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Fulop NJ, Ramsay AIG, Hunter RM, et al. Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study. Southampton (UK): NIHR Journals Library; 2019 Feb. (Health Services and Delivery Research, No. 7.7.)

Cover of Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study

Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study.

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Chapter 13Lessons from the planning and implementation of further reconfiguration in Greater Manchester

Overview

What was already known about this subject?

  • Service centralisation in GM led to significant reduction in LOS, but not in mortality, compared with in the RoE. Therefore, further reconfiguration of services was planned and implemented.
  • There is growing evidence about how approaches to leadership, use of feedback, stakeholder engagement and experience of previous changes influence implementation of MSC in acute stroke services (see Chapters 6, 7 and 10).

What this chapter adds

  • The GM acute stroke system – like the rest of the English NHS – faced significant obstacles over the period studied and these affected the time it took to agree a new model, plan it and implement it. Despite these obstacles, change was implemented.
  • Obstacles included turbulence caused by reforms to the NHS and national staffing shortages, which contributed to significant pressures on planning. Post implementation, these factors led to delays in the movement of patients through the system, in finding beds for stroke patients and in discharging stroke patients.
  • Issues relating to leadership and governance, and the use of service and process reviews, including the earlier findings from this study (see Chapter 3) were reported as important in enabling implementation.
  • Leaders of the GMB reconfiguration ‘held the line’ on approaches to implementation (e.g. the timing and degree of phasing of change). A key system enabler post implementation was identified as the Operational Delivery Network (ODN) governance model, funded by the providers, covering the whole stroke pathway. This enabled regular audits and a mechanism to facilitate the system-wide discussions needed to maintain effective system operation. Sources of pressure post implementation included not only staffing but also changes in the nature of workload at CSC, PSCs and DSCs caused by the reconfiguration.

Background

Further reconfiguration of the GM acute stroke pathway (GMB) was implemented from March 2015 (see Chapter 11). This chapter analysed the process of agreeing, planning and implementing this reconfiguration. The Best et al.5 framework of rules for MSC (see Chapter 6110) has been used to explain the previous centralisation of acute stroke services in GM, showing that feedback may need to be combined with other tools, such as financial incentives and engaging a range of stakeholders, not only physicians. Fraser et al.203 explored change management roles in the London reconfiguration, suggesting that evidence from clinical research can be used to frame change in a ‘depoliticised’ way. They identified discursive power, emphasising evidence, better patient outcomes and professional support as helpful in generating receptiveness to change. Many authors have emphasised the importance of context when analysing change, pointing out that much evaluative work seeks to eliminate contextual confounders rather than see context as the state into which change must be integrated215 and taken into account.216 This chapter explored how an analysis of GMB may further develop the understanding of MSC.

Methods

Design

This chapter presents a single case study, based in GM, as described in Chapter 1. Comparison is made with GMA, reported in Chapters 6 and 7, and is discussed in relation to the quantitative data analysis of GMB (see Chapter 11) and sustainability in London (see Chapter 14).

Data

As detailed in Chapter 2, we conducted interviews with 78 stakeholders (governance and service level) and 59 non-participant observations of relevant meetings and events (approximately 120 hours). We also collected > 100 documents (meeting minutes and papers, key local documents, etc.). Data were collected between December 2013 and March 2017 (see Table 2 and Chapter 2, Understanding development, implementation and sustainability), enabling analysis of the 2-year post-implementation qualitative data.

Analysis

We identified those factors that influenced the decision to change, the planning and the implementation approach of GMB, and GMB post implementation. We combined analyses of interviews, meeting notes and documents in order to develop an understanding of MSC in relation to previous evidence (see Chapter 6).

Results

This section describes the findings in relation to three phases of activity in GM (aligned to the framework described in Chapter 7):

  1. the ‘to agreement’ phase (decision to change and which model to implement)
  2. the ‘planning’ phase (implementation approach)
  3. the ‘post-implementation’ phase (implementation outcome).

Table 27 provides details of the activities undertaken up to the implementation date. Nearly 2 years elapsed between the recommendation for further reconfiguration and the formal agreement to the full implementation of the centralised acute stroke care pathway, and it was a further 18 months before the fully centralised pathway was launched: a total of 3.5 years between decision and implementation. We also studied GMB for 24 months post implementation and highlight here the issues relating to the sustainability of the model, which aligned with those identified in London (see Chapter 14).

TABLE 27

TABLE 27

Timeline: planning and implementation of GMB

To agreement

Activities that were undertaken during the ‘to agreement’ phase are outlined, as well as aspects of governance, which influenced the timescale.

The 12-month review

The 12-month review of GMA, which drew heavily on SINAP data, revealed that only 64% of patients presenting within 4 hours of symptom development were transported to a HASU (CSC/PSC).32 The review concluded that although progress had been made ‘there is further work still to be done in ensuring that all patients have equitable access to the best quality stroke and TIA services’.32

The EAG, established in 2008 to carry out an independent review of plans for GMA and oversee provider selection, reconvened in October 2011 to discuss the GM pathway in the light of the review and recommended that there should be further reconfiguration of acute stroke services, with the 4-hour cut-off for transportation to a CSC/PSC removed.

Peer reviews

Following the EAG recommendation, peer reviews were carried out in all SUs (HASUs and DSCs) because commissioners were concerned about the variation in services across GM commented on by the EAG, although some felt that this caused delay:

What needs to be done is further centralisation . . . but the immediate response was 12 months of peer reviews.

GM07(2), SCN

Governance

The reforms of the NHS following the Health and Social Care Act 2012,34 implemented in April 2013, were perceived as resulting in a lack of continuity in leadership, ownership of changes and decision-making, and in the loss of relationships and knowledge. The build-up to this reorganisation, when PCTs were being phased out and CCGs formed (during the ‘to agreement’ phase), affected decision-making:

. . . it was kind of difficult for people to make decisions about a GM-wide thing for about an 18-month period, maybe 2 years until things had settled down.

GM07(2), SCN

The loss of ‘organisational knowledge’ due to impending NHS changes was also noted:

The organisation at the top kept changing and the people changing. So there wasn’t that continual organisation memory you know and that impacted on their ability to make a decision.

GM07(2), SCN

Once new NHS structures were introduced in April 2013, it took time before they were functioning efficiently, contributing to further delays in decision-making. The reconfiguration was finally agreed by the newly formed Greater Manchester Association of Clinical Commissioning Groups Governing Group (AGG) in September 2013, rather than the original plan for agreement in April 2013 by a group disbanded post April. These delays were explained in terms of the ‘newness’ of the organisations and the different composition of the new NHS structures:

I don’t think they [newly formed AGG] were intentionally stalling, it was almost as though they couldn’t make a decision . . . they weren't mature as a group together.

GM02(2), SCN

. . . most GP chairs in CCGs hadn’t had any exposure to the policy and strategy world of the PCTs.

GM18, service commissioner/Implementation Board

Planning

Once agreement was reached in September 2013, formal planning for implementation began, although informal activities had already started. Issues of leadership, governance and feedback were highlighted as influencing process and timescale, with some other specific considerations during planning.

Leadership capacity

Concern was initially expressed about the scale of the changes:

It was kind of assumed that it was a relatively small change, when in fact it was probably as big a change as it had been the first time around.

GM05(3), stroke physician

Project management arrangements were put in place just after the start of the ‘planning’ phase (November 2013) by the AGG, something viewed as pivotal in moving the work forward:

A huge piece of work, it really does need someone who has experience in programme management full time against it, I think it’s a huge risk to not do that.

GM24, SCN

This role was seen as effective and important in supporting the decisions made through the new governance structures, as well as alleviating initial concerns.

Governance

The Stroke Centralisation Implementation Board was established in March 2014, to ensure that the centralisation of acute stroke services was undertaken in line with the agreed timescale and budget. It was accountable through the Chairperson (a new appointment; Senior Responsible Officer for stroke) to the AGG. A Chief Financial Officer was also appointed to act on behalf of all GM CCGs. The Implementation Board was perceived to work well and to involve clinicians in a way that was viewed positively: ‘there has been a culture where clinicians have become a bit marginalised and decisions are being made by the managers’ (GM23, stroke physician).

Feedback from external reviews

During the planning period, two reviews of the GM stroke pathways were undertaken, the findings of which were perceived as supporting the plans. A Gateway Review (which examines projects at key decision points in their life cycle to provide assurance that they can progress successfully to the next stage)217 in December 2013 made recommendations for governance, which were being planned anyway, and was viewed as helpful ‘. . . because we knew what we wanted to happen but sometimes it's better if it comes from somebody else’ [GM02(2), SCN]. A Clinical Senate Review to provide ‘clinical advice with regard to optimising the working of the network model’ (p. 3, reproduced with permission from Greater Manchester, Lancashire and South Cumbria Clinical Senate218) made recommendations regarding the provision of imaging and communication with other change planners, and the review was perceived as lending support to the reconfiguration plans.

Feedback from research findings

The publication of findings of this research (see Chapter 3) was widely attributed as helping to drive the planning of reconfiguration forward in GM and gain agreement on an implementation date:

being able to go to meetings and say to people we’re looking at fifty excess deaths a year . . . because of the publicity . . . because it was a paper and it was a medical journal not just another audit report or just another internal report, I think that has had a significant impact.

GM05(2), stroke physician

It would be extremely difficult to argue for e.g. 3–4 months [slippage] in light of the mortality data . . . which indicates that as many as 16 deaths from stroke could be avoided in that period of time if services were centralised.

Stroke Centralisation Implementation Board meeting, 12 September 2014

Other considerations

At one PSC, the ongoing failure to meet A&E waiting time targets led to nervousness about putting more patients through the department when MSC in GMB was being implemented. The same PSC had carried out financial modelling showing that GMB was more costly for them than the CSC and the other PSC. This led to uncertainty about whether or not this PSC would retain its status as well as to delays in planning by the CSC and other PSC.

The A&E issue was resolved by establishing a ‘stroke specific’ bay in the A&E department, staffed by the PSC, thus minimising impact on the wider A&E department. Following discussions between the CSC and PSCs, including input from the Chief Financial Officer, the modelling issue was resolved, but not until late 2014, which led to the GMB ‘go live’ date being moved back from January to March 2015. This also led to a loss of staff from the CSC who had been employed assuming the January start but who were not needed until March.

Staff morale was affected during this period, with those at DSCs concerned about the potential impact on their roles following reconfiguration, both in terms of losing their jobs and/or skills in acute stroke care. Doubt was also expressed about whether or not it would be possible to recruit sufficient staff – doctors, nurses and therapists – to provide the centralised services.

The delays in agreeing the final launch date meant that the CSC and PSCs were well prepared for launch, although the short time frame between the decision to confirm the second PSC and launch meant that there was a lot of preparation needed in just 3 months.

Implementation: a ‘big bang’ launch

Implementation of GMB took place on 30 March 2015, as a ‘big bang’ rather than a phased launch, as had been the case with GMA (see Chapter 7). Leaders held the line on this approach when phased implementation was proposed, because of the difficulties in phasing presented to the ambulance service and concern about capacity issues if a CSC and one PSC went ‘live’ while the second PSC was not fully operational (‘learning from history’).

Post implementation

Findings are presented here using the same framework for analysis as in Chapter 14, enabling us to compare the post-implementation periods in London and GM.

Enablers of governance: system leadership

Following implementation, a stroke ODN219 – the first in England – was established to support stroke services, as the clinical network no longer had capacity following the 2013 NHS reforms. The clinical network funded this for the first year, with providers taking over subsequently. Within 6 months of implementation, an ODN manager and project co-ordinator started work, and the newly formed ODN Board met. The ODN’s remit was to ‘work collaboratively with its stakeholders to develop high-quality services in terms of patient outcomes and experience across the whole care pathway for stroke’ (GM Stroke ODN, Terms of Reference).

Initially, there was confusion over the ODN’s role and there was a perception that because it was hosted at the CSC site that it might be biased. However, over the first year of its work, many of these worries were allayed, with clinicians becoming supportive of the work:

I think the ODN is a really good sort of go-between, and it’s a way of providing an independent interface for everybody.

GMF20, stroke physician

Most felt that the ODN, or similar, was necessary for the sustainability of the stroke care pathway, although there was uncertainty about how it linked with the evolving GM governance structures following devolution,121,122 whether or not it had any ‘clout’, and whether or not funding would be continued.

Challenges to sustained governance: local and national NHS changes

Changing priorities nationally – ‘stroke isn’t really an NHS priority anymore whereas it clearly was at one time’ [GM05(4), stroke physician] – and locally in GM caused concern. The implications for stroke of ongoing changes to general acute care provision resulting from merger and rationalisation in GM were highlighted, as was the challenge of providing a thrombectomy service in future.

Flow of patients through the hub and spoke model

In order for the stroke pathway to operate optimally, the timely flow of patients through the system is necessary and was a challenge in GMB and London (see Chapter 14).

Transfer of stroke patients to a Comprehensive Stroke Centre/Primary Stroke Centre

Prior to GMB, the local ambulance service called ahead to A&E departments when they were bringing in a suspected stroke patient (within 4 hours of symptom onset). Post implementation, patients within 48 hours of symptom onset were brought to CSC/PSCs, leading to a large increase in the volume of alert calls, which A&E departments were unable to handle. The situation, therefore, changed back to the GMA model in which an alert was radioed ahead only for those stroke patients whose symptoms had commenced within 4 hours. Initially, this resulted in stroke patients whose arrival had not been alerted waiting in A&Es without the knowledge of stroke teams. Local solutions were then developed to ensure that stroke teams saw these patients in a timely manner.

Six months after implementation, following advice from the National Clinical Director for Stroke, processes were changed so that only patients presenting within 48 hours of stroke symptoms were transported to a CSC/PSC, rather than all patients, although this change did not receive universal support. A patient presenting at a DSC within 48 hours of commencement of symptoms might be transferred to a CSC/PSC depending on the clinical presentation. After initial challenges, with staff at DSCs reporting that it could be difficult to contact CSC/PSC staff, the process improved, and audit data indicated that patients were being transferred appropriately.

By March 2016, 86% of stroke patients were being treated at a CSC/PSC and a local audit (by the ODN) indicated that the ambulance service was taking patients appropriately to a CSC/PSC.

Repatriation from a Comprehensive Stroke Centre/Primary Stroke Centre to a District Stroke Centre

Repatriation of stroke patients from a CSC/PSC to a DSC was challenging because of ‘stroke’ beds being used for other patients, or because of the difficulty of discharging people from hospital. DSCs were notified when one of ‘their’ patients was admitted to a CSC/PSC, allowing them to plan to have a bed available, and CSC/PSC staff then contacted DSCs each day with updates, using nhs.net e-mail accounts, supplemented by telephone calls. Responsibility for this contact usually lay with nursing staff, although at the CSC a repatriation co-ordinator was employed. Such contact led to general improvement in communication and the resultant flow of patients:

. . . lots of networking. I’ve then been going over to [CSC/PSC] as well to say, ‘Hello, you probably speak to me on a daily basis’.

GM25, senior nurse, DSC

As timely repatriation from CSC/PSCs was key to maintaining patient flow, a system of financial penalties was instituted: DSCs could be penalised for each day in excess of 72 hours that a patient was unable to move from a CSC/PSC. Some clinicians thought that these penalties were useful as a message to managers about the importance of ‘ring fencing’ stroke beds but, in practice, although financial penalty notices were issued, fines were never paid. Instead, a new system was introduced in 2017/18 whereby money would be ‘top-sliced’ from the DSC tariff using the same criteria.

Discharging patients into the community

Discharging patients could be challenging, partly because ESD provision varied across GM, although this was being addressed through a common specification being agreed across GM, facilitated by the ODN. Also problematic was discharge to social care, as in London:

There are no social care placements, it’s very difficult to get those people out.

GMH12(2), DSC senior nurse

Care provision in a Comprehensive Stroke Centre, Primary Stroke Centre and District Stroke Centre services

As outlined in Chapter 11, achievement of evidence-based clinical indicators either stayed the same or improved in GMB compared with the RoE, and improved over time in GMA compared with GMB. Challenges and enablers are presented here.

Challenges to care provision: system and staffing pressures

The issue of staffing levels continued to cause concern, with staff shortages seen as a threat to the sustainability of the system. This was understood to be a nationwide problem, although there were particular issues with medical staffing at the CSC, with the perception that physicians preferred not to work in a 24/7 service when there were positions at nearby ‘in-hours’ services.

The education of staff about the care pathway was key, including for those outside stroke (e.g. A&E staff and GPs). Staff at SUs delivered training to other staff in their hospitals, and training for GPs was developed through the ODN.

Difficulties arising from numerous trusts operating a single stroke care pathway were highlighted and it was suggested that, to be sustainable, the GM system needed to operate with similar job plans and staffing in all hospitals, with the same terms and conditions. Shared medical rotas were seen as desirable by some (although not all).

Having only one CSC operating 24/7 was perceived as placing significant pressure on it, especially out of hours, because of the volume of patients.

Challenges to care provision: changing workload

The centralised stroke care pathway resulted in changes to the workload and profile at the CSC, PSCs and DSCs. All patients with a suspected stroke were now eligible for CSC/PSC care and, thus, the proportion of admitted patients who were eligible for thrombolysis was smaller than previously. This was viewed as increasing the amount of time in which medical staff became proficient in thrombolysis.

Stroke mimics placed pressure on CSC/PSCs, and, although this had been the case in GMA, the increase in patients through CSC/PSCs increased the number of mimics. These patients were viewed as generally more difficult to manage, as there was no defined care pathway for them. Clinicians spent much time assessing and caring for people who did not ultimately have a stroke diagnosis, and they did not always feel well supported in this work.

The reality for DSCs post implementation was different from the modelling on which planning for change had been based, which assumed that 95% of stroke patients would be admitted to a CSC/PSC (as with London HASUs). Initially, 15–20% of patients were receiving all of their stroke care at a DSC ‘and yet arguably the DSCs now are not designed to cope with those kinds of patients’ (GM28, governance); the implementation of GMB did not result in a loss of beds in PSCs, but it did lead to the loss of, for example, stroke assessment teams. Over time this has become less of an issue because more patients are now going to CSC/PSCs and there is less concern from DSCs.

Enablers of care provision: reviewing care provision and performance

The review of stroke services was carried out primarily by analysis of SSNAP data, which had significant national coverage (and therefore better comparators) not available in GMA. Issues relating to the accurate and complete entry of SSNAP data were identified by the ODN, which ran improvement events for acute and community providers and liaised with the SSNAP team at the Royal College of Physicians over questions that arose. The ODN supported SUs to find the data entry solution that worked best for their organisation.

A year after the implementation of GMB, SSNAP data were described as ‘driving up the quality of the services’ (GM24, SCN). Interviewees spoke about SSNAP data being quite dated by the time results were available, and that with the help of the ODN they were planning to use ‘real-time’ data where possible.

Enablers of care provision: tariffs

In GM ‘unbundled’ local stroke tariffs were developed in order to reimburse both the CSC/PSCs and DSCs involved in a stroke hospital stay, similar to the arrangements for GMA. There was a tariff to cover the first 3 days in a CSC/PSC, and then a second bed-day rate for the DSCs. If the DSCs took a direct admission, they claimed national tariffs. During the initial year of the fully centralised service these tariffs were paid upfront; stroke services did not have to demonstrate that they were meeting particular targets. Future plans are that if performance indicators are not met there may be penalties. This remained different from London, where service standards were linked to financial incentives.

Discussion

Principal findings

The time taken from the original recommendation to further reconfigure stroke services in GM and to obtain formal agreement to do so and implementation of the new model was considerable. However, this was a period of great turbulence in the NHS, and that such system-wide change was achieved in this context may be significant in itself.

Changes in NHS structures and leadership contributed to delays in planning and implementation, with other local changes in context having an impact on planning.

The importance of having a governance structure to oversee and co-ordinate the planning of changes to services was demonstrated. Delays to the planned implementation date meant that the sites were ready on the launch date and there were few teething issues following implementation. This may have led to the achievement of improved outcomes within a year (see Chapter 11).

Challenges identified in GMA, such as dealing with stroke mimics, the repatriation of patients from CSC/PSCs to DSCs and discharging people to the community, continued post implementation. The importance of working collaboratively to find local solutions to these problems was shown, enabled by the governance model, which provided support for regular audits and a mechanism to facilitate the system-wide discussions needed to maintain effective system operation, as well as ensuring that SSNAP data were entered consistently across GM, so that it could be used for reviews. It is likely that the co-ordinating role of the ODN contributed to the improvements in the provision of evidence-based care and the reduction of mortality among those patients treated in a CSC/PSC.

Strengths and weaknesses

Strengths of this analysis included the contemporaneous study of both planning and implementation. A wide range of interviewees participated, including those involved in the planning, governance and review of stroke services and staff from the CSC, both PSCs and two DSCs. Staff from across GM participated in observed meetings, so a wide range of views and experiences were captured. Emerging findings were shared with local stakeholders in order to enhance validity.

Comparison with other studies

The importance of the context215,216 within which changes to stroke services were planned and implemented was evident in this analysis. However, despite this turbulent background, MSC was achieved, with the data showing how the context delayed change, had to be taken into account and was worked around.

As in the Midlands and East of England (see Chapter 10) and London (see Chapter 14), the 2013 NHS reforms disrupted system commissioning and governance. Changes in leadership, both designated and distributed, meant that it was difficult to get decisions made, and there was a consequent loss of knowledge and ownership of the plans for reconfiguration. This suggests that continuity of leadership could be added to designated and distributed leadership as necessary for large-scale transformation,5 given that it will always take place over a period of time.

Feedback was used throughout the ‘to agreement’, ‘planning’ and ‘implementation’ phases. Following the review of GMA, other reviews were carried out, which fed in to the planning process and justified decisions made. Agreement for reconfiguration was based mainly on an analysis of SSNAP data, which continued to be important after implementation, to monitor activity on the stroke pathway. Resource was dedicated to ensuring that staff appreciated the importance of accurate and complete data collection and understood the analysis of the data in relation to their own practice.

Financial penalties were not used in GMA (see Chapters 6 and 7)110,123 but were introduced in relation to delayed repatriation in GMB. However, there were changes to the mechanism used, with plans for ‘top slicing’ of the tariff paid to a DSC if a stroke patient was not repatriated in a timely manner, after a previous method of doing this was not imposed.

The use by leaders of discursive power to promote change,203 with an emphasis on evidence and better patient outcomes, was evident in the planning of GMB. Leaders used SSNAP data and then the publication of research findings in order to keep to the fore the reasons that reconfiguration was necessary.

Attending to history, that is, learning from previous transformations, was evident. A phased approach to implementation was not undertaken, largely because of previous experience in GM.

Despite system-wide disruption resulting from NHS reforms (reducing the extent to which stakeholders could engage) there is evidence that in addition to engaging a range of stakeholders,5,110 ‘ownership’ of the changes was engendered in stakeholders. For example, CCGs funded a project manager, stroke staff championed the changes through training other staff in their locality and provider Trusts funded the ODN beyond its initial year post implementation. ‘Ownership’ can be conceptualised as a step further than engagement, and ultimately as necessary for sustainability.

Implications

  • Major structural reorganisations have been shown to represent a significant obstacle to implementing MSC. However, GMB indicates that it is possible to mitigate or overcome such disruption.
  • Network support organisations (such as the ODN) can facilitate collaboration, service audit and support the development of standards and protocols for organisation and provision of care. Such organisations might maximise their impact if they support the whole patient pathway rather than just the acute phase.
  • MSC benefits from programme management support, within a framework of robust governance, which engages all key stakeholders.
  • Workload profile and the related skill requirements are important during and after change and may be underestimated. Insufficient attention may lead to skills shortages as well as low staff morale.
  • Continuity of leadership is important: steps should be taken to minimise the effect of contextual changes by the involvement of leaders with system-wide authority and collaborations of organisations where possible.
  • Consideration must be given to harmonisation of terms and conditions for staff across the system. Working in a 24/7 service, for example, poses additional requirements for night and weekend working that may not automatically be rewarded equitably and can lead to staff shortages.
Copyright © Queen’s Printer and Controller of HMSO 2019. This work was produced by Fulop et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Bookshelf ID: NBK537626
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