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The recent launch of the National Stroke Strategy by the Department of Health (DH 2007) is a welcome development for stroke patients.
The strategy addresses for the first time, the process across the whole stroke care pathway and aims to improve all aspects of care (prevention and awareness, emergency access and acute treatment, rehabilitation support and long term care available post discharge and involvement of the voluntary sector) using a number of quality markers.
Implementing the recommendations in an effective and efficient manner will be a major challenge for the NHS. For this development to be a success, it is crucial that adequate funding is made available to ensure that the recommendations are met. Surprisingly the strategy makes no reference to actual funding commitments. Spending proposals with initial pump priming for the strategy has been agreed centrally. Funding will be directed towards much needed stroke training posts, public awareness, stroke research and development of acute and community demonstration sites to pioneer best practice. The proposals at first glance appear to be very ambitious and even unrealistic, however aiming for high standards should be viewed as an opportunity and a challenge for both health providers and commissioners to improve the quality of stroke care.
Time is brain
A major theme emerging from the strategy is the need for urgent specialist assessment and intervention within an environment of organised stroke care. The strategy applies equally to patients suffering a TIA at high risk who will require assessment and appropriate imaging (MRI) within 24 hours of onset. There is a real need to improve access to thrombolysis services in the UK. The strategy’s proposal for this service is through a ‘hub’ and ‘spoke’ model based upon experience of cardiac networks. The suggestion that thrombolysis should only be delivered exclusively in hospitals with a 24 hour hyper-acute service is tempered by the fact that many hospitals are able to provide a ‘daytime’ (9-5) service, which has the advantage of treating patients locally, therefore potentially more quickly, while reducing the need for repatriating patients, thus enhancing their continuity of care. This approach is currently being piloted across the South West London Sector, led by Wandsworth PCT. Whichever structure is deployed, the clear message is that commissioners should work collaboratively with clinicians and other health care organisations to ensure that there is 24/7 coverage for all stroke patients.
Life after stroke
Throughout the strategy there is a commitment to life long specialist support in the community. Enhancing the smooth transition of patients from hospital to home through early supported discharge schemes, involvement of carers, social and voluntary services and providing opportunities to participate in work are highlighted as key action points. Although key targets and milestones have been set for acute care previously, which undoubtedly has been a strong driver for change, specific targets and standards for community rehabilitative services have not been made explicit enough here. There is no reason why we should not be adopting a seven day week rehabilitation service. Unbundling the national tariff for acute stroke care to direct funding for high quality specialist rehabilitation in the community also remains a challenge to commissioners.
Joint Working
The establishment of a stroke network approach appears to be logical one. The concept is to ensure that the relevant agencies are working together to support patients across the whole stroke pathway. Stroke networks may vary considerably according to geography with some centres specialising in hyper-acute care and other in specialist rehabilitation. Collaboration with the cardiac network may also be beneficial in delivering shared preventative strategies. Ultimately, high quality care will only be delivered if the appropriate workforce is in place and the strategy has outlined its intentions to address this through the NHS National Workforce Project.
This strategy is a 10 year framework to deliver the highest quality services to stroke patients. Some of the service proposals represent a big culture change to both primary care trusts and providers. The hope is that with adequate central support, we can begin to implement these changes with immediate effect.
References
Department of Health (2007) National Stroke Strategy.
Ajay Bhalla
Consultant Stroke Physician
St Helier Hospital, Epsom and St Helier University Hospitals NHS Trust
BGS Newsletter, March 2008
Issue 15 ISSN 1748-6343 15
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