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| Implementing the stroke strategy inclusivity is the key |
| Email your comments References Yet anxieties exist that the Strategy overemphasises the reorganisation of acute care and poses a real threat to post acute and long term care2. This article seeks to address those concerns. The Stroke Strategy was created as part of the response to the National Audit Office (NAO) report3 in November 2005 on the value for money of the nation’s stroke services. The NAO elegantly demonstrated that, despite a very high annual true cost of stroke of £7 billion, the UK rates poorly in stroke outcomes when compared to countries with similar economies in Western Europe. For example, a study of 12 centres in 7 European countries4, and two large multicentre trials in acute stroke5,6 all found the outcome was worst in the UK. It is important to understand why the UK has stroke services that are relatively expensive and yet have poor outcomes, before measures are taken to reorganise services. Limited data show that European countries with better outcomes focus resources more heavily on the acute aspects of care. The vast majority of cost of in-hospital care in the UK is for nursing and hotel overheads, with the cost of investigations and medical care being very low. One interpretation of this information is that ineffective and inefficient practices early on in the stroke care pathway expose patients to the hazard of complications, such as infections and hypoxia, leaving them with greater dependency and greater length of stay. The NAO did indeed recommend improving acute care but, importantly, recommended it as just one part of an overall reorganisation of services: that also included changing the perception of stroke, better prevention, better co-ordinated post-acute support services and better overall management of stroke services. The structure and content of the Stroke Strategy reflects these recommendations. The creation of the Strategy was a wholly inclusive process, with representation from all the professions and disciplines that contribute to the entire stroke care pathway. The 6 subgroups had a total membership of 130 people from diverse backgrounds, including 12 people with stroke, 6 from the voluntary sector, 4 from social services and 65 allied health professionals. Three of the 6 specialist chairs were geriatricians, and all emerging themes were debated at two national meetings, that were open to the public. Throughout the process of creating the Strategy, great emphasis was placed on ensuring that both the final policy, and the mechanisms to bring about its implementation, would ensure equitable development of the entire stroke care pathway. For instance, it was well recognised that at a population level, access to stroke units for all people with stroke is around 4 times more effective in reducing death and dependency after stroke than thrombolysis (100% of stroke patients eligible for stroke unit care, with 5.6% absolute risk reduction, giving population effect of 5.6%, versus 10% of stroke patients eligible for thrombolysis, with absolute risk reduction of 13.1%, giving population effect of 1.3%), and that early supported discharge (ESD) schemes for all eligible patients is around twice as effective (40% of stroke patients eligible for ESD, with absolute risk reduction of 5.5%, giving population effect of 2.2%). It was, however, also acknowledged in creating the Strategy, that in developing services with the capability to deliver thrombolysis, all patients benefit from early diagnosis, multiprofessional assessment and management, and not just the minority who receive tPA. The mechanisms to ensure implementation of the Strategy are designed to foster development of the whole care pathway. The NHS Operating Framework, published in December 2007, states that ‘all PCT’s are expected to set out, in plans for 2008/09, how they intend to improve stroke services’. The ASSET toolkits, available on the DH website, indicate where gains in improving stroke outcomes can be made along the care pathway, including an estimate of how many stroke unit beds will be required by each provider. The metrics that have been defined in the ‘Vital Signs’, by which the DH and SHAs will monitor progress, are ‘the proportion of patients who spend 90% of their hospital stay in a stroke unit, and ‘the proportion of high-risk TIA cases scanned and treated within 24 hours’. The £105 million central funding, over 3 years, that has been allocated by DH to foster the implementation of the Strategy, is likewise divided to support the whole pathway, with £32 m going to the NHS for demonstration sites, £45m to Local Authorities to support social care in stroke, £12m to improve public awareness and £16m on training & development. Lastly, the NHS Stroke Improvement Programme (www.improvement.nhs. uk/stroke) has been launched to support the implementation of the national Stroke Strategy, and is establishing stroke care networks across England. Working to support the whole pathway of stroke care, the Programme employs the substantial experiences of the most successful NHS service improvement programmes, including those of the cardiac, cancer and diagnostics networks. Network staff will work with local stroke practitioners, people with stroke, managers and commissioners to provide valuable advice and expertise on developing services. This is our greatest opportunity to redesign the whole stroke care pathway and truly collaborative working has never been more important. Damian Jenkinson Roger Boyle 1. Department of Health. National Stroke Strategy. 2007 2. Dudley N, Blacktop J. The ‘hype’ in hyper-acute stroke. Age and Ageing 2008;37:236 3. National Audit Office. Reducing brain damage: faster access to better stroke care. London: Stationery Office, 2005 4. Grieve R, Hutton J, Bhalla A, Rastenyte D, Ryglewicz D, Sarti C et al. A comparison of the costs and survival of hospital-admitted stroke patients across Europe. Stroke 2001;32:1684-91 5. Gray LJ, Sprigg N, Bath PM, Soorensen P, Lindenstrom E, Boysen G et al. Significant variation in mortality and functional outcome after ischaemic stroke between Western countries: data from the tinzaparin in acute ischaemic stroke trial (TAIST). J Neurol Neurosurg Psychiatry 2006;77:327-33 6. Weir NU, Sandercock PA, Lewis SC, Signorini DF, Warlow CP. Ariations between countries in outcome after stroke in the International Stroke Trial (IST). Stroke 2001;32:1370-7 Stroke Improvement Programme
supporting Stroke Services Damian Jenkinson |