Progress in jeopardy as stroke strategy ends
The national stroke strategy for England ends this year. Clinical leaders say a replacement is needed to build on its achievements and tackle variations in treatment and care.
The national stroke strategy for England ends this year. Clinical leaders say a replacement is needed to build on its achievements and tackle variations in treatment and care
When 36-year-old company director Nathan Ridgard went to his local A&E with an ‘excruciating’ headache and neck pain he was told he had a severe migraine and was admitted for tests.
‘Unfortunately it was New Year’s Eve, the hospital was shockingly understaffed, no stroke consultant was on duty and though nurses were extremely caring, I’m certain none were stroke specialists,’ he recalls.
Mr Ridgard waited three days for a scan, which led to a diagnosis of stroke affecting his eyesight, movement and energy levels.
‘After a week I was sent home, scared and unable to believe what had happened to me. With a wife, young daughter, mortgage to pay and unable to work, I felt angry that I’d been given no support or information on how to recover and just left to work things out for myself.’
Five years later, Mr Ridgard says the disabling after-effects of his stroke have ‘greatly improved’. He is back at work and campaigns to raise awareness of the devastating effects stroke can have on people’s lives.
Fortunately, stories like his are less common than they were. The ten-year National Stroke Strategy in England, introduced in 2007, has led to improved diagnosis and more effective, rapidly administered treatments and care in specialist stroke units. It has also raised public awareness of stroke symptoms through public health campaigns and contributed to the 46% reduction in stroke mortality between 1990 and 2010.
The improved outcomes delivered under the national strategy also saved the NHS an estimated £456 million between 2007 and 2014, evidence from the National Audit Office suggests.
However, the Stroke Association says improvement in hospital care has been patchy, with much of the country lagging behind London and Manchester, where services have been centralised around hyper-acute stroke units (HASUs).
Thousands lack access
Clinical audit continues to show that up to 15% of patients nationally are still not receiving clot-busting thrombolysis and 52% wait for more than the hour recommended in clinical guidelines for a brain scan to diagnose their stroke. Access to the important new treatment thrombectomy, a mechanical clot retrieval operation that reduces the after-effects of stroke, is limited to a few hundred people a year when thousands could benefit.
The association’s 2016 survey of stroke survivors also found a sharp fall in the quality of care people receive after they leave hospital, with more than 30% describing their care at home as poor or very poor. There is also evidence that almost half of stroke survivors don’t receive the recommended six-month assessment.
Worryingly, a report from the Stroke Alliance for Europe and King's College London suggests the UK’s ageing population means stroke incidence is set to increase by nearly half (44%) by 2035.
‘The guidelines have kept stroke professionals’ minds focused. Without this its messages will become diluted and progress in stroke diagnosis, treatment and after-care lost’
It is against this background that stroke survivors, clinical leaders including the National Stroke Nursing Forum, and the Stroke Association are calling on the government to commit to a new national stroke strategy to build on the progress achieved by the current one.
The government has said it has no plans to renew the strategy and insists that other initiatives such as the Cardiovascular Disease Outcomes Strategy and the NHS Five Year Forward View will continue to make progress on stroke.
Many clinical leaders argue that there is no substitute for the unique focus on stroke provided by a national strategy. RCN professional lead for long-term conditions Amanda Cheesley believes the ‘phenomenal progress’ achieved in improving stroke outcome must be attributed to the strategy. ‘The current stroke strategy’s specific guidelines have kept stroke professionals’ minds focused. Without this its messages will become diluted and progress in stroke diagnosis, treatment and after-care lost,’ she says.
Support for survivors
Imperial College Healthcare clinical nurse specialist in stroke Ismalia de Souza, a member of the RCNs neuroscience forum, also emphasises the strategy’s positive impact: ‘Over the past ten years there has been a major emphasis on stroke recognition, such as the public health FAST campaign. Acute stroke treatment has also improved, with increasing numbers of patients receiving thrombolysis and being directly admitted to specialist stroke units staffed by stroke care experts,’ she says.
Stroke is a leading cause of disability but stroke professionals and charities are concerned that stroke survivors are not getting the crucial after-care and support they need.
National clinical guidelines on stroke recommend stroke survivors receive health and social care reviews six and 12 months after their stroke, but only 30% receive even a six-monthly review. And despite the recommendation that those with mild to moderate stroke disability be offered Early Supported Discharge (ESD) from a multidisciplinary team, only a third of stroke survivors are discharged to such care.
‘Isolated and abandoned’
Stroke Association chief executive Juliet Bouverie highlights what she calls the NHS’s neglect of stroke survivors. ‘More than 46% of stroke patients, many of whom have serious physical disability, depression and psychological needs, told our recent survey that when they are discharged from hospital they feel isolated and abandoned,’ she says.
The association is campaigning for a new stroke strategy that would include improved support for stroke survivors (see box).
Clinical leaders from 19 stroke care bodies, including the National Stroke Nursing Forum, have also called on the government to give a ‘renewed national focus’ to improve stroke services following the end of the 2007 strategy. Rehabilitation is one of the three areas the joint statement says requires urgent action. The other two are implementation of new treatments and stroke prevention.
‘After stroke patients leave hospital, their care is much worse. So we need a national strategy that puts the emphasis on long-term stroke aftercare, self-management and rehabilitation’
Ismalia de Souza
Ms de Souza says: ‘We know that after stroke patients leave hospital, their care is much worse. So we need a national strategy that puts the emphasis on long-term stroke after-care, self-management and rehabilitation.
‘As health professionals we must stop working in silos, for example by establishing more nurse-led follow-up clinics. Stroke nurses with advanced diagnostic and clinical skills must also work more closely with community nurses and GPs.’
The current strategy’s successful promotion of specialist stroke units and its recognition of the crucial role and training needs of nurses working across the stroke pathway has raised the profile of stroke nursing over the past decade.
The Stroke Association says specialist stroke staff have been at the heart of the transformation in hospital stroke care that has saved lives. ‘With a growing ageing population, we urgently need more trained, specialist stroke nurses who can provide every stroke patient with a chance to make the best possible recovery,’ a spokesperson for the association says.
Stroke nurse specialist Stephanie Tempest of Pinderfields Hospital in Wakefield, West Yorkshire, established and leads a team of five specialist nurses providing 24-hour emergency nursing cover to a wide catchment area.
She says: ‘Our team always carry phones to take calls from ambulance crews, assess patients’ stroke symptoms and onset times and meet them at our hospital entrance. Then, bypassing A&E, we accompany them for immediate diagnostic scan, to ensure they meet a 4.5-hour treatment deadline.’
Once stroke patients have been further assessed by a doctor, stroke nurses assist in intravenous thrombolytic infusion administration, monitoring their patient’s condition at 15-minute intervals. ‘This can be very rewarding if stroke symptoms, such as facial droop, disappear within an hour,’ she says.
Reassure and advise
Pinderfields’ stroke unit ward staff liaise closely with community services.
Ms Tempest also runs TIA (transient ischaemic attack) clinics, where she assesses patients’ progress and well-being and offers health education advice. ‘My clinic provides a perfect opportunity to ensure patients have experienced no further TIA symptoms, reassure those who are anxious about their recovery and advise on future stroke prevention strategies, such as blood pressure reduction.’
Consultant stroke nurse Paula Beech has been involved in stroke nursing for 17 years and has an academic background in stroke research, gaining a master’s degree in TIA and a doctorate in stroke patient information provision.
She works at England’s largest stroke-admitting hospital, Salford Royal Foundation Trust, dividing her time between running the stroke unit’s 16-bed rehabilitation ward, a nurse-led stroke follow-up clinic held every two weeks, multidisciplinary discharge planning meetings and community liaison, plus staff education and management.
‘Not only may a stroke affect sight, movement, appetite, speech and continence, but also emotions and thinking processes. Nurses are ideally placed to help patients understand and find solutions to living with such disabilities’
‘I’m passionate about effective stroke rehabilitation,’ says Dr Beech, ‘because it helps stroke patients manage their lives as independently as possible.’
Dr Beech liaises closely with a multidisciplinary ESD team, which includes two nurses, using her follow-up clinics to iron out rehabilitation problems and help patients reduce stroke risk factors,
‘A stroke can affect every aspect of people’s lives and, unlike a heart attack, it is quite difficult for some to make sense of. Not only may it affect sight, movement, appetite, speech and continence, but also emotions and thinking processes. Nurses, with their holistic skills and patient accessibility, are ideally placed to help patients understand, normalise and find solutions to living with such disabilities.’
Under sustainability and transformation plans (STPs) in England, acute stroke care is likely to be centred within fewer, more effective specialist stroke units staffed by stroke nurses with advanced clinical skills.
‘There is currently a buzz around thrombectomy treatment, and its increased use should reduce stroke disability,’ says Dr Beech. ‘And hopefully, the current drive to centralise stroke care through STPs won’t risk leaving some areas too far from stroke services.
‘But stroke patients’ greatest current need is for good quality rehabilitation and support through multidisciplinary community teams that include nurses, to support stroke patients for at least six weeks after leaving hospital.’
Dr Beech has no doubt that a national strategy is required. ‘Over the past decade our current stroke strategy has shone a light on stroke care by driving change and development in acute services. But there is still so much more to do to ensure patients gain equal access to stroke care and rehabilitation nationwide. A new stroke strategy is therefore a must if we are to get this job finished satisfactorily.’
A new era for stroke strategy
The Stroke Association is calling for a new government stroke strategy to:
- Drive advances in stroke treatment to save lives and reduce post-stroke disability and social care costs.
- Stroke service reorganisation.
- Improve support and rehabilitation for stroke survivors returning home, enabling them to regain a fuller recovery and better quality of life.
- Address the unacceptable national variations in stroke treatment and aftercare.
Stroke: the figures
- About 85% of strokes are ischaemic (due to a blocked blood vessel) and the remainder are haemorrhagic (due to bleeding).
- Over a quarter of people who have a stroke have had a previous stroke or transient ischaemic attack (TIA or ‘mini-stroke’).
- Vascular dementia, which accounts for an estimated 20% of dementia cases, can be caused by stroke.
- Diabetes almost doubles stroke risk and hypertension contributes to around half of all strokes.
- Black people are twice as likely as white people to have a stroke, and more likely to have a stoke at a younger age.
- Only 50% of patients with suspected stroke are scanned within the recommended one hour of hospital arrival.
- There are more than 400 cases of childhood stroke in the UK each year.
- Strokes cause twice as many deaths in women in the UK as breast cancer and twice as many deaths in men as testicular and prostate cancer combined.
- Strokes cost England £1.7 billion a year in health and social care.
Source: State of the Nation, Stroke statistics January 2017, the Stroke Association
Catharine Sadler is a freelance health writer