Service changes need to be informed by best evidence – and stroke care is a great place to start, says Tara Lamont with Dr Muhibbur Chowdhury and Dr Stephen Webb.
What do you get when you put together STP stroke leads, commissioners, stroke physicians and neuroradiologists with leading researchers on stroke care in one room for an afternoon? No changing of lightbulbs perhaps, but some real insights into the difficult decisions facing service leaders of stroke care.
How can new technologies like thrombectomy be delivered fairly across a population? Should we adopt a drip ‘n ship (early thrombolysis at nearest centre before onward specialist care) or mothership (direct to central hub) approach to delivering endovascular services?
What are the lessons from centralising stroke services to improve patient outcomes for rural areas? How can we address shortages in skilled doctors, nurses and therapists for stroke care? What is the role of the ambulance services in remodelling stroke pathways?
These were the live issues we discussed at the first east of England stroke summit convened recently by Eastern Academic Health Science Network (AHSN). We considered emerging STP plans for stroke services from five neighbouring localities and heard about latest research on stroke care. There were common problems in the plans for each footprint, but different priorities. It was important to come together, given the need for strategic planning and partnerships over a broad population.
Overall, we had reason to be optimistic. We heard that the 15 medium sized units (500-700 stroke admissions a year) in this patch offering hyperacute services were performing well, with a general trend of improvement. We can see this at a national level, where stroke standards of care and patient outcomes have improved dramatically over recent years.
Research has played an important part in this, including a number of NHS-facing studies on organisation of stroke care pulled together in a National Institute of Health Research review released recently – Roads to Recovery.
We know what good care looks like, thanks to research. And with a comprehensive national audit (the Sentinel Stroke National Audit Programme run by the Royal College of Physicians), we can also see how well we are doing and where we need to improve.
The NIHR review highlights some important findings. This goes back to trials over 10 years ago showing the benefits of organised acute stroke care.
More recently, a study of London and Manchester found that a simpler, centralised model of stroke care led to fewer deaths and better quality of care. In London, this amounted to 96 lives a year saved and hospital stays shortened by a day and a half. We also heard how London benefited from strong system and clinical leadership which helped to drive radical change and improvements in stroke care.
Other research shows that stroke specific early supported discharge services can reduce a hospital stay by an average of seven days. Patients receiving this service are more likely to be alive and able to stay living at home longer.
But at our meeting, we heard from at least one locality which was not yet providing this. This was a top priority, with a strong business case for change. Audit modelling data suggests that every extra patient receiving early supported discharge can save the NHS £1600.
At the meeting, there was much discussion about siting of specialist services and remodelling urgent and emergency care pathways. The NIHR review shows how modelling and operational research can help with some of these complex decisions, for instance in changes to speed up thrombolysis or how to concentrate services into fewer centres.
‘There is still work to be done to identify cost-effective ways of supporting families to live well with stroke in the community’
And it’s not just about acute care. About two thirds of stroke patients leave hospital with a disability. NICE recommends reviews of health and care needs six months after a stroke – and researchers have developed a helpful tool for this. But audit shows less than a third of stroke survivors have had a six month review. There is still work to be done to identify cost-effective ways of supporting families to live well with stroke in the community.
There are important and difficult decisions to make. Eastern AHSN is helping the conversation to continue so that there is informed debate about trade-offs and options for improving care.
Overall, what we know from research is that how, where and who delivers stroke care really makes a difference. Investment in the right stroke care saves lives – and money. Good stroke care is cost-effective care. Our meeting showed us that we can learn from research and from each other in driving sustainable stroke services for the next 10 years.
Tara Lamont has worked for over 20 years at a national level in health services research, audit and patient safety. She is deputy director for the new NIHR Dissemination Centre. @TaraJLamont Dr Muhibbur Chowdhury works at Ipswich Hospital Trust and Dr Stephen Webb at Eastern AHSN and Papworth Hospital