Stroke services show progress

Stroke is the third biggest cause of death in the UK and the largest single cause of severe disability. Each year more than 110,000 people in England will suffer from a stroke, which costs the NHS over £2.8 billion.1 Despite this, stroke has not received the same interest as cancer and heart disease, and years of neglect have left the UK with some of the worst outcomes for stroke survivors in Western Europe. However, there is room for cautious optimism. Stroke is becoming a key focus for the Department of Health. In addition to its National Stroke Strategy, announced in December 2007, the DH recently launched a £12 million awareness campaign to help the public recognise signs of stroke using a simple “FAST” test, with the aim of improving survival and reducing disability. Significant progress is also now being achieved in the delivery of stroke services, throughout the care pathway, according to the Stroke Association. In the report, Getting Better, the Stroke Association provides examples of best practice which have helped to improve outcomes, as well as highlighting the challenges that need to be addressed to turn the national stroke strategy into a reality. Jon Barrick, Chief Executive for the Stroke Association, explained: “Just over a year ago the Government issued the National Stroke Strategy for England, which set out the blueprint for good stroke care. The race to deliver this strategy is now well and truly underway. “Our report shows what can happen when national direction is matched by local action. The Getting Better report outlines examples in providing the level of stroke care that ensures everyone who has a stroke, and their carers and loved ones, get the service they deserve, wherever they live.” The report shows what can be achieved when people across the health, care and voluntary services work together to champion stroke. It also highlights the importance of rapid treatment for stroke patients. It demonstrates how lives can be saved when stroke patients are transferred directly by ambulance to a hospital providing acute stroke services avoiding life-threatening delays in A&E.

Case study: John Radcliffe Hospital

Among the 12 success stories highlighted in the report is Oxford’s John Radcliffe Hospital. A review of services provided by the hospital cut the risk of major stroke by 80% through the provision of prompt treatment for people with minor stroke or transient ischaemic attack (TIA). The neurology team at John Radcliffe Hospital looked at why some patients failed to attend their appointments at the weekly TIA clinic. They discovered that more than one in 10 did not turn up because, between their TIA and their appointment, they had been admitted to hospital with a major stroke or a further deterioration in their condition. “The number of potentially preventable major strokes occurring before assessment was unacceptable,” commented Peter Rothwell, a professor of neurology based at John Radcliffe. There was, however, a lack of evidence to show that prompt assessment could cut the risk of stroke. The John Radcliffe team designed a study to research this and the results were startling. Working with local GPs, the hospital introduced a daily clinic to replace the standard weekly model. In phase one, which lasted 30 months, GPs referred any patient with suspected TIA or minor stroke to the study team, who then contacted the patient at home to arrange a clinic appointment. Although the aim was to arrange an appointment for the next working day, this wasn’t always possible. Following the appointment, which included brain imaging and an electrocardiogram (ECG) to measure heart activity, the team faxed an initial clinical assessment and treatment recommendations to the GP, usually within 24 hours. Patients were told to contact their GP as soon as possible, but were not given any treatment or prescription at the study clinic. The average wait between the TIA occurring and the assessment was three days. However, there was an average delay of 20 days before patients actually received the medication or treatment they had been prescribed. In the second phase of the study, beginning in October 2004, the team introduced an emergency, noappointment clinic. GPs were asked to send all patients directly to the study clinic each weekday afternoon. They were assessed as before, but this time they were given aspirin to take straight away, and a prescription for a four-week supply of medication which they could collect the same day from the hospital pharmacy. In the first phase of the study, just over one in 10 patients (10.3%) had a major stroke within 90 days of first seeking medical attention. This improved dramatically after October 2004, with only around one patient in 50 (2.1%) having a major stroke in the next 90 days. The John Radcliffe team is aware that, despite their success in cutting stroke risk within 90 days of first seeking medical attention, the long-term risk remains high. The team has now taken on the responsibility of long-term monitoring of patients to check risk factors such as blood pressure. They hope to show that this is an effective way of reducing strokes over the long term, and that guidelines and practice will again be updated to reflect their findings.