Project Board. These meetings will be minuted and the minutes will be available to the Executive Team, Clinical Directors and Trust Board upon request.

The Project Board will submit regular updates to the Trust Board and appropriate sub committees as required. The following committees will oversee key aspects of the delivery of the service before and after go-live:

Finance Committee – capital and revenue spend, performance against best practice tariff, approval of the tariff top-up that is to be negotiated with commissioners during implementation

Workforce Committee – national and international recruitment, development of new roles, organisational development programme to support the development of a high performing team including strong leadership skills

Quality and Safety Committee – governance and quality systems

10.2.3. STP Governance during Implementation

In addition to the Trust internal governance arrangements, the Trust will fully engage in the wider STP governance arrangements which will incorporate workstreams focusing on: clinical, operational, workforce, communications, estates, finance and IM&T. Further detail of the proposed STP governance arrangements can be found in Appendix A, Draft DMBC.

10.2.4. Impact analysis

Figure 10-4: Impact Analysis on Stroke Resources

Project Management

Role Name / Post Impact Analysis (% of time required)

Project Sponsor (Clinical)

Dr Aghoram (Stroke & Elderly Care Consultant) 20%

Project Sponsor (Managerial)

Sue Braysher (Director of Strategic Transformation) 30%

Project Manager Rachel Otley (Interim Project Manager) 100%

Delivery Support Team (from within service line / directorate)

Caroline Bates (Head of Nursing, ECAM) 20%

Tari Shanganya (CNS) 30%

Lisa Miles (Ward Manager) 10%

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Project Management

Role Name / Post Impact Analysis (% of time required)

Giles Brown (Financial Planning) 20%

Karen Costelloe (Therapies & Outpatients) 20%

Laurence Bunnett (Estates) 20%

Charlotte Bull (HR, ECAM) 20%

Felicity Canning (Radiology General Manager) 10%

General Manager Emergency Care & Adult Medicine (TBA)

10%

Executive Sponsor Sue Braysher (Director of Improvement) 30%

Project Board Members

Sue Braysher (Director of Improvement) 30%

Dr Aghoram (Stroke & Elderly Care Consultant) 20%

Steve Wilmshurst (Non-Executive Director) -

Caroline Bates (Head of Nursing, ECAM) 20%

Giles Brown (Financial Planning) 20%

Laurence Bunnett (Estates) 20%

Charlotte Bull (HR, ECAM) 20%

Rachel Otley (Interim Project Manager) 100%

Pam Dhesi (Director of Operations) 5%

Siobhan Callanan (Director of Nursing and Quality) 5%

Louise Lester (Director of HR) 5%

STP supporting staff Rachel Jones SRO

Nicola Smith Project Manager

Yetunde Oyewole Admin support

Ada Foreman Finance

Robert Nicholls Human Resources & Organisational Development

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Appendix B: Proposal for Investment in CaptureStroke

Overview The Trust’s SSNAP performance is a D rating and amongst the worst in the country for audit compliance. The table below summarises the Trust’s SSNAP audit performance6:

Figure 0-1: Trust SSNAP Audit Performance

The Trust has 10 hours of an admin post and relies heavily on clinical nurse specialists to complete the data on SSNAP. This impacts the overall Trust SSNAP rating. In November, the ECAM directorate took on a band 3 administrator from the bank to attempt to improve this position. However, there are more cost effective and accurate solutions to collecting and uploading the data. The Trust is aiming to accept a free three month trial of CaptureStroke following approval of this business case to improve the position.

This proposal presents the case for investing in CaptureStroke from the end of the trial period.

Introduction to CaptureStroke To optimise the treatment and care of stroke patients throughout the Trust (that includes both those in dedicated ward space and outliers) the implementation of a single specialised data capture and activity record system is needed. The CaptureStroke system is an established dedicated stroke database provided by Silverlink and is the market leading solution.

The CaptureStroke solution can be integrated with the hospital PAS data systems to enable population of patient demographic information, GP details, hospital arrival dates and time and other key data items. Its user-friendly and intuitive design will speed up the process of data collection. Not only does it reduce input time but it uploads to SSNAP directly from CaptureStroke and has a therapy database imbedded meaning no duplication would be needed.

The CaptureStroke system monitors national and local targets in the stroke pathway in real-time and provides staff with notifications when a performance target is close to being breached. Use of the system should therefore enable the stroke service to prioritise patients and workload to ensure that patients receive assessments on time and therefore optimum treatment, in accordance with guidelines. The alert will provide an opportunity to ensure that the target is achieved and no financial penalty is incurred.

The Care Overview screen which is viewed when users first log into CaptureStroke, provides an at-a-glance and real- time summary of the patients in the care of the stroke service. This screen automatically compiles the list of patients with the newest admissions first and displays in a highly visual format the care interventions the patient has received since admission and which targets have or have not been met, thus helping to ensure that no patient is overlooked. The Care Overview screen features a drop-down filter which can be used to filter the patients by diagnosis Stroke, TIA, Stroke Mimic, Other. We believe that this will help us to deliver better patient outcomes.

The CaptureTherapy module, contained within the core CaptureStroke system, enables therapists to record therapy sessions delivered to each patient on the stroke ward and reasons why a patient may not have been able to undertake the recommended 45 minutes of therapy per day. The data inputted into the system is collated into a Patient Therapy diary which can be used by the clinical/therapy team to show to patients and their families how many therapy sessions have been delivered and how the patient is coping with the therapy.

The system monitors and highlights trends in Best Practice Tariff revenue generation, enabling measures to be taken within the stroke service to increase this revenue stream. The system can also be used to highlight coding exceptions, ensuring that a patient’s stay is correctly coded so that the Trust is appropriately remunerated for the care that they have delivered.

In addition,

Data capture needs to start immediately upon arrival of a stroke patient at the hyper acute stroke unit

6 Dark red diamond indicates lowest 10% in the country, light red diamond indicates lowest quartile

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The data which is captured is used in statutory, clinical and compliance reporting and collecting and collating this data on paper forms, and manually in spreadsheets, is time consuming and inefficient

CaptureStroke will provide graphical presentations of real-time data and enable trend analysis and regular data comparisons

Avoid data duplication as patient demographic information, GP details, hospital arrival times etc will be automatically pulled from the PAS/EPR into CaptureStroke

Access to specialty specific data relating to the care of stroke patients can be critical to their successful care

Identification and treatment of outlier stroke patients can be critical to identifying stroke as a co-morbidity both from a treatment perspective and correctly charging for a procedure or stay

Having a paperless real time system will improve the quality of care of patients and improve the patient experience

CaptureStroke will streamline the handover of care between staff and care teams, a process which has a propensity for error when information is not readily available or up to date

Financial Implications Its terms of financial cost the capture stroke system (£40k for year one and £32k p.a. thereafter) could pay for its self by increased earnings from best practice tariffs. An additional 2 patients a month achieving best practice would cover the cost of the system. Whereas an additional 5 high risk patients seen within 24 hours would cover all the costs of the TIA add on system. The Stroke team currently have 10 hours of an admin person supporting the upload of data to SSNAP, relies heavily on Clinical Nurse Specialist (band 7) to also do this (taking them away from delivering patient education, supporting TIA clinics and managing complex stroke patients on the ward). In addition, as the Trust is one of the worst performing unit in the country for capturing and uploading data the Stroke team have taken on a band 3 administrator from the bank (as a cost pressure) to rectify this and minimise the backlog. The introduction of CaptureStroke will eliminate the need for this inputting of data as the system uploads to SSNAP at the click of a button.

Figure 0-2: CaptureStroke Costs

Year One Year Two Onwards

Capture Stroke and therapy system £24,000 £24,000

TIA Add On £6,000 £6,000

Additional interface £30,000 -

Implementation & Training – Go-live £8,000 -

Additional sever capacity £5,000 £2,000

ipads required £3,600

TOTAL £76,600 £32,000

Savings/cost avoidance: The Trust is currently using a Band 3 from the bank as well as 10 hours of admin time and time from the Clinical Nurse Specialists. The proposal would be to introduce a full time band 4 administrator for the combined HASU/ASU if the Trust chooses not to invest in the CaptureStroke solution. The cost of the band 4 administrator would be £5-8k more expensive than the annual cost of CaptureStroke. The Trust could stop the band 3 bank post (currently a cost pressure) and stop reliance on nursing time to complete this work.

Funding Source: Additional best practice tariff income is expected to be achieved by correctly capturing actions the team already undertakes and by allowing the team to monitor performance in live time which will focus activity to meet time specific standards.

Implementation From commitment to purchase system Go Live can be achieved in 2-4 weeks. The estimate is of 4 man-days being available from the Trust IT team for the project to liaise with the supplier’s team to undertake implementation and integration work. The supplier will deliver pre-awareness training to stroke team members prior to Go Live, so the team are familiar with the system prior to it being used operationally, and supplier Training & Support resources will be on site during Go Live to assist with any queries or issues which come up.

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For the system to be used to its full advantage it should be used in real time data capture, to achieve this the use of tablets and smart phones is recommended for use by medics, nurses and therapists on the ward and around the hospital (ED and outlying patients). The use of protective cases is also recommended.

Options 1. Do Nothing

The Trust could continue with current infrastructure to manage the capture and submission of data to SSNAP.

Figure 0-3 Do Nothing: Benefits and Risks

Benefits Risks

No revenue investment into IM&T solution No further systems to integrate with PAS and ED,

Radiology and Therapy systems

Continue to be the worst performing Trust in the country for recording and submitting data to SSNAP

Financially penalised for not achieving standards

Continue to wait for quarterly reports from SSNAP to monitor performance

Continue to invest clinical time in recording submitting information to SSNAP as well as using 10 hours of an admin member of the medical team and a full time band 3 from the bank (starting in November 18 at an annual cost of c.£30k)

Additional investment required (band 4 admin post) to be responsible to SSNAP data when the Trust expands the service to become a HASU/ASU and doubles activity at an annual cost of c.£38k (with on costs)

2. Invest in CaptureStroke – preferred option The Trust is being offered a three month free trial of CaptureStroke which it intends to accept following approval of this business case. Following this the Trust will be required to either invest in CaptureStroke or withdraw and introduce sufficient admin support to perform the role of collecting and inputting information into SSNAP.

Figure 0-4 Invest in CaptureStroke: Benefits and Risks

Benefits Risks

Improved ability to monitor compliance to National & Local guidelines, resulting in improved performance and therefore an improved patient experience and outcomes.

Monitors appropriate best practice tariffs to provide financial insight in an effort to increase revenue, and improves identification and coding of co-morbidities leading to more accurate tariff being applied.

Effectively monitors care performance in real- time, facilitating proactive rather than reactive management of the stroke service.

Generates built in reports and exports bulk data for custom analysis highlighting areas of performance which require attention / improvement / further analysis.

Streamlines data capture and avoids duplication therefore reducing staff time spent on inputting data.

Uploads to SSNAP at the click of a button. Integrates with other trust systems.

System is run by an external company and

dependant on Silver link software.

Data could at first be less accurate as staff adjust to a new way of working.

Yet to have confirmation from EKUHFT and MTW that they will also invest in CaptureStroke, their proposal is to proceed as is until Implementation and then explore possible solutions. This is likely to take longer than the three month trial period.

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Reduction in clinical and admin time spent inputting data.

An existing CaptureStroke user site has reported a 50% reduction in time spent on data entry, from

0.4 WTE to 0.2 WTE per 100 stroke patients The system should serve to increase the

productivity of consultants and nursing staff as time spent on collating information and completing forms will be reduced, also CaptureStroke will assist in prioritising patients and the workload of the clinical team as a whole

All of the above benefits have materialised almost immediately and sustained effectiveness has been demonstrated at all existing CaptureStroke sites

Longer term benefits, such as the ability to enact strategic pathway changes based upon the insights provided by CaptureStroke, have now been evidenced at all existing CaptureStroke sites, but typically longer term benefits are realised around 3 months following implementation

An existing CaptureStroke user site improved its overall SSNAP performance since implementing the system in October 2013, from a Band D to a Band A within a 12 month period (as shown in the table below) and has consistently maintained performance within Band A or B.

3. Wait for a STP wide decision and invest together in a single solution The Trust has led a discussion with EKUHFT and MTW about the use of a system such as CaptureStroke. Both of these trusts currently performs well against the audit of stroke data and so does not have the same urgency as DGT to proceed. EKUHFT are keen to either tailor make a solution that is fit for purpose as they believe that SSNAP will be changing in the next couple of years. They are also sceptical of CaptureStroke as only ten units currently use it.

Figure 0-5: Wait for an STP decision: Benefits and Risks

Benefits Risks

Single solution across each of the three combined HASU/ASUs

Potentially be able to negotiate a better financial deal

Will not introduce a system to then have to withdraw to then introduce a system that is suitable for all of the HASU/ASUs in Kent and Medway

Further delay in introducing the system will result in ongoing cost pressure of additional admin time

Unlikely to result in an improvement from worst in the country for audit or SSNAP rating until investment in a system is made

Ongoing loss of best practice tariff and fines for not meeting national standards

Ongoing inability to track real time performance and address issues in a timely way

Recommendation The preferred option is to proceed with CaptureStroke (option 2). The Trust can proceed with a contract and then if / when the other Trusts are ready to proceed with a solution, the Trust can compare the options and proceed accordingly. Whilst some Trusts have developed their own software to capture this information, this has its complexities especially designing a system across the three Trusts. CaptureStroke is the only software solution on the market currently.

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Glossary of Terms

Acronym Full Title

AHP Allied Health Professional

ALOS Average Length of Stay

ASU Acute Stroke Unit

CCG Clinical Commissioning Group

CRG Clinical Reference Group

DGS Dartford, Gravesham and Swanley

DGT Dartford and Gravesham NHS Trust

DVH Darent Valley Hospital

DMBC Decision Making Business Case

ESD Early Supported Discharge

FT Foundation Trust

HASU Hyper Acute Stroke Unit

IM&T Information Management and Technology

JCCC Joint Clinical Commissioning Committee

K&C Kent and Canterbury Hospital

K&M Kent and Medway

LAS London Ambulance Service

MFT Medway NHS Foundation Trust

MGH Maidstone General Hospital

MMH Medway Maritime Hospital

MTW Maidstone and Tunbridge Wells Hospitals NHS Trust

NHS National Health Service

NPV Net Present Value

OPG Operational Planning Group

PCBC Pre-Consultation Business Case

PRUH Princess Royal University Hospital

QEQM Queen Elizabeth, the Queen Mother Hospital

SRO Senior Responsible Officer

SSNAP Sentinel Stroke National Audit Programme

STP Sustainability and Transformation Partnerships

TIA Transient ischaemic attack

TWH Tunbridge Wells Hospital

WHH William Harvey Hospital

WTE Whole Time Equivalent

business case proforma · the business case was presented to the finance committee on tuesday 27th...

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