Clinical challenge
Gateshead and Newcastle hospitals serve population of approximately 0.5 million and are situated within 5 miles distance. Despite success of HASU model in London, there had been general reluctance to shut down hyperacute services in individual Trusts due to worry of perceived lack of support from local population for closure of units near residence and anxiety around joining of   workforce between two Foundation Trusts to form a larger unit.
 
In 2014, SSNAP audit performance for Gateshead and RVI, Newcastle stroke services were dipped to ‘D’ band and remained consistently at the lower end on performance table. Newcastle and Gateshead stroke services did not have weekend specialist therapy provision. Moreover, due to anticipated retirement of senior workforce, sustainability of smaller unit at Gateshead was threatened.  
 
Newcastle stroke service was amongst the top 10 selected units designated to perform complex hyperacute stroke research. As the population it was serving was small in comparison to other 9 English hyperacute stroke research centres, Newcastle was struggling to achieve desired performance on research front as well.
 
With consistent poor national audit performance, lack of sustainability and modest performance of hyperacute stroke research centre, a major overhaul of service was undertaken, to establish HASU in the region in 2015.
 
Its major aim was to improve SSNAP performance for hyperacute and acute care for population serving Gateshead and Newcastle upon Tyne. Other aims were to ensure that hyperacute stroke research centre performance improves.

Solution
‘Gap analysis’ was undertaken at various levels of workforce staffing. This included need for weekend therapy staffing, middle grade cover for managing hyperacute stroke patients 24/ 7, sustainable senior medical workforce requirement to manage 1100 patients in and out of hours at RVI, Newcastle upon Tyne. Repatriation arrangement was reviewed and agreed between two Foundation Trusts.
 
CCG led steering committee was conveyed with risk register management and individual business cases were drawn up at both Trusts to address the ‘gap’ analyses. These two business cases were then carefully coordinated to ensure all gaps in the service have been addressed. Contrary to London services, the total envelop cash available was unchanged. The business case was neutral to the CCG budget except payment of repatriation service, the cost of which was picked up by the CCG.

Standardised operating procedures (SOPs) were drawn for various strands of stroke pathways. These included SOPs for managing patients in QEH emergency department and rapid transfers for self-presenters to local ED, paramedics triage, repatriation and handover.
 
Protocols were drawn up based in SSNAP measure of clinical performance for speciality nursing assessments, neuroimaging, senior medical reviews, and specialist therapy assessments including weekend working.
 
It became apparent that the middle grade cover would be inadequate for management of high throughput in large unit at RVI. In particular, due to geographical location of unit, it was anticipated that attracting large pool of middle medical grade cover would be challenging. Moreover, there were insufficient funds to support these workforce arrangements.
Another challenge was relatively smaller workforce of stroke research staff, unable to provide hyperacute stroke research on weekends, let alone 24/7. Similarly, there was inadequate specialist nursing force to provide 24/7 service.
 
Innovative approach was undertaken, whereby some research money (0.8 WTE equivalent.) supported appointment of additional specialist nursing post. In addition to this, both research nursing staff and specialist nursing staff were trained to provide competencies for research and clinical care and a larger pool of specialist nursing posts were created. This allowed 24/7 specialist nursing staffing, capable of providing clinical care in addition to being research active. This allowed easing off pressure on medical registrar and specialist nursing provided much needed stroke expertise 24/7 at our HASU.

Impact
The impact was immediate with SSNAP performance improved from ‘D’ band in baseline (premerger) through to B in 2016 in run upto starting HASU as we appointed workforce. As we merged the units for managing first 72 hour care on 21^st November 2016, we have moved in band A of SSNAP performance and have consistently maintained this top band A performance. We did not receive a single complaint from Gateshead resident regarding change of pathway and have several positive feedbacks from patients, organisations in the region and even House of Lords, the excerpts of which are attached herewith. All the national audit measure has improved significantly. Since reconfiguration on 21^st November 2016, we have managed 2186 stroke patients and 1333 stroke mimics, 272 stroke patients received thrombolysis and 44 received thrombectomy. 54 Gateshead stroke patients could be offered stroke research including interventions through participation of complex interventional research.
Most recent median times for assessments have been - stroke specialist nurse assessments 1 minute as most patients are received by specialist nurses on the unit, stroke specialist consultant assessments median of 1.58 hours, OT, PT and SALT median times..
 
Hyperacute stroke research performance, not only improved, but did put us as the topmost performing centre amongst all 11 English centres (by 2018, HSRC centres in England increased from 10 to 11.). Newcastle HSRC was invited to share best practice example in the annual meeting in London in March 2018 and has been cited as an exemplar HSRC centre. In recent visit from RCP, London president (15/11/2018),our service was praised for its innovative approach for managing  service with high quality patient centred care and at the same time making them sustainable and in that process ensuring  wellbeing of staff.

Pre-reorganisation



​Latest SSNAP performance after reorganisation



Feedback
“The nurses, doctors, everyone was brilliant. Because it was a weekend, the team were called in specially to perform the operation. They answered any questions I had and reassured me every step of the way.” - Joanne Davies - initially taken to Queen Elizabeth Hospital after suffering a stroke and was quickly transferred to Royal Victoria Infirmary following a CT scan. 

Reflection
The stroke services and stroke research unit in Newcastle is considered an exemplar and triggered further reorganisation of services in Northeast England. Although the outcome of change management is extremely positive, it took several months to implement this change. This change has brought significant positive impact on patients’ lives in the region and this will leave a long term, year on year gains in quality of patient care. We are very grateful for RCP and SSNAP team to help us get where we are. The audit has transformed stroke care in the region for the best. The next step is to perform ‘gap’ analysis for SSNAP performance of post 72 hour care for patients at both units and addressing those. Another piece of work will involve implementing 24/7 thrombectomy service and we will be referring to SSNAP thrombectomy audit for further improvement.

This case study was written by Dr Anand K Dixit, Lead Clinician Newcastle-upon-Tyne Hospitals NHS Foundation Trust


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