‘More progress needed in rehab’

Acute care of stroke victims is much improved, but less progress has been made in rehabilitation, says national clinical director for stroke Professor Tony Rudd


Stroke care has improved dramatically since I was first appointed as a consultant 26 years ago. A patient admitted then would have been looked after on a general medical or geriatric ward. Very little would have happened as no one really believed there was anything you could usefully do that would make much difference.

If the person was lucky, they would have received some rehabilitation from the geriatric team while in hospital, but the chances of getting any rehabilitation after getting home would have been slight. Better than in earlier days though when treatments advocated for stroke or apoplexy, as it was called then, included stimulating enemas or vomits and blood-letting.

The most important development in stroke care was the demonstration about 20 years ago that managing patients on a specialist stroke unit saved lives and resulted in people having less long-term disability compared to management on a non-specialist ward.

This led to the government setting a target that by 2004 all hospitals treating stroke patients should have a stroke unit. This was achieved and at the same time it became possible for doctors, nurses and therapists to train as stroke specialists.

The Royal College of Physicians has been auditing the quality of stroke care since 1998 and has shown steady improvements. Data on all people admitted to hospital because of stroke has been collected documenting how quickly they arrive in hospital, whether they receive clot-busting treatment (thrombolysis) and, if so, how quickly it is delivered, as delays result in the treatment being less effective.

In addition, the data shows how soon patients get to the stroke unit and are seen, start treatment from therapists and how much therapy they receive each day. The quality and quantity of care once they are discharged into the community are also collected together with measures of the effectiveness of the care.

Having to report the anonymised data, which is then made public, enabling professionals and lay people to scrutinise how their local health services are performing, is a powerful tool to encourage improvements in services.

There is, however, still a great deal to do to ensure that all patients with stroke, regardless of where they live or what day or time they become ill, can be certain they receive the highest quality of care possible.

If we took the measures necessary to cut salt intake, reduce obesity, cut smoking rates and alcohol consumption, we would need far fewer stroke physicians

In London the organisation of stroke care was radically changed about four years ago. Until then, 32 hospitals in the capital were offering acute stroke care, and we knew from the national stroke audit that the quality provided varied dramatically from some of the best care available anywhere in the world to care that was at best ineffective and at worst actually causing harm.

The decision was made to centralise all the care that patients needed in the first two or three days after the stroke in just eight units, and to ensure that there were always well-trained and adequate numbers of staff available in these centres with access to all the equipment needed to investigate patients rapidly.

An additional tariff was paid to the hospitals for each patient treated to cover the increased costs of care, but only if the regular inspections carried out by the London clinical director and the commissioners deemed the required standards were being met.

If the patient still required in-patient care after the first 72 hours, they were transferred to their local stroke unit that also had to meet high standards of care requiring additional nurses and therapists to deliver them. More than 400 additional nurses and 100 therapists were recruited in London to deliver the new model.

It has been very successful with the outcomes of patients improving significantly in terms of reduced mortality and disability as well as shorter lengths of stay and fewer people needing to go into long-term nursing-home care. Despite an increased initial cost of care to the health service, when longer-term savings are taken into account, it is resulting in millions of pounds of savings to taxpayers.

As the national clinical director, I am determined to make sure that where possible similar standards of care are provided in the rest of the country. Plans are already being developed in some other urban areas. Manchester reconfigured their care at the same time as London and is currently making some further changes. Parts of the East and West Midlands are closely examining their services and are likely to make changes within the next year or two.

The London model would not be appropriate for rural areas where the population density is low and travel times to the local hospital long. Here many hospitals are either already using or are planning to implement telemedicine enabling the specialist stroke physician to see the patient being examined at the local hospital, talk to them and review their brain scans to provide advice about management.

Not everyone with a stroke is suitable for clot-busting treatment, probably only about 20 per cent, because there are many situations where it can be more likely to cause harm than do good.

In England, Wales and Northern Ireland, we are currently managing to treat about 12 per cent of stroke admissions. This is better than most other high-income countries and the figure is rising each year.

So the picture for acute care is getting much better. The same rate of progress is not being seen in rehabilitation. There are still many parts of the country where there are no specialist early supported discharge teams to continue care once people leave hospital. There are often long waits to continue rehabilitation after leaving hospital and patients are often discharged from therapy far too early in the misguided belief that there is little likelihood of further recovery after the first three to six months.

Access to psychological treatments is extremely poor despite up to 50 per cent of stroke patients suffering depression and about 30 per cent having significant cognitive problems.

We have to accept that major investment in new services is unlikely at the present time in the health service. We are going to struggle to maintain the investment that we currently have. But there are things that we can do to use the money that we currently have more effectively.

People are staying in hospital too long at huge expense because of the lack of community services or because of delays in providing services.

Separation of the budgets of health, social care, housing and employment has led to the nonsensical situation where it is difficult to spend more on effective health care that will save large amounts of money on providing social care or enabling people to get back to employment, paying taxes and supporting their families.

And about 70 per cent of all strokes are preventable. If as a country we took the measures necessary to cut salt intake, reduce obesity, cut smoking rates and alcohol consumption, we would need far fewer stroke physicians.

Stroke is an awful disease. Many cases could be prevented and there is effective treatment. There is still much that we need to learn and we must support the work of organisations such as the Stroke Association so there can be more research to answer the many unknowns and help provide the additional support the health service currently cannot or will not provide.