Conclusions and recommendations
1. Stroke is the third biggest cause of death
in England, after heart disease and cancer. It is also the leading
cause of adult disability.
Although historically stroke has been seen as an inevitable risk
of growing old, with little to be done for stroke patients other
than trying to make them comfortable, a quarter of strokes occur
in people under the age of 65. Fast and effective acute treatment,
and high quality rehabilitation, can significantly reduce death
and disability.
2. Stroke costs the economy £7 billion
a year, including £2.8 billion in direct care costs to the
NHS. Stroke costs the NHS more than heart
disease, and should receive the priority warranted by its impact
and cost. To raise the profile of stroke with commissioners and
clinicians, the Department of Health should work with the Healthcare
Commission and the Royal College of Physicians to develop benchmarks
for stroke care—for example the proportion of suspected
stroke patients receiving a brain scan within three hours, or
the proportion of stroke patients being treated on a stroke unit.
3. In most European countries stroke is regarded
as a neurological condition first and foremost, rather than an
older people's condition. In Sweden on
average patients take just three to five hours to arrive on a
stroke unit with early assessment of and access to rehabilitation.
In England the median time to arrival on a stroke unit is 2 days
and access to rehabilitation is patchy within and between hospitals.
In leading hospitals in Australia, thrombolytic (clot-busting)
drugs are given to around nine percent of eligible patients compared
to one per cent in England. The Department should benchmark performance
on these key performance indicators with other leading countries
to identify areas where further lessons may be learned.
4. The last clinical audit of stroke showed
that only 22% of stroke patients had a scan on the same day as
their stroke, and most waited more than two days. Scans
for stroke patients are being delayed, though 'time lost is brain
lost', and research shows that scanning patients immediately costs
less, and results in better patient outcomes than scanning later.
All suspected stroke patients should be scanned as soon as possible
after arrival at the acute hospital, ideally within three hours,
and none should wait more than 24 hours for a scan. All Accident
and Emergency and Radiology departments should have protocols
in place for the rapid admittance and referral for scanning of
stroke patients.
5. There are 640 patients per stroke consultant,
compared with 360 patients per cardiac consultant. The
limited number of health professionals with training in stroke
is a barrier to providing high quality acute care and rehabilitation.
Future workforce planning targets should enable the NHS to move
to a position where there are as many stroke consultants per patient
as heart disease consultants per patient.
6. Hospital staff are not always sufficiently
well informed on how to respond to stroke.
The education and training provided to new triage nurses and junior
doctors should include awareness of stroke and the need for urgent
brain scans for stroke patients. The Department should train stroke
consultants to interpret scans and make immediate treatment decisions.
It should also continue to develop its telemedicine programme
so that, by 2007, staff managing stroke patients can access neuro-radiological
expertise remotely.
7. By increasing the proportion of stroke
patients who spend the majority of their time in hospital on a
stroke unit by 25%, around 550 deaths per year could be prevented.
Although most hospitals now have such a unit, only around two
thirds of stroke patients spend time on one, and what constitutes
a stroke unit varies considerably between hospitals. All stroke
patients should be admitted to a specialist stroke unit as soon
as possible following diagnoses of their stroke. The Department
needs to communicate clear guidelines for an acceptable stroke
unit and Primary Care Trusts should deliver acute stroke care
through a stroke unit that meets these guidelines. The Department
should set challenging targets to improve the proportion of patients
treated on a stroke unit.
8. The risk of stroke in the four weeks following
a transient ischaemic attack (TIA, 'mini stroke') is around 20%.
All providers of primary and secondary
care should have protocols in place for the referral of suspected
or confirmed TIA patients, reflecting the Royal College of Physicians'
guidelines that all patients in whom a diagnosis is suspected
should be assessed and investigated within seven days. The indicator
in the Quality and Outcome Framework for assessing primary care
practices performance in relation to suspected stroke patients
and which simply states "referral for a scan" should
be amended to reflect the time bound element in the above protocol.
9. By reducing to 14 days the maximum waiting
time for surgery for patients with narrowing (stenosis) of the
carotid arteries in the neck, around 250 strokes a year could
be prevented, yielding savings to the NHS of around £4 million.
TIA patients with diagnosed stenosis should not have to wait longer
than 14 days after their TIA for surgery.
10. Three times more women die of a stroke
than of breast cancer each year, and stroke is the major cause
of adult disability, but public awareness of stroke and how to
prevent it is low. The Department should
run an awareness campaign for stroke, focussing on its symptoms
and the fact that it is a medical emergency requiring a 999 response.
In developing this campaign, it should consider particularly how
to engage with groups at higher risk of stroke, such as people
of Afro-Caribbean and South Asian ethnicity.
11. Stroke survivors and their carers need
support from many different health and social services, but about
50% of carers are not receiving needs assessments. The
Department should improve the provision of information to stroke
carers, so they become aware of the services available to support
them. Community services should be improved so that patients in
the community are not overlooked. The Department should take into
account in particular the needs of stroke survivors who live on
their own, and may be particularly vulnerable to being overlooked
by health and social care services.
12. Most of the burden of stroke occurs after
discharge but post-hospital support services for stroke patients
are often difficult to access. During
their hospital stay patients have access to on call help and care
but on discharge the transition from hospital to home can be traumatic.
Around half of stroke patients receive rehabilitation services
that meet their needs in the six months following discharge falling
to 25% 12 months after discharge. The Department should evaluate
the merits of Early Supported Discharge initiatives and other
ways of improving access to therapies, and promote the early adoption
of those that can be shown to reduce hospital stay and improve
patients' chance of recovery.
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