3.73. Stroke, a preventable disease, is the fourth single leading cause of death in the UK and the single largest cause of complex disability [123]. Stroke mortality has halved in the last two decades [124]. However, without further action, due to changing demographics, the number of people having a stroke will increase by almost half, and the number of stroke survivors living with disability will increase by a third by 2035 [125].

3.74. There is strong evidence that hyper acute interventions such as brain scanning and thrombolysis are best delivered as part of a networked 24/7 service [126]. Areas that have centralised hyper-acute stroke care into a smaller number of well-equipped and staffed hospitals have seen the greatest improvements [127]. This means a reduction in the number of stroke-receiving units, and an increase in the number of patients receiving high-quality specialist care. Integrated Stroke Delivery Networks (ISDNs) involving relevant agencies including ambulance services through to early supported discharge will ensure that all stroke units will, over the next five years, meet the NHS seven-day standards for stroke care and the National Clinical Guidelines for Stroke.

3.75. Mechanical thrombectomy and clot-busting treatment (thrombolysis) can significantly reduce the severity of disability caused by a stroke. These treatments carefully remove a blood clot from the blood vessel causing an interruption to the brain’s blood supply, or use drugs to dissolve the clot. ISDNs will support STPs and ICSs to reconfigure stroke services into specialist centres, improve the use of thrombolysis and further roll out mechanical thrombectomy. This will ensure 90 percent of stroke patients receive care on a specialist stroke unit and that all patients who could benefit from thrombolysis (about 20 percent) receive it, up from just over half of eligible patients now. Expanding mechanical thrombectomy – from 1% to 10% of stroke patients – will allow 1,600 more people to be independent after their stroke each year. This combination of specialist stroke care, thrombolysis and thrombectomy would result in the NHS having the best performance in Europe for people with stroke [128].

3.76. The NHS will work with Health Education England to modernise the stroke workforce with a focus on cross-specialty and in some cases cross-profession accreditation of particular ‘competencies’. This will include work with the medical Royal Colleges and specialty societies to develop a new credentialing programme for hospital consultants from a variety of relevant disciplines who will be trained to offer mechanical thrombectomy.

3.77. Implementation and further development of higher intensity care models for stroke rehabilitation are expected to show significant savings that can be reinvested in improved patient care. This includes reductions in hospital admissions and ongoing healthcare provision. Out of hospital, more integrated and higher intensity rehabilitation for people recovering from stroke, delivered in partnership with voluntary organisations including the Stroke Association, will support improved outcomes to six months and beyond. The existing national stroke audit (SSNAP) provides high quality information on the acute and inpatient rehabilitation care of stroke patients to improve stroke services. An update to SSNAP will provide a comprehensive dataset that meets the needs of clinicians, commissioners and patients by describing the quality of care provided for stroke patients from symptom onset through to rehabilitation and ongoing care.

3.78. National support for the scaling of technology will assist the expansion of life-changing treatments to more patients. This includes the use of CT perfusion scans to assess the reversibility of brain damage, improved access to MRI scanning and the potential use of artificial intelligence interpretation of CT and MRI scans to support clinical decisions regarding suitability for thrombolysis and thrombectomy. Interoperable information systems supported by telehealth will aid more timely transfer of information between providers, enabling more effective hyper-acute pathways and improving access to and intensity of rehabilitation.

References

123. Stroke Association (2018) State of the nation: Stroke statistics. Available from: https://www.stroke.org.uk/system/files/sotn_2018.pdf

124. NHS Digital (2018). Mortality from stroke. Available at https://digital.nhs.uk/data-and-information/publications/clinical-indicators/compendium-of-population-health-indicators/compendium-mortality/current/mortality-from-stroke

125. Patel, A., Berdunov, V., King, D., Quayyum, Z., Wittenberg, R. & Knapp, M. (2017) Current, future and avoidable costs of stroke in the UK. Available from: https://www.stroke.org.uk/sites/default/files/costs_of_stroke_in_the_uk_report_-executive_summary_part_2.pdf

126. Hunter, R., Davie, C., Rudd, A., Thompson, A. & Walker, H. (2013) Impact on Clinical and Cost Outcomes of a Centralized Approach to Acute Stroke Care in London: A Comparative Effectiveness Before and After Model. PLOS ONE. 8 (8), e70420. Available from: https://doi.org/10.1371/journal.pone.0070420

127. Morris, S., Hunter, R., Angus, R., Boaden, R., McKevitt, C., Perry, C., Pursani, N., Rudd, A., Schwamm, L., Turner, S., Tyrell, P., Wolfe, C. & Fulop N. (2014) Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. British Medical Journal. 349, g4757. Available from: https://doi.org/10.1136/bmj.g4757

128. Aguiar de Sousa, D., von Martial, R., Abilleira, S., Gattringer, T., Kobayashi, A., Gallofre, M., Fazekas, F., Szikora, I., Feigin, V., Caso, V. & Fischer, U. (2018) Access to and delivery of acute ischaemic stroke treatments: A survey of national scientific societies and stroke experts in 44 European countries. European Stroke Journal. 0(0) 1–16. Available from: https://doi.org/10.1177/2396987318786023