As a newly reformed National Health Service faces uncertainty, four experts tell Jason Hesse how Britain can continue to improve stroke services and avoid a postcode lottery on care
Professor Anthony Rudd is national clinical director for stroke; he is also a consultant stroke physician at Guy’s and St Thomas’ Hospital and vice chairman of the Stroke Association.
Professor Marion Walker is professor in stroke rehabilitation at the University of Nottingham; she is an occupational therapist by training and is a senior investigator at the National Institute for Health Research.
Joe Korner is director of communications at the Stroke Association, and is responsible for spearheading national campaigns to improve awareness of stroke and stroke symptoms.
Professor Helen Rodgers is a clinical professor of stroke care at Newcastle University’s Institute of Ageing and Health, and associate director for the Stroke Research Network.
An estimated 152,000 people in the UK have a stroke every year and more than half are left with disabilities that affect their daily lives. It is the largest cause of adult disability and costs the country more than £8.2 billion every year.
The biggest challenge affecting stroke care in the UK is ensuring the same quality of care across the country, says Professor Anthony Rudd, the newly appointed national clinical director for stroke, who is responsible for overseeing the implementation of a national stroke strategy.
“We need to make sure that people are given the right, effective treatments from start to finish, no matter where they are,” he says.
While, for acute care, that means ensuring people have access to thrombolysis treatment, which dissolves blood clots, Professor Rudd recognises it is equally important that patients are offered adequate rehabilitation and community care after they are discharged.
We need to make sure that people are given the right, effective treatments from start to finish, no matter where they are
“It is about ensuring decent services across the community and the hospital. All these things are done well in some parts of the country, but very few offer all aspects of care,” he says.
Healthcare commissioning – the decision-making process for how money is spent – is now done at a local level by a clinical commissioning group (CCG). There are very few structures that encourage them to look at the bigger picture and commission services across a wider area than their own, which makes it difficult to enforce the same standards everywhere, says Professor Rudd.
“All of the CCGs want to do their own thing, producing their own stroke services from beginning to end, as it means they can control the cost and everything else. There is very little incentive to work collaboratively; but it is my job to persuade them that this is necessary and desirable in terms of outcomes,” he adds.
Joe Korner, a director at the Stroke Association, says his organisation has also seen this problem develop. “Because stroke care is locally determined, it means that there is an un-evenness of provision and this is hard to tackle. Because of the changes in the NHS, the involvement and engagement of stroke survivors and professionals at the local level is absolutely crucial to understand and meet their needs,” says Mr Korner.
“The key to improving stroke services and patient outcomes is to look at how the entire stroke care pathway is delivered, rather than focusing on just one aspect of it,” says Professor Helen Rodgers, clinical professor of stroke care at Newcastle University’s Institute of Ageing and Health.
“Understandably, and for good reason, there has been a focus on acute services, and this has led to major and welcome changes,” she says. “Unfortunately, at the same time, the community side of things has lagged behind.”
Mr Korner says that the lack of joined-up services is hurting patients. “There has been a focus on the front-end, which in recent years has resulted in a dramatic improvement in acute care. But there is a lot of work to do afterwards – what are the needs of stroke survivors in the longer term, what support do they require? We need to see more research into stroke survivors’ longer-term needs. This evidence base is required for us to know where we direct our resources.”
While there has been a lot of research into acute care, studies looking at the therapeutic pathway have not been as prolific. Thankfully, as rehabilitation and therapy become more established, this is changing; 56 per cent of studies in the Stroke Research Network – which connects researchers, clinical and professional staff – are currently on rehabilitation.
“We’re catching up quickly,” says Professor Marion Walker, professor in stroke rehabilitation at the University of Nottingham. “We need to learn the best ways of facilitating recovery, but this needs to be done within the boundaries of a research study, so that we have evidence. Cost is a major driver today and community services are very expensive. We really do need good evidence to justify changes and improvements.”
Professor Walker adds that there is a direct correlation between improved quality of services and research activity. “The development of the Stroke Research Network has had a major contribution in driving the quality of stroke care. The investment in academic networks will lead to the implementation of what we know works and the gap in quality care will be shorter.”
Professor Rodgers also believes that national audit problems – for example, the Royal College of Physicians’ Sentinel Stroke National Audit Programme, which benchmarks services nationally and regionally to monitor progress – can also play an important role in improving care.
“We’re now collecting information about the care of all patients admitted into most UK hospitals and looking at our performance regularly. Being able to compare ourselves to units throughout the country is a real driver for change,” she explains.
While these programmes have been recording a general improvement over time, there are a number of units that still lag behind. Professor Rodgers adds: “We’re coming into a world where poor performance is unacceptable. If you’re not providing a quality of care that is reasonable, then the future of your unit needs to be considered.”
If you’re not providing a quality of care that is reasonable, then the future of your unit needs to be considered
Overall, the UK has seen dramatic improvements in stroke care. Mortality for stroke has fallen by around 40 per cent over the last ten years and Britain is a world leader in thrombolytic therapy, using the technique in around 10 per cent of stroke admissions.
The challenge for the future, says Professor Walker, is ensuring continuity of care.
“After an early supported discharge and a six-week rehabilitation programme, stroke patients and their carers often fall off the edge of a cliff,” she says. “We need to fight to ensure that the right care continues; just doing the basics well and implementing what we know works – using specialist therapists and community nurses to treat and prevent further problems – would make such a difference to improving patient outcomes.”
The situation is not all doom and gloom though, concludes Professor Rudd. There is good reason to be optimistic about the future of stroke care in Britain.
“We’ve pioneered a lot of aspects of rehabilitation and our tradition of multi-disciplinary working is more advanced than most European countries. Britain has some of the best stroke services in the world. In fact, if I were going to have a stroke myself, then I would want to have it here, in the UK.
“Yes, there is still a lot of work to do, but we know what we need to do.”