Memorandum from The Stroke Association
NATIONAL AUDIT OFFICE STROKE FOLLOW-UP REPORT:
PROGRESS IN IMPROVING STROKE CARE
ABOUT THE
STROKE ASSOCIATION
The Stroke Association is the only UK wide charity
solely concerned with combating stroke in people of all ages.
We fund research into prevention, treatment and better methods
of rehabilitation and help stroke survivors and their families
directly through our website and national helpline.
We also provide a range of community services
including support for people with communication difficulties as
a result of stroke, family support, information services and welfare
grants. In addition we campaign, educate and inform to increase
knowledge of stroke and act as a voice for people affected by
stroke.
STROKE FACTS
A stroke is the brain equivalent of a heart
attack caused by an interruption of blood supply to the brain.
Stroke is one of the top three causes of death
in England and the largest cause of adult disability. Around 300,000
people in England are living with moderate to severe disability
as a result of stroke.
Stroke is also one of the most expensive conditions,
with direct care costs to the NHS of £3 billion every single
year, within a wider economic cost of £8 billion.
EXECUTIVE SUMMARY
In 2005 the groundbreaking National Audit Office
report Reducing Brain Damage exposed the shameful state
of stroke services in England.
Five years on we are pleased that the NAO's
follow up study concludes that the subsequent actions taken by
the Department of Health have improved value-for-money in stroke
care and resulted in better outcomes including a reduction in
the chances of dying after a stroke. The Stroke Association welcomes
this conclusion and congratulates the Department, and all those
others who have contributed to this success.
However, despite improvements we would also
like to caution against stroke care now being seen as a "done
deal". The NAO make it clear that there remain areas of serious
concern and significant threats to achieving continued improvement
and value for money in stroke care over the medium to long term.
In particular the NAO are keen to point out
that the welcome improvements in acute stroke care are not yet
being matched in longer term support for survivors and their carers
in the community.
The study also exposes the threat posed to stroke
support services by the current financial pressures facing the
NHS and Local Authorities and the end of additional funding for
implementation of the National Stroke Strategy in 2010-11.
Although the Department of Health's ring fenced
funding for Local Authorities has significantly increased access
to longer term stroke support from organisations such as ourselves,
we have serious concerns about the sustainability of such services
and the level of support we will be able to offer to stroke survivors
and their carers after the funding period ends.
We fully agree with the NAO's recommendation
that NHS Organisations and Local Authorities must now plan how
they will sustain these services and we need a commitment from
the Department that these improvements will continue in the long
term.
Although the NAO are right to emphasise the
great improvements made in emergency and acute care since 2005
there are also areas in this part of the pathway where progress
has been too slow.
In particular it is unacceptable that only 17%
of stroke patients are admitted to a stroke unit within four hours
of arrival in hospital. There are also continuing problems with
access to brain scanning with only one in five eligible patients
having a scan within three hours of their stroke. Both of these
areas were the subject of key recommendations by Committee of
Public Accounts in 2006.
Despite the great strides that have been made
we feel that the concerns and threats to the sustainability of
recent improvements outlined by the NAO and the slow progress
in improving longer term support means that the true picture of
improvement in stroke care remains incomplete.
We would therefore recommend that as with the
Dementia Strategy the Committee of Public Accounts should request
a further review of progress in stroke care within three years
to ensure that developments in stroke care continue to provide
maximum value for money to the tax payer.
POST-HOSPITAL
AND LONGER-TERM
SUPPORT
1.1 Post-hospital and longer term support
in the community has traditionally been the weakest element or
care for many stroke survivors and the NAO find that the improvements
in acute stroke care in recent years are not yet matched by progress
delivering more effective post hospital care and support.
1.2 The NAO follow up report includes five
recommendations on post hospital longer term care compared to
two in the original 2005 report. We welcome the increased profile
that the NAO now gives to this area of support.
1.3 The 2005 NAO report acknowledged that
voluntary and community organisations can provide effective long
term support for stroke survivors and recommended that the Department
of Health encourage this.
1.4 The Stroke Association has taken up
this challenge and the ring fenced funding for Local Authorities
attached to the National Stroke Strategy along with increased
investment from PCTs has led to a massive increase in the number
of support services we are able provide to stroke survivors.
1.5 The additional funding has also allowed
significant innovations in the services we provide including moving
beyond our long running Information, Advice and Support and Communication
Support services to increased health promotion services, work
supporting re-enablement and social inclusion and targeted support
for high risk groups.
1.6 Our new model of provision for stroke
survivors, Life After Stroke Services, puts stroke survivors and
carers at the centre and offers services to meet individual needs;
it also sign posts stroke survivors to other services. We believe
this service will encourage integration and joint working between
health and social care systems and other services such as benefits
and employment support as identified by the NAO report as one
of the key areas of concern.
1.7 Once the current level of our services
reach full capacity, one in two eligible patients will be able
to access them, compared to one in five in 2005. The Stroke Association
can also report that the growth of our services has been greater
in areas where access has previously been relatively low.
1.8 However, there are still regional variations
in the services that we offer and problems with access to services
in rural areas. We hope to continue to develop these services
and ensure a more uniform distribution across the country.
The value of longer-term support
1.9 We believe our services offer effective
support for the post hospital needs of stroke survivors and their
carers but accept that it is sometimes difficult to demonstrate
their cost effectiveness. We do however monitor their impact on
people who use our services.
1.10 The report Changing Lives—The
Stroke Association Impact Survey showed that as result of
using our services 85% of people felt more in control and 75%
felt that stroke dominated their life less. Anecdotal evidence
shows the economic benefits that arise, for example through enabling
early discharge, helping people back to work and avoiding readmission
to hospital.
1.11 The Stroke Association is investing
£150,000 in researching the effectiveness and value of our
services. We believe this will provide an evidence base to demonstrate
the value and effectiveness of these services as well as their
obvious social value to stroke survivors and their families.
1.12 We welcome the NAO recommendation that
the Department of Health should evaluate the effectiveness of
the Local Authority stroke grants during 2010-11 and hope that
this will help improve the evidence base for longer term support.
1.13 The Department of Health should commit
to evaluating the effectiveness of the Local Authority stroke
grants during 2010-11.
1.14 The Department of Health should take
action to improve the research based evidence and guidance on
the costs and benefits of clinical and other support for long
term stroke care.
The risk to support services
1.15 The NAO report shows that 76% of Local
Authorities surveyed have used the Department of Health's ring
fenced grants to develop services such as the provision of information
training and support for stroke survivors with The Stroke Association.
1.16 However, this funding is only guaranteed
until 2010-11 and we are seriously concerned that with increased
pressure on Local Authority budgets these services may be at risk
of closure when grants end. We agree with the NAO that action
must be taken now to plan how to sustain support services.
1.17 The Department of Health should take
action to help ensure that those services currently funded through
the ring fenced grant to Local Authorities are sustained beyond
2010-11.
Outcome measures for longer term support
1.18 One of the reasons for the difficulty
in assessing the effectiveness of longer term care is that there
is a lack of agreement on outcomes measures to assess the quality
of long term care.
1.19 We support the NAO recommendation that
the Department of Health should develop a set of indicators of
high-quality long-term stroke care. We also support the suggestion
that the longer term care aspects of the Strategy should be re-examined
with a view to develop more measurable quality markers and a set
of specific milestones for improvement. We would like to see providers
of longer-term support services, stroke survivors and carers directly
involved in this process.
1.20 The Department of Health should involve
providers, stroke survivors and carers in discussions about how
best to define and measure good quality long term care.
Ongoing review and support of stroke patients
after discharge
1.21 The NAO state that 30% of patients
were not given a follow up appointment within six weeks of discharge
as required by the Stroke Strategy.
1.22 Without an effective review system
stroke survivors and carers may be denied access to those services
that could have a major impact on their quality of life.
1.23 The Department of Health must take
action to ensure that an effective review system is put in place
that can identify the long term needs of stroke survivors.
PUBLIC AND
PROFESSIONAL AWARENESS
OF STROKE
2.1 We welcome the Department's major advertising
campaign focusing on stroke symptoms and the fact that stroke
is a medical emergency. It is pleasing to see its success as demonstrated
by the increase in the number of calls registered by ambulance
trusts. However, the true measure of success will be if the key
messages (recognition of symptoms and dialling 999) are retained
and acted upon when a stroke occurs.
2.2 The Department of Health must make plans
to continue the campaign to improve awareness of stroke over the
medium to long term.
2.3 The Committee of Public Accounts in
its previous report recommended that the awareness campaign should
particularly focus on those groups at higher risk of stroke such
as people from Afro-Caribbean and South Asian ethnicity.
2.4 The Department of Health should outline
what work has been done to explicitly target higher risk groups
with key messages on stroke symptoms and commit to continuing
this over the medium to long term.
2.5 The NAO suggest that a lack of training
within A&E and Medical Assessment Units for recognising symptoms
of stroke is acting as a bar to patients accessing specialist
stroke units.
2.6 The Department of Health should ensure
that stroke training is provided to all staff involved in the
management of stroke patients whether or not they are working
on a stroke unit.
IMPROVING ACUTE
CARE
3.1 We welcome the transformation in acute
care which has taken place in most parts of England since the
last report. However, the NAO suggests that the extent of progress
is variable around the country and warns that future reorganisation
of services to provide better care could be complicated by the
challenging economic climate. The NAO highlight the following
issues that must be addressed to ensure continued improvement
and value for money:
EMERGENCY ASSESSMENT
AND TREATMENT
3.2 A brain scan is the only way of identifying
if a patient is experiencing a hemorrhagic (caused by bleeding)
or ischaemic (caused by clotting) stroke and deciding the appropriate
action to take.
3.3 Thrombolysis (treatment with clot busting
drugs) can reduce mortality and morbidity in eligible patients
but needs to be administered within three hours and is dangerous
for patients with hemorrhagic stroke making scanning essential.
3.4 Although access to brain scanning has
improved only one in five eligible patients had a scan within
three hours of their stroke and only 59% within 24 hours.
3.5 Although the number of sites in England
offering thrombolysis has increased greatly from 18% in 2006 to
71% in 2009 the number of patients treated is small and only one
in four sites provide thrombolysis at night and at weekends.
3.6 The Department of Health must take action
to encourage the rapid assessment, imaging and treatment of patients
with suspected stroke throughout the 24 hour period, seven days
a week.
ACCESS TO
STROKE UNIT
CARE
3.7 Stroke unit care is the single most
beneficial intervention that can be provided after stroke.
3.8 We welcome the fact that the proportion
of patients spending 90% of their stay on a stroke unit increased
to 57% in 2009 but it is important that all patients should be
treated this way.
3.9 The failure to admit directly to an
acute stroke unit remains the most important barrier to improving
acute stroke care. The report shows that only 17% of stroke patients
were admitted within four hours of arrival at A&E.
3.10 The Department of Health must take
action to ensure all patients are admitted directly to an acute
stroke unit and that they spend the majority of their time at
hospital in a high quality specialist stroke unit.
STAFFING
3.11 The unavailability of the full range
of appropriately trained staff is identified as a weakness in
the report. Although the number of stroke consultant sessions
has increased it is still well below the recommended minimum level
of two per 250,000 and there are particular problems with access
to psychological support.
3.12 The Department of Health should consider
what action is required to meet the necessary staffing levels
in stroke units to implement the Stroke Strategy.
TREATMENT OF
TIA (TRANSIENT ISCHAEMIC
ATTACKS OR
MINI STROKE)
4.1 It has been estimated that improving
the treatment of TIA (mini stroke) could prevent 1,200 strokes
and save the NHS £37 million.
4.2 The NAO find that specialist assessment
of suspected TIA has improved especially in the number of sites
with systems in place for higher risk patients to be seen and
treatment initiated within 24 hours.
4.3 However, we understand that the Vital
Signs measure chosen to assess improvement (the proportion of
higher risk patients treated within 24 hours) has unfortunately
created some difficulties and confusion and may have become a
disincentive to delivering best practice in this area.
4.4 We would therefore like to see other
efforts being made to drive the development and spread of good
practice on delivering treatment within 24 hours for those higher
risk TIA cases.
4.5 We are also concerned that 51% of hospitals
have a waiting time of over two weeks for carotid endarterectomy,
one of the main procedures for TIA. Providing such surgery within
two weeks could prevent around 250 strokes at a net saving of
£4 million to the NHS.
4.6 The Department of Health should take
further action to encourage the widespread use of best practice
in the management of TIA.
PREVENTING FURTHER
STROKES
5.1 The report notes that the best way to
reduce the human and economic costs of stroke is through prevention.
5.2 We would like to see further emphasis
on the management of risk factors for stroke and in particular
the effective treatment of atrial fibrillation (irregular heart
rhythm) which could prevent 4,500 strokes annually.
5.3 The risk of having another stroke or
TIA is very high so ongoing monitoring and support of secondary
prevention is important. The report shows that only half of stroke
survivors were given advice on further stroke prevention on leaving
hospital and many were not aware of the common risk factors.
5.4 Alongside improvements to the ongoing
assessment of secondary prevention the Department of Health must
take a lead at the national level to refer explicitly to stroke
in more public health campaigns.
CONTRAST WITH
DEMENTIA STRATEGY
6.1 The recent follow up report from the
NAO criticising progress on the Department's dementia strategy
highlighted a number of levers for change missing in that strategy
which have contributed to the success we have seen with the implementation
of the National Stroke Strategy.
6.2 Unlike dementia, the position of stroke
as a national priority for the NHS was supported by its inclusion
in the NHS Operating Framework as a Tier One "must do"
indicator.
6.3 The existence of a National Clinical
Director for Stroke has also been a key factor in driving change,
a position that wasn't filled for dementia until a year into the
Strategy.
6.4 The lack of extra funding for councils
to help improve services was also highlighted as a problem in
the NAO's dementia follow-up. The NAO stroke report showed that
there has been an increase in long term support services for stroke
survivors as a result of ring fenced grants for Local Authorities.
6.5 The Department of Health must ensure
that stroke care remains a national priority for the NHS with
strong leadership and adequate funding.
REQUEST FOR
FURTHER REVIEW
BY THE
NATIONAL AUDIT
OFFICE
7.1 Despite the great progress that has
been made since 2005 we agree with the NAO that there are ongoing
concerns to be addressed if the National Stroke Strategy is to
achieve its objectives in the medium to long term.
7.2 The future financial climate the NHS
must operate within and the end of the period of additional funding
that accompanied the Stroke Strategy also raises questions about
the sustainability of progress and further development of both
acute and longer term stroke care and support.
7.3 The slower movement on improving longer
term support for stroke survivors and the lack of evidence on
the cost effectiveness of such support means that the assessment
of progress to date does not give a full picture of improvement
across the whole care pathway for stroke.
7.4 We recommend that as with the Dementia
Strategy the Committee of Public Accounts should request a further
NAO review of progress in stroke care within three years to ensure
that developments in stroke care continue to provide maximum value
for money to the tax payer.
11 February 2010
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