Alastair Whitington summarises highlights from the Westminster Health Forum conference on stroke prevention, care, and treatment in England
The Westminster Health Forum, Stroke prevention, care and treatment in England—Integrated Stroke Delivery Networks, training, local delivery, and the impact of the COVID-19 pandemic, was held online on Tuesday 17 November 2020.
Juliet Bouverie OBE, Chief Executive Officer of the Stroke Association and Co-Chair of the Stroke Delivery Programme Board in England, outlined the context around stroke policy, what we know about the lived experience of stroke survivors and their carers, the implications of patient experience for the National Stroke Programme, and the role that the third sector can play in improving outcomes.
Juliet Bouverie advised that 100,000 people have a stroke each year—stroke is the fourth leading cause of death and single biggest cause of complex adult disability in the UK, with almost two-thirds of stroke survivors leaving hospital with a disability.1 The economic impact of stroke is estimated to cost the UK economy over £20 billion per annum.2 The good news is that around 90% of strokes are thought to be preventable with lifestyle changes;3 stroke is different from other neurological conditions, many of which are degenerative, as it is a brain injury and the brain is able to rebuild neural pathways. With the right support, stroke can be a recoverable condition.
… stroke is the fourth leading cause of death and single biggest cause of complex adult disability in the UK …
Juliet Bouverie stated that, following publication of the National Stroke Strategy in 2007,4 significant progress was made over the subsequent decade as a result of strong clinical leadership and dedicated funding. The FAST (face, arms, speech, time) campaign drew attention to the symptoms of stroke,5 and the establishment of specialist stroke units made a real difference to treatment and care. However, stroke was not identified as a clinical priority in the 2014 NHS Five Year Forward View,6 resulting in a loss of momentum. In 2016, the Stroke Association, in collaboration with the clinical community and general public, published a report called A new era for stroke,7 which culminated in the reprioritisation of stroke in The NHS Long Term Plan published in 2019.8
The NHS Long Term Plan makes some strong and ambitious commitments, including to:8
- prevent up to 150,000 heart attacks, strokes, and dementia cases over the next 10 years
- strengthen Integrated Stroke Delivery Networks (ISDNs) to ensure that all stroke survivors have access to evidence-based care 24/7
- build on the success of stroke units and create more specialist acute centres to provide world-class thrombolysis and thrombectomy rates.
To understand the impact of stroke on survivors and their carers, Juliet Bouverie advised that, in 2018, the Stroke Association had conducted a survey of 11,000 stroke survivors and carers.9 The findings were that too many stroke survivors feel abandoned on leaving hospital, that post-discharge rehabilitation was not provided for long enough, and that insufficient emotional and psychological support was available at a time when patients are coming to terms with a major change in their lives and carers are bearing a significant burden. Of the stroke survivors surveyed, 78% indicated that they had suffered mental health problems—nine out of 10 survivors stated that they had experienced at least one cognitive effect, such as fatigue, loss of concentration, difficulty making decisions, and problems with reading, writing, and memory, and a third of stroke survivors felt that the support offered focused more on their medical condition and not on them as a whole person.
… a third of stroke survivors felt that the support offered focused more on their medical condition and not on them as a whole person.
To understand the impact of COVID-19, Juliet Bouverie reported that 2000 stroke survivors had been interviewed over the summer of 2020, yielding recommendations for all four UK health services.10 The key findings were that survivors were worried about the impact of the pandemic, not only on access to care for their stroke and rehabilitation services to support their recovery, but also on their chances of a second stroke in the event that they contracted COVID-19. Although some patients had managed to access rehabilitation services remotely, many patients with aphasia and serious cognitive challenges weren’t able to engage with rehabilitation online. In addition, just under half of carers surveyed felt overwhelmed, unable to cope, and isolated by the pandemic. Worryingly, the COVID-19 pandemic resulted in a third of stroke survivors receiving delayed medical attention.
Juliet Bouverie outlined four key recommendations for moving forward identified in the Stroke recoveries at risk report:10
- health and care systems should evaluate all changes to the stroke pathway in response to COVID-19
- stroke teams should follow up all stroke survivors who had a stroke this year to review their needs
- health and care systems and local authorities should prioritise increasing mental health provision
- all stroke rehabilitation must meet national clinical guideline levels.
In terms of the National Stroke Programme, the NHS aims to launch ISDNs in all areas of the country, supported by a National Stroke Service Model that covers the whole pathway from prevention, to acute and emergency care, to rehabilitation.8,11 Juliet Bouverie said that it is pleasing that data collection is continuing, and that the Sentinel Stroke National Audit Programme (SSNAP) will not just focus on the hospital end of the pathway, but also collect data in respect to rehabilitation and patient-reported outcome measures.12
Lastly, Juliet Bouverie said that there is also more to do in terms of rehabilitation and life after stroke. Although early medical interventions are enabling more people to survive a stroke, we need to ensure that they are also living well. In response to COVID-19, the Stroke Association has launched two new services: Hear for You, a volunteer-led telephone service to help combat isolation and offer peer support;13 and, in association with NHS England, Stroke Association Connect, a service that checks on newly discharged stroke survivors and signposts them to support services.14
… the COVID-19 pandemic resulted in a third of stroke survivors receiving delayed medical attention.
Dr Deborah Lowe, NHS National Clinical Director for Stroke, stated that the last 8 months have been an extraordinarily difficult time in healthcare, but that the stroke care community has stepped up to ensure the delivery of safe care across the pathway. The pandemic has led to significant changes in how services are delivered that, in combination with an acceleration of policies and an explosion of innovation, have challenged long-held assumptions about stroke care. Change has occurred across the stroke pathway—in health promotion, support of vulnerable communities, how consultations are conducted, delivery of emergency care, support of mental health services, development of networks, and sharing of good practice.
Dr Lowe advised that, since publication of the National Stroke Strategy in 2007,4 the many quality achievements made have resulted from the redesign of hyperacute stroke services, whereas the focus on rehabilitation and life after stroke has been limited. Between 2001 and 2010, there was a spectacular reduction in the stroke mortality rate of 55%,15 but this improvement has tailed off over the last 7 years.1 The time between onset of symptoms and stroke thrombolysis—currently 55 minutes on average16—is outside the UK performance target (outside London) of 45 minutes or less;17 furthermore, data from the SSNAP database show that time to stroke unit admission and administration of intravenous thrombolysis has remained static.12
To deliver further improvements, the National Stroke Programme has been included in The NHS Long Term Plan,8 with emphasis on expanding mechanical thrombectomy, higher-intensity models for stroke rehabilitation, and life after stroke support. The programme will be delivered by establishing ISDNs across the country to support local health systems, which will be accountable for delivery of aspects of the stroke pathway including prevention, pre‑hospital care, and early supported discharge.
Dr Lowe stated that mechanical thrombectomy is a real game-changer for removing clots from the cerebral arteries, and can lead to a significant reduction in disability following a stroke.18 Thrombectomy services are currently being expanded across the country to increase access for patients with stroke. In terms of rehabilitation and life after stroke, pilots are about to be launched to implement the Integrated Community Stroke Service model, Phase II of which will focus on telerehabilitation, structured follow ups, and vocational and psychological models of care. Work will also include developing patient-reported outcomes and experiences measures, and determining how to improve outcomes. Dr Lowe said that she believed that there was a significant amount of work to be done, but she was confident that, with implementation of the NHS Long Term Plan, world-class stroke care will be delivered locally.
Dr David Hargroves, National Joint Clinical Lead for Stroke, Urgent and Acute Care Work Stream Lead, Getting It Right First Time (GIRFT), and National Clinical Director for Stroke Medicine, NHS England and NHS Improvement, advised that, to date, eight high-quality clinical trials have demonstrated that thrombectomy significantly reduces the chances of a severe disability requiring 24-hour care after stroke. Dr Hargroves reported that, in recent years, there has been a steady increase in the use of thrombectomy across the country, although the UK remains well behind levels of use elsewhere in Europe. Challenges related to funding, the provision of biplane equipment, workforce, and data collection all need to be addressed, and an important part of the solution to providing thrombectomy across the country will be pathway optimisation, consisting of sufficient centres providing the service nationwide 7 days a week; safely, with expertise, and with the ability to rapidly transfer all patients who may benefit from thrombectomy to an acute stroke unit and on to a stroke centre.
The pandemic has led to significant changes in how services are delivered that … have challenged long-held assumptions about stroke care.
Dr Hargroves stressed the importance of imaging in assessing which patients will benefit from thrombectomy. Work undertaken by the GIRFT programme has highlighted significant variations across the country in terms of patients getting the right scan at the right time; the aim must be to ensure that, across the UK, patients have access to a computed tomography (CT) scan of the head and a CT angiogram with the vessels imaged. Dr Hargroves stated that artificial intelligence (AI) is supporting decision making in selecting patients for thrombectomy, which is delivering results far more quickly than the manual processes that are currently undertaken. In addition, the GIRFT programme has identified 50 recommendations covering the whole pathway from prevention to life after stroke, but in particular relating to direct access to appropriate imaging 24 hours a day, using AI in supporting decision making, and adopting a network approach to the delivery of thrombectomy.
To deliver further improvements, the National Stroke Programme has been included in The NHS Long Term Plan …
Dr Kiruba Nagaratnam, Clinical Lead for Stroke Medicine and Consultant Stroke Physician and Geriatrician, Royal Berkshire NHS Foundation Trust, emphasised the importance of AI and digital communication in minimising ‘door‑in-door-out’ (DIDO) time to identify patients who may benefit from thrombolysis and transfer them from hyperacute stroke units to mechanical thrombectomy services at neurology centres. Ideally, DIDO should be achieved within 60 minutes, but access to CT angiogram imaging, time taken to transfer images, and their review—particularly out of hours—can be challenging. The use of AI to support decision making and transfer of images via the cloud has assisted the Royal Berkshire Hospital in this endeavour;19 if implemented nationally across the stroke pathway, this technology will enable more patients to receive thrombectomy within the 6-hour time window after onset.18
This conference report was prepared by Specialised Medicine and the speakers have not had the opportunity to make corrections.
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References
- Stroke Association. State of the nation—stroke statistics. London: Stroke Association, 2017. Available at: www.stroke.org.uk/sites/default/files/state_of_the_nation_2017_final_1.pdf
- Patel A, Berdunov V, Quayyum Z et al. Estimated societal costs of stroke in the UK based on a discrete event simulation. Age Ageing 2020; 49 (2): 270–276.
- O’Donnell M, Chin S, Rangarajan S et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 2016; 388 (10046): 761–775.
- DH. National Stroke Strategy. London: DH, 2007. Available at: nsnf.org.uk/assets/documents/dh_081059.pdf
- Public Health England. Act FAST—stroke. campaignresources.phe.gov.uk/resources/campaigns/9-act-fast—stroke/overview (accessed 24 December 2020).
- NHS England. Five year forward view. London: NHS England, 2014. Available at: www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
- Stroke Association. A new era for stroke. London: Stroke Association, 2016. Available at: www.stroke.org.uk/sites/default/files/anefs_report_web.pdf
- NHS England. Online version of the NHS Long Term Plan. www.longtermplan.nhs.uk/online-version/ (accessed 24 December 2020).
- Stroke Association. Lived experience of stroke report. www.stroke.org.uk/lived-experience-of-stroke-report (accessed 24 December 2020).
- Stroke Association. Stroke recoveries at risk—how the Covid-19 pandemic has affected stroke survivors’ lives and recoveries. London: Stroke Association, 2020. Available at: www.stroke.org.uk/sites/default/files/campaigning/jn_2021-121.1_-_covid_report_final.pdf
- Stroke Association. NHS England Long Term Plan and the National Stroke Programme. www.stroke.org.uk/get-involved/campaigning/nhs-long-term-plan (accessed 24 December 2020).
- King’s College London. Sentinel Stroke National Audit Programme. www.strokeaudit.org/ (accessed 24 December 2020).
- Stroke Association. Here For You—telephone support service. www.stroke.org.uk/finding-support/here-for-you (accessed 24 December 2020).
- Stroke Association. Stroke Association Connect. www.stroke.org.uk/professionals/stroke-association-connect (accessed 24 December 2020).
- Seminog O, Scarborough P, Wright L et al. Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults. BMJ 2019; 365: l1778.
- Royal College of Physicians. Stroke in the UK: mind the gap! www.rcplondon.ac.uk/news/stroke-uk-mind-gap (accessed 24 December 2020).
- Gill S. Reducing door to needle time for stroke thrombolysis. BMJ Quality Improvement Reports 2014; u204771: w2199.
- NHS England. Clinical Commissioning Policy: mechanical thrombectomy for acute ischaemic stroke (all ages). London: NHS England, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/05/Mechanical-thrombectomy-for-acute-ischaemic-stroke-ERRATA-29-05-19.pdf
- Nagaratnam K, Harston G, Flossmann E et al. Innovative use of artificial intelligence and digital communication in acute stroke pathway in response to COVID-19. Future Healthc J 2020; 7 (2): 169–173.