Agenda item

Rebecca Sheehy and Emma Richards gave a presentation on the Integrated Community Stroke Services and made the following points which included the following points:

·       Details of the reconfiguration of services

·       A pioneering approach which was integrated

·       Stroke was the fourth biggest killer in the UK and the highest cause of adult disability. It was set to increase with two thirds of patients with the greatest levels of disability. Lives were reduced by 5 years on average and it affected 35% of people of working age

·       There was an understanding of increased demand which the existing workforce was trying to mitigate, a need to tackle inequality and an acknowledgement that outcomes could vary

·       18,000 people were living with the impact of strokes throughout the BNSSG area – the numbers for each region were set out

·       Following the recent whole stroke pathway review, from May 2023 anyone who had a stroke related issue would be submitted to Southmead by hospital unless there was an additional cardiac issue involved

·       There was greater pressure on the service since more people were living with strokes although the level of disability was improving

·       Hospital stays for strokes were on average 7 days including weekends – there were 30 rehabilitation beds in South Bristol and 12 beds in Weston Hospital

·       The Integrated Community Stroke Service was based on the National Stroke Service model. A team of therapists, a dressing service and meal provision were all part of the service prior to a review of the amount of social care that was required

·       A list of different support staff types was provided

·       The process of those who had strokes was outlined – a referral was received, there was an initial assessment, a sixth month review, a complete follow up including information on support to access groups with the details then uploaded to the national data collection database

·       Workshops were provided for those people with aphasia and communication group workshops

·       Details of the deadlines involved in the process were set out

·       The benefits of integration were as follows – it provided a holistic service, it gave access to specialist advice, there was a smooth transition to facilitate discharge and provide referral back in where required, easy access advice to workers, provision of Integration of IT, there was support with wider projects such as the Stoke HIT Education Sessions (an online aphasia group)

·       There was a reduction of health inequalities and engagement through partnerships and with local community groups, working closely with health workers, engaging in ICE locality well-being initiatives and provision of cultural awareness training

·       Details of the role of stroke key workers was provided

·       There were a wide range of after stroke services including emotional support and peer support

·       Detail of life after stroke was set out on the Kubler Ross change curve – services were plotted on the curve, with counselling being provided if necessary

·       The Board noted the work of self-led volunteer groups and two case studies which were outlined to them

·       Details of the number of cases throughout the region were provided, including those still active and those which had been discharged

·       Details of services in South Gloucestershire were set out, including a stroke café, physiotherapy groups, weekly in reach into hospitals, stroke co-ordinator services and contribution to core costs

·       Opportunities and support – This worked in an integrated way to provide a whole life approach after stroke and proactively support those most in need and avoid delay of social care needs

·       Whilst getting people out of hospital was the main priority, there was a rehabilitation programme for longer term stroke victims

Board members made the following points:

·       Since stroke was the fourth highest killer, it was important to also work to reduce the three higher forms of death

·       The integrated approach was working well – effective engagement was required with the south, north and west of the region

·       It was important to address all communities with herald conditions, including the more deprived communities

·       The feedback of lived experience was important. Whilst the development of an integrated approach through a memorandum of understanding was not easy, it was key for this service