National report (2021)
Source: data.gov.uk (2023-09-06)

Sentinel Stroke National Audit Programme (SSNAP) - Post-acute organisational audit 2021. The SSNAP post-acute organisational audit is a snapshot audit which supersedes the first organisational audit of post-acute stroke service commissioning carried out in 2015. It reports on the structure and organisation of post-acute stroke services in England, Wales and Northern Ireland. The results reflect the organisation of post-acute stroke services as of 1 April 2021. In total 664 post-acute stroke service providers submitted information to the audit.

The results of the 2021 post-acute organisational audit contain national and service level findings on the organisation of stroke services, including collection and reporting on data such as staffing levels, access to timely multidisciplinary care and 7-day working.

National Report: Contains national results for many key aspects of post-acute stroke service organisation, including the 14 key indicators, it gives a comprehensive overview of the organisation of post-acute inpatient and community-based multidisciplinary services and highlights areas of good practice and areas requiring improvements.

The full results portfolio: Presents service level and national performance against the 14 key indicators (KIs) identified for the 2021 Post-acute organisational audit. The majority of which were applied to post-acute inpatient and community-based multidisciplinary teams only. It gives a comprehensive overview of the organisation of post-acute inpatient and community-based multidisciplinary services.

Post-acute Organisational Audit 2021

2021
Sentinel Stroke National
Audit Programme (SSNAP)
Post-acute Organisational Audit Report
National Report
England, Wales and Northern Ireland
December 2021
Prepared by
Sentinel Stroke National Audit Programme, King’s College London,
on behalf of the Intercollegiate Stroke Working Party

Post-acute Organisational Audit 2021
i

Document
purpose
To disseminate the results of the SSNAP 2021 Post-acute Organisational Audit of stroke
service providers.
Title
SSNAP 2021 Post-acute Organisational Audit report
Author
On behalf of the Intercollegiate Stroke Working Party
Publication
December 2021
Target
audience
Post-acute stroke services, managers, medical directors and trust executives of providers
that participated in the 2021 Post-acute Organisational Audit. Health and social care
professionals and healthcare management organisations including commissioners.
General public and stroke survivors and their carers. NHS England, NHS Wales, Northern
Ireland Department of Health, Isle of Man and Jersey.
Description
This is the second Post-acute Organisational Audit report published under the auspices of
the Sentinel Stroke National Audit Programme (SSNAP). The report publishes national
level findings on the organisation of post-acute stroke services that see at least twenty
stroke patients a year. These findings relate to post-acute care organisation, staffing and
the pathway at discharge. It reflects the organisation of post-acute stroke services as of 1
April 2021.
Services can use this report to benchmark their performance against national level
findings and compare themselves with national standards.
This report is addressed to everyone who is interested in post-acute stroke services. It
gives a picture of current services, and the style of the report should allow lay people as
well as experts to read it and extract relevant information.
The report presents key findings and recommendations, a look at the 14 key indicators
applied at team level and 3 key indicators applied at ISDN level, followed by other key
findings from the organisational audit. A full results portfolio (Excel file), which presents all
data items by named services, is also available and should be viewed in context with this
report.
Superseded
SSNAP Post-acute Organisational Audit 2015
Related
documents
The full results portfolio and appendices can be found here:
https://www.strokeaudit.org/results/PostAcute2021/National.aspx
Contact
xxx@xxx.xx

Post-acute Organisational Audit 2021
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Table of contents
Foreword ......................................................................................................................................................................................... 1
Executive summary .................................................................................................................................................................. 2
A brief look back to 2015 ................................................................................................................................................. 2
Summary of key findings and recommendations .............................................................................................. 3
Areas requiring further investigation and research ......................................................................................... 5
Introduction .................................................................................................................................................................................. 6
COVID-19 .................................................................................................................................................................................... 6
Aims of the audit ..................................................................................................................................................................... 6
Availability of this report in the public domain ......................................................................................................... 6
Section 1: Key performance indicators ......................................................................................................................... 7
Section 2: Participation ........................................................................................................................................................ 12
2.1 Patient numbers ............................................................................................................................................................. 12
2.2 Staff in participating services ................................................................................................................................. 13
2.3 Inpatient services ......................................................................................................................................................... 14
2.4 Other post-acute services ....................................................................................................................................... 16
Section 3: Resources and configurations ................................................................................................................. 18
3.1 Service specificity ......................................................................................................................................................... 18
3.2 Service configuration (community-based services) .................................................................................... 19
3.4 Multidisciplinary team composition (community-based services) ...................................................... 20
3.5 Staff and patient ratios (community-based services) ................................................................................ 21
3.6 Multidisciplinary team composition (inpatient services) .......................................................................... 22
3.7 Staff and patient ratios (inpatient services) ................................................................................................... 23
3.8 Nursing skill mix for inpatient services ............................................................................................................. 24
Section 4: Needs-based rehabilitation ....................................................................................................................... 25
4.1 Seven day working ...................................................................................................................................................... 25
4.2 Waiting times ................................................................................................................................................................. 25
4.3 Time limits and re-referrals .................................................................................................................................... 27
4.4 Mode of contact ........................................................................................................................................................... 29
4.5 Treatment of patients in care homes ................................................................................................................ 29
Section 5: Multidisciplinary team working ............................................................................................................... 30
Section 6: Education, information and training .................................................................................................... 32
6.1 Swallow assessment (post-acute inpatient teams) .................................................................................... 32
6.2 Stroke management (post-acute inpatient teams) .................................................................................... 32
6.3 Patient and carer training ........................................................................................................................................ 34

Post-acute Organisational Audit 2021
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Section 7: Vocational rehabilitation ............................................................................................................................. 35
7.1 Vocational rehabilitation providers ...................................................................................................................... 35
7.2 Commissioning of vocational rehabilitation .................................................................................................... 36
7.3 Where is vocational rehabilitation delivered? ................................................................................................ 37
7.4 Disciplines carrying out vocational rehabilitation ........................................................................................ 38
7.5 Who is offered vocational rehabilitation? ........................................................................................................ 38
7.7 Frequency of vocational rehabilitation sessions .......................................................................................... 39
Section 8: Six-month reviews .......................................................................................................................................... 40
Section 9: Participation in clinical audit and research, and use of outcome measures ................ 43
9.1 Audit and research ...................................................................................................................................................... 43
9.2 Outcome measures .................................................................................................................................................... 44
Glossary ....................................................................................................................................................................................... 45
References ................................................................................................................................................................................. 49
Thanks ........................................................................................................................................................................................... 50
Acknowledgements .............................................................................................................................................................. 50

Post-acute Organisational Audit 2021
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Report prepared by

Dr Rebecca Fisher
SSNAP Associate Clinical Director, King’s College London
Principal Research Fellow, University of Nottingham; Rehabilitation and Life after Stroke
Workstream Lead, NHS England and NHS Improvement (NHSEI)

Ms Louise Clark
SSNAP Associate Clinical Director, King’s College London
Consultant Therapist, Dorset County Hospital

Mr Edward Barrett
SSNAP Project Officer, King’s College London

Ms Fariat Odion-Esene
SSNAP Senior Operations Officer, King’s College London

Ms Jennifer Butt
Stroke Programme Manager, King’s College London

Mr Nahuel Durante
SSNAP Project Officer, King’s College London

Professor Martin James MD FRCP
SSNAP Clinical Director, King’s College London
Clinical Director, Stroke Programme, King’s College London
Consultant Stroke Physician, Royal Devon & Exeter Hospital

Report supported by
Ms Beenitaben Shah
Ms Sabrina Ralph
Ms Ellie McMullen
Ms Anisah Rothman

Post-acute Organisational Audit 2021
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Foreword

It is a great pleasure to present the findings of the 2021 SSNAP audit of post-acute and rehabilitation
services for people with stroke, the first such audit for six years. The priority for most people with stroke,
even after allowing for the advances we have seen in acute reperfusion, remains the maximum possible
access to specialist rehabilitation to help them recover from the disabling effects of their stroke, for as long
as they need it.
This report shows the reality of that expectation being met by stroke services across England, Wales and
Northern Ireland in 2021. The impression is of services that vary enormously in the extent to which they can
deliver the highly skilled multidisciplinary and seamless rehabilitation that people need. Fewer than half of all
in-patient services are providing staffing levels that match the expert recommendations; for community-
based teams, it is less than a third. Not all staff are receiving enough training to build and maintain the
specialist skills they need. A quarter of services are now providing vocational rehabilitation, despite many
not being commissioned to do so, but there is an almost complete absence in Wales. More needs to be done
to ensure that post-acute services are as fully involved with quality improvement through national audit as
has become the routine expectation for acute providers. Then there are the topics for which change has
proved to be difficult over quite some time: psychological support is not available at all in over a third of
teams, and for those where it is, the average waiting time of 10 weeks is unchanged from six years ago. The
review of people with stroke at 6 months, originally identified as a national policy priority 15 years ago, is for
many still not taking place. The sense of abandonment felt by people with stroke and their carers, recently
reiterated in the Stroke Association’s 2021 ‘Recoveries at Risk’ report of care and rehabilitation during the
COVID-19 pandemic (https://www.stroke.org.uk/stroke-recoveries-at-risk-report), still needs to be tackled,
as we know it results in declining mental health and wellbeing for many. Plainly put, the planning and
provision of stroke services in the UK has too often been service-based, not person-centred.
So there clearly remains a great deal to do to achieve the quality and quantity of post-acute rehabilitation
that people with stroke should receive, and the ‘green shoots’ of the engagement of post-acute teams and
the new Integrated Stroke Delivery Networks (ISDNs, in England) with this audit are an encouraging start.
The emerging English Integrated Care Systems and their equivalents in the devolved nations urgently need
to respond to the challenge of better provision laid out in the ambitious new Integrated Community Stroke
Service model (ICSS), recently published by NHS England. Urgent progress is also needed in research so
rehabilitation can be guided by knowing what works for people with stroke, and what doesn’t. The recent
James Lind Alliance Priority-Setting Partnership led by the Stroke Association
(https://www.stroke.org.uk/research/priority-setting-partnership) has identified the ‘Top 10’ areas of
uncertainty in stroke rehabilitation that need to be addressed. To do this we need much greater research
participation from teams than the current level of below 10%. Overall, the implementation of the 7 Key
Recommendations from this report would greatly improve the lives of many thousands of people with stroke
and their families, and at the same time reduce the cost and burden of stroke on the nation – a good old-
fashioned ‘win-win’. It’s time to put the person with stroke and their family at the centre of everything that
we do.
I wish to pay tribute to all the teams who have participated in this audit and who are working hard to deliver
the best care they can for people with stroke. I also pay tribute to those who have contributed to this report,
especially my colleagues Rebecca Fisher and Louise Clark, who have toiled long and hard with the team at
SSNAP to render a highly complex dataset into a sharply focussed report with clear messages for the way
forward. I commend this report to the stroke community and with you I relish the double-edged
challenge/opportunity contained within its pages: let’s make life better for people with stroke.

Professor Martin James MD FRCP
Clinical Director, Sentinel Stroke National Audit Programme, hosted by King’s College London

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Executive summary

A brief look back to 2015
The SSNAP Post-acute Organisational Audit was last conducted in 2015. During this time there
have been significant advances in evidence and policy regarding post-acute rehabilitation. The
following figure compares performance between the 2015 and 2021 audits.

Figure 1.1: Comparison between 2015 and 2021 performance

The areas identified as requiring improvement in the 2015 audit remain largely unchanged, with
significant improvement still necessary in vocational rehabilitation, timeliness of psychological
intervention and 7 day working. These data suggest a worsening position in relation to time limited
services, an indicator we would expect to improve as the ICSS model is adopted. The proportion of
teams meeting the Early Supported Discharge responsiveness standard of 1 day from discharge to
first treatment has decreased from 60% to 41%. This is likely to have been negatively influenced by
the COVID-19 pandemic, as teams have expanded criteria and experienced workforce challenges.
Performance for combined teams providing Early Supported Discharge is also lower at 48% (34
out of 71 teams). The standard for combined teams was adjusted to a 3-day average time to first
contact for combined teams to reflect a standard of 7 days to first contact for the Community
Rehabilitation team cohort. Timeliness of intervention for these services is a key feature of their
model and therefore a priority for improvement. Importantly however, the proportion of hospital
discharges to Early Supported Discharge teams has risen sharply in 2020-21 to 48%. This trend
may have resulted in teams being spread more thinly as they have responded to the urgency of
getting patients out of hospital.

Post-acute Organisational Audit 2021
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We acknowledge and commend the increase in post-acute services submitting clinical data to the
SSNAP audit and continue to work with teams to build on functionality and comprehensiveness of
the post-acute dataset.
An increase in commissioning of 6-month assessment providers is an important advance and is
explored more in section 8.
Summary of key findings and recommendations

Here we summarise positive (✓) and negative () findings under key recommendations together
with some additional recommendations (→) featured in the report.

Key recommendation 1: All inpatient and community rehabilitation services providing
rehabilitation for people with stroke should meet recommended staffing levels with appropriate
access to all disciplines required.

✓ Stroke or stroke/neuro specific services are the predominant type of post-acute service
provided.
 Staffing levels: Less than 50% of inpatient services have the recommended levels of any of the
core disciplines.
✓ Staffing levels: The majority of inpatient services (71%) meet recommended nurse staffing levels.
→ Inpatient nursing skill mix: Use of band 4 staff who can autonomously undertake some nursing
and rehabilitation tasks and increasing the numbers of nurses above band 7 level could increase
workforce capacity.
→ Inpatient medical care: Use of lower grade stroke specialist medical staff for post-acute inpatient
teams, supported by advanced or consultant practitioners (nurses or allied health professionals),
could be a more efficient use of workforce.
 Staffing levels: Fewer than a third of community-based multidisciplinary teams met recommended
staffing levels.
 Under-represented disciplines: Psychologists, dietitians, orthoptists, social workers and family
and carer support workers were all under-represented in hospital and community-based teams.
→ Care homes: Access to Life after Stroke services (such as communication, emotional and peer
support) should be improved for patients in care homes.
Key recommendation 2: All community-based services should adopt the Integrated Community
Stroke Service model and deliver needs-based rehabilitation 7 days a week starting promptly
after discharge.

 7-day services: There is still a predominance of 5-day services in community-based
multidisciplinary teams.
 Waiting times: Over a third of Community Rehabilitation teams have a waiting time of more than
2 weeks to commence therapy.
✓ Re-referrals: A high proportion of teams (80%+) of each service type (apart from Community
Rehabilitation teams) accept re-referrals.
✓ Care homes: High proportions of Early Supported Discharge (ESD), Community Rehabilitation
teams (CRT) and Combined ESD/CRT teams provide rehabilitation for patients in care homes.

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Key recommendation 3: Effective and specialist multidisciplinary team working should be
promoted by all team members and supported by senior managers and leaders.

✓ There is a good breadth of non-medical leadership with a high proportion of teams led by core
therapy disciplines.
 The lack of designated leadership for Community Rehabilitation teams is likely to impact on the
service quality.
✓ Attendance by clinical psychologists at multidisciplinary meetings could be an effective method
for psychology staff to provide an educational and consultatory role.
→ Every team requires a designated team leader.
→ Every post-acute service should hold weekly multidisciplinary team meetings attended by all
disciplines and should attend acute multidisciplinary team meetings.
Key recommendation 4: Staff, patients and family members should have dedicated (protected
time) and access in their workplace and at home to education, information and training relating
to stroke care, offered by reputable national bodies.

 Carer training: Insufficient training is provided for carers across all service types.
 Nurse training: Fewer inpatient nurses than therapists had access to training.
→ Patient information should be adapted appropriately for those with aphasia, cognitive or visual
difficulties. Training should be delivered on an individual patient basis, groups, in person or virtually.
→ The Stroke Specific Education Framework (SSEF) (https://stroke-education.org.uk/), should be
reviewed for all staff and staff should be released for training (including nurses).
Key recommendation 5: Vocational Rehabilitation should be available for all patients who need
it and should be formally commissioned in line with evidence-based recommendations.

 The majority (71%) of teams are providing vocational rehabilitation without it being formally
commissioned.
→ Eligibility for vocational rehabilitation should be standardised, such as anyone who wishes to
return to or take up paid or unpaid work after their stroke.
→ Vocational rehabilitation should be detailed in service specifications, with associated reporting
metrics and patient outcome data, to ensure optimal delivery is maintained regardless of provider
type.
Key recommendation 6: Six-month reviews should be conducted using a standardised tool and
offered to all patients. Reviews should cover stroke secondary prevention, stroke recovery and
disability management as well as reviewing unmet clinical and social care needs.

 Only half of ISDNs met the 6-month review key indicator.
→ The skill-mix of staff delivering reviews should be considered, such as lower grade staff
supported by advanced or consultant practitioners (nurses or allied health professionals) for a more
efficient use of workforce.
→ Lack of social worker involvement in 6-month reviews is a missed opportunity.

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Key recommendation 7: Services should use process and standardised patient outcome
measures to guide clinical delivery and service improvement. This should be as part of
participating in SSNAP, their local and regional systems and research.
/

→ Full participation in the SSNAP clinical audit is vital for data to be representative to drive local
and national improvement.
→ Participation in stroke rehabilitation research needs to be prioritised.
✓ A wide range of standardised outcome measures are being used routinely.
→ Use of a common set of outcome measures (including patient reported outcome measures),
collected across the stroke care pathway, would enable ISDNs and regions to drive the process of
quality improvement in stroke rehabilitation and evaluate services objectively.

Areas requiring further investigation and research

Commissioning and configurations of inpatient services: Inpatient pathways differ across the
country with varying access to inpatient rehabilitation and specialist commissioned rehabilitation
beds. This needs to be explored more fully to understand the optimal pathway; however, it is likely
that configuration of bed-based provision may need to differ according to local population, rurality
and configuration of acute and community services. It will be important to amalgamate data with
the upcoming SSNAP Acute Organisational Audit to clearly understand what changes there have
been in overall bed numbers.
Swallow assessments: Further investigation into the competencies of staff who are trained in
swallow assessment is required, as well as the impact on other professionals completing swallow
assessments such as speech and language therapists.
Remote delivery of rehabilitation to augment face to face therapy: This should be properly
evaluated as a method to increase the intensity of rehabilitation.
Education, information and training: Further exploration is required to understand what resources
are used, how information is adapted appropriately for those with aphasia, cognitive or visual
difficulties, and whether training is delivered on an individual patient basis, in groups, in person or
virtually.
Vocational rehabilitation (VR): Research evidence is required to inform effective and timely
delivery of VR, including appropriate dose/schedules, staff resource implications (e.g. occupational
therapists) and the interplay with rehabilitation focussed on non-vocational goals.

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Introduction

This report presents the results of the Sentinel Stroke National Audit Programme (SSNAP) Post-
acute Organisational Audit 2021 (PAOA). It describes the organisation of post-acute stroke care in
England, Wales, Northern Ireland, the Isle of Man and Jersey as of 1 April 2021.
A total of 664 post-acute services participated in this audit, of which 591 were in England, 42 in
Wales, 28 in Northern Ireland, one in the Isle of Man, one in Jersey and one was from the Stroke
Association Connect participating on a national level. Data were collected via a web-based audit
proforma, with inbuilt validations to ensure data accuracy. The key performance indicators (see
section 1) were devised by the SSNAP team.
Data was collected at service level using a standardised methodology, which is outlined in full in
Appendix 1. Two leads were selected for each service with overall responsibility for data quality.

COVID-19
Teams inputted data for this audit between 1 April 2021 and 30 April 2021. The audit applied to data
collected between 1 April 2020 and 31 March 2021. If teams had reorganised as a temporary
response to the COVID-19 pandemic they were asked to report as per their usual commissioned
service. For teams where changes had been made due to the pandemic but there was no intention
to revert to their usual service, they were asked to report on their current service structure.
Whilst the aim of this audit was not to directly investigate the impact of the COVID-19 pandemic,
we have commented on its impact on service provision in the relevant sections of the report.

Aims of the audit
The aims of the audit were:
•
To establish a baseline of current service organisation nationally to compare with
processes of care (SSNAP clinical audit) and to monitor changes over time.
•
To enable providers to benchmark the quality of the component elements of their service
organisation nationally and regionally.
•
To provide timely, transparent information to patients, the public and professionals about
the quality of stroke care organisation in the post-acute setting locally and nationally.
•
To provide commissioners with evidence of the quality of commissioned services and to
identify where improvements to services are needed and make recommendations.

Availability of this report in the public domain
Participating services received a national full results portfolio on 1st November 2021. The full results
portfolio was made available to the wider NHS, including NHS England and Improvement (NHSEI)
and the Care Quality Commission, and Integrated Stroke Delivery Networks (ISDNs in England,
NHS Wales (Welsh Government), the Department of Health and Social Services and Public Safety
in Northern Ireland) on 11th November 2021. The national report was published December 2021 in
line with the transparency agenda subject to HQIP’s standard reporting process.

Post-acute Organisational Audit 2021
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Section 1: Key performance indicators

Key performance indicators (KIs) have been selected to measure performance at a team, service
type and ISDN level (England only). Indicators are derived from the National Stroke Service Model
description of an Integrated Community Stroke Service (ICSS)
(https://www.england.nhs.uk/publication/national-stroke-service-model-integrated-stroke-
delivery-networks/) and the National Clinical Guideline for Stroke (RCP, 2016). Indicators
summarise the core principles underpinning evidence-based post-acute stroke rehabilitation. Our
ambitions are for these indicators to provide a baseline for all regions to drive local improvement,
and nationally to detect improvement over time as the audit is repeated and to demonstrate
progress towards the implementation of the ICSS model. Core features of the ICSS model are
explored in more detail throughout the body of the report.
How the key performance indicators are calculated can be found in Appendix 6. It should be noted
that not all aspects of rehabilitation or quality are covered by these metrics.

Table 1.1: Post-acute team level key performance indicators
KI
Key performance indicator*
Post-acute inpatient
teams (n=93)
Community-based
multidisciplinary
teams*** (n=245)
1.
Team is stroke/neuro specific

73.1% (68)
93.1% (228)

2.
Team has an appropriate level of
staffing for core disciplines**

12.9% (12) of services
meet KI2 for two points
0.8% (2) of services
meet KI2 for two points
1.1% (1) of services meet
KI2 for one point
8.2% (20) of services
meet KI2 for one point

3.
Team has appropriate access to all
relevant disciplines

18.3% (17)
16.7% (41)

4.
Team provides rehabilitation every
day**
9.7% (9) of services
meet KI4 for two points
10.2% (25) of services
meet KI4 for two points
12.9% (12) of services
meet KI4 for one point
5.3% (13) of services
meet KI4 for one point

5.
Team includes access to clinical
psychology
55.9% (52)
66.9% (164)

6.
Inpatient nurses are trained in stroke
assessment and management

58.1% (54)
N/A

7.
Team provides rehabilitation to
people in care homes
N/A
94.3% (231)

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KI
Key performance indicator*
Post-acute inpatient
teams (n=93)
Community-based
multidisciplinary
teams*** (n=245)
8.
Team regularly attends inpatient
MDT meetings
N/A
47.8% (117)

9.
Team service provision is not time-
limited
N/A
42.5% (104)

10.
Team has at least weekly formal
multidisciplinary team meetings with
core disciplines in attendance
60.2% (56)
27.4% (67)

11.
Team offers stroke training for all
disciplines
37.6% (35)
22.5% (55)

12.
Team commences rehabilitation
within recommended no. days from
discharge
N/A
44.5% (109)

13.
Team participates in SSNAP clinical
audit
86.0% (80)
86.1% (211)

14.
Team is actively involved in research
8.6% (8)
9.0% (22)

Median KI score (IQR)
4/10 (3, 6)
6/13 (4, 7)
*The criterion for each KI can be found in Appendix 6
**This is a multi-level KI which means one or two points can be achieved (see Glossary and Appendix 6 for further information)
***Community-based multidisciplinary teams: Early Supported Discharge (ESD), Community Rehabilitation teams, Combined
ESD/CRT

Table 1.1 shows significant variation in performance both regionally and across the stroke pathway.
Variation according to service type is explored throughout the report and appears to have an
influence on achievement of indicators, particularly staffing levels, 7-day working and timeliness.

Post-acute Organisational Audit 2021
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Figure 1.2: Post-acute inpatient team total KI performance

Figure 1.3: Community-based multidisciplinary team* total KI performance

*Community-based multidisciplinary teams include Early Supported Discharge, Community Rehabilitation teams and
Combined ESD/CRT.
Median performance for post-acute inpatient teams was 4 key indicator points with 23.6% of
teams receiving 7-10 of their relevant key performance indicator points. The median performance
for community-based multidisciplinary teams (Early Supported Discharge (ESD), Community
Rehabilitation teams (CRT) and Combined ESD/CRT) was 6 key performance indicators points
scored. 12.2% of community-based multidisciplinary teams received 75% or more of their relevant
key performance indicator points (9-13 KIs).

Post-acute Organisational Audit 2021
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Overall, 42.9% of all indicators have been met by qualifying teams who have participated in the
audit. This supports the clear improvement mandate of the NHSEI stroke plan, identifies key areas
of focus and indicates areas of good practice which need to be shared and amplified at pace.

Figure 1.4: Percentage of post-acute inpatient teams and community-based multidisciplinary
teams*** meeting key performance indicators

*Two points achieved for this KI, **One point achieved for this KI, ***Community-based multidisciplinary teams include
Early Supported Discharge teams, Community Rehabilitation teams and Combined ESD/CRT.
Note: Not all KIs are relevant to all service types (KI 7, 8, 9, 12)

It is encouraging to see a high proportion of stroke specificity in services (87.6%) as well as a high
proportion of services providing input to those in care homes (94.3%).
Priorities include reducing unwarranted variation; improving staffing levels to be able to deliver high
quality, needs-led rehabilitation (KI2, KI9); ensuring access to all necessary disciplines, particularly
0%
50%
100%
KI1: Team is stroke/ neurospecific
KI2:Team has an appropriate level of staffing for core
disciplines. *
KI2: Team has an appropriate level of staffing for core
disciplines**
KI3: Team has appropriate access to all relevant
disciplines
KI4:Team provides rehabilitation every day *
KI4:Team provides rehabilitation every day **
KI5:Team includes access to clinical psychology
KI6: In-patient nurses are trained in stroke assessment
and management
KI7:Team provides rehabilitation to people in care
homes
KI8:Team regularly attends inpatient MDT
KI9:Team service provision is not time-limited
KI10:Team has at least weekly formal multidisciplnary
team meeting with core disciplines in attendance
KI11: Team offers stroke training for all disciplines
KI12: Team commences rehabilitation with
recommended days from discharge
KI13: Team participate in SSNAP clinical audit
KI14: Team actively involved in research
Percentage of Teams meeting KI
Key indicators
Post-acute -inpatient teams
Community-based multidisciplinary teams

Post-acute Organisational Audit 2021
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psychology (KI3); having access to rehabilitation 7 days a week (KI4); and treatment commencing
promptly (KI12).
Many of these indicators were identified as areas requiring improvement in the 2015 audit and whilst
there has been some improvement (see executive summary), continued efforts are required to
meet these priorities.
Key aspects of effective team working, processes and quality such as formal, regular
multidisciplinary team meetings (KI10), training (KI11) and involvement in research (KI13) are
described in later sections of the report (sections 5, 6 and 9) and require improvement.

Table 1.2: Integrated Stroke Delivery Network key performance indicators
Key indicator
Integrated Stroke Delivery Networks who meet
this key indicator (n=20)
KI15: Access to commissioned vocational
rehabilitation
50% (10/20)
KI6: Provision of 6-month reviews
50% (10/20)
KI7: Provision of formally commissioned
support services
35% (7/20)

Table 1.2 shows insufficient commissioning of vocational rehabilitation services, 6-month review
providers and support services at an ISDN level. Further detail in sections 7 and 8 give a more
encouraging picture of the work being carried out in these areas.

Post-acute Organisational Audit 2021
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Section 2: Participation

This section presents participation data for the 2021 iteration of the Post-acute Organisational
Audit. Participation in 2021 is underpinned by a movement towards more integrated services,
which is explored more in section 3. For many teams these changes were initiated or accelerated
by the COVID-19 pandemic. As the ICSS model is adopted more widely, it is expected this
movement will continue over the span of future audits.

Table 2.1: 2021 Post-acute Organisational Audit participation (number of teams responding)

Service type
Count
Post-acute inpatient team
93
Early Supported Discharge team
88
Community Rehabilitation team
86
Combined ESD/CRT
71
6-month assessment provider
78
Single discipline service
66
Other post-acute provider
182

2.1 Patient numbers
Services that responded to the audit report a total patient caseload of 112,174 from 1 April 2020 to
31 March 2021. This provides some assurance that findings are likely to be representative of the
current clinical picture in the UK and shows a growth in provision and participation from 2015.
Due to the COVID-19 pandemic, teams were asked to indicate changes in patient numbers
compared to a usual year. Post-acute inpatient teams and community-based multidisciplinary
teams saw an increase in patient numbers (44% and 39% respectively) in comparison to a usual
year. This is likely to be due to an increase in rapid discharges from hospital to create acute
capacity. In contrast, about a quarter of teams saw a decrease in numbers of patients, representing
services having their criteria limited during COVID-19 and a reduction in stroke presentations to
many acute services.
Table 2.2: Reported caseload numbers by service type in 2015 and 2021
Service type
2015
2021
Post-acute inpatient teams
11,713
12,898
Community-based multidisciplinary teams (Early Supported
Discharge, Community Rehabilitation team, Combined
ESD/CRT)
57,291
68,086
Outpatient
Single discipline service
9273
10,388
Not
collected*
31,190
Total
88,885
112,174
Other post-acute provider
53,092
Not
reported**
*Outpatient services reported as a standalone/single discipline service in 2021
**Other post-acute providers from PAOA 2021 not reported as per the 2015 definition.

Post-acute Organisational Audit 2021
13

It is important to acknowledge this is a significantly higher number of patients than feature in the
SSNAP clinical audit, where community-based multidisciplinary teams report approximately 30,000
patients a year. This reflects that not all participating teams currently submit data to the clinical
audit and that the SSNAP clinical audit features patients up to 6 months after stroke, whereas
participating teams included here may be providing services to people at any point post stroke.
Caseload numbers may also reflect the same patient being counted more than once as they move
through various services, rather than as one continuous patient journey in the SSNAP clinical audit.

2.2 Staff in participating services
Services participating in the audit represent over 6,700 whole-time equivalents (WTE) of staff
delivering stroke rehabilitation. This does not include non-clinical staff, such as SSNAP data
administrators or staffing for any services who identified as an ‘other provider’, such as the Stroke
Association, who collectively would significantly increase this number. This is comparable with
staffing numbers reported in the 2015 audit.

Table 2.3: Total reported WTE and percentage per clinical discipline per service type
Clinical
discipline
Post-acute
inpatient
teams
(n=2886.4)
Community-
based
multidisciplinary
teams: ESD,
ESD/CRT, CRT
(n=3469.8)
6-month
assessment
providers
(n=150.3)
Single
discipline
service
(n=204.3)
Total
reported
WTE
(n=6710.85)
Occupational
therapy
9.3%
(267.3)
23.2%
(803.7)
5.8%
(8.7)
8.7%
(17.8)
16.4%
(1097.5)
Physiotherapy
9.8%
(283.8)
26.8%
(928.2)
6.9%
(10.4)
23.9%
(48.8)
(18.9%)
1271.2
SLT*
3.7%
(108.2)
8.3%
(287.4)
2.9%
(4.4)
44.6%
(91.2)
7.3%
(491.2)
Psychology**
1.5%
(44.1)
2.5%
(87.8)
0.5%
(0.8)
8.5%
(17.4)
2.2%
(150.1)
Dietician**
0.8%
(21.9)
(0.7%)
25.14
0.9%
(1.4)
0.5%
(1.1)
0.7%
(49.5)
Social worker**
0.4%
(12.9)
0.6%
(19.1)
0%
(0)
0%
(0)
0.5%
(32)
Doctor
4.8%
(139.8)
0.1%
(4.3)
7.8%
(11.8)
0%
(0)
2.3%
(155.9)
Nurse
xx-xxxx-xxxx
(58.7%)
249.3
(7.2%)
83.2
(55.3%)
0%
(0)
30.2%
(2027.3)
Rehab Assistant
10.9%
(313.6)
30.7%
(1064.9)
18.1%
(2.2)
13.7%
(28)
21.1%
(1418.7)
Family and carer
support worker**
0%
(0)
0%
(0)
11.6%
(17.5)
0%
(0)
0.3%
(17.5)
*Speech and language therapy
**Under-represented clinical disciplines
Workforce is explored in more detail in section 3. It is clear from these data that some professions
(psychology, dietician, social worker and family and carer support worker) remain under-
represented in the post-acute pathway; this needs to be addressed.

Post-acute Organisational Audit 2021
14

2.3 Inpatient services
The table below shows the number of inpatient teams participating in the audit this year compared
with 2015.
Table 2.4: Number of post-acute inpatient teams and beds

2015
2021
Number of post-acute inpatient teams participating in the post-acute audit
116
93
Number of post-acute inpatient beds that can be used by stroke patients
2,007
1,587

These data suggest a 20.9% reduction in post-acute inpatient team beds since 2015. It will be
important to amalgamate data with the upcoming SSNAP Acute Organisational Audit to determine
if there truly has been a reduction in overall bed numbers. However, an increasing focus on
community-based stroke care, pressures on acute hospitals and the implementation of ‘Discharge
to Assess’ could explain why bed numbers for rehabilitation have reduced. The appropriate bed
base needs to be investigated locally, ensuring an adequate inpatient bed base for those requiring
intensive rehabilitation to transition to the community safely. This is contingent on appropriately
resourced and responsive community-based services and should not be considered in isolation.
Size and location of these units should be explored closely to ensure equity of provision, support
for hyper acute services and appropriate length of stay is maintained. It is recognised that inpatient
pathways differ across the country with varying access to inpatient rehabilitation and specialist
commissioned rehabilitation beds. This needs to be explored more fully to understand the optimal
pathway; however, it is likely that configuration of bedded provision may need to differ according
to local population, rurality, and configuration of acute and community services.
A total of 12 specialist commissioned rehabilitation units participated and are included in the post-
acute inpatient team data throughout the report. This compares with 65 units listed by the UK
Rehabilitation Outcomes Collaborative (UKROC), excluding children’s units and those specialising
in cognitive behavioural rehabilitation.

Table 2.5: Participation of specialist commissioned rehabilitation units
Specialist commissioned rehabilitation unit*
Count
Level 1a Physical disability

1
Level 1b Mixed

3
Level 2a Supra district

2
Level 2b Local

6
Total

12
*For definitions of service types: http://www.ukroc.org and https://www.bsrm.org.uk/downloads/specialised-
neurorehabilitation-service-standards--7-30-4-2015-forweb.pdf

Data for these specialists commissioned units have been reviewed and whilst some units have
higher levels of staffing and 7 day working, overall, these data were not deemed to skew the dataset
or warrant the data being separated. Data for these units can be viewed and compared by applying
filters on the inpatient tab on the online dashboard.
It is recognised that provision of level 1 or 2 inpatient rehabilitation varies across regions; these are
an important part of the stroke pathway, delivering rehabilitation to those with complex needs
following stroke. Data regarding activity in such units is collected via the UKROC database
http://www.ukroc.org.

Post-acute Organisational Audit 2021
15

Figure 2.1: Number and proportion of post-acute inpatient teams by service type

Most post-acute inpatient beds are provided by a community trust, with a small number provided
by social enterprises and private providers. Communication and processes are key to ensure flow
and effectiveness. Collaboration between providers across the pathway is essential.

Figure 2.2: Size of post-acute inpatient units by bed numbers

The size and location of post-acute inpatient units is of significant interest, particularly in areas
where reconfiguration is being considered. Median unit size is 15 beds. There are a reasonable
number of units below ten beds. Cost and resource efficiency should be considered for units of this
size. Stroke specificity of inpatient provision is described in section 3.

0%
20%
40%
60%
80%
100%
Number of services
Acute trust
34
Community trust
42
Acute and community
12
Social enterprise
3
Private provider
2
Acute trust
Community
trust
Acute and
community
Social
enterprise
Private
provider
(n=93)

0%
20%
40%
60%
80%
100%
Number of Services
0-10
28
11-15
25
16-20
22
21-30
10
31-50
6
50+
2
0-10
11-15
16-20
21-30
31-50
50+
Number
of
beds/unit
(n=93)

Post-acute Organisational Audit 2021
16

Figure 2.3: Map showing distribution of Early Supported Discharge, Community Rehabilitation
teams and Combined ESD/CRT

The map shows a good coverage of teams which is comparable with the 2015 audit, with an
increased number of Combined ESD/CRT services (shown in purple). In Northern Ireland more
than 50% of teams are Combined ESD/CRT services, compared to Wales with 100% of Early
Supported Discharge teams (however it is recognised that the figures may not be accurate as audit
participation may have been low in Wales). In England there appears to be a higher proportion of
combined teams in the North. Areas such as the Southwest and the East of England continue to
have a lower distribution of teams, likely relating to patient population, caseloads, and the
geographical area that they operate within. See Appendix 8 for more detailed area-specific maps.

2.4 Other post-acute services
A programme of engagement was undertaken with clinical teams ahead of the audit, to encourage
participation from services who traditionally may not have engaged with the SSNAP clinical audit
or previous organisational audits. We were keen to represent and acknowledge the broad and wide-
ranging network of services that contribute to post-acute stroke care in 2021.

Post-acute Organisational Audit 2021
17

Table 2.6: Services delivered by other post-acute support providers
Service provided
Percentage
Count (n=182)
Information and signposting service
88.5%
161
Benefit support
18.1%
33
Patient, family and carer support
89.6%
163
Communication support
82.4%
150
Emotional support
84.1%
153
Exercise and educational service
12.6%
23
Reablement service
11.0%
20
Equipment support
5.5%
10
Peer support service
34.6%
63
Intermediate care beds
1.1%
2
Level 1/Level 2/Level 2b
neurological rehabilitation unit
0%
0
Residential facility
1.7%
3

Table 2.6 shows encouragingly high numbers of formally commissioned emotional support and
communication support services exist, alongside information and signposting, and patient and
family support. We had created a category in the ‘other post-acute providers’ section of the audit,
but as can be seen in Table 2.6 none of the 12 specialist commissioned rehabilitation units identified
themselves in this category. UKROC list 65 specialist commissioned rehabilitation units, many of
which will accept patients following stroke. Therefore, there are a significant number (up to 53) are
unfortunately not represented in this audit. Gaining a full understanding of the services offered to
stroke patients by these units would be helpful in future audits.

Table 2.7: Commissioners of other care providers
Commissioners*
Count (n=182)
Health trust
154
Social care authority
31
Voluntary sector
1
Other
4
* Some services can be commissioned by more than one authority.
The majority of other care providers are commissioned by health trusts (Table 2.7). The contribution
of the ‘other post-acute providers’ is significant, and teams make a valuable contribution to stroke
rehabilitation at different stages of the pathway.

Post-acute Organisational Audit 2021
18

Section 3: Resources and configurations

In this section we report on how services are configured and whether appropriate access and
numbers of staff are available, benchmarked against the National Stroke Service Model, ICSS
model and National Clinical Guideline recommendations.

3.1 Service specificity

Standard: The service is stroke or neurology specific.

Providing treatment to stroke patients either as a stroke only service or as part of a stroke and
neurology service is recommended to enable specialist stroke rehabilitation.

Figure 3.1: Post-acute service specificity

It is encouraging to see that only a small percentage of inpatient and Combined ESD/CRT are
general services, and that stroke or stroke/neuro specific services are the predominant type of
post-acute service provided.

0%
20%
40%
60%
80%
100%
Post-acute inpatient team
Early Supported Discharge team
Community Rehabilitation Team
Combined ESD/CRT
Percentage
Post-acute service
Stroke specific
Stroke and neurology patients
General service

Post-acute Organisational Audit 2021
19

3.2 Service configuration (community-based services)

Standard: The Integrated Community Stroke Service model is adopted.

We set criteria to understand how Combined ESD/CRT team types were organised.
Table 3.1: Combined ESD/CRT rehabilitation teams criteria
Combined ESD/CRT teams (n=71)
Shared
clinical
caseload
One
management
structure
Single point of
access/referral
route
Flexible
staff
No internal re-
referral required
No criteria
met
91.5%
(65)
90.1%
(64)
91.5%
(65)
91.5%
(65)
71.8%
(51)
1.4%
(1)

The high percentages of services meeting these criteria, as reported in Table 3.1, shows that for
this service type integration has been achieved, reflecting adoption of the ICSS model. Integration
of services offers opportunities for a more seamless, needs-based approach for patients. However,
it is important that appropriate staff to patient ratios are met to manage caseloads and to offer the
intensity of rehabilitation required.

3.3 Caseload (community-based services)

Standard: Services treat predominantly stroke or stroke and neurology patients.

We asked services to report both numbers of stroke patients and numbers of all patients.
Table 3.2: Patients seen by team
Service

Median number of
stroke patients seen
(IQR)
Median number of all
patients seen (IQR)
Percentage of stroke
patients seen by team’s
median (IQR)
Early Supported
Discharge team
(n=88)
248.5 (150.5, 364.5)
293.5 xx-xxxx-xxxx, 407.0)
100 % (100.0, 100.0)
Community
Rehabilitation team
(n=86)
157.5 (77.0, 247.5)
553.5 (241.3, 906.5)
37.3% (17.0, 100.0)
Combined
ESD/CRT (n=71)
341.0 (213.0, 448.5)
485.0 (332.5, 796.0)
97% (40.1, 100.0)

Caseload numbers are larger than expected, given the stroke patient numbers featured in the
SSNAP clinical audit. This is particularly the case for community-based multidisciplinary teams and
when considering all patients treated by services. This likely reflects continued reductions in length
of hospital stay and a focus on provision of community-based services.
The percentage of stroke patients treated as part of a larger patient cohort remains high in
Combined ESD/CRT teams, suggesting that the stroke specificity of rehabilitation delivered is
being maintained. Community Rehabilitation teams treat a lower proportion of stroke patients, and
14% of these teams are generalist services. A move toward the ICSS model would ensure patients
receive the specialist rehabilitation they need.

Post-acute Organisational Audit 2021
20

3.4 Multidisciplinary team composition (community-based services)

Standard: The team is multidisciplinary with access to appropriate disciplines.

As recommended in the ICSS model and the National Clinical Guideline for Stroke, it is important
that a variety of disciplines are part of the core multidisciplinary team and that access to further
disciplines is available where required. As can be seen in the following three figures, a high
percentage of Early Supported Discharge services have occupational therapists, physiotherapists,
speech and language therapists and rehabilitation assistants as members of the core team as well
as access to a range of other core disciplines. This is maintained in Combined ESD/CRT teams.

Figure 3.2: Early Supported Discharge team composition

Figure 3.3: Community Rehabilitation team composition

0%
20%
40%
60%
80%
100%
Occupational therapist
Physiotherapist
Speech and language therapist
Clinical psychologist
Dietitian
Social worker
Doctor
Nurse
Rehabilitation assistant
Family/Carer Support worker
Orthotist
Orthoptist
Podiatrist
Percentage
Clinical Disicpline
Yes
Yes but not in team
No
0%
20%
40%
60%
80%
100%
Occupational therapist
Physiotherapist
Speech and language therapist
Clinical psychologist
Dietitian
Social worker
Doctor
Nurse
Rehabilitation assistant
Family/Carer support worker
Orthotist
Orthoptist
Podiatrist
Percentage
Clinical Discipline
Yes
Yes but not in team
No

Post-acute Organisational Audit 2021
21

Figure 3.4: Combined ESD/CRT team composition

3.5 Staff and patient ratios (community-based services)

Standard: Services meet resource recommendations in the ICSS model.

We investigated whether services met the recommended ratios of staff and patients.
Table 3.3: Staffing levels: whole time equivalent of staff per 100 patients
Discipline
Recommen
ded level of
staffing per
100
patients
(whole time
equivalent)
Early
Supported
Discharge
teams
(n=88) who
met this
threshold
Community
Rehabilitatio
n teams
(n=86) who
met this
threshold
Combined
ESD/CRT
(n=71)
who met
this
threshold
National
median of
staffing
per 100
patients
(whole
time
equivalent)
Inter-
quartile
range
Occupational
therapist
1.0
34.1%
(30)
20.9%
(18)
22.5%
(16)
0.69
0.44-1.02
Physiotherapist
1.0
37.5%
(33)
27.9%
(24)
28.2%
(20)

0.75
0.53-1.1
Speech and
language
therapist
0.4
46.6%
(41)
29.1%
(25)
33.8%
(24)
0.38
0.25-0.54

The ICSS model recommends staffing levels per patients for all core disciplines and that the whole
service is appropriately resourced. Table 3.3 features data on just the three core disciplines from
which part of key indicator 2 was derived (see Appendix 1). This shows that a third or less of
services met recommended staffing levels for these disciplines and these levels were more likely
0%
20%
40%
60%
80%
100%
Occupational therapist
Physiotherapist
Speech and language therapist
Clinical psychologist
Dietitian
Social worker
Doctor
Nurse
Rehabiliation assistant
Family/Carer support worker
Orthotist
Orthoptist
Podiatrist
Percentage
Clinical Dscipline
Yes
Yes but not in team
No

Post-acute Organisational Audit 2021
22

to be met by ESD teams. The national median figures show that services are close to meeting these
criteria. These figures suggest that whilst integration of Early Supported Discharge teams and
Community Rehabilitation teams offers advantages, appropriate resource is still required to ensure
recommended staff to patient ratios are met to manage caseloads and to offer the intensity of
rehabilitation required.

3.6 Multidisciplinary team composition (inpatient services)

Standard: The team is multidisciplinary with access to appropriate disciplines.

We investigated who provided medical care in post-acute inpatient care settings.

Figure 3.5: Specialty of doctors providing medical care for post-acute inpatient teams

Although 47% of post-acute inpatient services offer care from stroke specialist staff, 51% of
services have medical care provided by non-specialists and in total 80% of services are consultant
led. Use of lower grade stroke specialist medical staff for post-acute care, supported by advanced
or consultant practitioners (nurses or allied health professionals), could be a more efficient use of
workforce, releasing stroke physician sessions for management of acute care.

47.3%
33.3%
3.2%
5.4%
12.9%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Stroke Consultant
Non Specialist
Consultant
Neurorehabilitation
Consultant
GP
Junior Doctor
Percentage of services
Doctor

Post-acute Organisational Audit 2021
23

Figure 3.6: Multidisciplinary team composition for post-acute inpatient teams

Like community-based services, it is important for post-acute inpatient services to include a variety
of disciplines as part of the core multidisciplinary team, with access to further disciplines where
required. A significant number of post-acute inpatient teams (44%) do not have access to clinical
psychologists and 29% do not have access to orthoptists. A high percentage of services have
access to a social worker.

3.7 Staff and patient ratios (inpatient services)

Standard: The service meets National Clinical Guideline for Stroke recommendations for
staffing levels.

We also investigated whether services meet the recommended ratios of staff to patients.
Recommended staffing levels have been taken from the National Clinical Guideline for Stroke
(RCP, 2016). It should be noted that at the time this was written, staffing recommendations
pertained to 5 day working.
Table 3.4: Inpatient staffing levels
Disciplines
Recommended
whole time
equivalent per 5
beds
Percentage of
teams who met
the
recommended
whole time
equivalent
(n=93)
National median
of whole time
equivalent per 5
beds
Interquartile
range
Occupational
therapist
0.81
49.5% (46)
0.81
0.6-1.08
Physiotherapist
0.84
47.3% (44)
0.84
0.67-1.14
0%
20%
40%
60%
80%
100%
Occupational therapist
Physiotherapist
Speech and language therapist
Clinical psychologist
Dietitian
Social worker
Doctor
Nurse
Rehabiliation assistant
Family/Carer support worker
Orthotist
Orthoptist
Podiatrist
Percentage
Clinical Disicpline
Yes
Yes but not in team
No

Post-acute Organisational Audit 2021
24

Disciplines
Recommended
whole time
equivalent per 5
beds
Percentage of
teams who met
the
recommended
whole time
equivalent
(n=93)
National median
of whole time
equivalent per 5
beds
Interquartile
range
Speech and
language therapist
0.4
37.6% (35)
0.38
0.29-0.47
Clinical
psychologist
0.2
21.5% (20)
0.18
0.13-0.41
Dietitian
0.15
19.5% (18)
0.14
0.10-0.17

Recommended
level per stroke
bed
Percentage of
teams who met
the
recommended
level per
bed(n=93)
National median
of whole time
equivalent per
bed
Interquartile
range
Nurse
1.35
71% (66)
1.58
1.27-2.12

It is of significance that less than 50% of services have recommended levels of any of the core
disciplines, which needs to be addressed Very few individual services meet the recommended level
for each of the core disciplines (occupational therapists, physiotherapists and speech and language
therapists). The majority of services nearly meet, meet or exceed the recommended nurse staffing
levels.
3.8 Nursing skill mix for inpatient services

The table below shows the median skill mix of the nursing workforce in inpatient services. Where
the median is used as the average the total may not add up to 100%.

Table 3.5: Nursing skill mix; median percentage of nursing bandings across all post-acute
inpatient teams
Nursing band
Median percentage of nursing bandings (n=93)*
Band 1
0%
Band 2
37%
Band 3
8%
Band 4
0%
Band 5
32%
Band 6
10%
Band 7
4%
Band 8a
0%
Band 8b
0%
Band 8c
0%
* This table shows an expected high reliance on band 2s and 5s.
Notably there is a lack of band 4 staff, who can autonomously undertake some nursing and
rehabilitation tasks, and low numbers of nurses above band 7 level. Section 5 discusses team
leadership in more detail and highlights that post-acute rehabilitation beds are well placed for non-
medical advanced and consultant practitioner roles, most of which are band 8a and above.

Post-acute Organisational Audit 2021
25

Section 4: Needs-based rehabilitation

As emphasised in the National Stroke Service Model and the Integrated Community Stroke Service
model, it is important to provide a seamless stroke care pathway with 7-day working and avoidance
of waiting times. Services should be provided based on needs, rather than being time limited.
4.1 Seven day working

Standard: The service delivers rehabilitation 7 days per week.

We asked providers to tell us how many days per week their service was provided.

Table 4.1: Number of days per week service provided
Service type*
<5 days per
week
5 days per
week
6 days per
week
7 days
per week
Early Supported Discharge team (n=88)
1.1% (1)
64.8% (57)
8.0% (7)
26.1%
(23)
Community Rehabilitation team (n=86)
1.2% (1)
83.7% (72)
1.2% (1)
14.0%
(12)
Combined ESD/CRT (n=71)
0% (0)
53.5% (38)
21.1% (15)
25.4%
(18)
Single discipline service (n=66)
31.8% (21)
66.7% (44)
1.5% (1)
0% (0)
*Question only asked of community-based teams.
This table shows there is still a predominance of 5-day services, particularly with regard to
Community Rehabilitation teams. Although 25% of combined ESD/CRTs offer a 7-day a week
service, the full complement of core disciplines is not available. These issues need to be addressed.

4.2 Waiting times

Standard: First contact and treatment is to be provided within 24 hours for patients receiving
Early Supported Discharge.

Table 4.2: Waiting time for treatment
Service type
Median waiting time for treatment (days)
Early Supported Discharge team (n=88)
2
Community Rehabilitation team (n=86)
14
Combined ESD/CRT (n=71)
4
Singe discipline service (n=66)
37.5

Whilst this table suggests that some patients accessing Early Support Discharge may not be
treated within 24 hours, it is positive responsiveness for Combined ESD/CRT is close to the 3-day
standard.
The following three figures show the range of waiting times for each service type, with blue bars
indicating teams that meet the waiting time to treatment standard, and red bars for those who do
not.
Some Early Supported Discharge services have a waiting list of 2 days or more. We would argue
that services with a waiting list of over a week, and certainly with a 15-day waiting list, are not Early
Supported Discharge services.

Post-acute Organisational Audit 2021
26

Community Rehabilitation teams have a median waiting time of 14 days for treatment, and 37% of
services have waiting times of 15 days or over. This emphasises the need for more progress
towards implementing the Integrated Community Stroke Service model.
56.7% of community-based multidisciplinary teams reported no change in waiting times as a result
of COVID-19. However, 32% reported an increase in time to first intervention.

Figure 4.1: Early Supported Discharge team median waiting times from discharge/referral to
treatment

Figure 4.2: Community Rehabilitation team median waiting times from discharge/referral to
treatment

Meets standard
Doesn’t meet standard
Meets standard
Doesn’t meet standard

Post-acute Organisational Audit 2021
27

Figure 4.3: Combined ESD/CRT median waiting times from discharge/referral to treatment

4.3 Time limits and re-referrals

Standard: Rehabilitation is provided for as long as the patient needs it.

We asked whether services had a time limit and were encouraged that 60% of Combined ESD/CRT
did not. There is a high percentage of time limited Early Supported Discharge services which is to
be expected. However, given the waiting times associated with access to Community Rehabilitation
teams, this suggests many patients will be left without access to specialist rehabilitation beyond
Early Supported Discharge, which is likely to impede their recovery.
Table 4.3: Time limits of services
Teams without time limit to service

Service Type
Percentage
Count
Early Supported Discharge team (n=88)
12.5%
11
Community Rehabilitation team (n=86)

59.3%
51
Combined ESD/CRT (n=71)

59.2%
42
6-month assessment provider (n=78)
76.92
60
Single discipline service (n=66)
83.3%
55

Meets standard
Doesn’t meet standard

Post-acute Organisational Audit 2021
28

Figure 4.4: Community-based multidisciplinary team time limits (duration by weeks)

*1 Early Supported Discharge team reported a time limit of 6-10 sessions, 5 Community Rehabilitation teams reported a time
limit of 6-10 sessions, so therefore are excluded from this graph.

We also investigated the length of time over which services were provided. As expected, most Early
Supported Discharge services (79%) operate over a 6 week period. 86% of Combined ESD/CRT
teams operate over a longer period. Services need to be provided so that each individual patient
has access to specialist rehabilitation over the period that they need it.
We also asked if patients could be re-referred into the service following discharge.

Table 4.4: Re-referral to stroke service
Service type
Percentage
Count
Early Supported Discharge team (n=88)
80.7%
71
Community Rehabilitation team (n=86)
38.4%
33
Combined ESD/CRT (n=71)
85.9%
61
Single discipline service (n=66)
97%
64

A high percentage of teams (80%+) of each service type (apart from Community Rehabilitation
teams) accept re-referrals. That the percentage of Community Rehabilitation teams is much lower
again suggests that implementation of the ICSS model would enable a more needs-based service
to be provided.
0%
20%
40%
60%
80%
100%
Early Supported Discharge team* (77)
Community Rehabilitation team (35)
Combined ESD/CRT (29)
Percentage
Service
0-6 weeks
7-12 weeks
13-26 weeks
>26 weeks

Post-acute Organisational Audit 2021
29

4.4 Mode of contact
Delivery of face-to-face therapy was maintained, and adoption of video consultation was overall
quite small, despite the challenges posed by the COVID-19 pandemic. Adoption of remote delivery
of rehabilitation to augment face to face therapy may offer opportunities to increase intensity of
rehabilitation provided; however, this does need to be evaluated further.
Table 4.5: Mode of contact comparison*
Treatment/assessment sessions
Current median
percentage (March
2021)
Median percentage one
year ago (March 2020)
Face to face (individual)

80%
90%
Face to face (in groups)

0%
0%
By video consultation (individual)

5%
0%
By video consultation (in groups)

0%
0%
By telephone

12%
5%
*Estimated by teams, not formally recorded; medians do not add up to 100%

4.5 Treatment of patients in care homes

Standard: Services should be provided to stroke patients in care homes.

Table 4.6: Treatment of patients in care home
Service type
Percentage of services which
deliver treatment to patients
in care homes
Count
Early Supported Discharge team (n=88)

93.2%
82
Community Rehabilitation team (n=86)

93.2%
80
Combined ESD/CRT (n=71)

97.2%
69
Single discipline service (n=66)
75.8%
50
Other post-acute provider (n=182)
66.5%
121

Notably there are high percentages of Early Supported Discharge, Community Rehabilitation teams
and Combined ESD/CRT provide rehabilitation and care for patients in care homes, in line with
ICSS model recommendations. Access to other post-acute provider services (66.5%), such as Life
after Stroke services (e.g. communication, emotional and peer support) needs to be improved for
patients in care homes.

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Section 5: Multidisciplinary team working

Standard: Services have good leadership and effective multidisciplinary team working practices
to provide optimal evidence-based rehabilitation.

Clinical leadership is known to improve team processes and clinical outcomes.

Figure 5.1: Clinical disciplines which provide leadership*

*Teams could submit multiple responses to this question.

Figure 5.1 shows which disciplines have a leadership role within each service type. Team leadership
is varied, with a high percentage of teams being led by the core therapy disciplines. Some
Community Rehabilitation teams do not have a designated leader; this is likely to impact on service
quality and effectiveness and will be detrimental to multi and interdisciplinary working.
Nurse and allied health professional advanced and consultant roles are well placed in rehabilitation
services and assist in meeting the British Association of Stroke Physicians (BASP) recommended
consultant sessions for inpatient rehabilitation and ESD teams, especially considering stroke
physician workforce challenges.

0%
20%
40%
60%
80%
100%
Occupational therapist
Physiotherapist
Speech and language
therapist
Clinical psychologist
Dietician
Doctor
Nurse
Orthotist
Orthoptist
Podiatrist
No leadership
Percentage
Clinical Discipline
Post-acute inpatient team
Early Supported Discharge team
Community Rehabilitation team
Combined ESD/CRT

Post-acute Organisational Audit 2021
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Figure 5.2: Attendance of clinical disciplines at multidisciplinary meetings

Effective multidisciplinary team meetings require that all core disciplines attend. Figure 5.2
suggests that whereas the majority of services have strong representation from occupational
therapy and physiotherapy, representation of other disciplines across service types is varied.
Attendance by clinical psychologists at multidisciplinary meetings could be an effective method of
psychology staff providing an educational and consulting role to support other members of the
community-based multidisciplinary teams to deliver appropriate levels of psychological care as
described in the stepped care model. (RCP, 2016)

0%
20%
40%
60%
80%
100%
Occupational therapist
Physiotherapist
Clinical psychologist
Speech and language
therapist
Dietitian
Social worker
Doctor
Nurse
Rehabilitation assistant
Family/Carer support worker
Orthotist
Orthoptist
Podiatrist
Percentage
Clinical Discipline
Post-acute inpatient team
Early Supported Discharge team
Community Rehabilitation team
Combined ESD/CRT

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Section 6: Education, information and training

6.1 Swallow assessment (post-acute inpatient teams)

Standard: Early swallow assessment is required to ensure safe nutrition and hydration, to
prevent secondary complications and improve outcomes.

Table 6.1: Registered nurses trained in swallow screening (all post-acute inpatient teams)

Shift
Percentage of
registered nurses on
duty trained in
swallow screening
Count of registered
nurses on duty
trained in swallow
screening
Total number of registered
nurses on duty (all post-
acute inpatient teams)
Weekday
morning shift
31.7%
90
284
Saturday
morning shift
29.1%
80
275
Sunday
morning shift
29.5%
81
275
Weekday
evening shift
26.7%
58
217
Saturday
evening shift
26.7%
58
217
Sunday
evening shift
26.7%
58
217

Table 6.1 presents data relating to nurses trained in swallow assessment in post-acute inpatient
teams. The proportion of nursing staff trained in swallow screening is low. With a mean total of
three WTE nursing staff on a weekday shift, this may mean only one nurse is swallow trained, which
is limiting. For instance, if they are senior staff, they may have other competing demands; or it is
challenging for a single person if multiple admissions require swallow screening. This will contribute
significantly to clinical performance regarding early swallow assessment and the associated
risks. Further investigation into banding of staff who are trained in swallow assessment is required
to better understand the implications of this finding, as well as the impact on other professionals
completing swallow assessments such as speech and language therapists.

6.2 Stroke management (post-acute inpatient teams)

Standard: Staff providing care for patients following stroke should be stroke specialist or stroke
skilled staff.

Stroke is a complex specialty requiring knowledge and skills across a broad range of domains
including stroke presentation, acute management, positioning and manual handling,
communication, dysphagia and end of life care.

Table 6.2: Registered nurses on duty trained in stroke management (all post-acute inpatient
teams)
Shift
Percentage of
registered nurses on
duty trained in stroke
management
Count of registered
nurses on duty trained
in stroke management
Number of
registered nurses
on duty (all post-
acute inpatient
teams)
Weekday morning
shift
61.3%
174
284
Saturday morning
shift
60%
165
275

Post-acute Organisational Audit 2021
33

Shift
Percentage of
registered nurses on
duty trained in stroke
management
Count of registered
nurses on duty trained
in stroke management
Number of
registered nurses
on duty (all post-
acute inpatient
teams)
Sunday morning
shift
59.6%
164
275
Weekday evening
shift
58.5%
127
217
Saturday evening
shift
58.9%
128
217
Sunday evening
shift
58.9%
128
217

Table 6.2 presents data relating to nurses trained in stroke management in inpatient services. The
proportion of staff trained in stroke management does not vary across shifts. Approximately 40%
of registered nurses on any given shift have received no stroke management training, contravening
stroke unit standards. A number (26/93) of the participating inpatient units are mixed units seeing
patients with various conditions. Ward processes such as how staff are distributed across units,
multidisciplinary team handovers, joint working, and communication (such as diet and fluid
recommendations and mobility signs above beds) may mitigate the impact of staff not being trained
in stroke management. Wider access to stroke management training is preferable.

Table 6.3: Training sessions* attended by staff 1st April 2020-31st March 2021
Service Type
Number of
training sessions
attended by all
staff
Number of
training sessions
attended by
nurses
Number of
training sessions
attended by
therapists
Number of
training
sessions
attended by
therapy
assistants
Post-acute
inpatient teams
(n=93)
2,467
721 (29.2%)
1,061 (43.0%)
685 (27.8%)
Early Supported
Discharge team
(n=88)
717
103 (14.1%)
420 (58.6%)
194 (27.1%)
Community
Rehabilitation
team (n=86)
717
45 (6.3%)
434 (60.5%)
238 (33.2%)
Combined
ESD/CRT (n=71)
1,800
232 (12.9%)
996 (55.3%)
572 (31.8%)
6-month
assessment
provider (n=78)
571
291 (51%)
215 (37.7%)
65 (11.4%)
Single
discipline
service (n=66)
513
3 (0.6%)
363 (70.8%)
147 (28.7%)
*1 session is approximately equivalent to half a day training.
Regular and relevant training is an important feature for teams; guidance recommends that stroke
care is delivered by stroke specialist or stroke skilled staff (RCP, 2016). A total of 6,785 sessions
of stroke related training were attended in the year from 1 April 2020 to 31 March 2021. The COVID-
19 pandemic will have significantly limited training and how it is delivered and therefore it is a priority
that this improves as services return to business as usual. Inpatient nurses attended 29% of all
training attended by the post-acute inpatient teams yet make up 58.7% of the post-acute inpatient
team’s workforce (see section 2). Data suggest that therapy staff are attending significantly more

Post-acute Organisational Audit 2021
34

training than nursing colleagues in the inpatient setting. This can be a cause of contention within
multidisciplinary teams. The total number of training sessions attended by nurses was 1,395. Given
that 1,694.8 WTE nurses were reported to work within these services (section 2), this equates to
0.8 sessions per WTE nurse in a year. Considering the breadth of stroke rehabilitation, this requires
improvement. Efforts should be made to ensure nurses can be released to attend training, whilst
ensuring care needs continue to be met. This is equally important for those working predominantly
night shifts, who may attend a disproportionately low amount of training.
Distribution of training across staff groups appears to be in line with workforce size (see section 2)
in all other service types, including 6-month assessment providers.
Provision of high-quality multidisciplinary in-service training should be prioritised for all service
types. ensuring arrangements are made for all team members to attend, as well as external courses
and conferences. This is especially important for Community Rehabilitation teams with mixed
caseloads, who may not be aware of or able to access specialist training.
The Stroke Specific Education Framework (SSEF) developed by the University of Central
Lancashire for NHSEI (https://stroke-education.org.uk), should be reviewed for all staff to ensure
training is being provided across all relevant domains of care for each discipline.

6.3 Patient and carer training

Standard: Training should be provided for stroke patients and carers.

Table 6.4: Training for stroke survivors and their carers
Service type
Percentage of services
who provide training for
patients
Count
Percentage of services
who provide training for
carers
Count
Post-acute
inpatient teams
(n=93)
36.6%
34
24.7%
23
Early Supported
Discharge team
(n=88)
54.5%
48
14.8%
13
Community
Rehabilitation
team (n=86)
82.5%
71
17.4%
15
Combined
ESD/CRT (n=71)
53.5%
38
18.3%
13
6-month
assessment
provider (n=78)
61.5%
48
1.3%
1
Single discipline
service (n=66)
24.2%
16
7.5%
5

Reported levels of training provided for carers are insufficient across all service types. Carer
training is an expectation of services as stated in the National Clinical Guideline for Stroke (RCP,
2016). Carer training is likely to improve the discharge experience and should aim to ensure carers
are well informed about stroke, patient needs, rehabilitation treatment plans, care arrangements
and support options. In particular, inpatient units are not providing training consistently to patients
or carers to support the often-daunting transition into the community.
A higher percentage of teams provide training for patients than for carers particularly in the
community. Further exploration is required to understand how resources are used, how information
is adapted appropriately for those with aphasia, cognitive or visual difficulties, and whether training
is delivered on an individual patient basis, in groups, in person or virtually.

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35

Section 7: Vocational rehabilitation

Standard: Vocational rehabilitation should be available for all stroke patients who need it.

Vocational rehabilitation (VR) is defined as a service that supports stroke patients to return and
remain in work.
7.1 Vocational rehabilitation providers

Figure 7.1: Location of vocational rehabilitation providers

Figure 7.1 displays a good coverage of teams; however, there is a lack of VR services in Wales that
needs to be investigated (keeping in mind that it is possible that participation of Welsh organisations
in the audit was not representative).

Table 7.1: Achievement of KI15 by English NHS region
NHS region

Number of ISDNs
Number of ISDNs
meeting KI15
Percentage
East of England

2
2
100%
London

1
1
100%
Midlands

3
2
66%
North East and
Yorkshire
4
2
50%
Key: Dot colour indicates the type of service
delivering vocational rehabilitation:

Post-acute Inpatient Team
Early Supported Discharge
Community Rehabilitation Team
Combined ESD/CRT
Single Discipline service
Other Post-Acute Provider service

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NHS region

Number of ISDNs
Number of ISDNs
meeting KI15
Percentage
North West

3
2
66%
South East

5
1
20%
South West

2
0
0%
Total

20
10
50%

Table 7.1 shows the number of ISDNs within NHS regions that have met KI15, which we have defined
as at least 50% of services within the ISDN providing VR. The table demonstrates significant
variability in access to VR across ISDNs.

Table 7.2: Number of services providing Vocational rehabilitation
Service type (n=167)
Percentage
Count
Standalone

18%
30
Early Supported Discharge, Community Rehabilitation team,
Combined ESD/CRT
82%
137

Table 7.2 shows that the majority of VR services are provided by community MDTs, rather than
standalone VR services. This demonstrates an increase in VR provision from the previous audit in
2015 and supports the movement towards the ICSS model. Data regarding VR were collected
differently than in 2015, so it is not possible to demonstrate if there was a change in service model
towards VR being delivered predominantly by community multidisciplinary teams. However, we
suspect there was a significant shift, with community teams perhaps picking up the remit of this
work in the absence of formally commissioned services.

7.2 Commissioning of vocational rehabilitation

Standard: Vocational rehabilitation should be formally commissioned by either a clinical
commissioning group or a Health Board.

Table 7.3: Vocational rehabilitation commissioning (percentage per service type)
Service type
Yes, service
commissioned and
provided
Service provided
but not
commissioned
Service not
provided but
provider has
access to VR
No VR
available
Post-acute
inpatient teams
(n=93)
5.4% (5)
7.5% (7)
63.4% (59)
23.7% (22)
Early
Supported
Discharge team
(n=88)
11.4% (10)
37.5% (33)
33.0% (29)
18.0% (16)
Community
Rehabilitation
team (n=86)
14.0% (12)
44.1% (38)
30.2% (26)
11.6% (10)
Combined
ESD/CRT
(n=71)
23.9% (17)
38.0% (27)
22.5% (16)
15.5% (11)
Single discipline
service (n=66)
7.6% (5)
16.7% (11)
37.9% (25)
37.9% (25)

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37

The majority (71%) of teams provide VR without it being formally commissioned. Formal
commissioning of VR services has reduced since the 2015 audit from 15% to 7.4% (of all post-
acute services participating in the audit). Therefore, formal commissioning remains a significant
priority. VR should be detailed in service specifications, with associated reporting metrics and
patient outcome data.
The table above shows that around 50% of community-based multidisciplinary teams (Early
Supported Discharge, Community Rehabilitation teams and Combined ESD/CRT) provide VR. VR
being delivered as an integral part of a holistic rehabilitation plan has notable advantages (such as
continuity of staff and treatment; no waiting times following referral onto a separate service). It will
be important as the ICSS model is adopted that the issue of provision of VR is addressed.
Efforts should be focussed on ensuring that VR is prioritised; is not diluted by other aspects of
rehabilitation programmes; and remains true to the definition of VR whether it is delivered by a
specific VR service or as part of a community rehabilitation service (Early Supported Discharge or
Combined ESD/CRT).

7.3 Where is vocational rehabilitation delivered?

Table 7.4: Location* in which vocational rehabilitation is delivered (all service types)
Location
Number of services providing vocational
rehabilitation in this location
Acute hospital
12
Community hospital
33
Doctors’ surgery, health centre/ clinic/
community centre
23
Leisure centre/ gym
48
Patient/ carer/ family member’s home
156
Care home
28
Patient's workplace
107
*Teams were able to select more than one location

Appropriately, the majority of VR sessions are delivered in the patient’s own home and workplace.
Distribution of where VR sessions are delivered does not vary significantly by service type.

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7.4 Disciplines carrying out vocational rehabilitation

Figure 7.2: Clinical disciplines providing vocational rehabilitation (all service types)

The multidisciplinary team approach to VR demonstrated in Figure 7.2 is recommended and likely
reflects the number of community-based multidisciplinary teams which deliver VR. Lack of access
to psychology is a limiting factor for VR, as it is across the rest of the pathway. It was observed that
higher proportions of inpatient services have psychologists delivering VR. Staff resource
implications for VR and particularly for occupational therapy need to be explored to ensure that
effective and timely VR can be delivered alongside other aspects of rehabilitation.

7.5 Who is offered vocational rehabilitation?

Figure 7.3: Criteria for vocational rehabilitation services (all service types)

There is variation in who is considered eligible for VR. Standardisation of eligibility criteria would
ensure access for those who have a goal to explore commencing or returning to paid or voluntary
employment or education. Variability may be explained in part by services which are not
commissioned to deliver VR, and which have taken on this remit alongside their primary
responsibilities. Formal commissioning with detailed service specifications should address this
issue.
0%
20%
40%
60%
80%
100%
All stroke patients of working age
Only patients considered fit enough to return to
work
Only patients considered fit enough to return to
work and not previously unemployed
Percentage of teams
Which patients are provided vocational rehabilitation
0%
20%
40%
60%
80%
100%
Occupational therapist
Physiotherapist
Speech and language therapist
Clinical pyschologist
Social worker
Nurse
Rehabiliation assistant
Family/carer support worker
Percentage
Clinical Discipline

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7.6 Duration of vocational rehabilitation, by number of sessions

Figure 7.4: Mean number of vocational rehabilitation sessions provided to patients (all service
types)

Figure 7.4 above shows that the majority of teams report providing 0-5 sessions per patient. There
is no recommended number of sessions as this should be tailored to the individual’s needs,
workplace and goals. The number of sessions provided may be limited by the proportion of services
which have a time limit. VR should not be limited by any constraints of service time limits, as VR may
need to start later than other aspects of rehabilitation.

7.7 Frequency of vocational rehabilitation sessions

Figure 7.5: Frequency of vocational rehabilitation sessions provided (all service types)

Figure 7.5 shows the majority (74.9%) of services which deliver VR have no set schedule for doing
so, suggesting the programme is tailored to the individual. Further investigation into whether VR is
being delivered in appropriate doses/schedules is warranted, as well as understanding the interplay
between VR and rehabilitation focussed on non-vocational goals also delivered by community-
based multidisciplinary teams.
0%
20%
40%
60%
80%
100%
Daily
Twice weekly
Weekly
Fortnightly
Monthly
No set schedule
Percentage
Frequency

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Section 8: Six-month reviews

Standard: Every stroke patient is offered a 6-month review

Reviews at 6-months are an essential part of the stroke patient pathway, ensuring that patients’
needs are met, their progress reviewed, and future goals set if further support is needed.

Figure 8.1: Map of location of 6-month assessment providers

Figure 8.1 shows the location of the different service types providing 6-month reviews across
England, Wales and Northern Ireland. Whilst there appears to be quite good coverage across these
countries, there are still a number of mainly rural areas where 6-month reviews are not being
conducted. Patients are missing out on a vital review of their stroke secondary prevention, stroke
recovery and disability management, as well as any unmet clinical and social care needs.

Table 8.1: 6-month review providers
Service type
Percentage of services
providing 6-month reviews
Count
Post-acute inpatient team (n=93)
12.9%
12
Early Supported Discharge team (n=88)
33.0%
29
Key:

Post-acute inpatient team
Early Supported Discharge
Community Rehabilitation team
Combined ESD/CRT
6-month assessment provider
Single discipline service

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41

Service type
Percentage of services
providing 6-month reviews
Count
Community Rehabilitation teams (n=86)
34.9%
30
Combined ESD/CRT (n=71)
67.6%
48
6-month assessment provider (n=78)
100%
78
Single discipline service (n=66)
1.5%
1

Figure 8.1 and Table 8.1 show that 6-month reviews are provided by a variety of different service
types. This presents options for commissioners locally. 18.2% of services returned from 6-month
assessment providers were provided by the Stroke Association. Importantly, providers need to use
a standardised 6-month review process, which enables a comprehensive review of needs and
facilitates appropriate onward referral.
The SSNAP clinical audit collects outcome measures data at 6 months, and it is important that all
6-month review providers participate in this audit. Without such outcome data it is difficult for
services and their commissioners to make appropriate clinical service improvements and
demonstrate clinical and cost effectiveness.

Table 8.2: Total number of 6-month reviews completed
Service type
Total number of
stroke patients seen
in 12 months
Total number of
reviews completed
(over 12 month
period)
Median number of
reviews competed by
each service (over 12
month period)
Post-acute inpatient
team (n=12)
2674
1422
115
Early Supported
Discharge team
(n=29)
7373
5575
139
Community
Rehabilitation team
(n=30)
9099
4021
88
Combined ESD/CRT
(n=48)
16562
12534
173
6-month assessment
provider (n=78)
28679
xx-xxxx-xxxx
174
Single discipline
service (n=1)
235
56
56
All (n=198)
64613
40481
157

KI16 is an ISDN level indicator which was deemed to be met if the total number of patients seen for
a 6-month review for all teams in an ISDN was at least 50% of the total stroke patients recorded in
the SSNAP clinical audit (number of stroke patients at 72 hrs in all routinely admitting hospitals in
that ISDN from October 2020 to March 2021, multiplied by 2). Only 50% of ISDNs meet that
indicator, suggesting many patients are missing out on being offered a review.
Table 8.2 shows that the total number of stroke patients seen by each service type is higher than
the total number of reviews completed. This could mean that not all patients offered a review
accepted one. Or it could mean that not all patients associated with that service were offered a
review or required a review during the time of interest. It is important that every stroke patient is
offered a 6-month review and that processes are in place to ensure that every stroke patient who
leaves hospital is followed up.

Post-acute Organisational Audit 2021
42

Figure 8. 2: Clinical disciplines who provide 6-month reviews

Figure 8.2 shows the different disciplines that conduct or are involved in the 6-month review
process and some of this appears related to the setting. It suggests there is multidisciplinary input
into a review and also flexibility in who can carry out a review, which should facilitate capacity and
tailoring. It might also offer commissioners different options for wider provision of 6-month reviews
as well as the opportunity for patients to be seen by the most relevant professional. It is important
that people conducting the review have had sufficient training and that a standardised tool is used.
Every Early Supported Discharge team involved specialist doctors in the 6-month review process,
which is noteworthy when a significant proportion of teams reported not having a doctor within the
team. Use of lower grade staff for reviews, supported by advanced or consultant practitioners
(nurse or allied health professional), could be a more efficient use of workforce.
In community rehabilitation services all the core therapy disciplines are involved in delivering 6-
month reviews. Social workers have little to no involvement, which may be a missed opportunity to
holistically consider the needs of patients and carers.
0%
20%
40%
60%
80%
100%
Occupational therapist
Physiotherapist
Speech and language therapist
Clinical psychologist
Dietician
Specialist doctor
Non-specialist doctor
Junior doctor
GP
Nurse
Social worker
Family/Carer support worker
Orthotist
Orthoptist
Podiatrist
Percentage
Clinical Discipline
Post-acute inpatient team
Early Supported Discharge team
Community Rehabilitation team
Combined ESD/CRT
Single disicpline service
Six-month assessment provider

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Section 9: Participation in clinical audit and research, and use of outcome measures

9.1 Audit and research

Standard: Teams participate in clinical audit and research.

Teams indicated whether they were registered with the SSNAP clinical audit. Full participation in
the SSNAP clinical audit is vital in order for data to be representative and to drive local and national
improvement.
Table 9.1: Participation in SSNAP clinical audit
Service type
Percentage
Count
Post-acute inpatient team (n=93)

86%
80
Early Supported Discharge team (n=88)

98.9%
87
Community Rehabilitation team (n=86)

65.1%
56
Combined ESD/CRT (n=71)

98.6%
70
6-month assessment provider (n=78)
92.3%
72

Table 9.1 shows that high percentages of all service types responded positively, as reflected in 86%
of services meeting KI13 (see section 1). There is a lower percentage for Community Rehabilitation
teams (likely reflecting generalist services).

Table 9.2: Participation in research
Service type
Total number of
patients
recruited to
research
Median number of
patients recruited
Range
Post-acute inpatient team
(n=93)
152
0
0-53
Early Supported Discharge
team (n=88)
155
0
0-86
Community Rehabilitation
team (n=86)
399
0
0-394
Combined ESD/CRT (n=71)

35
0
0-15
6-month assessment
provider (n=78)
287
0
0-212
Single discipline service
(n=66)
88
0
0-22

The median number of patients recruited to research studies is zero for all service types, reflecting
the fact that very few services participate in research. This was reflected in only 9% of services
meeting KI14 (see section 1). We acknowledge that stroke research was significantly affected by
the COVID-19 pandemic. It is known that involvement in research correlates highly with improved
quality of services and patient outcomes. Participation in stroke rehabilitation research needs to be
prioritised.

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9.2 Outcome measures

Standard: Teams should use standardised outcome measures to monitor performance.

The use of outcome measures is an important feature of stroke services, demonstrating the clinical
and cost effectiveness of rehabilitation, which is crucial in developing services further. It should
form part of regular reporting. Ideally, a common set of outcome measures needs to be aligned
across and within service types. This would enable ISDNs and regions to collate and review
community stroke data that complements what is collected in SSNAP. This should be a focus for
ISDNs.
Figure 9.1: Outcome measures collected

It is encouraging to see that a wide range of standardised outcome measures are being routinely
used across all service types. Figure 9.1 shows inconsistent use of outcome measures across
services, with the modified Rankin Scale most commonly used, perhaps due to this measure being
entered into the SSNAP clinical audit. There are some clear differences between measures used
by Early Supported Discharge services compared with Combined ESD/CRT services (especially
the Barthel index) that require further exploration. Outcome measures are infrequently completed
at 6-month reviews and use of EQ5D is low across teams but is expected to increase following its
inclusion in the SSNAP clinical audit for 6-month review services from July 2021. Patient reported
outcome measures (PROMs) are recommended across pathways, with completion of EQ5D earlier
in the pathway allowing the opportunity to detect changes over time when compared with measures
completed at 6-month reviews.

0%
20%
40%
60%
80%
100%
Modified Rankin Scale
Barthel Index
Nottingham Extended Activities of Daily Living
Berg Balance Scale
EQ-5D-5L
PHQ-9
GAD7
Other measures
Percentage
Outcome measure
Early Supported Discharge team
Community Rehabiliation team
Combined ESD/CRT
Single Discipline Service
Six-month assessment provider

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Glossary

6-month
assessment
provider

Providers who only carry out a 6-month outcome assessment of patients. For the
purpose of this audit, acute hospitals providing 6-month assessments fall under
this. This option excludes ESD, CRT, Combined ESD/CRT and standalone/single
discipline services that provide 6-month assessments as part of their service
function.
6-month reviews
A review of a stroke patient’s progress 6 months after their stroke. This review
provides the opportunity to assess whether a patient's needs have been met, to
have their progress reviewed and future goals set if further support is needed.
Carer
A person (commonly the patient’s spouse, a close relative or friend) who provides
ongoing, unpaid support and personal care at home.
Commissioners
Funding bodies of NHS services.

Combined
ESD/CRT
(ESDCRT)

A team that provides both Early Supported Discharge and Community
Rehabilitation services and meets the following criteria:
•
Shared clinical caseload
•
One management structure
•
Single point of access/referral route
•
Staffing establishment/budget is combined, with staff able to work
flexibly across team functions as required
•
No re-referral to another part of the team (i.e. from ESD to CST).
Community-
based multi-
disciplinary teams
Used to refer to Early Supported Discharge services (ESD), Community
Rehabilitation teams (CRT) and Combined ESD/CRT as a collective.
Community
Rehabilitation
team/service
A multidisciplinary team that provides rehabilitation for patients in their own home
or other community setting (including care homes and nursing homes). This may
be following hospital discharge, post ESD rehabilitation or at any point post
stroke where rehabilitation needs are identified. The intensity or duration of this
service should be determined by patient need.
Designated
stroke inpatient
unit
This designated unit can be called a ‘Stroke Unit’ or a ‘Stroke Rehabilitation Unit’,
or be geographically defined beds within a generic ward where stroke patients
can receive specialist support and care.
This unit may be based on an acute site, but must have designated, ringfenced
rehabilitation beds with separate staffing and leadership.
Early Supported
Discharge (ESD)
team
A coordinated multidisciplinary team intended to facilitate the earlier transfer of
care from hospital into the community and providing intensive stroke
rehabilitation in the patient’s place of residence.
General service
A service which provides care to stroke and patients with other neurological
conditions as well as patients with other conditions.
Health Boards

These are administrative units in Wales that plan, secure and deliver healthcare
services in their areas. http://www.wales.nhs.uk/nhswalesaboutus/structure

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Interquartile
range (IQR)
The interquartile range (IQR) is the range between 25th and 75th centile which is
equivalent to the middle half of all values.
ISDN
Integrated Stroke Delivery Network.
ISDN level key
indicator (KI)
A key indicator applied only at Integrated Stroke Delivery Network level.
Ischaemic stroke
Ischaemic strokes are the most common type of stroke. They occur when a blood
clot blocks the flow of blood and oxygen to the brain.
Key performance
indicator
A standard used to measure performance.
Long Term Plan
The NHS England Long Term Plan launched in January 2019. It sets out a plan for
the NHS to improve patient care and health outcomes in the future.
https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-
plan-version-1.2.pdf
Median
The median is the middle point of a dataset; half of the values are below this point,
and half are above this point.
Multidisciplinary
team (MDT)
A team or service which is composed of staff from different healthcare
professions with specialist skills and expertise. The members work together to
ensure patients receive comprehensive, coordinated treatment.
Multi-level key
indicator
KI2 and KI4 are multi-level key indicators, meaning that there are multiple
thresholds in order for the KI to be met. If some of the thresholds are partially
met, then one point is given. If all the thresholds are met, then two points are
given. So, although there are 14 KIs it was possible to score double points for
some KIs.
National Clinical
Guideline for
Stroke (2016)
A national evidence-based guideline for stroke care published by the
Intercollegiate
Stroke
Working
Party,
fifth
edition
2016
https://www.strokeaudit.org/Guideline/Guideline-Home.aspx
Organisational
Audit
Audit of the organisation of services, particularly relevant in stroke audit due to
the evidence supporting organised stroke services.
Orthotics
Health professionals concerned with the application and manufacture of
orthoses, devices which support or correct the function of a limb.
Orthoptics
Health professionals concerned with the evaluation and nonsurgical treatment of
visual disorders caused by imbalance of the eye muscles.
Other: Support
services
A support service whose primary function is to provide support and/or
promote practice for patients, carers and their families.
Patient, family and carer support: including information provision and support
services for caregivers delivered by health, voluntary sector or social care.
Communication support: Primary function is support and practice rather
than a targeted SLT programme
Emotional support: Primary function is support rather than a formal
psychological therapy programme than targeted SLT programme)

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Podiatry
A specialism which looks at the diagnosis, medical and surgical treatment of
disorders of the foot, ankle and lower extremity.
Post-acute
inpatient team
Team which provides bed-based service for patients who continue to need
inpatient (hospital) care with consultant review, but this no longer needs to be at
an acute level, i.e. they are no longer based in a hyper acute stroke unit and do
not require 24hr medical consultant cover. Patients predominantly require
rehabilitation support prior to being able to reside in the community. May be
provided in step down units such as in community hospitals.
Rehabilitation
The structure necessary for rehabilitation is the existence of a multidisciplinary
team of people who can assess and treat most problems commonly faced by
their patients. The process of rehabilitation is one of assessment (collecting and
interpreting data), setting goals, intervening to provide support (which maintains
the status quo) and treatment (which alters something), and then re-assessing to
compare the situation after intervention with that aimed for. (Wade DT, 2003)
Secondary
prevention
Measures to prevent recurrence of the same illness.
Sentinel Stroke
National Audit
Programme
(SSNAP)
National stroke clinical audit programme funded by NHS England, the Welsh
Government and, with some individual projects, other devolved administrations
and crown dependencies. In addition to the Post-acute Organisational Audit
reported on in this document, SSNAP runs a clinical audit (see below) and carries
out a biennial Acute Organisational Audit and various other stroke-related audit
activities. SSNAP is now the single source of stroke data for England, Wales and
Northern Ireland.
SSNAP clinical
audit
A continuous clinical audit prospectively collecting a minimum dataset for every
stroke patient in England, Wales and Northern Ireland, covering acute care,
rehabilitation, 6-month follow up and outcome measures since December 2012.
Sessions
A term used to describe a junior doctor's time. One session represents half a
day.
Standalone/
single discipline
service
A standalone service with a specific rehabilitation function or single discipline
rehabilitation (e.g. outpatients). These services do not function as a
multidisciplinary team and may be clinic or domiciliary based.
Stroke specific
A service which provides care to stroke patients only.
Stroke/neurology
specific
A service which provides care to stroke and/or neurological patients only.
Swallow
screening
Swallow screening refers to a process which broadly identifies the safety of a
patient's ability to swallow. This screening process, which may be performed by
any member of the team trained to do this, acts to establish whether the patient
requires further formal assessment regarding their ability to swallow (either fluids
or solid foods).
Team level KI
Key indicators applied to all relevant teams individually.
Trusts
In the context of the National Health Service (NHS), trusts are organisational
units, e.g., hospital trusts, community trusts, primary care trusts or combinations
thereof. In this report it usually refers to hospitals.

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Vocational
rehabilitation
Vocational rehabilitation programmes for people after stroke should include:
•
assessment of potential problems in returning to work, based on the work
role and demands from both the employee’s and employer’s perspectives;
•
an action plan for how problems may be overcome;
•
interventions specifically designed for the individual which may include:
vocational counselling and coaching, emotional support, adaptation of the
working environment, strategies to compensate for functional limitations
in mobility and arm function, and fatigue management;
•
clear communication between primary and secondary care teams and
including the person with stroke, to aid benefit claims or to support a
return to work. RCP National Clinical Guideline for stroke 2016 (p56):
https://www.strokeaudit.org/Guideline/Guideline-Home.aspx
Whole time
equivalent (WTE)
The whole time equivalent (WTE) of staff is the number of hours staffing
disciplines are contracted to work within a typical working week. For example, a
WTE number of 1.0 means that the person is a full-time worker (and works e.g.
37.5 hours per week); while a WTE of 0.5 signals that the worker is half-time (and
works e.g. 18.75 hours). This should not be confused with the number of
individuals, which is the number of people (bodies) a service has to deliver those
hours.

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References

Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke. 5th ed. London, UK:
Royal College of Physicians; 2016.
(https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-
Guideline-for-Stroke-5t-(1).aspx)
National Stroke Service Model description of an Integrated Community Stroke Service (ICSS).
(https://www.england.nhs.uk/publication/national-stroke-service-model-integrated-stroke-
delivery-networks/)
British Association of Stroke Physicians. (https://www.basp.org/wp-
content/uploads/2019/07/BASP-Stroke-Medicine-Workforce-Requirements-Report-FINAL.pdf)
British Society of Rehabilitation Medicine. Specialised Neurorehabilitation Service Standards 7 30
4 2015-PCATV2-forweb-4-5-16.doc Update 30.4.2015.
https://www.bsrm.org.uk/downloads/specialised-neurorehabilitation-service-standards--7-30-4-
2015-forweb.pdf
UK Rehabilitation Outcomes Collaborative http://www.ukroc.org
Wade DT, 2003. Community Rehabilitation, or Rehabilitation in the Community, Disability and
Rehabilitation, no. 15, vol. 25, p 875-881)

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Thanks

We would like to express our thanks to the following people and organisations for their invaluable
contribution in producing this report:
King’s College London and the Intercollegiate Stroke Working Party (Appendix 2) thank all who
have participated in the piloting and development of the audit.
The web-based data collection tool was developed by Net Solving Ltd (www.netsolving.com).
The hospitals and community teams who participated in the SSNAP 2021 Post-acute
Organisational Audit.
The many team members who contributed to organising the collection and retrieval of data
including audit staff, IT and coding staff in addition to members of the clinical teams.

Acknowledgements

The Sentinel Stroke National Audit Programme (SSNAP) is commissioned by the Healthcare Quality
Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes
Programme (NCAPOP).
HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of
Nursing, and National Voices. Its aim is to promote quality improvement in patient outcomes, and in
particular, to increase the impact that clinical audit, outcome review programmes and registries
have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage,
and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising
around 40 projects covering care provided to people with a wide range of medical, surgical and
mental health conditions.
The HQIP programme is funded by NHS England, the Welsh Government and, with some individual
projects, other devolved administrations and crown dependencies.
https://www.hqip.org.uk/national-programmes/
© 2021 Healthcare Quality Improvement Partnership (HQIP)

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