National Audit Office
Department of Health
Progress in Improving Stroke Care
In November 2005 the NAO published Reducing brain damage: faster access to better stroke care, which concluded that stroke had a low priority within the NHS, and that medical and technological advances that could improve patient outcomes were not implemented widely.
This report formed the basis of a hearing of the Committee of Public Accounts who concluded that the human and economic cost of stroke could be reduced by the reorganising of services and using existing capacity more wisely. The Committee made a number of recommendations for the DoH and NHS organisations, and was asked to report back on progress in improving stroke care.
This newly published report sets out an evaluation of how stroke care has changed over the past four years, the extent to which these changes have improved value for money and the risks and issues to be managed to ensure that stroke services continue to improve in the future. The methodology for this report included:
Commissioned a census of all hospitals
A survey of 760 stroke patients and carers
Building an economic model of stroke services
What has changed since the report in 2005?
Change in the DoH’s approach to stroke care with the publication of the national Stroke Strategy in 2007. The strategy defines markers for high quality stroke care, setting out action and progress measures for achievement of these
The DoH announced funding for stroke care (£105 million over 3 years) to support the implementation of the strategy. The DoH enhanced the tariff payment for stroke to reimburse hospitals for thrombolysing patients. Implementation of the strategy was made a ‘Vital Sign’ Tier 1 national requirement in PCT’s operating plans
England has been divided into 28 Stroke Networks to improve the co-ordination of stroke care
Implementation of the Strategy has been supported by strong leadership at national level as well as at regional and local level
Emergency response and acute hospital care
There is better public and professional awareness of the symptoms of stroke following the Act FAST campaign. The number of calls to ambulance trust’s categorised as being a suspected stroke during Apr to Jun 2009 increased by 54% in comparison to the same period in 2008. Ambulance staff are better trained in recognising stroke and in taking patients to appropriate centres
Acute care is being reorganised to deliver the key elements of care that are known to improve outcome. NICE recommends immediate admission to a specialist stroke unit to optimise outcome. The proportion of stroke patients who spend 90% of their time on a stroke unit has also increased. More patients are accessing brain scans 24 hours per day, 7 days a week. More trusts are offering thrombolysis with the overall number of patients receiving it doubling in 2008-09
Acute stroke is funded by PbR tariff (around £4,000 per episode). Most service reorganisation has been achieved without additional funding, apart from uplift in Apr 08 of £800 per patient thrombolysed
The strategy also requires Strategic Health Authorities to reconfigure services to optimise access to specialist care, requiring different solutions in rural and urban areas. Some hospitals in rural areas are now using technologies such as telemedicine
Rehabilitation, post-hospital support and meeting long term care needs
Improvements in acute care are not yet matched by progress in delivering effective post-hospital support for stroke survivors due to barriers in joint working between agencies. Patients and their carers also lack information about services they may need and how to access them on discharge
Community based teams (such as ESD) can provide better and more cost effective outcomes than exclusively hospital based rehabilitation for stroke patients, but there remains only limited teams in existence and uncertainty as to how to fund them
Long term follow up of patients remains problematic. Patients should be reviewed at 6 weeks, 6 months and annually thereafter, but it remains unclear to commissioners and providers as to how and where this should be done and what the objectives are. This is compounded by a lack of a long term outcome measure to assess quality of long term care for stroke survivors. At least one third of stroke patients have depression following stroke, but psychology was rated the least satisfactory service in long-term care
The DoH allocated £30M to local authorities to improve post-hospital support over two years, predominantly used to increase social support from voluntary organisations
The strategy highlighted the need for stroke training of front line staff, but their remain shortcomings in training particularly for those staff in residential and nursing homes
Prevention of Stroke
Stroke prevention continues to be challenging, although improvements have been made through the targeted use of statins. The DoH launched the NHS Health Checks programme in 2009 as a targeted approach to prevention of all vascular diseases
People remain unaware of risks associated with lack of exercise, diabetes and AF. Guidance suggests anti-coagulation of all people with AF (NICE recommends use of warfarin) but in 2008 only 24% of patients with AF were discharged with this treatment
Value for Money Conclusion
The DoH approach has increased the priority given to stroke care. Early indicators are that the implementation of the strategy is delivering improved levels of service and outcomes.
Improved patient outcomes from reductions in death and disability can be measured in quality-adjusted life years (QALY’s). It is estimated that the average QALY’s per patient has increased from 2.3 to 2.5. The NAO report concludes that the actions taken by the DoH since 2006 to date, improved value for money
Needs continued partnership working between the DoH, NHS, Local Authorities and the third sector to sustain value for money gains made
Recommendations
SHA’s need to undertake and review robust cost-benefit analyses to identify the optimum organisation of acute stroke services
The DoH to consider whether ambulance trusts should use measures such as call to hospital time as a way of evaluating emergency response. PCT’s should ensure that data is fed back to ambulance trusts
PCT’s should require hospitals whose audit results indicate that patients are not being admitted to stroke units quickly enough to demonstrate their admission protocol
SHA’s should agree with their PCT’s a stroke action plan and timeline for all hospitals who are failing to achieve the expected level on their Vital Sign indicator.
As part of developing Best Practice Tariff for stroke, the DoH should review all levers within the tariff structure to ensure they reward cost effective practice
The Stroke Improvement Programme should collate and disseminate examples of good practice. PCT’s should contractually require stroke care providers to give comprehensive d/ch summaries by 2012
Stroke Networks should work with organisations to ensure that community based stroke rehab is available for all appropriate patients. The DoH should provide practical guidance on how the tariff can support provision of community rehab teams
The DoH and Stroke Improvement Programme along with other stakeholders should develop a set of indicators of high quality long term stroke care.
Local Authorities and NHS organisations must begin planning how they will sustain support services when the additional funding for stroke ceases in 2010-11
DoH to work with Skills for Care to develop a training programme for care home based staff, based on the SSEF. Care Quality Commission should check the needs of this group of residents are being met
Strategic health Authorities, PCT’s and Stroke Networks should develop and implement strategies for managing AF
DoH should refer explicitly to stroke in relevant public health campaigns to ensure the public and NHS benefit by preventing strokes
Part One
The Framework for providing stroke care
Funding and organising services
Stroke patients require urgent access to hospital care, including a brain scan. They should spend their time in a specialist stroke unit, under the care of an MDT trained in dealing with needs such as difficulties with swallowing, speech and communication and mobility. Rehabilitation should start in hospital, may continue after discharge and ongoing support may be required
England is now covered by 28 Stroke Networks (most of who have merged with existing cardiac networks). These Networks receive funding and should be addressing the following:
Fully engage with Social Care staff and services
Support improvement in post-acute services
Further development of stroke survivors and carers in service improvement and commissioning
Funding allocated to deliver the strategy
The available funding has been used in part to:
Improve availability of thrombolysis through investment in equipment such as telemedicine
Funded training programmes for staff involved in stroke care
Improved local information systems
Development of Stroke Association services
Establish stroke related jobs
Funded breaks for carers of stroke survivors
Commissioning better stroke care
Although ASSET 1 & 2 is available to commissioners it is not widely used. In June 2009 continuous data collection of the first 72 hours was approved – the Stroke Improvement National Audit Programme (SINAP).
The strategy outlined the need to implement existing guidance on unbundling the tariff for in-pt stroke care into acute and rehab elements. The tariff can then be used to fund specialist rehabilitation, such as ESD schemes. Very few areas are unbundling and in anyway, clinical guidance suggests that rehabilitation commences at the acute phase
Bridging the language gap between health and social care services is key.
Part two
Treating stroke patients
Awareness of the symptoms of stroke
Stroke needs to be acknowledged as a medical emergency. It is important that the public and health professionals recognise the signs / symptoms of stroke. Initial indications suggest that the Act FAST campaign has been successful, with an increase in the numbers of strokes admitted to hospital
AcuteHospital care
Urgent stroke care
Stroke patients should be admitted to a stroke unit capable of providing hyper-acute stroke care. The stroke pathway needs to be made explicit to the local ambulance trust. There should be improved access to brain scanning and thrombolysis (over 24 hours)
Access to Stroke units
It is expected that 80% of patients will spend 90% of their time on a Stroke Unit by end of 2010-11
Patients are still admitted to medical assessment units instead of directly to Stroke Unit from A&E or direct admission to the Stroke Unit
In 2009, 30% of stroke units providing rehabilitation excluded patients with ‘no rehabilitation potential’, a practice described as unacceptable by the RCP
Staffing and standard of stroke units
The number of stroke consultant sessions has doubled, but is still below the BASP recommendation of 2 WTE per 250,000 population
There has been an increase in some of the other members of the MDT, although they remain below suggested minimum staffing levels in some cases and in particular there is limited Clinical Psychology input
Shortfalls in areas such as Clinical Psychology and Speech and Language Therapy can be partially addressed by training other MDT members
Community Rehabilitation
Early supported discharge can reduce long term dependency and admission to institutional care as well as releasing hospital beds by reducing LoS.
TIA Treatment
Strategy recommends that TIA patients should be assessed by a specialist and treated with 24 hours / 7 days. The risk should be determined by using the ABCD2 tool. Better organised TIA services can result in efficiency improvements.
There needs to be improvement in access to carotid endarterectomy to meet the standards set by NICE and the Strategy
Part Three
Supporting stroke survivors and preventing strokes
The importance of post-hospital care
Many patients still do not feel that they were informed effectively about many post hospital needs, although this has improved since 2005
Ongoing monitoring and support of stroke patients after discharge
Patients should have a review of their health and social care status within 6 weeks of d/ch and again within 6 months. This should be followed by an annual check, providing access to specialist services if they are required. These reviews should also include secondary prevention advice. GP’s have an important role to play in secondary prevention, and more patients are now receiving preventative services than at the time of the original report
Long term care and support
Need evidence to support long term interventions following stroke, to decide on the relative benefits of OT, PT and S<.
Many patients are depressed following stroke but access to clinical psychology is poor
Work more closely with the voluntary sector to improve long term support and service provision. Patients are referred to the Stroke Association, but not all patients are able to access their services, particularly in rural areas
Carers
The strategy acknowledges that carers are vital in providing support. When asked to rate the quality of services for carers, less than a third felt that these were good or very good
Stroke patients in care homes
There are between 25% and 45% of patients in care homes that have had a stroke
Staff in care homes should be familiar with the common clinical features of a stroke and how to manage them
Preventing more strokes
Manage and reduce risk factors by methods such as the DoH NHS Health Checks programme launched in 2009
AF is a major risk factor for a stroke, and warfarin is an effective treatment for this (as recommended by NICE)
There are also differences in the optimal blood pressure and cholesterol levels, these needs to be reviewed to ensure consistency
Progress against Public Accounts Committee (PAC) recommendations in 2005
Main PAC Recommendation / Progress made to dateThe DoH should work with the Healthcare Commission and RCP to develop benchmarks for stroke care, e.g. The proportion of strokes receiving a brain scan within 3 hours or proportion treated on a Stroke Unit / The proportion of time a patients spends on a stroke unit and the percentage of patients treated for higher risk TIA in 24 hours are now a Tier 1 Vital Sign in the NHS Operating Framework
All suspected strokes should be scanned as soon as possible, ideally within 3 hours / NICE recommends that stroke patients should be scanned immediately (for urgent cases) and within 24 hours
The limited number of health professionals with training in stroke is a barrier to receiving high quality care. Should move to a position where there are as many stroke as heart disease consultants / There has been some progress in improving staffing, although the recommendations have not yet been achieved.
The DoH should train stroke consultants to interpret scans and make immediate treatment decisions. It should also develop its telemedicine programme / Extra training has been made available for stroke consultants to interpret scans. A quarter of hospitals now use telemedicine for radiology
The DoH needs to communicate clear guidelines for an acceptable stroke unit and PCT’s should deliver stroke care to meet these guidelines / The Vital Signs stroke unit measure requires PCT’s to publish benchmark information on the proportion of patients spending 90% of their time on a Stroke Unit
All providers of primary and secondary care should have agreed protocols for the referral of TIA. / Risk scoring for TIA has been introduced and higher risk TIA’s referred within 24 hours is a Tier 1 Vital Sign
TIA patients diagnosed with stenosis should not have to wait more than 14 days for surgery / Currently more than 51% of sites have an average waiting time from diagnosis to surgery of over 2 weeks
The DOH should run an awareness campaign for stroke / The DoH has developed and ran the Act FAST campaign, successfully raising awareness of stroke symptoms
The DoH should improve the provision of information to carers / Further work is required to improve information provision
The DoH should evaluate the methods of ESD initiatives and other ways of improving access to therapies to reduce LoS and improve recovery / There has been an increase in the provision of ESD services, although there is scope for improvement