1 Reducing variation in stroke care
in hospitals
1. A stroke occurs when blood flow to the brain is
interrupted, resulting in damage to brain tissue. The most common
causes of the 110,000 or so strokes in England each year were
blood clots blocking arteries (Ischaemic) or arteries bursting
(Haemorrhagic). Stroke is one of the top three causes of death
and one in four people who had a stroke died. It is also the largest
cause of adult disability in England, with around 300,000 people
disabled as a result of stroke. The direct cost of stroke to the
National Health Service (NHS) is at least £3 billion annually
with the wider economic cost around £8 billion.[3]
2. In July 2006, we reported that stroke services
in England were poor. Vital brain scans for stroke patients were
being delayed and a significant proportion of stroke patients
were not being treated on a stroke unit. Even though most of the
burden of stroke occurred after discharge, post-hospital support
services were scarce and difficult to access. Public awareness
of the symptoms and impact of stroke, and stroke prevention, was
also low. We reported that the cost of stroke, in both economic
and human terms, could be reduced by re-organising services and
using existing capacity more wisely.[4]
3. The Department recognised that it was vital that
stroke patients arriving at hospital soon after their stroke had
an immediate brain scan to determine the type of stroke and consequently
the most effective treatment.[5]
Thrombolysis might reduce significantly the extent of disability
for those who arrived at hospital within three to four and a half
hours of their stroke, and who had a clot rather than a bleed.
Scanning all other patients within 24 hours was important to ascertain
whether they should start taking aspirin or not.[6]
4. In 2008, only 59% of patients had been scanned
after 24 hours. There remained substantial variation in access
to brain imaging, with some hospitals having high average waiting
times for scans. The weekday average scanning time at the Diana,
Princess of Wales Hospital in Grimsby, for example, was 25-48
hours.[7] Obstacles to
providing immediate scanning included some scanners being locked
out of hours, even though there were radiographers present who
were capable of interpreting the scans, and slow implementation
of video link-ups and other technology in areas where scans had
to be interpreted off-site. Other barriers included a lack of
pre-alert systems to inform hospitals in advance of the arrival
of stroke patients, and inefficient location of the scanners with
respect to the Accident and Emergency department.[8]
5. The Department of Health (the Department) acknowledged
that the waiting times for scans in some hospitals was unacceptable
and it announced a number of initiatives aimed at addressing this
issue. The Department, working through the Stroke Improvement
Team's accelerated delivery programme, has required Primary Care
Trusts to develop proposals by March 2010 for configuring brain
imaging services to give every patient access to scanners 24 hours
a day seven days a week.[9]
From April 2010, there will also be a financial incentive (with
the introduction of a new Best Practice Tariff) for hospitals
to provide timely scanning.[10]
The Department told us that increased public expectations of what
to expect from ambulances and Accident and Emergency Departments
would also lead to improvements.[11]
6. The Department agreed that the one intervention
that made the most difference was treatment on a stroke unit where
patients receive multidisciplinary care from staff skilled in
dealing with a stroke.[12]
Following the Treasury's Comprehensive Spending Review in 2007,
the Department introduced as a 'Vital Sign' Tier One target, the
proportion of patients spending 90% of their stay on a stroke
unit. Responsibility for delivery of this target rested with Primary
Care Trusts and it was included in their operating plans for 2008-09
to 2010-11.[13] While
performance against this measure has increased from 47% in the
three months from January 2009 to 58% nine months later, substantial
progress would be required to meet the Department's expectations
of 80% by the end of 2010-11, with some areas falling well below
this level (Figure 1).[14]
Figure 1: Proportion of patients spending 90%
of their time on a stroke unit at the end of 2009
7. The Department recognised that hospitals started
from very different points and acknowledged that the worst performers
were an embarrassment.[15]
The Department considered that there were sufficient stroke unit
beds across the country to ensure that all patients could receive
care on a stroke unit, and that it was unacceptable that people
were still spending time in Medical Assessment Units or on general
wards. The main reasons for patients not being treated on a stroke
unit were poor bed management and poor patient prioritisation
(triage) protocols. All of these obstacles to treatment on a stroke
unit were avoidable. Unlike in coronary care units, sometimes
stroke unit beds were occupied by patients with other conditions.[16]
8. The Department expected the introduction of the
Best Practice Tariff in April 2010, and Strategic Health Authorities'
performance management of their Primary Care Trusts, to improve
the results of poor performers.[17]
The Department also recognised the importance of the Stroke
Improvement Programme, and of the 28 Stroke Networks to drive
up improvements in this area.[18]
9. Despite increases in the level of staffing in
stroke units generally, some stroke units still had less staff
than the Department's expected levels.[19]
The Department acknowledged that addressing these shortfalls would
not necessarily lead to additional costs as better stroke care
usually reduced costs. It considered that some staffing shortfalls,
such as in clinical psychology and speech and language therapy,
could be partially addressed by training existing members of the
stroke team.[20]
10. Early Supported Discharge, whereby suitable stroke
patients were discharged from hospital into the care of a specialist
multi-disciplinary team based in the community had improved stroke
care. It was better for patients and was cost-neutral or cost-saving,
as it reduced the length of stay and hence the pressure on hospital
beds.[21] There was significant
variation in what hospitals deemed to be an early supported discharge
programme and only 36% of hospitals offered such a service.[22]
11. The Department acknowledged that a lack of clarity
about who should fund Early Supported Discharge services was a
barrier to providing them.[23]
Although providing Early Supported Discharge could save money
in the long-run, it required initial investment to set up the
service before the savings, from reducing bed numbers could be
realised. The Department recognised the importance of making improvements.
It told us that, as the NHS had a 5.5% growth in funding in 2010-11,
it has requested that every Primary Care Trust identify 2% of
its budget to invest in initiatives such as early supported discharge,
that could lead to savings.[24]
3 C&AG's Report, Session 2009-10, Progress in
Improving Stroke Care, HC 291 Back
4
Committee of Public Accounts, Fifty -second Report of Session
2005-06: Reducing brain damage: faster access to better stroke
care, HC 911 Back
5
Qq 7-9, 23, 36-37, 39-40 and 43 Back
6
Qq 8, 11 and 36 Back
7
Qq 8, 10-11, 29, 38 and 61; C&AG's Report, para 9 Back
8
Qq 15, 25-26, 67 and 69 Back
9
Qq 67 and 68 Back
10
Qq 8 and 46-47 Back
11
Qq 15 and 68 Back
12
Q 50 Back
13
C&AG's Report, para 5 Back
14
Q 74; C&AG's Report, para 2.16; Department of Health, Vital
Signs data, 2009-10, October-December Back
15
Q 59 Back
16
Qq 9, 15-16, 18 and 74 Back
17
Qq 5 and 6 Back
18
Q 5 Back
19
C&AG's Report, Figure 10 Back
20
Q 52 Back
21
Qq 14 and 48 Back
22
C&AG's Report, para 2.26 Back
23
Qq 14 and 77 Back
24
Qq 48 and 77 Back
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