Shared learning database

NHS Improvement- Stroke
Published date:
January 2012

This national project encompasses both the NICE quality standard for depression in adults with a chronic physical health problem and the NICE stroke quality standard 9 to routinely screen people for mood and cognitive disorders. Assessment and management of psychological disorders after stroke is poorly organised with patients receiving sub optimal services and support (National Audit Office report, 2010 and Care Quality Commission stroke review, 2011). These national projects demonstrate effective improvement in organisation and delivery of psychological care after stroke.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To improve national availability of services capable of managing psychological issues after stroke, and increase numbers of patients accessing these services. 1) To increase the number of cardiac and stroke networks reporting on the ASI measure (and therefore providing psychological care for people with stroke) from 0% to 40% 2) To increase numbers of people with stroke project teams routinely screen for mood and cognition. 3) To establish the key learning points for successful implementation of comprehensive routine mood and cognition screening for people with stroke for national dissemination. 4) To increase access to psychological care for all stroke patients who required it. 5) To develop pragmatic implementation guidance for stroke teams to provide tools and techniques for improved access to psychological care after stroke.

Reasons for implementing your project

The need for this project was established following the National Audit Office review of stroke services(2010) and the Care Quality Commission review stroke (2011). Both reports demonstrated limited availability and poor access to psychological care especially post-hospital. The Public Accounts Committee asked the NHS to improve psychological care for stroke through the NHS Improvement stroke team. The role of NHS Improvement-Stroke was set out clearly in the National Stroke Strategy (2007)and since then the team-working closely with the Department of Health, trusts, clinical networks, other health sector partners, professional bodies and charities, has helped to deliver a number of benefits to patient outcomes and experience through its practical service improvement work. Improvements to services following the NAO report were planned through the Accelerating Stroke Improvement (ASI) programme, which included a suite of national measures to monitor progress. Additional leverage was provided by the NICE stroke quality standards and NICE clinical guidance for depression in adults. The initiative took the form of a national drive for measurable improvement through development of online resources and specific project work. A national baseline was provided through the ASI measure-the number of providers able to report on the proportions of patients receiving psychological care after stroke. Local project team baselines were provided for numbers of patients routinely screened for mood and cognition, patient experience of and satisfaction with psychological care and staff confidence and competence in dealing with psychological issues. There is a strong association between reduced function and psychological symptoms and depression is linked to increased use of health and social care services. Support for psychological issues alongside physical rehabilitation, increases patients' opportunities to engage with rehabilitation and maximise outcomes.

How did you implement the project

There was a high profile national drive by NHS Improvement-Stroke to raise awareness, develop widely accessible resources, and motivate achievement of the psychological care ASI measure. In this context seven project teams were recruited. York - implemented routine screening of all patients on an acute stroke ward and established a befriending service within existing resources. Connect- the communication disability network implemented a peer befriending scheme jointly funded by Wandsworth Borough Council and NHS Wandsworth, £55,200 for one year. Dorchester implemented collaborative working between the community and mental health trusts to improve assessment and access to psychological care. Training costs were £12000 and a project manager for a day a week for six months-cost £3,300. Croydon and St Georges developed psychosocial education groups to meet patients' psychological needs in acute and community stroke services. One year contract for two assistant psychologists costed £27,500, other costs such as transport, education materials and admin came to £16,000. Bassetlaw and Nottinghamshire implemented new clinical psychologist led services to increase routine screening and access to psychological care using stepped care. Psychology posts were funded prior to the start of the national project. The three main barriers to overcome were time, culture and competence. Time to manage the project and implement the changes was managed by sharing resources developed by each of the teams, including pathways, questionnaires, information packs and teaching materials reducing duplication. Cultural change of stroke teams was needed to give equal status to psychological and physical care. This was improved by embedding process changes into team routines and paperwork. Low levels of innate ability of staff to identify psychological difficulties, understand adjustment after stroke, and provide compassionate care was improved by shared training programmes and online resources.

Key findings

The proportion of stroke networks reporting the ASI measure "access to psychological care" increased from 0 to 37%. Proportions of patients recieving formalised mood screening increased. Nottinghamshire from 0-100%, Bassetlaw 0-50%, Croydon 36-63%, Dorchester 3-27%. Proportions of patients receiving psychological care increased from 42%-92% (Dorchester) and by three and a half times in Croydon (24-84 patients) Patient and carers views about psychological care received were measured and all improved. Quality of life scores (EQ5D) showed improvement in anxiety and depression and all patients agreed or strongly agreed psychological care met their needs (Nottinghamshire). 100% patients were satisfied with their psychological support (Croydon). Reduced isolation, greater feelings of support, and greater confidence was reported especially for people with aphasia (Connect). Strong satisfaction with all aspects of emotional care (Nottinghamshire). Staff confidence and competence in dealing with psychological issues were surveyed using questionnaires and audit. In Bassetlaw confidence dealing with patients in distress increased from 43 to 86%, confidence dealing with family or carers in distress increased from 15 to 82%, and staff reporting worrying about patients outside of work reduced from 86 to 57%. In Nottinghamshire confidence increased in dealing with patients in distress, and goal setting for patients with depression/ anxiety. In Dorchester confidence, knowledge and skills improved in managing psychological issues and implementation of learning into practice. Sustainable services were established- New befriending services established in York and St Georges and recommissioned in Wandsworth. The collaborative mental/physical health approach in Dorchester was extended to all of Dorset. Psychosocial education groups were established in Croydon and St Georges. Stepped care models of psychological care established in Nottinghamshire and Bassetlaw.

Key learning points

-Ask patients what they think about the psychological care they received and what they would like to have received. Use patients to help to improve services by sharing stories, defining the vision and being involved in service development. -Make the most of existing resources in the team, some professions already have additional competence in management of psychological care. Some improvements can be made from raised awareness of the issues and formalisation of pathways. -Make local connections with mental health trusts and the voluntary sector. Collaborative working and shared training can develop a psychologically aware stroke skilled workforce. Volunteers from the stroke community are a potential resource for psychological support with the right training and governance arrangements. -Use a stepped approach as advocated by NICE and the DH Improving Access to Psychological Therapies (IAPT) programme. This is a hierarchical approach, offering simpler interventions first and progressing to more complex interventions if required. It makes best use of skills of the team for lower levels of support and utilises specialist staff for patients with complex problems. -Get a clinical psychologist, they are an essential member of the stroke team. They educate and support the team to provide psychological care for patients as well as working directly with the patient and families. -Aim to make psychological care part of the culture. Sitting with patients exploring and supporting the impact of the stroke should be considered a valid use of clincal time. Routine psychosocial education groups for patients and carers can provide very effective psychological support All of the learning from the projects has been published in an implementation guide 'Psychological care after stroke-improving stroke services for people with mood and cognitive disorders' (attached) and a web resource.

Contact details

Sarah Gillham
National Improvement Lead- Stroke
NHS Improvement- Stroke

Is the example industry-sponsored in any way?