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The first article that I wrote for this blog was a brief note on the introduction of the National Stroke Strategy which expressed some concern about some of the detail but generally welcomed anything which would improve stoke care and move the UK nearer to levels achieved by other countries.
On February 3rd the National Audit Office (NAO) produced a report on the strategy's progress. In brief, hospital treatment and care of stroke patients has significantly improved but much needs to be done with regard to care in the community after the patient has been discharged.
The 2008 NICE guidance on stroke describes stroke as a "major health problem in the UK" which accounted for over 56,000 deaths in England and Wales (11% of all deaths). The guidance estimate that more than 900,000 people in England are living with the effects of stroke and calculates that this condition costs the English economy about ?7 billion per year.
According to the NAO, 25% of strokes are fatal, 50% of stroke survivors are left dependent on others for help with everyday activities. For those who experience a stroke, long term problems may include:
The risk factors for stroke include:
The NAO has found that there are 'measurable improvements' in the initial treatment and care of stroke patients since 2006. All relevant hospitals now have a specialist stroke unit, however the NICE guidance stipulates that suspected stroke patients should be immediately admitted to these units and the NAO has found that in 2008 only 17% of stroke patients actually reached the stroke unit within four hours of their arrival. The number of patients given a brain scan within 24 hours of admission had risen from 42% in 2006 to 59% in 2008 although the report notes that access to scans is significantly more limited during evenings and at weekends. With regard to TIAs, 95% of trusts now offer a specialist neurovascular clinic for the assessment and treatment of these attacks. The median number of these clinics held each week has risen from one to three over the past two years.
For those with atrial fibrilation, the NICE guidance recommends treatment with warfarin but only 24% of stroke patients with atrial fibrillation were discharged on this treatment.
The number of patients receiving thrombolysis (treatment with 'clot-busting' drugs) doubled between 2007-8 to 2008-9. The report recognises that it is easier in urban areas to configure services for faster treatment than it is in rural districts with much greater distances to travel.
The report finds that the progress in acute care has not been matched in the delivery of post-hospital support which it blames on poor joint working between the health service, social care and other services in thye community. Only 36% of hospitals have community-based rehabilitation for stroke patients with moderate disabilities even though it is recognised that these provide better and more cost-effective outcomes than hospital-based rehab.
30% of patients were not reviewed within 6 weeks of discharge, only half of stroke survivors said they were given advice on stroke prevention, 20% were not aware that a lack of exercise increases their risk of stroke.
Some improvement has taken place, especially in early treatment and scanning. We need to see a much higher proportion of patients being admitted to the stroke units within 4 hours. It isn't acceptable that whether or not you receive a timely brain scan depends on whether you are admitted during 'normal' office hours. Scans need to be available round the clock, seven days a week- to do otherwise is to suggest that the needs of the system are given priority over the life or death needs of patients. We also have the majority of clinicians ignoring NICE guidance with regard to atrial fibrillation - this is completely unacceptable as the guidance team considers all the best evidence and is thus in a position to stipulate the benchmark for best practice. Those clinicians that choose to ignore this benchmark should be named and asked to explain themselves.
With regard to post-hospital care, health services and local authorities consistently fail to work together. This is primarily because each party sees joint working as a way of reducing costs and off-loading responsibility to the other party. This is a well-known and seemingly intractable problem that is especially entrenched when funds are tight. The only way to sort this out is for central government to fine those agencies who fail to work together effectively.
One of the original reasons for having a national strategy for stroke was the fact that the UK survival rate for stroke lagged far behind those of other European countries- the NAO report doesn't say whether or not this gap has been narrowed.
