Impact case study database

This research has contributed to further centralisation and the lives of more stroke patients being saved in Greater Manchester (GM). Furthermore, it has supported sustained effectiveness of the London stroke care system; helped shape national policy in England, Scotland and Northern Ireland; and has been cited in documents making the case for regional stroke service reorganisations.

Driving improvements in care delivery and outcomes in Greater Manchester

Between 2012 and 2014, GM hospitals had attempted to centralise their stroke services, but changes were delayed, as a result of national reorganisations of governance and commissioning of healthcare, and local challenges with governance and service provision. UCL evidence [R1], [R2] on patient mortality was pivotal in driving further change in GM. The researchers shared their findings with senior members of the GM Stroke Network in February 2014 at the project steering committee meeting. At GM stakeholders’ request, in May 2014, the UCL team calculated the potential impact of further reorganisation and estimated that an additional 50 lives per year could be saved by doing this. GM stroke leaders used this figure to argue against any further delays. One senior stroke physician stated: “ being able to go to meetings and say to people ‘We’re looking at fifty excess deaths a year …’ 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.” [R1]

Supporting local buy-in: The argument that further change would increase access to evidence-based care, also saving 50 additional lives per year, was central to a large regional publicity campaign, gaining support for the new system from the public, local authorities, commissioners, and providers in GM. This included tweets from local providers and commissioners, an infographic (see below) and a briefing, which stated: “ if a similar approach is taken in GM it could result in 50 fewer deaths each year. The changes we are introducing in GM are based on a strong evidence base that it works”.

**Fewer deaths from stroke: Findings [R1], [R5] showed that, following further centralisation, 86% of GM stroke patients were treated in a HASU, resulting in an estimated 68 fewer deaths per year than if GM had reduced mortality at the same rate as other large urban areas in England (improvements in other large urban areas are likely to have been achieved through wider efforts to achieve national quality standards combined with public health interventions). National stroke audit data from July to September 2020 [S1] confirm that GM stroke services remain among the highest performing in England, with all routinely-admitting stroke services regularly achieving ‘A’ or ‘B’ national audit ratings – classified as indicating world-class stroke care as defined by the Royal College of Physicians.

Providing evidence to sustain centralised stroke services in London

Fulop and colleagues presented their clinical outcomes findings to London’s stroke clinical leaders in November 2014. From December 2014, these findings were cited in London’s Stroke acute commissioning and tariff guidance, published by the NHS Strategic Clinical Network. The guidance presents the clinical standards used to assess London stroke services [S2] and cites the finding from [R2] that: “reconfiguration resulted in a significant decline in risk-adjusted mortality, with approximately 168 lives saved at 90 days after admission, and a 7% reduction in length of stay in the first 21 months”. Senior management and frontline clinicians have said that the UCL research on outcomes has played an important part in sustaining the London system. For example, a representative of NHS England in London described making the case to commissioners to continue funding the London system:

“The team bringing their findings to the Stroke Clinical Leadership Group was really valuable […] it gave us a really good understanding of the research. This ‘heads up’ was crucial in helping clinical leads understand and share the main messages more widely. Your evidence was instrumental in addressing pushback from local commissioners and trusts [...] the fact that we could point to impartial research showing the London system had saved lives and reduced length of stay really swayed CCGs to support the tariff. Your work has also helped London to be seen as an aspirational model or ‘gold standard’ at regional and national level” [S2].

The research team’s follow-up analysis [R5] suggests that, from April 2013 to March 2016, London patients were significantly more likely to receive evidence-based care than patients elsewhere, and the impact on patient mortality was sustained. National stroke audit data from July to September 2020 [S1] suggest that London remains a high-performing system. Like GM, London is amongst the only areas in the English NHS where all routinely admitting stroke services regularly achieve ‘A’ or ‘B’ ratings, which indicate world class stroke care.

Influencing national policy and regional planning

National and regional leadership have used UCL’s work on impact of centralisation of stroke services on patient outcomes [R2], [R5] and quality of care [R3], [R5] as key evidence in their recommendations to centralise hospital stroke services. Findings on the impact on stroke patient outcomes [R2] have been cited in NHS England’s ‘Five Year Forward View’ [S3], the Scottish Government’s ‘National Clinical Strategy for Scotland’ [S4], NHS England’s ‘Configuration support guide for stroke services’ (2015) and proposals to reorganise stroke services in Northern Ireland [S5]. Fulop and colleagues’ findings of impact on stroke care delivery [R3] are cited in England’s ‘National Clinical Guidelines for Stroke’ [S6]. UCL’s work on both implementation and impact of change [R2], [R3], [R6] was cited in the Stroke Association’s position paper on stroke service reorganisation [S7], and 15 ‘case for change’ documents across the English NHS, of which three stroke service centralisations – in South Yorkshire and Bassetlaw; West Yorkshire and Harrogate; and North Cumbria – have been implemented [S8]. Finally, the UCL findings of lives saved per year in London [R2], and Greater Manchester [R5], were cited by change leaders in Kent and Medway in their submission to a judicial review of their proposal to centralise local stroke services into three HASUs; the judicial review ruled in favour of the changes in early 2020 [S9].

Shaping the ‘NHS Long Term Plan’: UCL’s 2014 research on stroke outcomes was one of just 11 documents cited in an internal paper resulting in stroke’s inclusion as a priority in the ‘NHS Long Term Plan’ [S10]. This followed considerable engagement activity carried out through an NIHR Knowledge mobilisation Fellowship held by Ramsay, who, for example, presented key findings at national workshops for development of the ‘NHS Long Term Plan’. A representative of the team leading its development stated: “ *The research was clearly presented in initial publication, ensuring it was accessible to less academic audiences, with clear messages more easily translated into policy initiatives. This led us to highlight the work as one of a small number of key references within our internal proposal for ‘NHS Long Term Plan’ prioritisation. The research clearly strengthened our case, and helped support its ultimate success. We have subsequently continued to refer back to this research and to reference within further documentation.*”- Team member, ‘NHS England Long Term Plan’ [S10].

Prioritisation in the ‘NHS Long Term Plan’ has resulted in additional resources for development of stroke services across England, including the new Integrated Stroke Delivery Networks, which will reshape organisation and delivery of stroke care across the whole of the English NHS over the coming years.