Despite being one of the country's biggest killers and the largest cause of disability, stroke only recently gained a national strategy. Now the drive for faster intervention is giving it a much needed boost. Jennifer Taylor reports
Five per cent of the NHS budget is spent on stroke but just 7 per cent of that£7bn goes on acute stroke care.
In 2008 the National Institute for Health and Clinical Excellence and the Royal College of Physicians both published new guidelines on stroke.
Telemedicine is being considered in the East of England to ensure equal access to stroke care in rural areas.
It is more than a year since the launch of the national stroke strategy, when services across the country were charged with improving patient care for the condition. It is the single biggest cause of adult disability in England and the third largest cause of death.
There is now a growing sense that things are improving, although hard evidence is not yet available. Data from the last Royal College of Physicians national sentinel stroke audit - which is carried out every two years and is to date the best measure of performance in the sector - was collected in April 2008, just a few months after the strategy was published. While it did show improvement on 2006, it was still early days.
National director for heart disease and stroke Roger Boyle is "hoping and praying" that the next round of data collections will show an improvement. The National Audit Office will shorten the suspense by funding a separate, interim data collection for 2009, which it will publish in a report on stroke in December 2009.
But while the extent of progress on the strategy has yet to be demonstrated, it can be said with confidence that in the past stroke services in some parts of England have not been up to scratch.
"The reason progress in the past has been slow is that stroke has never been given any priority at all," says Professor Boyle.
"There's never been a national policy on stroke before we published the first one in December 2007."
Although 5 per cent of the NHS budget is spent on stroke, just 7 per cent of that£7bn a year goes towards acute stroke care.
And decades of underinvestment have led to a paucity of stroke physicians. While England boasts roughly 800 cardiologists, it has just 80 whole time equivalent stroke physicians.
Extra training places
The Department of Health last year funded 10 extra training places for stroke physicians. This year it is funding 30. As just one extra year of training on top of a doctor's parent specialty is required to qualify as a stroke physician, it is possible to increase their numbers rapidly.
"There is no shortage of people showing an interest in the area," says Professor Boyle.
Stroke has also suffered from a less well funded research infrastructure - for every£20 plugged into heart research, only£1 is given to stroke. As a result, the evidence base for stroke treatment is 10 years behind that for heart disease. And the fact that heart disease has in recent years benefited from high-tech interventions that make a real difference to patients has contributed to the flood of doctors entering the relatively glamorous specialty. Now the advent of brain scans and clot busting thrombolysis treatments means there is also greater interest in practising stroke medicine.
"It's [now] a much more positive area," says Professor Boyle. "And with the development of stroke units in every hospital in England they're becoming quite exciting places to work."
The recent drive for improvement was kick-started by a hard hitting 2005 National Audit Office report, which brought stroke services under close scrutiny.
Before that, stroke was "a blind spot on the part of the government", says Damian Jenkinson, national clinical lead for the NHS stroke improvement programme and a stroke consultant in Bournemouth.
"I would go as far as saying that [the government] did not truly realise the parlous state of our stroke services until the NAO spelt it out. I think they couldn't disagree with that," claims Dr Jenkinson.
The 2005 report revealed the nation's stroke services were in a poor state, were not providing effective or efficient services and were giving poor value for money.
Despite the vast sums spent on the condition, clinical outcomes for stroke were worse than in other countries spending less per capita. The DH had to admit the analysis was correct and a string of initiatives followed, starting with the national stroke strategy.
This made stroke a top priority in the NHS operating framework, meaning primary care trusts were charged with delivering the strategy and creating two specific targets - vital signs - to provide a regular update on performance.
In 2008 two sets of clinical guidelines for the condition - one from the National Institute for Health and Clinical Excellence and the other from the Royal College of Physicians - were published.
And last April stroke networks were set up across England to drive improvement by bringing together local stroke care providers.
Taken together, these efforts have made stroke a priority across the country. Professor Boyle says he has "not yet come across a primary care trust that isn't fully engaged in the whole process".
Dr Jenkinson's patch, the South West, has taken the national stroke strategy a step further by pledging to meet quality standards in three years, rather than within the 10 year target of the strategy.
Dr Jenkinson describes this as "a very shrewd step", one that recognises other competing national priorities will emerge during the strategy's lifetime. The move prompted an intense service review last summer. Every local provider now has a clear action plan to meet the strategy's quality standards.
"I believe we have the clearest position of our baseline in stroke care of any of the strategic health authorities," adds Dr Jenkinson.
Best practice in stroke care means working quickly in the early stages of an attack. Patients need rapid access to brain imaging and, if appropriate, treatment with clot busting drugs within half an hour of arriving in hospital.
While that requires a rota of trained specialists to be in place, plus the appropriate equipment and medication to be available, getting help at all hinges on the public recognising stroke as an emergency.
That is why in February the DH launched a three year stroke awareness campaign to publicise the FAST - Face, Arm, Speech, Time to call 999 - test. The goal is to help people recognise the signs of stroke and then treat it as an emergency.
Professor Boyle says the twin aim is "to drive the NHS to take stroke more seriously and to emphasise that it's important to treat stroke like an emergency, just like a heart attack".
At service level, with different approaches to redesigning stroke care being adopted across the country, London has the most ambitious programme in mind for redesigning these services, according to Professor Boyle.
Currently there is a density of good providers in the centre of London, which has created excess capacity there but left a shortage of high quality capacity in the city's suburban doughnut, where most strokes occur because of its elderly population.
Now the city has opted for a competitive tendering process for three parts of care: hyperacute services for emergency treatment, stroke recovery units, and transient ischaemic attack services for minor strokes.
The process is being managed by the Healthcare for London programme run on behalf of London's primary care trusts and consultation is under way on eight hyperacute services, which will see a slimming down in the number of hospitals in the city offering stroke care.
The proposal was determined on the basis of quality, population concentrations and journey times, with the aim of the shake-up being to provide 24 hour access to complex and relatively expensive interventions which cannot be provided at every hospital all the time.
But there are concerns that geography and quality do not marry up in the proposals; a mismatch that has "caused a lot of grief", according to King's College Hospital foundation trust professor of stroke medicine Lalit Kalra. Under the current proposals, the trust will have a hyperacute stroke unit.
"It's all right to have a vision, but it's also a question of taking into account what the reality is. The trouble is that if you close units down, you will not have the capacity to even offer the quality of treatment that's being offered now."
Professor Kalra believes interim proposals are needed to take into account the need for new services to develop capacity and expertise.
"I'm sure the will is there, but this will be expensive and the people that run such services are hard to come by."
Healthcare for London clinical director for stroke Chris Streather acknowledges stroke services have been proposed for some areas "where the historic track record is not brilliant", but says there is unlikely to be any rejigging of the proposal.
"What's needed is a joined up [approach] based probably on networks, to raise the quality of care in units which are currently not delivering the best stroke care, but are geographically necessary because of the incidence of stroke where they are and the travel times of getting people into the centre of London."
Conveniently, there are collaborative commissioning groups that are mostly coterminous with the stroke and cardiac networks.
The hope is that the high performing units in the centre will mentor some of the outer London units and that some staff will work across more than one site.
Around 130 hyperacute stroke unit beds are needed for the first 72 hours of patient care but only 40 are currently in place, some of which will be closed down under the proposals.
But Dr Streather says: "The last thing we want to do is close 12 of those before we've opened the 90 extra ones we need. There will have to be some double running."
At the same time, he believes services improve when they see more patients, so it is important not to concentrate care in a few places and risk diluting the quality of care elsewhere.
Crucial amid the upheaval will be looking after the workforce at the three units - at the Royal Free Hampstead trust, Guy's and St Thomas' foundation trust and Chelsea and Westminster foundation trust - that are currently delivering hyperacute stroke care but are unlikely to be doing so in the future. It is hoped their skills can be used across the networks.
While there will be blood on the carpet for some providers, Dr Streather is unapologetic about the need for change.
"There's some sort of assumption that if we did nothing it would get better anyway. We tested that over the last four years and it failed."
Hugh Markus, professor of neurology at St George's University of London and a consultant neurologist at St George's Healthcare trust - designated for a hyperacute unit - agrees that doing nothing is not an option.
"Currently there are some very good units offering very good quality of care to their local region but there are other patches of London where if you have a stroke you just won't get thrombolysis at all because you're too far from any centre that delivers it," he says.
London's plans for hyperacute centres differ from other areas, which plan to spread out the delivery of thrombolysis to every district general hospital on their respective patches, with centralised telemedicine for support.
Telemedicine is being considered in the East Midlands to ensure equal access in rural areas, says head of stroke services at Nottingham University Hospitals trust and Nottinghamshire stroke lead Dawn Good.
"If you see stroke as being something exciting and sexy and raise its profile within your own hospital then others start to see it as being a disease that you can make a difference with."
But there are concerns that a focus on acute aspects of stroke care will be to the detriment of patient rehabilitation.
Professor Kalra is concerned that rehabilitation services could flounder, and he likens the system to plumbing that has inflows but no drainage. "You'd flood over very soon," he says. "We started off developing good rehabilitation services because at the end of the day, that's what underpins stroke. Acute services then become a top layer, which gives you an edge."
Breaking the rule of thirds: why the right treatment is crucial
"The major problem with stroke is that the public's perception of it is of an old person's disease for which nothing can be done," says NHS stroke improvement programme clinical lead Damian Jenkinson. "And that's often the view in professionals' minds too."
The top cause of adult disability in England, stroke can cause mobility problems, difficulties using one hand and aphasia - speech disabilities.
But it is getting things wrong early on that often leads to unnecessary disability and death, whereas doing simple things right can reduce mortality by half and get people home quickly.
Getting it right means admitting patients with stroke into specialist units as early as possible since care from specialist staff is crucial - a cup of tea given to a stroke victim at the wrong time, for example, can lead to aspiration pneumonia and death. Patients on specialist units are also more likely to get physiotherapy and speech and language therapy early.
For patients who need it, giving thrombolysis (clot busting drugs) early can mean they walk out of the hospital in a week or two, instead of a month or two, with a need for less intensive physiotherapy and speech and language therapy.
Stroke Association director of communications Joe Korner says that in extreme cases patients who are almost totally paralysed down one side after a stroke and cannot speak can still walk out of hospital after a day or two.
"We sometimes call it the Lazarus effect because you get people up and restored very, very quickly."
Early discharge support teams and home based rehabilitation are also important. A gap between returning home and services kicking in can lead to depression, which affects about a third of stroke patients.
Stroke survivors say they carry on recovering for months and years after their stroke but the differences in their condition and quality of life can be hard to measure in clinical - and therefore financial - terms.
To date, stroke has been governed by a rule of thirds, which says that for everybody who has a stroke, a third will die within a month, a third will make a full recovery and a third will remain permanently disabled.
But Mr Korner says: "With thrombolysis and stroke unit care, we should be able to reduce mortality rates [and] increase recovery rates. The rule of thirds is set to be broken."
HSJ's Advancing Stroke Services conference is in London on 19 May, www.hsj.co.uk/conferences