Action is needed now to reverse shocking decline in stroke care

 This is where the stroke associations need the correct goal to shoot for; it's not 'care'; it is RESULTS AND RECOVERY! Current leadership is a total fucking failure. This is why we need survivors in charge

Action is needed now to reverse shocking decline in stroke care

To tackle declining performance in stroke care, investment in well-evidenced interventions, and a sustainable stroke workforce is the need of the hour, writes Juliet Bouverie

Stroke occupies a unique position as a condition that touches nearly every element of our health and care system. There are over 100,000 strokes in the UK every year.

Every stroke requires a treatment pathway that bridge the boundaries between pre-hospital, inpatient, and community care. Stroke care is highly multidisciplinary, which makes it an effective litmus test for the whole of the health and care system.

And unlike many other neurological illnesses, it’s a condition that is treatable and recoverable with early and high intensity treatment and rehabilitation. This means that targeted quality improvement interventions in stroke will have outsized and cost-effective benefits for all.

Getting stroke care right, through investment in well-evidenced stroke interventions, will help to alleviate the now chronic pressures being placed on staff, infrastructure, and wider healthcare delivery systems.

The recently updated National Clinical Guideline for Stroke for the UK and Ireland, endorsed for use in clinical practice by the Royal College of Physicians of London, the Scottish Intercollegiate Guidelines Network, and the RCP of Ireland, is an example of how advances in research and evidence-based clinical practice can be foundational to policy development and quality improvement of services and draw us closer to the aspirations of the NHS long-term plan.

Stroke care has not been immune to the immense and well-known challenges facing the health system in recent years. The national stroke audit, SSNAP, has opened a window to declining performance on key indicators.

In 2022, only around 45 per cent of stroke patients in England, Wales, and Northern Ireland accessed a specialist stroke unit within four hours of admission, down from nearly 60 per cent in 2017-18. The median time between someone having a stroke and being admitted to a stroke unit has crept up to shocking levels, from around three hours 30 minutes in 2020 to nearly five hours in late 2022.

In turn, blood pressure monitoring rates of those with hypertension, a key risk factor for stroke, are still 10 per cent below where they were before the pandemic. Our attempts to implement the new stroke guidelines must take account of the deterioration of stroke care of recent years and face up to the realities of the present situation.

The current reduced ability to offer patients the specialist treatment they need and deserve shows how our healthcare system’s varied structural weaknesses – understaffing, low hospital bed numbers, inadequate social care provision – have come up against declining population health and the shock of the pandemic. Longer ambulance waiting times, the elective backlog, and slower patient flow through hospitals are similarly products of this head-on collision between low pre-existing levels of system resilience and the unprecedented pressures brought about by the pandemic.

Many of the stroke interventions in the guideline have dual impacts, improving the outcomes of stroke patients while simultaneously reducing the burden on other areas of the health and care system

The updated guideline has synthesised an increasingly robust research and evidence base to outline what matters in delivering high quality stroke outcomes. This includes early recognition and assessment of stroke, rapid access to specialist stroke interventions such as specialist stroke units, thrombolysis and thrombectomy, the importance of secondary prevention, and the need for ongoing rehabilitation, and life after stroke support for stroke survivors.

Many of the stroke interventions in the guideline have dual impacts, improving the outcomes of stroke patients while simultaneously reducing the burden on other areas of the health and care system. Manual clot removal, thrombectomy, has been shown to be effective in reducing post-stroke disability. And yet, current implementation lags far behind the 10 per cent ambition set in the NHS long-term plan and the even more aspirational benchmarks set by the updated guideline.

It is estimated that around 9,000 patients a year could benefit from thrombectomy in the UK, but less than a quarter of those eligible actually receive the treatment. And the inequalities in access to thrombectomy are huge: the thrombectomy rate ranges from less than 1 per cent in some regions to 8 per cent in London. Supporting Integrated Stroke Delivery Networks with workforce and capital funding where needed puts resource in the right place to be used intelligently.

We know that thousands of stroke survivors aren’t receiving the right level of stroke rehabilitation either in hospital or in the community, meaning that they’re more likely to need the support of costly primary and emergency care systems. That’s why the guideline recommends an expansion of stroke rehabilitation from time-based to needs-based, a shift which can achieve cost savings and reduce the burden on social care.

In this light, we hope that the Major Conditions Strategy, which has the potential to focus on common risk factors across multiple long-term conditions and ensure more person-centred holistic support in the community, will shine a spotlight on existing evidence-based interventions such as well-resourced rehab and thrombectomy and invest behind these.

We know what works. We need investment in the right evidence-based interventions across the pathway as set out in this guideline. We need support for the Integrated Stroke Delivery Networks which are key to driving success. And we need a sustainable stroke workforce with the right roles and capabilities to deliver for the future. Only then can we have stroke services that live up to the ambitions in the NHS long-term plan and that we all feel proud of.

Juliet BouverieJuliet Bouverie OBE is chief executive of the Stroke Association.