Saturday, 18 December 2010

Stroke services in London – the NHS at its best

I was at a lovely party last week and at first glance you would say this was a standard office party. A jolly atmosphere – everyone relaxed and chatty – men dressed casually, women in their sparkly party outfits.

As we sat down to dinner – a man stood up to give a brief welcome speech. He firstly made reference to their colleagues who were ‘holding the fort’ while they partied. ‘The fort’ is a specialist stroke unit in North West London. The clinical lead for stroke continued by reminding everyone of their fantastic achievements this year. The massive input of time, money and effort into producing a wonderful stroke service for their local patients. As I glanced round the room, and forgive me if I sound a little romantic about this, every face was glowing with pride.

This team, like others in London have been implementing the ‘New London Stroke Model’ This lays out targets and performance measures for Hyperacute stroke units and Stroke units in London. The patient pathway is minutely mapped from onset of symptoms, through to arrival at an emergency department in the nearest hospital with specialist services. With the clock still ticking, the patient is then scanned if appropriate and then, again if appropriate and within the right ‘time window’, thrombolysed (given clot busting drugs). This clot busting process can be life saving and brain saving. Even if you nothing about stroke, this most catastrophic of events, we all know that time is of the essence in providing treatment to ‘save the brain’ and improve chances for a full recovery or  at least a reasonable quality of life post-stroke.

The new London Stroke Model is a perfect example of multidisciplinary working across the NHS. Performance measures for London Ambulance Services, A & E departments, stroke physicians, neurologists, specialist nurses and therapists have all being clearly outlined. These measures include staff levels, expertise within each unit, quality of care, treatment protocols and vital signs measurement (i.e. if the protocols and pathways are constantly achieved).

Each specialist unit is assessed and monitored on a regular basis and this performance is directly linked to the tariff the hospital earns for this specialist service. It is all perfectly logical – quality care is provided in specialist units, measured and monitored and the Hospital Trust rewarded accordingly. The unit must constantly achieve these performance targets to earn the tariff uplift.

I have been in the privileged position to be part of these assessment teams and I can assure you that this is a rigorous process. The results speak volumes. Since ‘go live’ in July, all acute stroke patients in London are taken to a specialist hyperacute stroke unit (HASU). The distribution of these units has enabled the average door to HASU time in an ambulance to be 14 minutes and the average ‘call to arrival at hospital’ time is 55 minutes. The number of patients receiving thrombolysis in London has now quadrupled and is reported as the highest rate for any large city throughout the world.

One of the patient pathways I checked last week went thus:

Onset of symptoms: 20.33
Arrival at Emergency Dept: 21.07
CT scan: 21.11
Thrombolysis: 21.12

Yes – the thrombolysis team literally wait with the patient as the scan takes place and are ready to start treatment immediately if the diagnosis shows that the patient would benefit from thrombolysis.
This patient was discharged three days later and with secondary prevention will hopefully continue to live an active life.

There are many more stories such as this, along with less dramatic but nonetheless as vital cases where patients who have suffered disabling damage from stroke receive wonderful acute treatment and commencement of rehabilitation in a stroke unit.

I can understand the desire of Andrew Lansley (UK Secretary of State for Health) to measure outcomes rather than targets. But aren’t they really the same thing? Targets produce outcomes. There will be more information regarding stroke outcomes published soon but I have no doubt that as the stroke model ‘targets’ (performance measures) have been met, outcomes for the stroke patients of London will continue to improve.

This really is the NHS at its best. As I mentioned in my previous blog, let's not throw the baby out with the bath water. There is some amazing work going on now and every day in the NHS, so please Mr Lansley – improve performance of individuals, make managers more accountable,  by all means measure outcomes too – but  don’t try to ‘fix what ain’t broke’!

And the party? Well – I’ve always been a fan of work hard, play hard….


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