Introduction
Stroke is one of the most common causes of death and complex disability in the UK. By the age of 75, one in five women and one in six men will have a stroke, and over a third of stoke survivors in the UK are dependent on others[1]. One in four people die within the first year of a stroke and one in eight within the first 30 days[2].
The term ‘stroke’ refers to a sudden change to the blood supply to the brain, depriving it of oxygen and potentially leading to brain damage or death. Blood supply to the brain can be affected by either a haemorrhage, when a blood vessel to the brain bursts, or blockage in one of the arteries in the brain. Approximately 85% of strokes are due to a blockage in one of the arteries (ischaemic stroke). Disabilities caused by a stroke depend on the site of the affected blood vessel - most commonly, there will be weakness on one side of the body, communication problems or vision problems.
Transient ischemic attacks (TIA) are a type of ischaemic stroke where the effects last for a maximum of 24 hours and then completely resolve. A TIA is a warning sign for an impending stroke, and 8% of people who have a TIA will go on to have a stroke in the next seven days[3].
Most strokes are due to common risk factors such as high blood pressure, irregular heart beat (atrial fibrillation), smoking and high cholesterol, but there are rarer causes too. Stroke disease costs the UK on average £7 billion a year in direct care, informal care, lost productivity and disability costs. Investment in organised stroke services improves patient outcomes and saves overall costs for health and social care.
Modern care involves direct access to an acute stroke unit. This should provide immediate brain imaging and evidence-based interventions such as thrombolysis[4], thrombecotomy[5], the lowering of blood pressure and the use of intermittent compression stockings, as well as neuroscience services to manage patients with subarachnoid[6] and intracerebral haemorrhage[7].
For optimal recovery this acute treatment needs to be followed on discharge by specialist stroke rehabilitation in a community setting. The aim of stroke rehabilitation is to maximise activity and quality of life following a stroke. Fewer people die after a stroke than in previous decades, but more people live with a disability. Recovery can take many years – some people never regain all of their brain function and have continued problems with speech, mobility or continence, but others make a full recovery over time. Whatever the level of disability, it is not easy to adjust to life after stroke for both the survivor and their family.
Unmet need and gaps
- There is some variance across the county in the detection and management in primary care of those with undiagnosed risk factors such as high blood pressure and AF to reduce the burden of stroke.
- There is no specialist stroke community rehabilitation service in Mid-Nottinghamshire for those who have been discharged from the Early Supported Discharge (ESD) service. This gap is likely to affect patients’ quality of life following a stroke and can make a difference to their eventual outcome. It may also exacerbate health inequalities and lead to extra long-term costs across the health and social care system in the area.
- Six monthly (and annual thereafter) reviews after discharge from hospital following a stroke have not been routinely carried out in Nottinghamshire County, despite recommendations in the National Stroke Strategy[8] and NICE guidelines[9] to the contrary. However, they have recently been commissioned in the south of the county for all stroke survivors. A structured health and social care review at six months and annually thereafter allows patients and their carers to discuss the issues that continue to concern them and formulate plans of action. This lack of provision may lead to increased pressure on primary care for treatment of preventable symptoms and also further risk of re-admission into hospital for stroke-related problems due to a lack of secondary prevention.
- It is reported that there is insufficient provision of services for carers, family members and partners of stroke survivors locally. By the very nature of stroke, they become carers very suddenly and may have difficulty accessing the help and information that they need in a timely way. It is also reported that there is a lack of appropriate services to support those of working age back into the workplace.
- Psychological problems such as depression and anxiety are very common after stroke and can be as debilitating as a physical disability. It is therefore essential that these are identified quickly. However, there are only a small number of patients locally who are able to access appropriate input from a qualified clinical psychologist. Other options for providing psychological support can also be considered, such as through specialist mental health nurses.
Recommendations for consideration by commissioners
Strategic
- Clinical commissioning group (CCG) and social care commissioners should plan appropriately for the forecast that:
- there will be a rise in the actual number of people having strokes in the future (due to an increasing and ageing population).
- there will be more stroke survivors living with disability in the community who need access to support (due to reducing mortality from stroke because of advancements in treatment and rehabilitation).
- CCGs should undertake a health equity audit in relation to access to services; variation across the county of stroke mortality rates; feedback from local stroke survivors; outcomes; and the implications of variable performance around discharge of patients with a joint health and social care plan.
Prevention
- CCG commissioners should continue to support GP practices to prevent stroke by increasing the detection, diagnosis and effective treatment of high blood pressure, atrial fibrillation and diabetes.
- Public Health commissioners should continue to support GP practices to prevent stroke by increasing patient uptake of the NHS Health Check programme, especially within high risk groups.
Acute
- Providers should aim to continue improving performance in ensuring that all people with suspected stroke are admitted directly to a specialist acute stroke unit following initial assessment - acute stroke units should provide equity of care across the region. Providers should also ensure that ESD services are effective in enabling eligible patients to be discharged sooner, so that stroke unit beds are used more efficiently.
- Providers should ensure that there is sufficient weekend nurse and therapy cover on stroke wards.
- Providers should address variability across the county in terms of both access to intra-arterial (thrombectomy) treatment and the use of intermittent pneumatic compression devices. (The local Clinical Advisory Group is currently looking at how to address the thrombectomy service.)
- CCG commissioners and providers should ensure that there is access to sufficient psychological support for stroke survivors, including qualified clinical psychologists or specialist mental health nurse support where required.
Rehabilitation
- CCG commissioners should ensure that community rehabilitation services (multi-disciplinary teams with stroke specialist skills and experience) are available for all Nottinghamshire stroke survivors who require rehabilitation in their place of residence after discharge and beyond ESD services.
- CCG commissioners should commission structured assessments at six months following discharge from hospital for all stroke survivors and annually thereafter.
- CCG and social care commissioners should ensure that there is sufficient accessible provision of services for carers, family members and partners of stroke survivors, including respite care.
CCG and social care commissioners should ensure that appropriate services are in place to support stroke survivors of working age to return to the workplace
[1] Stroke Association - State of the Nation (2016)
[2] Ibid
[3] Ibid
[4] Treatment with a clot-busting drug to try to disperse the clot and return the blood supply to the brain. The medicine itself is called alteplase, or recombinant tissue plasminogen activator (rt-PA).
[5] The mechanical removal of a thrombus (solid mass stationary blood clot) to help restore blood flow and prevent or limit the damage caused by the stroke.
[6] A subarachnoid haemorrhage is an uncommon type of stroke caused by bleeding on the surface of the brain.
[7] Intracerebral haemorrhage occurs when a diseased blood vessel within the brain bursts, allowing blood to leak inside the brain.
[8] Department of Health - National Stroke Strategy (2007)
[9] NICE CG 162 (2013) - Stroke Rehabilitation in Adults