1. Stroke Rehabilitation in Tower Hamlets Tom Penman Head of Stroke Services Tower Hamlets Community Health Services Sue Perkins Commissioning Manager for Long Term Conditions NHS Tower Hamlets

2. Every PCT should commission a community rehabilitation service for stroke patients delivered by staff with stroke specialist skills Service configuration should be locally determined and the service must meet all of the performance standards HfL stroke recommendation 2

3. Tower Hamlets context • Tower Hamlets demographics … • Deprived • Overcrowded • Diverse • Young • Growing population • High unemployment • 20% families live on less than £15,000 • And our health our needs assessment tells us … • Low life expectancy • Health inequalities (male life expectancy vs national average) • High burden of cardiovascular disease • Health inequalities within the borough • But … • Ranked 1st nationally for economic growth

4. Stroke Data for Tower Hamlets Health Needs Assessment – Stroke in North East London • Approx 2,000 residents on GP stroke registers • Absolute number of deaths from stroke low compared to London (young population)..but.. • Deaths in under 75s (“preventable”) from Stroke third highest in London • Death rates in under 65s fourth highest in London • Highest hospital admission rates for Stroke in London

5. Developing the commissioning relationship • Parts of the jigsaw in place in 2008 • Agreed, mapped Stroke pathway • Service development & innovation driven by staff • Staff working across acute and community pathway • Inpatient community rehabilitation ward • Multi-disciplinary Community Stroke Team (CST) established • Stroke a priority area - Commissioning Strategic Plan • Missing pieces • Capacity of CST and inpatient rehabilitation • Accountability for stroke pathway • Clear service specification for community rehab team and structured Performance Monitoring process • Ongoing patient and public involvement • Clear link to prevention

6. Capacity: CST pre-commissioning investment 2008-2010 Post discharge 12 week input

7. Capacity: community inpatient rehabilitation Some staff shared across Acute Stroke Unit, or across Older People’s Ward, or all Community Intermediate Care & Rehab services

8. How do we know what’s needed? Investment and redesign needed Early Supported Discharge Pathway available to stroke survivors without an acute admission Post 12 week follow up Specialist vocational rehab service

9. Commissioning investment 2008-2010 Head of Stroke Services, Clinical Nurse Specialist – leadership and management accountability

10. CST and community inpatient service specification & performance monitoring

11. Where are we now

12. Ongoing issues - Commissioning Where does community rehab start and stop e.g. in-reach The role of Local Authority commissioner and LA Stroke funding How to “share” savings in social care package costs How to capture data for performance monitoring How to engage primary care in what we develop How to commission for a pathway rather than for a care setting

13. Ongoing issues - Provider Where does community rehab start and stop e.g. in-reach The role of Local Authority and / or third sector providers How does the service work with more general reablement teams How to engage primary care and the role of GPs in rehab Can we combine uni-disciplinary budgets for a multidisciplinary service How to capture data for performance monitoring Who manages new posts across disciplines e.g. Rehab Support Workers

14. Lessons learned so far Additional resources sometimes distract from bigger issues Transitions can be improved (acute to community and community to long term support) without investment Stroke Networks have information about best practice Important to engage GPs – 12 month follow up Be clear what you want to commission (service specification) Meaningful PPI is difficult in short timescales and needs to be embedded in whole process Establish an explicit performance management process