Description
1. Please complete the two worksheets as per the attached templates: 4 Strategic Issues & 5 Strategy Statement 2. Complete Worksheet 6 3. Use worksheet 7 as a template for assembling your strategic plan. 4. Using a presentation tool of your choice (narrated Power Point or Kaltura are fine) please develop a short Power Point that follows the same outline as your strategic plan (background, SWOT, mission/vision/values, critical issues, etc.). Imagine that this presentation will be shown to key stakeholders such as Board of Trustees, local government officials, and patient advocates. Use bullet points and add detail with a voice-over narration. Do NOT read your slides and use bullet points rather than dense text on the slides. The total presentation should be 15 minutes maximum. You may also include an optional summary slide that provides any follow up information on the organization you studied, or other information that might be of interest to the audience.No worksheet for this assignment. Instructions on how to set up Kaltura are attached..
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Week 4: Strategy Formulation
Worksheet 4: Identification of Strategic Issues for __________________________.
Copy the critical issues described in Table 3b (from last week) into the first column of this table and
complete the grid. These become your strategic issues. You may add issues that you identified since
building 3b. Likewise If you determine that the issue is in fact not important to achieving the mission and
vision for the organization, you should list it but report in the second column that is no longer
considered a strategic issue; include a one-sentence explanation.
Critical Issue
Why is this a strategic
issue (HINT: Start with
SWOT matrix pairing)
How does the action
relate to
mission/vision/values?
EXAMPLE:
Community support
and advocacy is
needed to
discourage state
government from
removing protective
regulations.
Long term growth of
rural health system
requires state
government support to
maintain positive
bottom line while
caring for underserved
population; positive
community relations
ensures long term
support and stability
for organization as a
whole
Mission of offering a
comprehensive health
program to a diverse and
underserved population is
preserved by
strengthening both
community and state
support.
What potential
obstacles exist to
implementing this
action?
New competition in
region might lobby
against state support
Worksheet 5: Strategy Statement for ____________________________________
Formulate a strategy statement for your organization as defined by Collis and Rukstad. The strategy
statement should be no more than about ½ page typed and contain three elements:
OBJECTIVE: What is the aim of the organization? This question differs from the mission in that it is
measureable and achievable within a stated time period. Look back at your work from week 1 and reevaluate your response to the last question, “Describe in a paragraph what success would look like for
this organization,” to define the objective. Like the mission statement, this should start with an infinitive
“TO….”, but will emphasize the direction for the next 3-5 years.
SCOPE: For healthcare institutions, scope might be geographic or it might be a segment of the
population: “Underserved rural populations; single parents and their children; orthopedic patients.”
Scope should be reasonably well-defined in the case although your planning team might consider a
change in scope for a given institution.
ADVANTAGE: What distinguishes your organization from competition? Perhaps it is a focus on a
particular disease, or a financial advantage derived from operational efficiency. Blue Ocean strategy
thinking can be helpful here.
Note that you can break up the statement into more than one paragraph if that helps clarity. APA not
required but be sure to label your case.
Week 4: Strategy Formulation
Worksheet 4: Identification of Strategic Issues for __________________________.
Copy the critical issues described in Table 3b (from last week) into the first column of this table and
complete the grid. These become your strategic issues. You may add issues that you identified since
building 3b. Likewise If you determine that the issue is in fact not important to achieving the mission and
vision for the organization, you should list it but report in the second column that is no longer
considered a strategic issue; include a one-sentence explanation.
Critical Issue
Why is this a strategic
issue (HINT: Start with
SWOT matrix pairing)
How does the action
relate to
mission/vision/values?
EXAMPLE:
Community support
and advocacy is
needed to
discourage state
government from
removing protective
regulations.
Long term growth of
rural health system
requires state
government support to
maintain positive
bottom line while
caring for underserved
population; positive
community relations
ensures long term
support and stability
for organization as a
whole
Mission of offering a
comprehensive health
program to a diverse and
underserved population is
preserved by
strengthening both
community and state
support.
What potential
obstacles exist to
implementing this
action?
New competition in
region might lobby
against state support
Worksheet 5: Strategy Statement for ____________________________________
Formulate a strategy statement for your organization as defined by Collis and Rukstad. The strategy
statement should be no more than about ½ page typed and contain three elements:
OBJECTIVE: What is the aim of the organization? This question differs from the mission in that it is
measureable and achievable within a stated time period. Look back at your work from week 1 and reevaluate your response to the last question, “Describe in a paragraph what success would look like for
this organization,” to define the objective. Like the mission statement, this should start with an infinitive
“TO….”, but will emphasize the direction for the next 3-5 years.
SCOPE: For healthcare institutions, scope might be geographic or it might be a segment of the
population: “Underserved rural populations; single parents and their children; orthopedic patients.”
Scope should be reasonably well-defined in the case although your planning team might consider a
change in scope for a given institution.
ADVANTAGE: What distinguishes your organization from competition? Perhaps it is a focus on a
particular disease, or a financial advantage derived from operational efficiency. Blue Ocean strategy
thinking can be helpful here.
Note that you can break up the statement into more than one paragraph if that helps clarity. APA not
required but be sure to label your case.
For the exclusive use of A. Adom, 2024.
9 -7 1 2 -4 9 6
JUNE 5, 2012
MICHAEL E. PORTER
JAMES MOUNTFORD
KAMALINI RAMDAS
SAMUEL TAKVORIAN
Reconfiguring Stroke Care in North Central
London
I have heard such great things about the way we treat stroke patients in London and the role that this
hospital plays that I wanted to come to see it for myself.
– Prime Minister David Cameron, speech at UCLH, 7 June 2011
In 2011, Dr. Charles Davie, consultant neurologist and clinical lead for the North Central London
Stroke Network, reflected on the progress made in reconfiguring stroke care in London. Two years
earlier, as stroke lead for The Royal Free Hospital, he brought together Royal Free Hospital and
University College London Hospital (UCLH), two historically competitive institutions, to create a
single, shared hyper-acute stroke center serving all of North Central London. Staffed by stroke
specialists drawn from all four acute stroke providers in North Central London, the unit saw higher
volumes and achieved better outcomes compared to the separate units that existed previously.
Dr. Davie wondered how this new model could be expanded to benefit patients from areas
outside of London. In addition, the next step was to examine ways to extend the model earlier in the
stroke care cycle.
Overview of the English Health Care System
Established in 1948, England’s National Health Service (NHS) was a publicly funded health
system providing universal access to health care free at the point of use for all who needed it,
irrespective of ability to pay. The NHS was the world’s largest integrated health system and fourth
largest employer.1 With an annual budget of more than £100 billion and 1.4 million direct employees,
the NHS provided comprehensive care to 52 million people.
Primary and community-based care services were provided by General Practitioners (GPs) and
commissioned by Primary Care Trusts (PCTs). In 2011, there were 152 PCTs that controlled the
majority of the NHS budget, each responsible for a geographically-defined patient population. GP
________________________________________________________________________________________________________________
Professor Michael E. Porter of Harvard Business School, Dr. James Mountford of University College London Partners (“UCLP”), Professor
Kamalini Ramdas of London Business School, and Research Associate Samuel Takvorian prepared this case. Dr. Charles Davie of Royal Free
Hospital was the lead clinical contact. Hilary Walker, Director of the North West and North Central London Cardiac and Stroke Network, Dr.
Caleb Stowell and Craig Szela, Senior Researchers with the HBS Institute for Strategy and Competitiveness provided valuable input. University
College London Partners (“UCLP”) is an umbrella academic health science centre involved in research, teaching and curriculum development,
which is partly informed by the activities of the hospitals in its system, including University College London Hospital, a founding member of
UCLP. HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary
data,or illustrations of effective or ineffective management.
Copyright © 2012 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685,
write Harvard Business School Publishing, Boston, MA 02163, or go to www.hbsp.harvard.edu/educators. This publication may not be digitized,
photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School.
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For the exclusive use of A. Adom, 2024.
712-496
Reconfiguring Stroke Care in North Central London
practices contracted directly with PCTs. Practice budgets were adjusted according to the underlying
morbidity and age/sex distribution of a given patient panel so that a practice with more sick and
elderly patients received more funding than a practice with relatively healthy and young patients.2
There were 34,101 GPs in England in 2010. Each GP was typically responsible for a wide range of
patients, including children, expectant mothers, and frail elderly. An average GP practice cared for a
panel of 8,500 patients, seeing 35-50 patients per day. An individual consultation lasted about 11
minutes on average. Visits to a GP were free, but there were out-of-pocket charges for prescriptions
and optician care.
GPs served as gatekeepers to the rest of the health care system, referring patients to specialty care
when needed. Consultants were the most senior doctors, whose salaries ranged from £74,504 to
£100,446 per annum depending on length of service, with additional local and national clinical
excellence supplements. Staff and Associate Specialist (SAS) doctors were clinicians who had finished
their training but practiced under the direction of consultants. They received salaries ranging from
£36,807 to £70,126 per annum. Junior doctors were those in specialist training – mirroring residents
and fellows in the U.S. – with a basic starting salary of £29,075 and an additional supplement for
working more than 40 hours a week.
Hospital and outpatient specialty care services were commissioned by Acute and Foundation
Trusts. Acute Trusts were managed directly by the government. Foundation Trusts, introduced in
April 2004, had an elected independent board of governors, and could retain surpluses and borrow to
invest in new and improved patient services. By April 2011, there were 137 Foundation Trusts across
the country providing over half of all NHS hospital and mental health services.
Two statutory public bodies regulated hospital care, both directly accountable to Parliament.
Monitor, an independent organization established in 2004, assessed applications for NHS Foundation
Trust status as well as ongoing Trust performance by evaluating management quality, financial
stability, and organizational development. The Care Quality Commission (CQC), established in 2009,
regulated the quality of health care delivered by hospitals and performed unannounced inspections
enforcing government quality standards.
From 2001 to 2011, the total tax-funded NHS budget more than doubled from £49 billion to £103
billion. Despite spending only 9.8% of GDP on health care, compared to 17.4% in the US, the
economic stability of the NHS was in doubt. In 2010, a new government was elected and instituted a
four-year cap on NHS spending increases. In 2011, new legislation was proposed that would
fundamentally restructure the NHS, abolishing PCTs and shifting clinical commissioning largely to
GP practices. Underlying these reforms was the need to improve quality while harnessing efficiency
gains. Where to find such gains was a matter of ongoing debate.
Overview of Stroke and Stroke Care
Stroke was a medical condition that resulted from sudden interruption in the blood supply to the
brain, leading to brain injury and sometimes death. The majority (85%) of strokes were ischaemic,
caused by an abrupt blockage by clots of arteries leading to the brain. The remaining 15% were
haemorrhagic, due to rupture of intra-cerebral or sub-arachnoid blood vessels with resultant bleeding
into the brain.
Stroke typically presented as sudden onset disturbances in motor or sensory function, speech, or
vision, depending on the area of the brain injured and the severity of injury. Common signs included
2
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Reconfiguring Stroke Care in North Central London
712-496
sudden numbness or weakness, especially on one side of the body or face. This often resulted in an
abnormal gait or loss of balance. Abrupt confusion and difficulty speaking or understanding speech
were also concerning signs. Visual symptoms included sudden-onset blurred vision or complete loss
of vision in one or both eyes. These symptoms developed rapidly because the brain was unable to
function with even a short interruption in its blood supply. Sometimes symptoms resolved on their
own, with complete return to normal function within 24 hours. These episodes were called Transient
Ischemic Attacks (TIAs) and were usually caused by temporary blockage of an artery from a clot that
subsequently dissolved. TIAs were a major risk factor for subsequent strokes.
Over 70% of strokes occurred in people over the age of 65, and the risk of stroke more than
doubled for each decade after the age of 55. Beyond age, risk factors common to all strokes included:
smoking, high blood pressure, elevated cholesterol, diabetes, obesity, physical inactivity, and social
deprivation. Atrial fibrillation, a common form of irregular heart rhythm that predisposed to clot
formation in the heart, was an independent risk factor for stroke, increasing risk about five-fold.
Additional risk factors for haemorrhagic stroke included excessive alcohol consumption and
recreational drug use.
Stroke was the third most common cause of death in the UK in 2010 and a leading cause of
serious, long-term physical and psychological disability. Stroke survivors often required intensive
physical rehabilitation to achieve independence in daily functioning, and approximately one-third
remained permanently disabled. One in seven stroke survivors required permanent institutional
care.3 Population changes over the previous 15 years, such as reduced smoking and better control of
blood pressure and diabetes, had led to decreasing stroke incidence and mortality (in line with other
cardiovascular diseases). Still, 110,000 people in the UK suffered a stroke in 2010, of which half would
die as a direct result or from a related complication.
The direct costs of treating stroke patients and the indirect costs of lost productivity in the UK
were substantial. Direct health and social care costs for stroke patients were estimated at £4.5b/year,
representing 5% of total UK health care spending; indirect costs represented another £4.5b.4
Accounting for a broader set of social costs (e.g., lost productivity from family members taking on
caregiver roles), the total cost to the UK was estimated to be as high as £15.5b/year.
The stroke care cycle was divided into the pre-hospital care phase, the hospital phase, and the
post-hospital phase. Patients generally suffered symptoms of stroke in the community, which, when
recognized by family members or bystanders, prompted a call to emergency services. Patients were
then transferred by ambulance to the nearest emergency room for further evaluation. After hospital
care, patients entered a rehabilitative phase, often in an outpatient facility with physical, occupational
and speech therapists.
In 1995, the first substantive clinical trial was published showing that morbidity and mortality
from ischaemic stroke could be substantially improved if rapid thrombolysis5 was used to open up
blocked vessels within three hours of onset of symptoms.6 However, thrombolysis of a haemorrhagic
stroke could worsen the patient’s clinical state and could even cause death.
The differentiation of ischaemic from haemorrhagic strokes required a CT scan to visualise the
brain and surrounding tissue. Haemorrhagic stroke showed up immediately on CT as blood in or
around the brain. In the early stages of ischaemic stroke, the CT scan was often normal. CT changes
from ischaemia developed after the window for thrombolysis. Therefore, patients who received
thrombolysis typically had a convincing clinical presentation for stroke and a normal CT scan. While
MRI provided superior characterization of ischemic stroke, CT was generally preferred in the acute
setting due to its lower cost and better availability, as well as its ability to distinguish between
3
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For the exclusive use of A. Adom, 2024.
712-496
Reconfiguring Stroke Care in North Central London
hemorrhagic and ischemic strokes. About one-third of patients went on to have an MRI for further
diagnostic purposes or to localize the stroke more clearly, usually within 48 hours of the event.
Stroke units cared for a high volume of stroke patients and were staffed by experienced,
multidisciplinary teams. Stroke units were jointly led by a stroke nurse and physician expert in
stroke, assisted by the full range of personnel needed for optimal care and recovery, including:
medical, nursing, speech therapy, physical therapy, occupational therapy, dieticians and
psychological therapists. Stroke units maintained an early focus on rehabilitation and on patient and
family education.
Since the 1980s, there had been increasingly robust clinical evidence that patients treated in
dedicated stroke units had better outcomes than patients treated in general medical wards.7 For
example, in a 1991 randomized-controlled trial in Finland, patients treated on a stroke unit
experienced 6-week mortality of 7.3% compared to 17.3% in a general medical ward. Patients treated
on a stroke unit were also more likely to be home at 6 weeks (56.4% vs. 32.8%) and be independent in
walking, personal hygiene and dressing.8
History of Stroke Care in London
Following success in improving care for heart attacks in the early 2000s through a national audit
and the development of national cardiac care standards,9 the Department of Health published a set of
quality standards for stroke care in 2007 highlighting the need for immediate access to CT scanning
and expert multidisciplinary assessment for stroke patients. 10 It was clear from the NHS assessment
that parts of London lagged behind the rest of the country on several key process measures that were
linked to better stroke outcomes, such as screening for swallowing disorders within 24 hours and a
brain scan within 24 hours, and that things were getting worse, not better. See Exhibit 1 for a
summary of the key results of the 2006 National Sentinel Stroke Audit for London.
Until 2009, the dominant model of care for stroke patients in London, as well as the rest of
England, had centered on the local hospital. In 2006, 34 London hospitals were designated to receive
‘blue-light’ ambulances transporting patients who had suffered an acute stroke. There was wide
variation in the number of patients treated across settings, and analysis showed that more strokes
occurred in outer London (where the majority of the elderly population lived) but most hospital beds
were located in inner London.
Exhibit 2 shows the typical care pathway for stroke in London until 2009, though there was
substantial variation across hospitals in the diagnostic process and the subsequent care pathway, as
well as variation within each hospital by time of day and day of the week. Sometimes patients would
be cared for by a stroke specialist and would undergo a diagnostic CT scan to determine whether
thrombolysis was a viable therapy, but this was more the exception than the rule. While national
guidelines stated that stroke patients should undergo CT scan within 24 hours of admission, none of
London’s 34 hospitals treating stroke met the benchmark of 90% compliance in 2006 (see Exhibit 1).
Following the abrupt development of visual or speech disturbance and weakness of an arm or leg,
the patient or witness would typically call emergency services on 999, and an ambulance would take
the patient to the nearest Accident and Emergency (A&E) Department. There, A&E medical and
nursing staff would assess the patient and arrange admission to a medical assessment unit where a
general medical or geriatric physician would take over the patient’s care and arrange admission to a
general medical ward.
4
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Reconfiguring Stroke Care in North Central London
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While most London hospitals had a dedicated stroke unit, patients suffering from acute stroke
were not always admitted to these units as beds were often full or inaccessible, especially on
weekends. This was partly due to the fact that only stroke physicians typically had admitting
privileges to stroke units. Thus, a patient presenting to A&E at 5 pm on a Friday would typically be
admitted to an acute medical or geriatric ward where they would stay over the weekend. They might
be picked-up by the stroke service team on Monday morning and transferred to the stroke unit by
Monday evening, but even this was highly variable. In 2008 in the UK, only 16% of suspected stroke
patients were admitted directly to a stroke unit, 81% to a generic admissions unit, and 3% elsewhere.
In 2006, the NHS in London was organized for administrative purposes around five sectors,
defined geographically. Three sectors were north of the River Thames, and two sectors covered the
area south of the River. North Central London (NCL) was one of these sectors, with a population of
1.2m in 2006. Given the population demographics, the social and health care needs in NCL were
above the London average. Within the NCL catchment area, there were approximately 1,500 stroke
cases in 2006.
Five acute hospital trusts served NCL’s population: Barnet and Chase Farm, North Middlesex,
Royal Free, University College London Hospital (UCLH) and the Whittington. Each of these received
stroke patients through their A&E Departments, with volumes ranging from 200 to 400 patients per
year (see Exhibit 3). Across these hospitals, the availability of dedicated stroke beds and care
resources ranged from 24/7 access in some to an exception basis in others. The proportion of patients
treated in dedicated acute stroke units ranged from 16%–99%, the proportion of patients receiving
full physiotherapy assessment within 72 hours of admission ranged from 17%–90%, and the
proportion of patients receiving a CT scan within 24 hours of admission ranged from 22%-83%. Acute
stroke mortality (measured at 30 days post stroke) ranged from 12% to over 30%.
Designing a New Model of Stroke Care for London
In 2006, surgeon Ara Darzi (who would shortly become Lord Darzi of Denham, a Health Minister
in Prime Minister Gordon Brown’s Labour Government) identified several key areas, including
stroke, for improving health and health care across London in his report, Healthcare for London: A
framework for action.11 London’s Regional Health Authority prioritised stroke as a focus condition for
early adoption of a new model of care that was designed and managed by clinicians rather than nonclinical administrators. The aim was to ensure a uniformly high treatment standard for stroke
patients, irrespective of where in London they suffered their stroke.
After extensive analysis of clinical evidence and other models of stroke care in the UK and
overseas, the decision was made to re-organise the earliest phase of care around eight “stroke hubs”
called Hyper Acute Stroke Units (HASUs) covering London’s five sectors. These would be equipped
with all the staff and investigative equipment necessary to perform a thorough assessment and
treatment of the most acute stroke patients in the first 48 to 72 hours. From there, patients who were
not yet ready to be discharged to home would typically pass to one of 24 Acute Stroke Units (ASUs),
and from there to home or community services.
The new model of care in London was different from other recent models in the UK and
internationally. For example, in Manchester, UK, all patients were taken to a HASU but only
remained there if initial clinical assessment and CT confirmed they were eligible for thrombolysis. In
Connecticut, USA, patients were still taken to their local hospital, but CT images for the whole state
were sent to a single on-call expert clinician at a regional hospital who discussed optimal care
planning with the local clinical team.
5
This document is authorized for use only by Atta Adom in Copy of Copy of NHA-602-SP-24 taught by Joel Rodriguez, Pennsylvania College of Health Sciences from Jan 2024 to Jul 2024.
For the exclusive use of A. Adom, 2024.
712-496
Reconfiguring Stroke Care in North Central London
Although the majority of physicians were behind the change, not all senior clinicians were
supportive. One said: “I don’t understand how all this is in patients’ best interests. First, we can
thrombolyse patients at their local hospital perfectly well if we can arrange for the CT scans to be
done. Second, how does it benefit a frail, elderly, demented patient to be taken an hour across
London only to be told they are not a candidate for thrombolysis and to be brought back to the local
hospital or to their home?”
All units interested in providing HASU and ASU services submitted a bid to an expert panel of
stroke clinicians from outside London assembled by NHS London. Sites were chosen on the basis of
past performance, commitment to meeting the challenging new quality standards, multidisciplinary
expertise, and geographic ‘fit’ to ensure adequate coverage and provision across London, and
capacity to expand to treat a much larger patient group. Eight units were chosen to provide
hyperacute stroke care while others would no longer be reimbursed for doing so. Exhibit 4 shows the
location of London HASUs and ASUs.
In North Central London, Dr. Charles Davie submitted a bid on behalf of the Royal Free, as did his
colleagues at UCLH. Both institutions had a history of excellent outcomes. Royal Free had performed
better in the National Audits12 for stroke in 2006 and 2008, but UCLH achieved a higher score during
the bidding process, in part due to its capacity to expand its unit to develop stroke related research
and training programmes.13 To limit travel distances and times between existing sites and adequate
patient volumes, NHS London decided that the NCL sector required only one HASU whereas all
other London sectors were allocated two or more. UCLH was chosen as the preferred site.
With the selection of UCLH, the Royal Free stroke team faced a choice: contest the decision, exit
hyper-acute stroke care, or collaborate with UCLH. Initially, there was a strong feeling at the Royal
Free to fight the committee’s decision given its demonstrated record of high performance. Also, Royal
Free was equipped with an advanced neuro-interventional service for very complex stroke patients
which was not available at UCLH or any other hospital in North Central London. This aspect of
stroke care was not included in the 2008 assessment.
However, Dr. Davie and others were concerned whether the Royal Free had the capacity to
expand significantly, and also worried that competing with UCLH would further entrench hostilities
in the sector and prevent a budding academic partnership from forming. 14 Presenting to the Royal
Free executive board in February 2009, he advocated “ruthless collaboration.” After much debate, the
decision was made to work with colleagues across NCL to develop a ‘flagship’ HASU at UCLH.
Implementing the New Model
Ensuring the flow of patients through HASU and ASU beds and determining how best to
‘repatriate’ patients from HASUs to their local ASU were immediate and complex challenges. There
were also significant challenges of coordination among health and social care, physiotherapy,
occupational therapy, dieticians, and medical and nursing care.
In the new model, clinicians of many types were required to work not only in their local hospital
but also in the relevant HASUs and ASUs to which their institutions were now affiliated. There was
concern about ‘de-skilling’ units. For example, stroke neurologists and physicians at hospitals
without a HASU might discontinue providing acute stroke care at their local hospital and move to
jobs elsewhere. There were also concerns about breaking up local teams and the potential economic
impact on local hospitals of losing stroke care volume. However, only one of 13 consultants in NCL
chose not to be part of the new stroke service.
6
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Reconfiguring Stroke Care in North Central London
712-496
A major public health education campaign, including advertisements in local press and radio/TV,
was mounted about the classic signs and symptoms of stroke and the importance of rapid action by
patients and relatives to ensure early definitive clinical assessment and treatment. These campaigns
centered on “FAST,” which stood for Facial or Arm weakness and Sight problems = Time to
telephone for an ambulance (see Exhibit 5).
London Ambulance Service needed to be educated to recognise signs of stroke and to take
patients directly to the nearest HASU, which in most cases was no longer the nearest hospital. The
ambulance network had to prepare for longer journeys, which increased overall demand for services.
A commitment was made that no journey to a HASU would take longer than 30 minutes, which was
achieved in 96% of cases based on 2010 data.
Most challenging of all, patients and relatives (often frail and elderly) had to understand why
their local hospital was no longer the best place for stroke care to begin, unless it happened to have a
HASU. Relatives now had to travel further (often via public transport) to visit loved ones in the
HASU.
Between 2009 and 2010, the new model was implemented London-wide through a combination of
planning, certification and investment by NHS London and local clinical leadership. An overall
capital investment of £7m was made to upgrade units to HASU and ASU status (for example,
installing CT scanners and refurbishing facilities). The total additional staffing cost of the model
across London in the first year was approximately £20m, with £13m in additional staffing for HASUs
and £7m for ASUs. Reimbursement for stroke care was increased: the national tariff of £4,765 for
stroke care was increased in London by 50% per patient to £7,193 (£1,343 for the HASU phase of care
and £5,850 for the ASU phase).
In February 2010, stroke care in North Central London was consolidated into a single HASU at
University College London Hospital. This unit received all ‘FAST’ positive strokes (e.g., patients
exhibiting facial/arm weakness or sight problems), which totaled over 100 per month. Exhibit 3
shows the effect of the change on patient volume. A single standard of care was now delivered to all
stroke patients from North Central London. Exhibit 6 shows the care pathway post reconfiguration.
The model included rapid, thorough clinical assessment by stroke physicians and a careful clinical
history and neu
