Providing first class stroke care is problematic in the East of England.

There is much evidence about what constitutes good stroke care and how it saves lives, but it does not always sit easily with small district general hospitals preserving services.

The East of England currently has 17 hospitals providing stroke services, and almost all offer 24/7 thrombolysis – often through a telemedicine link that allows hospitals to send scans to an on-call specialist out of hours.

This was seen as an imaginative solution that supported smaller hospitals and meant patients could be treated relatively locally. But NHS Midlands and East has a long way to go to match the outcomes achieved in London hospitals.

Thirty-day mortality rates for stroke patients in the capital are 25 per cent below the national average while East of England’s are slightly above. Nearly 90 per cent of higher rate transient ischaemic attack patients in London are treated within 24 hours, compared with around 55 per cent in the East.

The East has improved rapidly over the last two years but must do so faster. As a report to NHS Midlands and East makes clear, part of London’s success has come from sending stroke patients to fewer units, which have then become hyperacute stroke units.

The East of England may have achieved universal access to 24/7 thrombolysis but there are other factors that could help bring mortality closer to London levels.

The strategic health authority has now launched a review of stroke services in the area. If it decides that successful ones need a critical mass of patients, commissioners will have to make some harsh decisions about how to weigh up access against potential outcome improvements