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More than half of strokes could be prevented if all risk factors were managed effectively

Stroke affects about 100,000 people in England each year, of whom about 10 per cent will die within the first month and half of the remainder, will be left with significant long term disability. Management is well supported by evidence showing how services should be delivered for maximum benefit, as Anthony Rudd, National Clinical Director for Stroke with NHS England explains.

We know that there has been a transformation in stroke outcomes and patient experience since most patients have been managed by specialist teams of professionals but there is still significant inequity across the country and between different times of the day and the week.

  • Stroke units save lives and reduce long term disability
  • Early treatment with intravenous thrombolysis is a powerful treatment that for about 20 per cent of the stroke population offers the prospect of reversing the effects of stroke and now we have the prospect of the even more powerful intervention of intra-arterial clot retrieval.

So early recognition and rapid transfer to a unit providing specialist assessment and management is critical. However, even with access to all these interventions at least half of all patients will sustain permanent neurological damage and require rehabilitation services.

  • Early supported discharge, providing stroke unit like care in a patient’s own home with intensive specialist rehabilitation produces better outcomes for many patients than those obtained by a more prolonged stay in hospital. But even then, many patients will remain with long term disability often feeling abandoned at home and with little access to further rehabilitation or support with only about a third of patients having the recommended regular reviews at six months and even fewer getting the subsequent annual check.

We spend about £9 billion per year treating and supporting stroke patients, most of this on longer term care, both formal and informal. It is unacceptable that there are patients who do not receive treatment that could transform their lives and at the same time reduce the burden on the Treasury. The potential for reducing the amount spent on stroke is significant but does require commissioners to be prepared to look beyond the costs of the acute care. Apart from intra-arterial clot retrieval all of stroke care is commissioned by the Clinical Commissioning Groups (CCGs).

Surveys show that stroke is one of the most feared diseases among the general public and people say that they would rather die of a heart attack than suffer long term disability and dependency from stroke. Over 50 per cent of stroke could be prevented if all risk factors were managed effectively. For stroke this means detection and treatment of hypertension, atrial fibrillation, hypercholesterolaemia and diabetes amongst others. Again there are major variations in management of risk factors between different CCGs.

The RightCare stroke pathway shows exactly what CCGs should be purchasing and therefore what patients should expect to receive. The opportunities for better patient outcomes are enormous.

  • 3,800 more people would be admitted to a stroke unit
  • 2,200 would be admitted within four hours if CCGs had the rate of their best five peers.
  • £51 million could be saved on emergency admissions
  • Over 600 lives saved if CCGs achieved the rate of their best five peers.
  • 5,200 more people would be on treatment  to prevent another stroke if CCGs had the same rate as their best five peers
  • 6,200 more people would return to their usual place of residence if CCGs had the same rate as their best five peers.

For those not familiar with NHS RightCare, it is a national, NHS England supported programme committed to delivering the best care to patients, making the NHS’s money go as far as possible and improving patient outcomes.

You can see an overview of our work, projects and resources on the RightCare website including information and resources on the stroke pathway.

Anthony Rudd

Tony Rudd is a Stroke Consultant at St Thomas’ Hospital, the National Clinical Director for Stroke with NHS England and the London Stroke Clinical Director. He is Professor of Stroke Medicine at Kings College London and chairs the Intercollegiate Stroke Working Party at the Royal College of Physicians which has been responsible for developing the National Clinical Guidelines for Stroke and running the National Sentinel Stroke Audit programme. He chaired the NICE Guidelines Group for Acute Stroke and TIA and the NICE Stroke Quality Standards Development Group. His research interests are stroke rehabilitation, organisation of care and quality improvement and he has over 300 peer reviewed publications. He is a past president of the British Association of Stroke Physicians and is Hon Vice President of the Stroke Association. He was awarded a CBE in the Queen’s birthday honours in 2013