Inviting peers to help improve stroke services

Stroke is a major challenge for the NHS, affecting 150,000 people in the UK each year. It remains one of the biggest killers and is the leading cause of adult-onset disability. In addition to this human cost, it is a major burden on health and social care services, with annual direct and indirect costs of at least £7bn (using 2005 prices). 

People with stroke occupy 5 per cent of all hospital bed days, and their care presents a particular challenge for acute providers with long lengths of stay, and specialist rehabilitation needs. Stroke is one of the priority areas in the NHS Outcomes Framework and the clinical commissioning groups’ outcomes indicator set. It is clear that NHS England regulators and commissioners will expect providers, in particular acute trusts, to continue to deliver significant improvements in stroke care quality and outcomes.

Better stroke care

National audits have shown major improvements in stroke care over the past decade. Eighty-six per cent of people with stroke now spend more than 90 per cent of their in-hospital stay in a specialist unit, and over 10 per cent of patients now receive stroke thrombolysis (clot-busting therapy), overtaking the US in providing access to this National Institute for Health and Care Excellence-approved treatment.

‘We’re very aware of the evidence that producing expert guidelines is not enough on its own to result in quality improvement’

Outcomes have also been improved by several major regional reconfigurations of stroke services, creating flagship “hyperacute” stroke services in London and Greater Manchester. However, stroke services are complex and delivering improvements can be challenging for acute trusts. For this reason, in 2006 the Royal College of Physicians, the British Association of Stroke Physicians (BASP) and the Stroke Association charity set up a joint stroke peer review scheme. 

The scheme gives trusts the opportunity to receive assistance and support in improving their stroke services. Participating trusts receive a site visit and detailed report from a small multidisciplinary group of experts. The remit of the advisory visit is agreed with the trust in advance, and this can vary from a broad review along the entire stroke pathway to a focus on one particular aspect of the stroke service (see box below).

Dr Martin James, stroke physician at Royal Devon and Exeter Foundation Trust, recent president of BASP and an associate director of the RCP stroke programme, says: “We’re very aware of the evidence that producing expert guidelines is not enough on its own to result in quality improvement. We could see from the national audit figures that there were certain providers that changed very little in their relative performance from one audit to the next, and simply brow-beating them with their poor results wasn’t going to be enough to bring about change. 

“So we developed the stroke services peer review scheme to allow trusts to invite a small multi-professional team of stroke experts and lay people to visit and give their independent advice on any number of difficult issues. 

“The team is able to provide the external view that is sometimes missing when the local health economy is bogged down with the effort to improve.”

Creating action plans

‘We have managed to avoid being labelled as a ‘hit squad’ − the invitation for a visit is always sanctioned by the chief executive’

Since its launch, the scheme has carried out 26 visits to trusts and networks across the country, working with local providers to produce detailed action plans for progress, and securing agreements on timescales for implementation. The composition of the visiting team varies according to the requirements of the trust, but typically includes stroke physicians, nurses and allied health professionals, managers and stroke survivors. 

Dr James highlights this collaborative approach to quality improvement: “We have managed to avoid being labelled as a ‘hit squad’ − the invitation for a visit is always sanctioned by the chief executive, usually with the support of their local cardiac and stroke network, and we recognise that most trusts have tried long and hard to improve their services before turning to us for assistance. So our approach is strictly by invitation and is very deliberately supportive and collaborative.”

The response to external support and advice seems to be uniformly positive, Dr James explains.

“The peer review process involves the engagement of clinicians and managers, and local commissioners, so there is widespread commitment to getting the most out of the visit and that in itself can act as a catalyst for progress where it has proved too difficult before. When we have followed up on our visits a year later, over 75 per cent of our recommendations have been partly or fully implemented, and feedback highlights how the peer review process has helped to jump-start improvement,” he adds. (See case study below.)

A job to do

So what of the future? While the quality of acute stroke care has improved dramatically over recent years, progress is still uneven and many providers lag behind the best. In addition, quality improvement in stroke care is likely to increasingly focus on rehabilitation and recovery, with integrated care provided across a variety of providers.

Commissioners and providers will be supported by the new sentinel stroke national audit programme, which will for the first time measure quality along the whole stroke pathway, including in the community.

Trusts and other providers will find that the stroke peer review scheme offers an effective and independent way of helping to deliver quality improvement in stroke services. As Dr James puts it: “We’ve always seen external peer support as an essential component of the process of national audit and continuous quality improvement, and we’re not anywhere near thinking the job is done yet.”

Dr Ben Bray is a quality improvement fellow at the Royal College of Physicians