House of Commons - Public Accounts

Select Committee on Public Accounts Fifty-Second Report

2 Improving the response to and treatment of stroke

8. Rapid access to a brain scan is vital for all stroke patients. A scan is required to determine whether the stroke is caused by a clot or a bleed, and hence to determine the appropriate treatment as soon as possible, to maximise the chance of preventing death and disability. For example, patients whose stroke is caused by a clot (around 85% of all stroke patients) can benefit from treatment with clot-busting drugs, provided that they are diagnosed and scanned within three hours of the stroke. Yet the National Sentinel Audit of stroke carried out by the Royal College of Physicians in 2004 showed that, for patients who were registered as requiring an urgent (within 30 minutes) CT scan, only 30% actually got the scan on the same day, and less than 1% of patients received clot-busting treatment. Figure 2 shows the key points at which delays to treatment can occur. The shorter the time between the stroke and the treatment, the more chance there is of saving brain tissue at risk of damage.[9]

Figure 2: Delays that can prevent patients receiving urgent medical treatment

Source: National Audit Office

9. The key requirements for improving scanning capacity for stroke patients are the availability of sufficient staff, with the necessary skills to carry out, read and interpret scans, and that stroke has emergency priority with ambulance staff and triage nurses in accident and emergency departments. Nearly all hospitals have the necessary equipment to carry out scans, but at present the health service is not gaining the full benefit from its investment in this equipment because it is not being used to provide a scanning service for stroke patients that is available 24 hours a day, seven days a week. The volume of scans required for stroke patients is not sufficient to affect overall capacity significantly, but better prioritisation of stroke would ensure that existing capacity is used more wisely.[10]

10. The Department recognises this as a major concern. They told us that radiographers work at night and on weekends, and that in most hospitals it is possible to get an acute scan done out of hours. However the radiological expertise required to interpret the scan is not always available out of hours; and accessing this expertise can also build in delays to treatment even when the scan is carried out during normal working hours. To address this problem, the existing workforce involved in the management of acute stroke must be trained to enable them to interpret scans, and specialist radiological input must be made more accessible. Additionally, the Department is aiming to develop a telemedicine capacity by 2007, through its PACS picture archiving system, that will allow scans to be digitally transmitted to off-site neuro-radiologists for interpretation.[11]

11. The National Audit Office was told by hospitals that, even without the use of telemedicine, over twice as many CT scans could be achieved without compromising necessary scans for other patients, by better planning and organisation The Department accepts that it would not be unreasonable to aim to double the number of people receiving emergency scans within the required time period over a six month period.[12]

12. Once a patient has been diagnosed with stroke, the most effective model for acute care is care delivered through an acute stroke unit: a physically separate unit staffed by a multidisciplinary team of stroke specialists including consultants, therapists and nurses trained in the management of stroke. Treatment in a stroke unit has been shown to save lives and reduce disability. A key milestone in the National Service Framework for Older People was that by April 2004, 100% of all general hospitals should have a specialised stroke service. Although most hospitals do now have a stroke unit, a significant proportion of stroke patients do not spend the majority of their time in one. Although there has been some improvement in the proportion of stroke patients who spend more than half of their hospital stay on a stroke unit, from 41% in 2004 to around two-thirds in 2005, the Department accepted that its new stroke strategy needs to address the issue of improving stroke unit capacity.[13]

13. There is considerable variation between hospitals as to what a specialised stroke service actually entails, with, for example, only about a quarter of units providing continuous physiological monitoring, and only a third having access to scanning around the clock. Less than half of hospitals have agreed stroke protocols in place with primary care, despite the target in the National Service Framework for Older People that by 2004, every general practice should be able to identify people with stroke and to treat them according to protocols agreed with specialist services. While there are clear examples of good practice in delivering specialist stroke care in England, the challenge for the Department now is to move from a situation where local champions of stroke services are self-selected individuals with a strong interest in the area, to a position in which the stroke workforce has been built up so that there are champions throughout the country.[14]

14. Stroke patients require good rehabilitation, such as access to physiotherapy, as soon as possible after their stroke. The NAO found that access to professionals such as physiotherapists, occupational therapists, speech and language therapists, psychologists and dieticians was patchy across stroke units, even though such access is likely to result in fewer delayed discharges.[15]

15. Guidelines published by the Royal College of Physicians state that all patients in whom a diagnosis of transient ischaemic attack (TIA, 'minor stroke') is suspected should be assessed and investigated within seven days. The NAO found that in practice only around half of people with suspected TIA are assessed in a clinic within 14 days. 58% of TIA patients get their scans outside the most effective time window. This represents a resource cost of around £1.2 million that could be used more effectively. The Department needs to use its new stroke strategy to bring about improvements in the capacity and responsiveness of TIA clinics.[16]

16. Reducing the delays in providing preventative interventions to people who have had a TIA or a first stroke can lead to savings for the health service. For example, when stenosis (narrowing) of the carotid arteries in the neck is found to be the cause of a previous stroke or TIA, surgery to remove the deposits from the arteries should be performed preferably within two weeks of the stroke or TIA. After this time interval, the benefits of surgery decline rapidly. An ultrasound scan of the carotid arteries is needed to detect whether stenosis is present, and this forms part of the normal series of tests and investigations that would be provided in a TIA or vascular clinic. However in 2004 only half of patients had an ultrasound scan within 12 weeks of their stroke or TIA. The NAO's economic analysis showed that providing surgery within 14 days of their TIA for patients with stenosis could prevent about 250 strokes a year, and yield a net saving to the NHS in care costs avoided of around £4 million.[17]

17. Many stroke survivors need considerable levels of rehabilitation, support and nursing care, and need to access many different health and social care services. If these are not provided in a joined up manner, patients can feel abandoned on leaving hospital. The Department should ensure that patients in the community are not overlooked, and that community services improve. It accepts that there is scope for increased integration between health and social care. Hospitals estimated that around half of stroke patients were receiving rehabilitation services that met their needs in the first six months after discharge. This proportion fell to about a fifth by 12 months after discharge, however, putting a heavy burden on carers. The Sentinel Audit found that 28% of carers had experienced problems with their jobs, 63% had problems with their physical health, and 56% had experienced problems with their mental health since becoming a carer of someone with a stroke.[18]

18. Although carers have a statutory right to a needs assessment, in over half the cases examined in the Sentinel Audit carers' needs were not assessed. The Department, through the White Paper Our Health, Our Care, Our Say: A New Direction for Community Services (Cm 6737, 30 January 2006), is aiming to improve three aspects of support for carers in particular: improving the information available to carers, so they become aware of the services that might support them; improving emergency respite, to ensure that care services are available for their loved one during times of crisis or emergency; and development of better training for carers to help them undertake their caring role. It is important that support is also available for stroke survivors who live on their own, and may be particularly vulnerable to being overlooked by health and social care services.[19]



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