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Update – Hyper Acute Stroke Services

HEALTH EXECUTIVE GROUP

SOUTH YORKSHIRE AND BASSETLAW INTEGRATED CARE SYSTEM

Tuesday 9th July 2019

Author(s) Marianna Hargreaves, Transformation Programme Lead, South Yorkshire and Bassetlaw Shadow Integrated Care System

Sponsor(s) Dr Richard Jenkins, Provider Lead, South Yorkshire and Bassetlaw Integrated Care System, CE Barnsley Hospital Will Cleary-Gray, Chief Operating Officer, South Yorkshire and Bassetlaw Integrated Care System Lesley Smith, SRO, South Yorkshire and Bassetlaw Integrated Care System

Is your report for Approval / Consideration / Noting

To note

Are there any resource implications (including Financial, Staffing, etc.)?

N/A

Summary of key issues

All providers are on track to deliver the new HASU model as per the agreed implementation dates and the changes in Rotherham have been enacted as planned on 1st July.

The ‘Regional Stroke Patient Flow Policy’ has been developed through the HASU

Implementation Group and has been signed off through appropriate internal governance by all Trusts directly involved in the changes.

Work has been initiated to look at how best to enable the changes to hyper acute stroke services to become managed as business as usual within the South Yorkshire and Bassetlaw Integrated Care System.

Recommendations

The HEG is asked to note:

Plans are on track to deliver the new HASU model as per the agreed implementation dates and the changes in Rotherham have been enacted as planned on 1st July.

The ‘Regional Stroke Patient Flow Policy’ has been signed off by all Trusts directly

involved in the changes and will be reviewed as agreed as we progress implementation.

Enclosure J

Item 20bv (to support main agenda item 19 (oral update))

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South Yorkshire, Bassetlaw and

Mid Yorkshire

Regional Stroke Services

Patient Flow Policy

V11 FINAL DRAFT – Patient Flow Policy

Author J Shepherd, with contributions from the

HASU Implementation Group

Date Written During 2019

Approved by HASU Implementation Group

Individual Trusts/SYB Health Executive

Group

Date of Approval; HASU Implementation Group 23/4/2019

See Appendix 1 – Individual Trusts

Date Issued: End June 2019

Next Review Date: September 2019

Target Audience: Trust Staff

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1. Introduction and Purpose

The Stroke Services Pathway for patients in South Yorkshire, Bassetlaw (SYB) and Mid Yorkshire relies upon the timely, safe and appropriate transfer of patients between provider Trusts. This policy explains how patients with stroke, Transient Ischaemic Attack (TIA) or a Stroke Mimic will flow within the agreed pathway. The policy articulates the standards expected to ensure that patients are transferred and discharged safely within agreed timescales and that they are always cared for in the appropriate place. 2. Scope

The scope of this policy is region wide across South Yorkshire, Bassetlaw and Mid Yorkshire. Those who provide the following services are expected to adhere to this policy:

Emergency Ambulance Services

Emergency Departments

Regional Hyper Acute Stroke Services

Neurological Assessment Units

Acute Stroke Services

Inpatient Stroke Rehabilitation Services

Early Supported Discharge Services

Community Stroke Rehabilitation Services

Patient Transport Services 3. Aims

• To support safe, effective patient flow and automatic seamless transfer of patients between services

within the region with clinical priority being the key determinant of when and where a patient is treated and cared for.

• To support a collaborative approach to patient flow across providers within the region fostering a ‘one service’ ethos with automatic transition between services and organisations. Enabling the emphasis to be on automatic patient flow rather than waiting for permission or agreement ahead of movement.

• To enable capacity and flow to be proactively managed as a coordinated system, with no action to be

taken by any constituent part of the region that could undermine the ability of another part without appropriate prior discussion.

• To provide equitable access to comprehensive stroke care and tertiary treatments in a timely manner,

delivered as close to home as possible. • To outline the transfer and discharge pathways for the different patient groups who present to

hospital. • To maximise the efficient use of resources, including stroke beds, non-stroke beds, outpatient

appointments and staffing. • To support a positive patient and carer experience of care. • To outline the escalation process in response to delays in flow and discharge, and assist the effective

implementation of escalation procedures.

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4. Organisations Committed to this Policy

The organisations that have been involved in the development of this policy and have declared their commitment to it are listed in Appendix 1.

5. Stroke Services in South Yorkshire, Bassetlaw and Mid Yorkshire

SYB patients flow between key stroke services, in a seamless pathway, from symptom onset through to discharge (Figure 1).

Figure 1: Stroke Services Pathway

Hyper Acute Stroke unit (HASU) care for stroke patients in SYB is delivered at SYB Regional HASU centres in Sheffield, Doncaster, with some SYB residents receiving HASU care at Pinderfields in Mid Yorkshire. From here, patients are transferred to a local Acute Stroke Unit (ASU), Stroke Rehabilitation Unit (SRU) or discharged home with or without community based rehabilitation. Local ASU care is provided by all acute hospital provider Trusts within the region. Patients will be transferred to the ASU or SRU that is closest to their Clinical Commissioning Group area as determined by their GP. A definition of each hospital based service and their location is provided in Appendix 2. 6. Communication Between Providers

All providers will work together to ensure that patients flow seamlessly between services. This will involve ongoing proactive communication and collaboration. A daily teleconference call will enable forward planning and provide oversight of this communication. 7. Managing Capacity and Demand

All providers will contribute to the effective management of demand and capacity, using the Daily Teleconference Call to communicate information on admissions and expected discharges to enable forward planning. 7.1 Daily Teleconference Call The Daily Teleconference Call will run according to the agreed Standard Operating Procedure (SOP). It will take place 7 days per week at 9.30am with representation from each place and will focus on demand and capacity for:

HASUs in Sheffield, Doncaster and Mid Yorkshire

Local ASUs in Rotherham and Barnsley

Early Supported Discharge (ESD) / Community Stroke Team (CST) in Rotherham and Barnsley

Interfacility transport for repatriation

Pre-Hospital Hyper acute Acute Rehabilitation

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The daily telecall will have a pivotal role in forward planning and providing oversight of communication to facilitate cross boundary patient flows. Agreed escalation procedures will be used where delays and issues with flow or discharge occur. Delays will be logged and reasons for the delay agreed on the daily call as appropriate. A delay occurs when a patient has not transferred within 24 hours of the HASU Team confirming that the patient is ready for transfer. For more details see the Daily Teleconference Call SOP. 7.2 Capacity Issues

Services should be open to admissions at all times and there should always be availability of HASU and ASU beds for new admissions 7 days a week, 365 days per year. SRU, ESD and CST capacity is also essential to facilitate patient flow out of HASUs and ASUs. If a service has reached capacity this should be managed locally in the first instance and escalated in accordance with local procedures. If capacity issues cannot be resolved locally, these should be logged at the Daily Teleconference Call and escalated in line with agreed escalation procedures. When a service is experiencing significant challenges resulting in considering the potential to divert new patients to other HASU units this will be carried out in accordance with the agreed local policies and procedures with decisions made at an Executive Level. All services will have Business Continuity Plans in place which would be activated appropriately. 8. Patient Pathways and Flow

Most patients will present to hospital where there is a Regional HASU in accordance with the Pre-Hospital Pathway. The patient will be assessed, investigations commenced and a clinical impression made. 8.1 Strokes Patients with stroke will be admitted to a HASU Bed. When the patient’s immediate management has been commenced a clinical decision will be made to determine when the patient is ready to transfer to an ASU at their local hospital or requires discharge. Patients will be repatriated to non-HASU hospital ASUs / SRUs when they are clinically deemed to be no longer in the hyper acute phase and all of the first 72 hour SSNAP care bundle has been undertaken including assessment by all relevant therapy disciplines (it is fully expected that all therapy assessments will be completed however if there are exceptional circumstances, the therapy assessment alone would not delay transfer). This decision will be made by the patients' HASU Consultant with support from the multidisciplinary team and it will be communicated to the appropriate non-HASU hospital ASU or SRU. A Local ASU bed or SRU bed will be allocated and the date and time of transfer jointly agreed. Practical arrangements to transfer patients will take place within normal day-to-day working through proactive dialogue between units. The Daily Teleconference Call will enable forward planning and provide daily oversight of the cross boundary flows for stroke patients. Where a patient can be discharged directly from HASU appropriate local follow up arrangement will be made (Appendix 3). People dying of stroke should have timely transfer of care to a hospital close to home, their own home (including a care home) or a hospice according to what is clinically appropriate and practically possible and the wishes of the person and their family/carers.

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8.2 Stroke Mimics

Stroke Mimics may be identified at point of initial assessment (in the ED or NAU) or following admission to a HASU. A clinical decision will be made regarding the most appropriate care pathway for these patients. Where stroke is excluded in ED or the Neuro Assessment Unit a clinical judgement will be made and the patient may be:

Discharged home direct from Emergency Department (ED) - or Neuro Assessment Unit (NAU) +/- appropriate outpatient referrals being made. If the outpatient referral is non-urgent, then the Trust may advise the patient’s GP to make the onward referral. Providers will as appropriate utilise processes for HASUs to be able to access urgent outpatient/ambulatory care facilities for patients at Barnsley and Rotherham Hospitals.

Referred to which ever speciality is appropriate at the HASU Trust, which may or may not result in the patient being admitted. If the patient requires further inpatient care but no longer requires treatment at the HASU site then the patient should be referred to the appropriate speciality at Barnsley or Rotherham hospital. That patient should be accepted and transferred immediately.

Repatriated from the NAU / ED to Barnsley or Rotherham Hospital – the responsible doctor/clinician should refer the patient directly to the appropriate speciality at the receiving hospital and the patient will be directly admitted to their medical assessment unit or other relevant ward of the speciality referred to and not go through the ED at the receiving site.

Where a patient has been identified as a stroke mimic whilst on HASU or another ward clinicians will utilise their clinical judgement as to when it is clinically appropriate to repatriate the patient to their local hospital. It is very unlikely to be clinically appropriate (or to offer a good patient experience) to repatriate patients with stroke mimic conditions for very short periods of time. Patients with a very short predicted length of stay will be cared for at the hospital of initial assessment until time of discharge. If a longer stay is anticipated then patients should be repatriated at the earliest clinically appropriate opportunity. Patients will not be repatriated via the ED but a provisional diagnosis must be made by the HASU Trust and the patient referred directly to the appropriate speciality of the receiving hospital. Where a patient can be discharged directly from the HASU site, appropriate local follow up arrangement will be made by the discharging team (Appendix 4). 8.3 Transient Ischaemic Attacks (TIAs)

Patients whose symptoms have resolved by the time of initial assessment by the Regional HASU team and who are felt to have had a transient ischaemic attack, will be assessed, receive appropriate urgent investigation, treatment and advice by a doctor before being urgently referred to their local TIA service. Here they will receive urgent assessment and investigations within 24 hours of referral by a specialist clinician. Prior to discharge from the Regional HASU site, the patient’s appointment should be fixed and the time/date given to the patient. While a system is being set up to facilitate 24/7 remote booking of clinic appointments, as a temporary measure the HASU will arrange for the local clinic to contact the patient the following morning with an appointment time. The HASU Trust will confirm that the local clinic has picked up the referral and offered the patient an appointment the following day for patients who have not had full initial investigations. The patient will be advised not to drive until seen in clinic.

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If a patient has been admitted to the Regional HASU site and then identified as a TIA they will be assessed by a specialist physician and receive appropriate investigations (e.g. carotid Dopplers) and commencement of secondary prevention measures within 24 hours while on the ward and be discharged with appropriate follow up locally (Appendix 4). 8.4 Self-Presenters to Emergency Departments (ED)

Some patients will continue to self-present to EDs not located with a regional HASU. It is expected that initial assessments of self-presenters with symptoms of stroke will take place at the arriving hospital if symptom onset is within 48 hours contact will be made with the nearest HASU and urgent transfer arranged as appropriate. For those presenting with symptom onset greater than 48 hours to Barnsley or Rotherham ED direct admission to the ASU should be arranged as this is co-located. For those presenting whose symptoms resolve and are thought to have had a TIA, a referral to their local TIA clinic should be made. 8.5 Inpatient Strokes

It is expected that hospitals will provide assessment and appropriate care to patients who have a stroke whilst already an inpatient. Advice should be sought from the nearest HASU unit (Barnsley will seek advice from the Mid Yorkshire HASU and Rotherham will seek advice from the Sheffield HASU) and if deemed clinically appropriate a transfer arranged to a regional HASU. If not, patients should be managed locally with internal transfers to local stroke services where deemed appropriate. 8.6 Thrombectomy Patients requiring Thrombectomy will be assessed, referred, transferred and repatriated in accordance with Regional Thrombectomy Policies and Procedures. 9. Transfer and Discharge Timeframes

All patients, once assessed as clinically fit for transfer should be transferred. Transfers to local ASUs should be timely with arrival planned prior to 10pm, unless in exceptional circumstances. Planning for transfers should commence as soon as possible and transfer dates and times should be agreed as soon as the patient has been assessed as ready for transfer. All patients once assessed as clinically fit for discharge should be discharged and the HASU team will ensure the following prior to discharge:

Follow up services and equipment arranged and are in place as appropriate (liaising directly to arrange equipment)

Onward referrals made

Patient and their carer are aware of all follow up arrangements

10. HASU Site Length of Stay

On average patients will require hyper acute care for up to 72 hours (length of stay 0 – 3 nights) but the duration of hyper acute care needs to be tailored to the individual clinical needs of the patients. Some patients will be stable enough and have had all of their assessments undertaken well within 72 hours and

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be able to be discharged or transferred to an ASU in under 72 hours. Others will require a longer period of hyper acute care. Patients should not be repatriated to non-HASU hospital ASUs / SRUs until they are clinically deemed to be no longer in the hyper acute phase and all of the first 72 hour SSNAP care bundle (Appendix 5) has been undertaken including assessment by all relevant therapy disciplines. Where a patient from Barnsley or Rotherham has a planned discharge date with a total length of stay of 4 or 5 days, then the patients should remain on the HASU site and be discharged directly home, rather than being repatriated for a very short duration. This will be closely monitored to ensure that any implications on patient flow are identified early, particularly the identification of delays for those patients with a planned discharge date with a total length of stay of 4 or 5 days. A clear discharge plan should be in place for these patients and delays escalated as per the escalation processes and logged on the Daily Teleconference Call. Patients awaiting repatriation or discharge directly home, who are deemed to be now clinically outside of the hyper acute window and who have had all of the initial nursing and therapy assessments completed may be moved as per the HASU Trust local policy whilst awaiting onward transfer/discharge. The Regional HASU site will actively monitor HASU length of stay and where individual or general issues occur they will be escalated appropriately. 11. Patient Flow into Inpatient Rehabilitation, Early Supported Rehabilitation and Community Stroke

Team Services

Stroke patients requiring ongoing inpatient rehabilitation at a SRU, ESD or CST will be referred directly from the Regional HASU or local ASU in accordance with the agreed criteria as outlined in the SYB and Mid Yorkshire Directory of Services. 11.1 Transfers to Inpatient Rehabilitation A clinical decision will be made and where a patient requires inpatient rehabilitation they will be transferred once assessed as clinically fit for transfer. 11.2 Discharge with ESD or CST

Patients requiring ESD or CST will be discharged home with a plan for assessment / intervention at home. For ESD patients this will be delivered within 24-48 hours of referral. For CST patients this will be delivered within 72 hours. Delays in these pathways will be escalated as per the escalation processes and logged via the teleconference call. All referrals will be made using the SYB Regional Stroke Services Transfer of Care Document. The document has been designed to be transferred via secure nhs net. 11.3 Transfer of Patient Information

To support seamless patient flow all clinical records will be transferred in line with the ‘Regional Stroke Services Transfer of Clinical Records Policy’. Transfer of information will occur adhering to local and regional Information Governance Guidelines.

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12. Communication with Patients and their Carers 12.1 On admission to the HASU

The views of the patient and their consent will be sought, to establish the extent to which they wish carers and others to be involved in the planning and delivery of their care.

The patient and their families/carers will be told about the role of the HASU and that their care will be transferred after the hyper acute period to local units if necessary.

They will be given the ‘SYB Stroke Pathway Patient and Carer Information Leaflet’.

12.2 Involvement in Decision Making and Care Planning

Patients and their families/carers will be informed and are active participants in discussions throughout the care pathway on a regular and timely basis. If the person with stroke agrees/consents, family/carers should be actively involved in day to day care, rehabilitation and decisions about the planning and delivery of their care. Table 1 details how patients and their families/carers will be involved:

Table 1: Patient and Carer Involvement in Decision Making and Care Planning

Patients and their families/carers will be informed of and involved in decision making regarding:

Their condition, their prognosis and situation

What is likely to happen to them next e.g. how soon they will be seen, frequency of contact, contact information for the new team, how goals will be carried over

Who is taking care of them and who is responsible for their care

What they need to be doing to facilitate their care and recovery (e.g. advice and information about exercises or other activities that they can practice independently) and to decrease their risk of further strokes

What are their views and concerns about their current and future care

12.3 Transfer of Care, Discharge and Follow Up

Patients and their families/carers will be made aware of the pathway upon admission to HASU and as appropriate the plans for transfer of care and/or discharge arrangements. Patients will be offered copies of written communication between organisations and teams involved in their care. Table 2 details the information and advice stroke patients and their families/carers will be offered prior to discharge.

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Table 2: Information and Advice For Stroke Patients and their families/carers

Prior to discharge patients and their families/carers should be given:

Information and offered contact with relevant statutory and voluntary agencies

Information about services available to support people who have had a stroke and how to access them, including practical or emotional support, peer support groups

Information / opportunity to have a carers assessment of their own needs

Written information about their diagnosis and management plan

Guidance regarding any prescriptions – verbally and supported by written information

Advice about driving

A named contact person for information and advice

Guidance on how to seek help if problems develop

Details of follow up plans

13. Interfacility Transport 13.1 Repatriation Effective patient flow along the Stroke Pathway relies upon the efficient, effective and safe movement of patients using patient transport services. Where patients are repatriated from a Regional HASU site to a local hospital this will take place in line with Interfacility Transport Policies, taking into consideration the acuity of the patient. Wherever possible transport will be pre-booked in advance of a transfer taking place. The specification for core Patient Transport Services outlines that journeys can be pre-booked anytime up until 6pm the day before the planned journey, and changes to existing bookings can also be facilitated until this time. Transport that has been pre booked may need to be cancelled if circumstances change. For ‘on the day’ discharges/transfers it is also expected that timeliness should be in line with the requirements set out in the core specification for Patient Transport Services with most patients (99%) collected no later than 120 minutes after their booked ready time. Transport delays will be escalated via the escalation process (Appendix 5) and logged on the Daily Teleconference Call. 13.2 Mechanical Thrombectomy

Transport for patients following the Mechanical Thrombectomy Pathway will be requested and take place in line with the Regional Mechanical Thrombectomy policies.

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14. Roles and Responsibilities 14.1 Receiving Trust / Clinical Team In all cases the clinical team at the receiving service must:

Accept the patient’s transfer / referral into the service to facilitate automatic transfer

Agree the date and time of transfer /discharge

Arrange for a bed to be available for the patient’s admission (applicable to ASU / SRU)

Arrange for the clinical team to carry out the appropriate assessments on arrival

Ensure that all relevant clinical and handover information has been received prior to transfer

Ensure that they are ready to receive patients within agreed timescales in accordance with this policy

Utilise agreed escalation processes and seek local resolution where capacity issues arise in order to accept referrals and facilitate patient transfer.

14.2 Transferring Trust / Team

Once a patient’s transfer or discharge has been agreed it is the responsibility of the transferring / discharging Trust’s team to:

Provide all relevant clinical details and arrange for the transfer of documentation / records

Arrange TTOs and transfer patients with any non-stock drugs

Complete the Transfer of Care Document as part of the handover. Form 1 is for transfers from HASU to Inpatient Stroke Services and Form 2 is for transfers to Community Stroke Services and Early Supported Discharge. See Appendix 7.

Arrange transport via the agreed booking process

Confirm the date and time of transfer

Ensure the patient and family are advised of the plan and transfer details

Escalate and log any delays experienced in the transfer process. 14.3 Trust Management Teams

If delays and issues are encountered Trust management teams will support the Clinical Teams in line with agreed escalation processes. 14.4 Trust Site / Flow Teams

Trust site / flow teams will support the Clinical Teams / Trust Management Teams to manage any issues related to demand and capacity, according to agreed internal and regional escalation processes. 15. Delays and Issues with Patient Flow: Escalation It is imperative that patients are transferred between sites/services or discharged when they are ready in order to maintain patient flow. Patient flow and the quality of patient care may be negatively affected when there are issues with:

Delayed transfers

Delayed discharges

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Contributing factors to delayed transfers and discharges may include:

High demand and/or limited capacity within services

Transport delays

Social Care provision delays

Equipment provision These issues will be escalated in accordance with local escalation procedures and those within this Policy. 15.1 Readiness for Transfer or Discharge A patient is ready for transfer or discharge when:

The 72 Hour SSNAP Care Bundle has been undertaken including assessment by all relevant therapy disciplines

All appropriate hyper acute investigations have been completed

A clinical decision by the HASU consultant has been made that the patient is ready for transfer or discharge, and

The patient is safe to transfer or be discharged. The clinical team at the receiving service must clinically accept the patients transfer / referral into the service without delay and agree the time of transfer. Where a patient is transferring from a Regional HASU to a local ASU at another site or being discharged they need to be clinically safe to travel using the most appropriate transport. Where a patient is transferring from a Regional HASU to an on-site ASU this is not a factor in need of consideration. When a patient is identified as ready for transfer: The Regional HASU Team will:

Identify the patient as ready for transfer and communicate this to the ASU / SRU team by telephone

Record the time (clock start) on local Electronic Patient Records / patient administration systems

Log the date/time of the communication between HASU / ASU / SRU

Send the receiving team a completed Transfer of Care Document as appropriate for the transfer with the patient’s clinical details

Patients transferring will be discussed and noted at the Daily Teleconference Call, but this will not delay the automatic transfer of patients between services

The ASU / SRU team will:

Accept the patient’s transfer / referral into the service to facilitate automatic transfer

Review the received Transfer of Care Document and seek clarity if required

Arrange for a bed for the patient

Agree the date and time of transfer

Arrange for the clinical team to carry out the appropriate assessments on arrival

Communicate any issues with arranging a bed

Utilise agreed escalation processes and seek local resolution where capacity issues arise in order to accept referrals and facilitate patient transfer.

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15.2 Delayed Transfer

As soon as a patient is ready for transfer and this has been communicated to the receiving team and they have accepted the referral the ‘clock’ starts. If a patient does not transfer within 24 hours of this time this would constitute a delay. The referring and receiving team must agree that there has been a delayed transfer of care. For stroke patients the following information should be logged at the Daily Teleconference Call:

Date and time of when the patient was ready for transfer and when this was communicated

The date and time of when the delay occurred

The reason for the delay (category to be agreed)

Agreed actions to overcome the delay and any escalation procedures carried out

Date and time of actual transfer For stroke mimic patients the same information will be collected by the Clinical Operations team as part of the escalation process for delayed transfers. Any delays to transfer should be dealt with according to Trust escalation processes via Clinical Operations and Chief Operating Officers. A delay report for both stroke and stroke mimics will be collated by the HASU Trust each month and submitted to the CCG as part of the reporting schedule. This will inform the financial reimbursement process. 15.3 Delayed Discharge

If a patient is waiting to be discharged home to a supported care facility (care home) or a community hospital, or awaiting care and they are ready to leave but are still occupying a hospital bed, they may be reported as a ‘delayed transfer of care’ (DTOC) under national guidance. Internal transfer delays are not reported under national DTOC guidance. Where a patient is being directly discharged from a HASU and there is a delay in discharge that constitutes a DTOC the patient will be transferred to their local hospital. 15.4 Escalation of Delayed Transfers and Discharges

Where delayed transfers and discharges occur which cannot be immediately resolved they should be escalated according to the agreed escalation process (Appendix 6). 15.5 Issues with Demand and Capacity

In the first instance any concerns or issues that cannot be resolved locally should be raised in the Daily Teleconference Call where the teams can work together to find a suitable solution. If a solution is not possible from within the Stroke pathway teams this should be escalated according to the agreed escalation process (Appendix 6). When escalating issues teams need to consider:

The nature of the problem

The impact of the problem – both locally and regionally, it’s severity and the duration of the impact

Possible solutions

Sources of support to help resolve the issue – locally and regionally

15.6 Transport Delays

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There will be a collaborative approach to resolving any delays attributed to delays in transport. Where delays are due to transport they should be escalated according to the agreed escalation process (Appendix 6.2). 15.7 Social Care Delays

There will be a collaborative approach to resolving any delays attributed to delays in social care provision. Where delays are due to social care they should be escalated according to the agreed escalation process (Appendix 6.3). 16. Monitoring: Patient Flow and Policy

A collaborative approach will be taken to monitoring patient flow and the application of this policy. The SYB Hosted Network will have a key role in this. The Daily Teleconference will support the collection of data on delays and issues. Where it is deemed that a transfer to any service within the pathway has been inappropriate the concerned team should contact the transferring unit to discuss their concerns. Where a concern is considered serious this should be reported as a Clinical Incident, in line with local policies, so that it can be investigated and learning gained. The Hosted Network will lead on regional forums where learning can take place from such incidents and any general issues regarding flow. Delays and timeframes for transfer and discharges will be carefully monitored. The Daily Teleconference Call will play a key role in this. HASU Trusts will collate data on stroke internal transfer delays and report these as directed. This will inform a financial reimbursement mechanism between Trusts. Clinical Case Reviews will take place on a regular basis as part of Regional Forum / Debrief Meeting supported by the Hosted Network Structure to determine and share lessons learnt which will inform future developments of the pathway. This Policy, its application and use will be reviewed at 1 and 3 months post implementation to establish if further amendments may be required.

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Appendix 1: Policy Commitment

Organisation Executive Approval Given By Date

Sheffield Teaching Hospitals NHS

Foundation Trust

Neurosciences Clinical

Governance Meeting

Trust Healthcare Governance

Committee

14.06.2019

Put forward for

15.07.2019

Doncaster and Bassetlaw Hospitals NHS

Foundation Trust

Divisional Clinical Governance

Meeting

12.06.2019

The Mid Yorkshire Hospitals NHS Trust

Mid Yorkshire Hospital

Stroke Board

14.06.2019

Barnsley Hospital NHS Foundation Trust

Central Business Unit

Monthly Governance Meeting

31.05.2019

The Rotherham Hospital NHS Foundation

Trust

Trust Clinical Governance

Committee

2.05.2019

South West Partnership Foundation NHS

Foundation Trust

Governance Meeting 10.07.2019

Yorkshire Ambulance Service NHS Trust

999 and Patient Transport Services

Clinical Governance Meeting TBC.05.2019

Chesterfield Royal Hospital NHS Foundation

Trust

Nottinghamshire Healthcare NHS

Foundation Trust

Rotherham, Doncaster and South Humber

NHS Foundation Trust

East Midlands Ambulance Service

NHS Trust

Thames Ambulance Service (TBC)

N/A

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Appendix 2: Regional Stroke Services and Service Definitions

Neurological Assessment Unit (NAU) Regional Hyper Acute Stroke Unit (HASU) Local Acute Stroke Unit (ASU) Stroke Rehabilitation Unit

(SRU)

Patients in Sheffield present to a Neurological Assessment Unit which provides early investigations, assessments and management to stroke patients. Care in this unit is provided by the Neurological Assessment Unit team which consists of a neurological and stroke specialist multidisciplinary team led by a Neurologist or Stroke Physician. Once stroke is confirmed or still suspected patients are then transferred to a HASU bed.

Includes, but is not limited to, the initial assessment, investigation and management of patients who have had a stroke. Patients will require brain imaging, thrombolysis if clinically indicated and neurological and physiological monitoring until they are stable. Patients who are potential candidates for carotid interventions will receive carotid imaging (Doppler +/- angiography) and vascular surgical review while on the HASU as clinically indicated. Patients will receive the first 72 hour care bundle as defined in national clinical guidelines and SSNAP (e.g. stroke nurse assessment, swallow screening, SALT, physiotherapy, OT assessments) and after initial therapy assessment will commence therapy as clinically indicated while on the HASU. On average patients require hyper acute care for up to 72 hours (LOS 3 days). Some patients will be stable enough and have had all their assessments undertaken before 72 hours and be able to be discharged or transferred to an ASU in under 72 hours. Others will require a longer period of hyper acute care. Patients requiring mechanical thrombectomy will be transferred to a neuroscience centre for the procedure.

ASUs provide sub-acute specialist stroke unit care which includes ongoing management of stroke and early rehabilitation. Patients are transferred to ASUs directly from HASUs. Care in these units is provided by the ASU team which consists of a stroke specialist multidisciplinary team typically led by a Stroke Consultant.

Stroke Rehabilitation Units provide specialist rehabilitation after the acute phase of stroke. They have dedicated beds for stroke patients and are supported by a stroke specialist multidisciplinary team. SRU’s may be combined with other beds such as general rehabilitation beds or acute stroke unit beds.

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Regional Stroke Services

Hospital Site Hospital Trust Stroke

admission

route

(most

common)

Neurological

Assessment

Unit (NAU)

Regional

Hyper Acute

Stroke Unit

(HASU)

Local

Acute

Stroke

Unit

(ASU)

Stroke

Rehabilitatio

n Unit (SRU)

Barnsley Hospital Barnsley Hospital NHS Foundation Trust Transfer

In

X x √ X

Bassetlaw Hospital Doncaster and Bassetlaw Teaching Hospitals Foundation Trust

Transfer in

X x X √

Doncaster Royal Infirmary Doncaster and Bassetlaw Teaching Hospitals Foundation Trust

ED X √ √ x

Kendray Hospital South West Yorkshire Partnership NHS Foundation Trust

Transfer X x X √

Montagu Hospital Doncaster and Bassetlaw Teaching Hospitals Foundation Trust

Transfer in

X x X √

Pinderfields Hospital The Mid Yorkshire Hospitals NHS Foundation Trust Direct to HASU

X √ √ √

Rotherham Hospital The Rotherham Hospital NHS Foundation Trust Transfer in

X x √ √

Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust Via NAU √ √ √ x

Stroke Pathway Assessment Rehab Centre (SPARC)

Sheffield Teaching Hospitals NHS Foundation Trust Transfer in

X x X √

Barnsley Hospital Barnsley Hospital NHS Foundation Trust Transfer X x √ x

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Appendix 3: Patient Pathway: Patients admitted to HASU Site

Patient presents

at HASU site

Assessment, investigation, diagnosis

and early management

CCG of patient identified

Patient registered on SSNAP

Local Trust notified of admission

via teleconference

Clinical decision re patient pathway

Discussed with patient / family

Decision: Discharge Decision: Transfer

Teleconference Call

Follow up agreed and referrals made

as appropriate:

ESD / CST /Social Care/equipment

Bed allocated at

receiving Trust

Patient transport

booked

Date and time of

transfer agreed

Transfer documentation

completed & sent

Clinical records & SSNAP

record transferred

Patient Transferred

Discharge date and

time agreed

Patient Discharged

Discharge documentation

completed & sent. SSNAP

record completed

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Appendix 4: Stroke Mimics and TIAs: Patient Pathway

Local follow up

arrangements

made

Contact local

hospital (who?)

to refer

Local bed allocated

and time of transfer

agreed

Transport booked

Transfer documentation

completed

Transfer of appropriate

clinical records arranged

Patient transferred within

4 hours

TIA Patients

Anticoagulant unless

contraindicated,

CT scan urgently if on an

anticoagulant

Reviewed by or

discussed with a doctor

prior to discharge

Referral made to local

neurovascular / TIA

service and appointment

allocated

Patient presents to Regional HASU Site

Assessment, investigation,

diagnosis and early

management

CCG of patient identified

Clinical Decision re Patient Pathway

Discussed with patient /carer

Stroke Mimic / TIA

Decision: Discharge Decision: Transfer to local

hospital bed Decision: Admit

to HASU

Decision: Admit to

other bed at HASU site

Local follow up

arrangements

made

Contact local

hospital to arrange

transfer

Local bed allocated

and time of transfer

agreed

Transport booked

Transfer documentation

completed

Transfer of appropriate

clinical records arranged

TIA Patients

Anticoagulant unless

contraindicated,

CT scan urgently if on an

antiplatelet

Reviewed by or

discussed with a doctor

prior to discharge

Referral made to local

neurovascular / TIA

service and appointment

allocated

If admitted to

HASU and

subsequently

identified as a

stroke mimic

Contact local

hospital to

arrange transfer

if/when clinically

appropriate

Patient

transferred

within 4 hours

If admitted to a

non HASU bed

at HASU site.

Contact local

hospital to

arrange transfer

if/when

clinically

appropriate

Patient

transferred

within 4 hours

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Appendix 5: First 72 hour Care Bundle

The First 72 Hour Care Bundle as detailed in the Sentinel Stroke National Audit Programme includes:

Assessments by a stroke nurse

Assessment by a Stroke Consultant within 14 hours

Patients will be assessed and managed by stroke nursing staff and at least one member

of the stroke therapy team within 24 hours of admission to hospital.

Swallow screening (within 4 hours of admission) with ongoing management plan for

provision of adequate nutrition.

Patients who fail swallow screen to be assessed by Speech and Language Therapist

within 24 hours

Patients are assessed by all relevant members of the Stroke MDT within 72 hours.

Hyper acute treatments including thrombolysis, thrombectomy, management of acute

physiology as appropriate

Palliative care decisions if appropriate

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Appendix 6: Escalation of Patient Specific Delays

6.1 Delayed Transfer: Escalation Process

To be used when the Regional HASU team have communicated readiness to transfer, the receiving team have accepted

the patient for transfer and there are delays of more than 4 hours in obtaining a bed or agreed transfer date as per

patient flow policy

Delay identified at 4 hours

Bed Allocated? Yes No

Receiving Trust seeks local solution

to create bed and communicates

outcome to the transferring Trust

Yes No

Transferring trust escalates

internally to senior manager /

matron who contacts receiving

trust to resolve

Nee

NEEDS TO BE CLEAR TO WHO? Bed Allocated? Yes No

+8 hours referring trust escalate

to nominated divisional /

directorate manager who

contacts equivalent at receiving

trust to resolve. Progress

highlighted at next Teleconf Call

Bed Allocated?

Bed Allocated? Yes No

Transferring trust escalates

to Deputy COO who

contacts Deputy COO at

receiving trust to resolve.

Daily escalation until

resolved.

Outcome logged

at teleconference

call

Date and time of

transfer confirmed and

arrangements

completed

Bed Allocated Yes

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Appendix xx Escalation of Demand and Capacity Issues

Patient ready

for transfer

6.2 Delayed Transport: Escalation Process

To be used when the Regional HASU team have communicated readiness to transfer, the receiving team have accepted

the patient for transfer, a bed is available and there are delays of more than 4 hours in obtaining transport.

Delay identified by transferring ward at 4 hours after YAS

notified bed available at the receiving hospital

Transport available at 4 hours? Yes

Date and time of transport

booked and transfer

arrangements completed

No

PTS escalates internally,

seeks local resolution and

communicates outcome to

transferring Trust.

Transport available at 6 hours? Yes No

Transferring trust escalates to

senior manager, matron,

Transport Lead who contacts

PTS to resolve. PTS escalates

to Regional Operation Centre.

Transport available at 8 hours? Yes No

Transferring trust escalate to

nominated divisional / directorate

manager who contacts equivalent

at PTS/ROC to resolve. Progress

highlighted at Teleconference

Transport available at +12 hours? No Yes

Transferring trust escalates to Deputy COO who

contacts ROC and Executive level at YAS. Delay

logged at daily Teleconference call.

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6.3 Delayed Discharge: Escalation Process

To be used when a patient is ready for discharge and there are delays of more than 24 hours in securing community based

services that are essential for discharge. E.g. ESD, Community Stroke Team, Social Care

Discharge date and time

agreed?

Discharge date and time

agreed?

Transferring trust escalates to

Deputy COO who contacts Deputy

COO at receiving trust to resolve.

Daily escalation until resolved.

Action agreed to facilitate

discharge

Yes No

Discharging trusts escalates to senior

manager / matron who contacts

receiving service to resolve delay

Yes No

Discharge Plan

confirmed including

follow up arrangements

and patient discharged

Delay identified and agreed as a delay by Discharging /

receiving team logged at Daily Teleconference Call

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Appendix 7: South Yorkshire, Bassetlaw and Mid Yorkshire Stroke Pathway TOC Form 1 HASU to Inpatient Stroke Service (ASU/SRU) Transfer of Care Form V3 Guidance Notes: Please complete this summary transfer of care document for transfers from a Regional HASU to inpatient stroke services (Acute Stroke Unit – ASU or Stroke Rehabilitation Unit – SRU) at another site only.

SECTION 1: PATIENT DETAILS

PERSONAL DETAILS

Full Name: NHS Number:

Date of Birth: Next of Kin:

Address: Preferred Contact Number:

Ethnicity: Religion:

Date and Time of Admission to HASU: SSNAP ID:

GP DETAILS:

Address including postcode:

Telephone no:

RESUS STATUS

DNAR in place: □ YES □ NO Date of Issue: Review Date: ReSPECT Documentation in place: □ YES □ NO Agreed ceiling of care:

Patient Details completed by (Name) : Signature: Designation: Date / Time:

SECTION 2: HASU TO ASU TRANSFER ONLY

Referring Regional HASU: □ STH □ DBTH □ MYT Receiving Inpatient Stroke Service: □ BHFT □ TRHFT □ SWYFT

Referring Consultant:

MEDICAL SUMMARY

Date and Time of Stroke: Type of Stroke: Immediate Management: □ Thrombolysis □ Thrombectomy Relevant details:

Investigations completed: □ MRI □ CT □ Bloods □ Carotid Doppler Current Medical Status and Neurology: Key current medical management information: Medication: □ TTO / Electronic Prescription Attached / Transferred with patient record Allergies:

Completing Doctor Name: Signature: Date / Time:

TOC Page 1

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Transfer of Care continued: Page 2 Patient Full Name: NHS Number:

NURSING SUMMARY

Key current nursing management/treatment information: Infection control status: Pressure Care/Tissue Viability Issues: Current Mobility: Seating Requirements:

Nutrition: IDDSI Food Descriptor: IDDSI Fluid Level: □ NG in situ □ PEG in situ Identified Risks: (e.g. agitation, falls, safeguarding, DoLS) Current NEWS (2) Score: Current GCS:

Completing Nurse: Signature: Date / Time:

THERAPY SUMMARY

Admission Barthel: Professions required: □ OT □ PT □ SLT □ Dietetics □ Psychology Details:

Completing Therapist: Signature: Date / Time:

SECTION 3: TRANSFER OF CARE / REFERRER DETAILS

Date and Time Communicates to receiving unit that patient is ready for transfer:

Communicated at Daily Teleconference Call: □ Yes □No

Agreed Date and Time of Transfer: TOC Checked and Sent by: (Name/signature/designation/contact email or tel number)

TOC Page 2

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Appendix 7: South Yorkshire, Bassetlaw and Mid Yorkshire Stroke Pathway TOC FORM 2

Early Supported Discharge and Community Rehabilitation Transfer of Care Form V6 Guidance Notes: Please complete this summary transfer of care document for referrals to Early Supported Discharge, Intermediate Care,

Community Rehabilitation or Review Services only. This document is designed to be completed electronically but can be completed by hand and

scanned to be sent electronically. Electronic referrals must be sent via a secure email such as NHSMail.

SECTION 1: PERSONAL DETAILS:

Full Name: NHS Number:

Date of Birth: Next of Kin:

Address:

Preferred Contact Number:

Ethnicity: Religion:

Date of Current Admission: Date of Transfer/Discharge:

SECTION 2: GP DETAILS:

Address including postcode:

Telephone no:

SECTION 3: REFERRAL DETAILS: Referring Organisation: STH / DBTH / MYT / BHFT / RHFT / SWYFT *delete as applicable Name of Consultant/referrer:

Has patient consent been gained for the referral? YES / NO*delete as applicable

Does the patient have capacity to consent? YES / NO*delete as applicable

If the person does not have capacity, was the decision made in a best interest meeting? YES / NO

If no, give details:

DNACPR in place: YES /NO Date of issue: Review date: ReSPECT Documentation in place: YES / NO

Referral destination: *delete as applicable Service required: *delete as applicable Professions required: *delete as applicable

o Barnsley o Early Supported Discharge o Clinical Psychology

o Bassetlaw o Community Stroke Team o Dietetics

o Chesterfield o Intermediate Care o Medical

o Doncaster o 6/52 review o Nursing

o Rotherham o 6/12 review o Occupational Therapy

o Sheffield o Other o Physiotherapy

o Other/OOA o Speech & Language Therapy

o Social care

o Other

SECTION 4: MEDICAL HISTORY:

Date of Stroke: Relevant Details of Stroke: (Thrombolysis / CT / MRI / Diagnosis)

Past Medical History:

Current Medication: TTO / Electronic Prescription Attached / Transferred with patient record *delete as applicable

Allergies or Sensitivities: Known Risks: (e.g. Falls / Infection / Safeguarding Concerns)

Social History/Circumstances:

Other Services Involved and Onward Referrals to date: (e.g. Social Care / Orthotics / Spasticity Clinic / Splinting / FES / Wheelchairs)

SECTION 5: PATIENT PRESENTATION: Medical Status: BP/Pulse: Observation record attached? YES/NO *delete as applicable Respiratory status: Skin Integrity/ Waterlow Score:

27

Infection status (MRSA, Clostridium Difficile, Loose stools):

Nutrition, Eating, Drinking and Swallowing: Dysphagia: YES/NO Delete as applicable and expand: Enteral feeding: YES /NO Delete as applicable and expand:

MUST score:

IDDSI Framework (*delete as applicable) Fluids: 0 Thin (normal) 1 Slightly thick, 2 Mildly thick, 3 Moderately thick, 4 Extremely thick Diet: 7 Regular (normal), 6 Soft & bite sized, 5 Minced & moist, 4 Pureed, 3 Liquidised.

Communication: Aphasia: YES/NO Receptive / Expressive Delete as applicable and expand:

Dysarthria YES/NO Delete as applicable and expand:

Other: Continence:

Catheter YES/NO If YES state rationale for catheter in situ: Physical Ability:

Modified Rankin Score: Transfer ability: Mobility: Upper/Lower Limb Function: Tonal issues: Functional Ability: Current Barthel Score:

Assistance required for Washing / Dressing / Toileting: Cognition:

Assessment completed: MOCA / OCS / Other Delete as applicable and detail relevant score: Other assessment/relevant details: Behaviour and Emotions: Mood assessment and relevant score: Any special requirements / considerations: Sensory:

Vision: Referred to / assessed by Orthoptist: Delete as applicable Hearing: Touch/proprioception: Other: Known Risks: (e.g. falls, safeguarding

Other relevant information:

SECTION 6: IDENTIFIED PATIENT NEEDS / GOALS:

1. 2. 3.

Secondary Prevention:

SECTION 7: EQUIPMENT AND CARE PROVISION REQUIRED BEFORE TRANSFER:

Equipment in place:

Equipment outstanding: Action/date:

Care Package in place: Relevant details

SECTION 8: REFERRER DETAILS:

Date / time Communicated to receiving service that patient is ready for transfer / discharge:

Date / time TOC completed: Date/time TOC Sent:

Communicated at Daily Teleconference Call: YES / NO

Agreed Date and Time of Transfer/Discharge: (if known) TOC completed by: (Name / signature / designation / contact email or tel

number)

Please attach any additional relevant information/documents.

2

Update – Hyper Acute Stroke Services

HEALTH EXECUTIVE GROUP

SOUTH YORKSHIRE AND BASSETLAW INTEGRATED CARE SYSTEM

Tuesday 9th July 2019

1. Purpose To update the Health Executive Group on the progress to implement the

changes to hyper acute stroke services and to share the ‘Regional Stroke

Patient Flow Policy’, which has been signed off by appropriate internal governance in all Trusts directly involved in the changes.

2. Update on Implementation

The following implementation dates were agreed at the HASU Implementation Group in February 2019 and confirmed at the Acute Federation in March 2019.

o The Rotherham HASU will cease to operate on 1st July 2019 o The Barnsley HASU will cease to operate on 1st October 2019

All providers confirmed at the June HASU Implementation Group that they

were on track to deliver the changes as per the agreed implementation dates, and the changes were enacted in Rotherham as planned on 1st July.

System wide comms have been developed to support the implementation including key messages, tailored for different audiences and a press release. All public facing comms can be found here - https://www.healthandcaretogethersyb.co.uk/what-we-do/working-together-network/regional-stroke-service>

In order to successfully commission the changes and contract for the new HASU model Sheffield Clinical Commissioning Group (SCCG) acted as the Contract Coordinator, and led the development of the contract documentation to enable a consistent approach. Commissioners also worked together to develop a monitoring framework to monitor patient flow, activity, key performance indicators and quality requirements. The contract documentation includes a Service Development improvement Plan (SDIP) with milestones tailored to each HASU to enable them to demonstrate progress towards delivering the full specification in 2 years.

3

Commissioners also reached agreement with YAS on the level of investment required to secure the additional transport requirements for the new model and the mechanism through which to vary the investment into contracts. In addition to working with YAS to finalise contract variations a letter was sent to confirm that we have finalised all substantive matters, this has been positively acknowledged by YAS.

A more detailed summary of the work undertaken to commission, contract

and agree the financial arrangements for the new model is in appendix 1.

Simultaneously providers have worked together through the HASU Implementation Group chaired by Dr Richard Jenkins, with representation from all Trusts, the ambulance service and the Stroke Association. This group has met monthly and provided oversight of implementation, coordinating capital/estates plans, workforce planning/recruitment and operational plans.

Recruitment plans are on track with Sheffield Teaching Hospital having successfully recruited additional nursing and therapy staff and secured changes to medial rotas. Sheffield and Rotherham Hospital have successfully recruited a joint Consultant post due to start in September. Doncaster and Bassetlaw Hospital is currently out to recruitment for nursing and therapy roles, and a joint Consultant post with Barnsley Hospital.

All capital/estate changes are on track, including work at Mid Yorkshire Hospital ahead of enacting the changes in Barnsley on 1st October.

Mid Yorkshire Hospital continues to make good progress to implement their action plan to drive quality improvements. Through this they have secured improvements in their in hospital stroke mortality.

The HASU Implementation Group collaboratively developed a Regional Stroke Patient Flow Policy and this has been signed off through appropriate governance by all Trusts directly involved in the changes. It is enclosed as appendix 3. The plan is to review together initially in September 2019.

There are a number of other organisations we are in the process of sharing the Patient Flow Policy that are not directly involved in the changes, but are peripherally and have been engaged in dialog with us, including Chesterfield Royal Hospital and East Midlands Ambulance Service.

In addition to the Regional Patient Flow Policy an SYB/MY Directory of Services has been developed, a Regional SYB TIA referral form and a Standard Operating Procedure for a daily teleconference call. The purpose of

4

this call is to provide oversight of communication across the region to facilitate cross boundary patient flows. A patient information leaflet has also been developed through dialog with patient groups and the Stroke Association.

An updated summary of the detailed progress by providers to implement the

new model is in a table in appendix 2.

As we progress implementation of the new HASU model consideration is now being given as to how best to enable the changes to hyper acute stroke services to become managed as business as usual within the South Yorkshire and Bassetlaw Integrated Care System.

This will include managing an effective transition for ongoing commissioning, contracting and financial arrangements and operational delivery. It is anticipated that the latter will be through the development of the Stroke Hosted Network.

The transition will need to ensure that across the system we continue to identify, manage and mitigate risks as we fully implement and embed the new model to enable it to become business as usual.

There will need to be an ongoing focus on ensuring that we work together to realise the anticipated benefits of the new HASU model.

3. Risks

A summary of the high level risks can be found in a table in Appendix 3. A full risk register is regularly shared with the HASU Implementation Group and it has been possible to reduce the risk scoring on a number of fronts as we have effectively managed or mitigated them throughout the process so far.

4. Recommendations

The HEG is asked to note:

Plans are on track to deliver the new HASU model as per the agreed implementation dates and the changes in Rotherham have been enacted as planned on 1st July.

The ‘Regional Stroke Patient Flow Policy’ has been signed off by all Trusts

directly involved in the changes and will be reviewed as agreed as we progress implementation.

5

Appendix 1: Update Commissioning, Contracting and Financial Arrangements

Progress Next Steps

Commissioning and Contracting

SCCG lead/contract coordinator and approach to work through existing contracts agreed Sept 2018

Joint letter of intent sent on behalf of JCCCG November 2018 to signal intent to commission/contract new model.

Neighbouring CCGs informed of plan for the new SYB HASU model via letters at the end of 2018 and again June 2019.

Final specification shared formally with the letter of intent Key performance indicators reviewed in light of current performance

and plans to incentivise

Monitoring dashboard drafted to include KPIs, activity, patient flow monitoring, quality (patient feedback etc)

Service Development Plan (SDIP) developed. RCCG and BCCG issued contract notice

SCCG contract coordinator developed contract documentation to ensure consistent approach and CVs in process.

Advice sought via the SYB Citizens Panel on the best way to enable meaningful engagement in the next phase. Patient leaflet finalised.

NHSE informed of likely changes to onward referral pathways for vascular and neurosurgery as advised by Clinical Quality Group, anticipate minimal flow changes.

Dialog required to manage transition into commissioning as

‘business as usual’.

Monitoring framework/dashboard to be implemented, with CCGs to work together to gather/review info as per MOU.

Ongoing dialog re SDIP(s) and progress to deliver against milestones in a coordinated way.

Work with providers to monitor the transition to the new model, patient flow and activity.

Financial arrangements

Joint approach to develop HASU tariff via task group. Proposed HASU tariff value shared with providers mid Oct, followed

by CCG & Trust impact assessments. SYB ICS Executive Group agreed transition funding (£200k per

HASU) and additional funds for Mid Yorkshire Hospital to convert to capital in January 2019. Funds invoiced for.

Formal HASU Tariff Offer, including base tariff, incentivised KPI’s and transition funding shared with HASU providers 23/1, discussed tariff task group 24/1. Feedback requested by 15/2, slippage due to competing prioritise.

HASU Tariff included in contract documentation. Work undertaken on proposed financial reimbursement mechanism. CCG CFOs and deputies regularly updated. CCGs progressing individual discussions re ASU funding

Finance Task and Finish Group to meet again in circa 12 months, if not required before.

6

Yorkshire Ambulance Service

Quality impact assessment jointly reviewed

Met 2/8 to confirm assumptions and clarify cost drivers. Joint understanding of cost drivers, including turnaround times,

vehicle utilisation, staff utilisation, shift allowances YAS updated costings, further joint work. Detailed update provided for CFOs. Level of investment agreed with YAS, into 999 and PTS contracts

Monitoring patient flow/activity via monitoring framework to inform

Mid Yorkshire Hospital

Correspondence with Mid Yorkshire (MY) identified issues and areas of concern, detail worked through.

Mid Yorkshire Hospital identified as an outlier for in hospital stroke mortality (SSNAP 2016/17).

Dr Rudd visited Sept 2018, confirmed delivery of safe and effective stroke care and well placed for SYB patients.

MY developed an action plan to progress Dr Rudd’s recommendations.

Agreed JCCCG will be updated on progress with delivery of the MY action plan via WCCG. WCCG Quality Lead assured work progressing, mortality rates decreasing and now within control limits.

MY In Hospital Stroke Mortality improving, now not statistically different to the national average.

Monthly meetings between MY Hospital and Barnsley Hospital.

Ensure JCCCG subgroup continue to be updated on MY progress to deliver their action plan ahead of October.

Continue monthly meetings between Barnsley Hospital and Mid Yorkshire Hospital.

7

Appendix 2: Update Provider Implementation Planning

Progress Next Steps

HASU Implementation Group

HASU Implementation Group established December 2018, chaired by Richard Jenkins (Provider Development Lead).

Group has representation from all Trusts, the ambulance service, lead commissioner (TBC) and the Stroke Association. TOR agreed. Accountable to the Acute Federation. Meetings scheduled monthly.

Sub groups, Clinical Quality, Post HASU Pathway established, workforce to be progressed through HASU Implementation Group.

Group agreed HASU Implementation dates in February 2019. Group providing oversight of SYB HASU Implementation plan,

coordinating capital/estate plans, workforce planning/recruitment and operational planning. All confirmed on track for the agreement implementation dates at June HASU Implementation Meeting.

Regional Patient Flow Policy finalised and signed off by all Trusts directly involved and the ambulance service.

Daily teleconference call SOP developed and call established. Monthly comms briefs developed and a ‘pre go live comms’ pack.

Formally share the Regional Stroke Patient Flow Policy with neighbouring Trusts.

Review the Regional Stroke Patient Flow Policy as agreed post implementation in Rotherham after a month/three months. Thereafter Hosted Network to maintain.

Collectively manage identified issues upon enacting the changes in Rotherham and ensure learning shared ahead of changes in Barnsley.

Develop business continuity plans for the new model.

Build on the collaborative work to enable development of the Stroke Hosted Network.

Workforce planning

All Trusts finalising workforce plans – requested to share. Lead HR Director in place to provide oversight and ensure consistent

HR advice. JDs developed for joint medical posts, Sheffield and Rotherham,

Doncaster and Barnsley. Sheffield/ Rotherham post successfully recruited and Doncaster and Barnsley post out to advert.

Changes to medical rotas enacted in Sheffield. STHFT successfully recruited non medic roles, nurses and AHPs.

DBTH currently recruiting. MY full complement SNPs. Staff potentially affected identified in Barnsley and Rotherham and no

TUPE implications identified. SYB Staff Partnership Forum and local staff side briefed. Stroke Workforce Role, HEE funded 12 mths commenced.

Support recruitment, particularly DBTH and joint medic post with Barnsley Hospital.

Support new Stroke Workforce role (HEE funding for 12 months) and bring into the Stroke Hosted Network.

Clinical Quality Group

Clinical Quality Group chaired by Dr Pete Anderton meets monthly. Regional SYB TIA referral form developed and agreed. Patient leaflet informed by clinicians, patient groups and the Stroke

Association developed and agreed. ICS supported first print run.

Continue to progress work as agreed on clinically related tasks, including reviewing the SYB thrombolysis checklist/protocol.

Progress the plan to change the telemedicine rota and procure

8

Onward referral pathways for vascular surgery and neurosurgery agreed.

Dialog ongoing with ED teams – slide set developed to support Work ongoing to review SYB thrombolysis checklist/protocol Work ongoing to review the telemedicine rota and progress plans to

procure new telemedicine equipment.

new equipment.

Build on the Clinical Quality Group to develop a broader Clinical Reference Group for the Stroke Hosted Network that will drive clinically focused quality improvement work.

Work with commissioners to monitor the transition to the new model and broader evaluation.

Post HASU Pathway

Developed from the Rehabilitation Group/TOR agreed. Transfer of Care Forms finalised and included in the Regional Stroke

Patient Flow Policy. Directory of Services finalised (NB – live document) Work undertaken to understand and agree processes for onward

referral routes, including social care and equipment – with an initial focus on Rotherham.

Review the Directory of Services in September 2019 ahead of enacting the changes in Barnsley. Thereafter support the Hosted Network to maintain.

Collectively manage identified issues upon enacting the changes in Rotherham and ensure learning shared ahead of changes in Barnsley.

Continue work to understand and agree processes for onward referral routes, including social care and equipment – with a focus on Barnsley.

9

Appendix 3 Summary High Level Risks

Risks Pre-mitigation RAG

Post-mitigation RAG

Mitigating Action

Delivery timeline – Although the JR was not granted it resulted in significant time where it was not possible to take any irreversible steps. Subsequently there has already been timeline slippage and there is a risk that the delivery timeline could slip even further into 2019/20. .

15 12

In order to mitigate the risk work is underway with providers to enable implementation planning – via the HASU Implementation Group. Implementation dates were agreed 18/2. The changes have been enacted as planned in Rotherham and are on track for Barnsley and as such the risk of further slippage has been mitigated.

Fragility of existing provision – There is a risk that fragile services in Barnsley will find it increasingly difficult to operate as timescales are extended and they may need to enact unplanned service change.

15 12

The model has already been implemented in Rotherham from 1/7. A divert is in place for Barnsley residents eligible for thrombolysis. Trusts will continue to work closely though out this transition period and contingency arrangements are in place.

Financial - There was a risk that it may not be possible to agree local tariff arrangements and providers may not have been able to agree internal business cases. Upon implementation there are financial risks for both providers and commissioners, in relation to assumptions.

12 9

The HASU Tariff has been captured in contracting arrangements. Transition funding was agreed and has been utilised by Trusts.

Operational – There are a number of risks associated with operationalising the model, including providers securing the skilled workforce (medical cover, specialist nurses and ward nurses), ensuring sufficient capacity for CT scanning and impact on other services (if displaced). There is a risk that if quality issues are not resolved Mid Yorkshire Hospital may not be in a position to accept additional patients as part of the new model (for more detail see full risk log). There is a risk that without cross organisational capacity to progress collaborative actions providers will be unable to deliver the new model. There is also a risk if the additional transport requirements are not sufficiently secured or mobilised.

16 12

To mitigate the risk around the medical workforce a joint post STHFT/TRFT has been recruited and DBTH and BHFT are out to advert. The capital bid for a CT Scanner for Doncaster was approved. MY have had a positive visit from the National Clinical Director for Stroke to review both quality and efficiency of their service. MY is making good progress with their action plan and in hospital stroke mortality has improved. To mitigate the risk around collaborative mobilisation a HASU Implementation Group is well established and Richard Jenkins is the chair in his role as SYB Lead for Provider Development.