Sarah Warmington, an Associate Director at Attain, outlines the challenges posed by balancing centralisation against localisation and how these challenges have been addressed through redesign of stroke services in the Midlands.
With increasing pressure and expectation of clinical services to demonstrate effectiveness, efficiency and improving clinical outcomes that also reduce the longer term burden on the health and social care economy, a balance between centralisation of services needs to be struck against the public’s expectations for local service delivery.
Moving to specialised and centralised services provides many benefits in terms of having a more focused and sustainable delivery model, but also brings with it an array of considerations for the population that the service covers and the staff that it needs to attract and retain to deliver it.
An example of striking this sensitive balance is illustrated in stroke services, where local health economies are striving to ensure equity of access, value for money, improved clinical outcomes and achieving the recommendations of the national stroke strategy (2013).
The advocated stroke pathway
The direction of travel for improvement in Stroke and TIA services was set nationally by the Department of Health’s National Stroke Strategy 2007-2017 (2007). The evidence based strategy advocates:
- Provision of specialist stroke units;
- Acute strokes to be regarded as an emergency;
- Rapid access to services for people who have had a TIA;
- Immediate access to diagnostic scans and to thrombolysis for patients whose stroke was caused by a clot;
- Early supported discharge for people with moderate disability as a result of a stroke;
- More emphasis on prevention and public awareness; and
- Better support for all people living with stroke in the long term. This was enhanced by the Cardiovascular Disease Outcomes Strategy in 2013, which identified that not all patients are receiving optimal initial management and ongoing support in primary care and that 7,000 strokes could be avoided every year if everyone with AF was managed appropriately.
The diagram below illustrates the complete stroke pathway, identifying the acute stroke service provision in red, which are the focus of the centralisation approach.
Impact for patients and relatives
Acute stroke services are often centralised onto large university hospital sites who also provide a wide range of tertiary services, and as such attract a patient cohort from a wider geographical catchment area. This increases the travel required to access the service for many relatives and carers, compared to accessing their local DGH. Coupled with the consideration of parking at the centralised site and visiting hours, this can cause further stress and worry for the patient’s visitors.
Balancing this against the certainty of the stroke patient receiving the right care in the right place immediately after conveyance to hospital needs to be a key consideration when proposing these changes, and needs to be emphasised to the patients, public, Health and Wellbeing Boards and Health Overview and Scrutiny Committee as part of engaging them during the redesign process.
Many people are able to accept travelling further to a specialised service for a limited amount of time if they are assured that this will offer the patient the optimum opportunities for clinical care, access to the diagnostic and treatment interventions, and most critically guaranteed access to specialist staff.
Designing a service that enables people to return home as quickly as possible, or to a local rehabilitation service closer to home as part of the clinical pathway, is likely to make this a more acceptable change to the service provision. It will also enable investment in local out of hospital service provision – which will in turn enable patient flow out of acute services in a timely and appropriate way and ensure that acute beds are available for those who need to access them.
Impact for staff
The need to provide specialised acute stroke services for patients in the first 72 hours after their stroke is dependent upon a highly skilled and scarce resource within the NHS. Nationally there is a shortage of specialist stroke physicians, and as such a more concentrated and creative way of delivering services is often the most effective way of optimising recruitment and retention of these staff to stroke services. This will, however, remove this cohort of staff from local hospitals – reducing their contribution to wider medical rotas and sharing of skills and expertise.
Moving towards a more centralised service model can bring about a time of uncertainty for some staff, but also offers opportunities to be involved in the provision of care through a centre of excellence and drives evidenced-based services.
For staff in the local services that are proposed to be centralised, this can be an unsettling time as they seek to be assured about their future employment opportunities and how they balance this with their career aspirations, work/life balance requirements, and the maintenance and development of their clinical skills. For some this offers the opportunity to consider working in a different element of the clinical pathway. For others it is about considering moving jobs to work in the centralised element of service and the implications this may have for them in respect of TUPE rights, travel arrangements and contracted hours of working.
For staff in the centralised element of service, this can offer the opportunity to be involved in the acute end of the service provision and a high turnover of patients progressing through the acute element of the pathway. For some staff, losing the mix of acute and less acute patients will bring about some consideration as to their job satisfaction and caseload balance, and some may seek to pursue employment in other parts of the pathway as a result. Retaining the skills and expertise within the wider pathway, however, is critical and will contribute to the success of the clinical pathway redesign.
All of the above lead to a requirement for clear workforce plans that enable the safe transition to a centralised service and ensure the skills and competencies across the whole pathway are identified. The workforce plan also needs to ensure the future viability and sustainability of the clinical pathway, which will require consideration for future skill mix, and succession planning in the medium and long term.
Making the case for centralisation
When making the case for centralisation of services the benefits realisation and clinical outcomes need to be clearly defined and articulated. Understanding who will lose out as a result of the changes needs to be considered and defined.
Following on from the National Stroke Strategy and NHS London’s Framework for Action document (2007), the London Stroke Model was developed to look at care across the stroke pathway in London, including the establishment of HASUs, with the treatment of patients taking place in fewer such specialist HASUs, Acute Stroke Units (ASUs), and being provided with improved Early Supported Discharge. Having implemented the model in July 2010, the London Cardiac and Stroke Networks reported in November 2010 that:
- The average lengths of stay for Stroke patients had decreased from 15 to 11.5 days;
- Vital Signs data indicated that the acute hospitals in London were performing better than any Strategic Health Authority in England:
- 84% of patients spending 90% of their time on a dedicated stroke unit against a national average is 68%; and
- 85% of high-risk TIA patients were being treated within 24 hours, against a national average is 56%.
In the recent development of plans to centralise stroke services in the Midlands, we were able to demonstrate that no patient would be disadvantaged from a centralised acute stroke service provision. A single centralised acute stroke service will ensure that all suspected stroke patients are conveyed to the centralised site, making this clearer for ambulance service personnel to make a decision as to where to take the patient. Once at the centralised site, the patient will have 24/7 access to the specialist stroke service including diagnostic and treatment interventions including thrombolysis, and to the specialist stroke workforce to asses, monitor and treat them. With the first 72 hours after a stroke being the critical time in which long term clinical outcomes are significantly impacted, this provision will ensure that all patients accessing the centralised stroke service will be offered optimum evidence-based interventions to minimise the long term impact of their stroke. As such the service will endeavour to optimise future independence, reduce disability and thus reduce the long term demand placed upon the health and social care economy.
Clinical leadership of the service redesign is critical to the success of the programme of work to be undertaken. Without meaningful clinical engagement and ownership of the case for change, the desired changes to the clinical pathway will be not be achieved. It is the staff that deliver the services who are critical to the presentation of the case for change and leading wider staff through the implementation of the changes. As part of the redesign process, there is a requirement of senior clinical leaders to be able to distance themselves from their other management and leadership roles within their provider organisations, and to consider the clinical perspectives of the service redesign and the impact that this will have on patient experiences and outcomes.
Striking the balance between the provision of centralised of localised services will be dependent upon the level of specialised clinical interventions and treatments required, the minimum level of demand required to maintain the specialist skills of the workforce and viability of the service, and the ability of the wider health economy to work together collaboratively to redesign the service and implement the required changes. The timescale to achieve this level of service redesign should not be underestimated, with the requirement to ensure all stakeholders are actively and purposefully engaged and involved, and that all the regulatory assurance processes can be successfully navigated before full implementation can be achieved.
In times of increasing austerity and scrutiny, making the most effective and efficient use of specialised resources is critical to delivering equitable clinical services that seek to optimise clinical outcomes for all patients that access the service, and as such centralisation will be a consideration for many specialised services.
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