House of Commons - Public Accounts

Select Committee on Public Accounts Fifty-Second Report

1 The cost and impact of, and priority given to, stroke

1. Approximately 110,000 strokes, and a further 20,000 transient ischaemic attacks ('mini strokes') occur in England each year. There are around 300,000 people in England living with moderate to severe disabilities as a result of stroke. Stroke care costs the NHS and the wider economy about £7 billion a year. This figure is comprised of direct care costs to the NHS of £2.8 billion a year, informal care costs (e.g. costs of nursing homes borne by patients' families) of £2.4 billion a year, and a further £1.8 billion of wider economic costs (eg lost productivity due to mortality and morbidity).[2]

2. Stroke is more expensive for the NHS than coronary heart disease both because of longer hospital stays (an average of 28 days for stroke in comparison with 7 days for heart disease) and the greater burden of disability. The incidence of, and mortality rates for, stroke and coronary heart disease have decreased in recent years, probably due in part to better management of blood pressure, lower rates of smoking and greater awareness of the importance of a healthy diet and exercise. However, stroke mortality has decreased at a slower rate. Over the decade from 1992 to 2002 the chance that a stroke patient would die of their stroke remained constant (at around 24%), while for heart attack patients the chance of dying from their heart attack declined by about 1.5% each year.[3]

3. Despite the impact and cost of stroke, the Department of Health in setting priorities and allocating resources has up to now focussed on cancer and coronary heart disease, for each of which there is a dedicated published strategy and a national clinical director. The strategy for stroke has to date formed part of the National Service Framework for Older People, even though a quarter of strokes occur in people under the age of 65. Figure 1 shows that stroke receives significantly less research funding than coronary heart disease, has far fewer registered specialist trainees, and attracts fewer points in the General Medical Services contract that determines GPs' pay. There are also 640 patients per stroke consultant, compared with 360 per cardiac consultant.[4]

Figure 1: Costs and resources for stroke and coronary heart disease

Stroke Coronary heart disease

Annual direct healthcare costs £2.8 billion £1.9 billion

Number of in-patient hospital bed days annually 2.6 million 3 million

Average length of stay 28 days 7 days

Proportion of deaths caused by the condition in England and Wales in 2002 11% 19%

Department of Health research funding 2003-04 £9.4 million £52 million

Number of research posts funded by charities and government agencies in the United Kingdom, 2000-01 7 455

Charity research funding in the United Kingdom, 2000-01 £2.6 million £43 million

Percentage of hospitals with protocols with the ambulance service for managing patients (over and above the regular system) 16% 100%

Percentage of patients seen as an outpatient within 14 days 37% 95%

Percentage of patients treated at some time on a specialist unit 47% 100%

Number of patients per consultant 640 360

Status in the Joint Council for Higher Medical Training As of 2004, a sub-specialty A specialty

Number of trainees registered in England 6 430

Source: C&AG's Report, Figure 4

4. The Department has acknowledged that it is now time to give a great deal more attention to stroke, and in 2004 established a Vascular Programme Board to develop a stroke strategy that draws on the approaches it has taken to improve coronary care over the last five years. In responding to the C&AG's Report, Care Services Minister Liam Byrne, MP, said that 'we have already made good progress on stroke, as the NAO acknowledges, but we too believe there is more to be done. Over 2000 people suffer a stroke each week - implementing the NAO recommendations could save as many as an extra ten lives a week'.[5]

5. Professor Roger Boyle, the national clinical director for heart disease, has been given the leadership role for stroke. He will be supported by the clinical directors for older peoples' services and for emergency access. He has been charged with overall responsibility for delivering improvements in stroke care.[6]

6. The message that stroke is a medical emergency requiring a 999 response and treatment on a specialist stroke unit by staff trained in the management of stroke has not yet fully filtered through to the public and to all healthcare professionals. Stroke has a higher profile in countries such as Australia, Sweden, Germany, the USA and Canada, which have been quicker to adopt new technologies such as thrombolysis (clot busting drugs for the treatment of strokes caused by a blood clot), and to provide more intensive rehabilitation for stroke patients sooner after their stroke. The National Audit Office's analysis shows that a greater focus on delivering clinical good practice in stroke care in England would save lives, reduce disability and result in savings for the health service.[7]

7. For example, less than half of stroke patients in 2004 spent the majority of their time on a specialist stroke unit. Increasing this proportion to 75% of patients would save about 550 deaths, and reduce the number of patients disabled and dependent on leaving hospital by over 200. Currently less than 1% of stroke patients in England receive thrombolysis. Increasing this rate to nine percent—a rate being achieved in leading hospitals in Australia—could result in more than 1,500 patients fully recovering from their strokes each year who would not otherwise have done so, generating net savings to the health service, in care costs avoided, of over £16 million a year.[8]



© Parliamentary copyright 2006	Prepared 11 July 2006