Managers and Medicine

Published: 27/03/2003, Volume II3, No. 5848 Page 42 43

Despite landmark guidance and a raft of targets, trusts are struggling to improve the standard of care for stroke victims. Jeremy Davies explains

The NHS may be known as a tortoise rather than a hare when it comes to modernisation, but even the most seasoned health service manager might find 72 years a rather long timescale for introducing reform.

And yet some experts argue that is how long the 130,000 patients who suffer stroke in the UK each year will have to wait before they receive co-ordinated care from the NHS.

In landmark guidance on how stroke should be treated, issued in March 2000, the Royal College of Physicians stated that all inpatient hospital care should be delivered in specialist stroke units. But according to its most recent audit of NHS provision, published in July 2002, only 25 per cent of stroke patients were spending at least half their time in hospital on such a unit in 1999, and by 2001 the percentage had risen to 27 per cent - an increase of just 1 per cent per year.

At this rate of progress, the Stroke Association says, it would take the NHS until 2075 to meet RCP's target.

Stroke is the third biggest killer and the largest single cause of disability in the UK, and evidence shows that stroke victims treated in a stroke unit are 20 per cent less likely to die or suffer a serious disability. In recognition of this, the government included a section on stroke in its national service framework for older people, published in March 2001.

The framework set targets that by April 2002 every hospital should have produced clear plans to introduce a specialist stroke service from April 2004; and by April 2003 they should have established clinical audit systems, including stroke registers, to ensure delivery of RCP's clinical guidelines.

Primary care targets stated that by April 2004 GP practices, using agreed protocols, should be:

identifying, treating and managing patients at risk of stroke and those who have had a stroke;

be using agreed protocols for rapid referral of patients to local specialist services;

have established clinical audit systems for stroke.

But there was no new money attached to the framework and so far, performance against them looks patchy. The Department of Health claims 83 per cent of hospitals met the April 2002 framework target, but the consensus among stroke specialists is that few, if any, will have the resources to establish units that produce a step-change in stroke services.

Professor Caroline Watkins, head of the North West stroke taskforce and the only nurse to hold a professorial stroke care post in the UK, says many hospitals are starting off from an extremely low baseline in terms of previous stroke provision.

She points to insufficient staff, a dearth of training and a simple lack of beds as factors which will militate against hospitals setting up stroke units big enough to cope with more than a fraction of patient need. Many hospitals also lack the necessary stroke data and IT facilities to establish useful clinical audit systems, and the picture in general practice is probably even worse, she warns.

'The framework targets are fine on paper, but There is been little guidance on how to achieve them and no extra money to bring about improvements. We are still at a point where a lot of people do not really know what a good stroke service looks like, let alone having the resources to get there.'

RCP's July 2002 audit found that, although 73 per cent of hospitals had a stroke unit in 2001, only 36 per cent of stroke patients admitted to hospital spent any time on one. The survey also found that 80 per cent of trusts now have a clinician with responsibility for stroke, but they devote an average of just two sessions per week to the condition, despite RCP estimates that an average district should have two full-time stroke physicians.

Stroke Association director Eoin Redahan agrees that these figures show significant improvements as compared to five or 10 years ago, but says the NHS is suffering from 'broom cupboard syndrome' in its attempts to meet the government's targets.

'There are thousands of dedicated staff doing their best with the limited resources they've got, but sometimes they're having to meet the letter of the targets rather than the spirit. The proof of the pudding is not sticking a sign on the wall to say You have got a stroke unit, It is how many patients get to use it.

The RCP audit showed that units are way too small and with too few staff.'

'It is a shame the framework didn't set targets for a certain percentage of patients to be seen in a specialist stroke unit. That would have been much more meaningful, ' suggests one stroke nurse consultant.

This month, the Stroke Association is stepping up its campaign by publishing new figures from the RCP audit showing the extent of regional and local variations in stroke provision. It is also helping set up an all-party parliamentary stroke group, chaired by Jim Cunningham MP.

For its part, the DoH has published several pieces of guidance in recent months, including good practice guidelines, What Makes a Good Stroke Service and How Do We Get There? and New Ways of Working in Stroke Care, a document detailing examples of how developing new roles in stroke care can assist in achieving service improvements.

The latter document, published in November, is the first of a series of outputs from the DoH's Changing Workforce programme for stroke, led by workforce designer Philip Shields, based at Bradford Hospitals trust.

Mr Shields explains that, as many other healthcare communities have discovered when they have attempted to map out local stroke care 'pathways', Bradford's stroke patients have traditionally been seen by as many as 30 staff from different disciplines and in various locations during their treatment.

'By looking at the tasks and competencies needed and redesigning roles accordingly, It is possible to rationalise the care patients receive and make it much more seamless and focused, ' he says. 'The new jobs that develop out of pathway mapping can also help with staff recruitment and retention.'

Examples of new ways of working being piloted include nurses being trained to perform swallowing assessments - traditionally done by speech therapists, who are in extremely short supply; generic rehabilitation assistants who work across several therapeutic specialties; and home helps who have been recast as enablement workers, following focused therapy training.

Whether such innovations will bring about the scale of change stroke experts say is necessary, and at a pace faster than a tortoise's, remains to be seen.

When HSJ contacted Bradford Social Services' stroke enablement team to discuss their service, they told us that, although the service had dealt with 90 stroke sufferers in the year to October 2002 and was of proven effectiveness, it was now 'on hold' because of uncertainties over funding. Plus ça change... l Case study: Epsom and St Helier trust St Helier Hospital in Carshalton, Surrey - recently highlighted as an example of good stroke practice by older people's services czar Professor Ian Philp - has had a 15-bed stroke rehabilitation unit since February 2002.

The unit includes a dedicated 'neurogym', featuring a range of intensive therapeutic rehabilitation facilities, an occupational therapy assessment suite, and a speech and language therapy unit.

Staffed by a multi-disciplinary team including a full-time stroke physician, stroke nurse consultant, occupational and other therapists, and a share of a clinical psychologist, the unit takes patients from a range of acute wards on the hospital.

It runs a comprehensive programme of education and training for hospital and social care staff, patients and carers and an intermediate care nurse from the community nursing team identifies patients ready to be discharged and manages the transition to home-based care. A stroke register is already in place at the hospital.

Epsom and St Helier trust director of operations Mary Wells says it took around 18 months of negotiation and planning between the trust, health authority and primary care group - now Sutton and Merton primary care trust - to establish the unit, which was created from existing elderly care beds.

'There was strong local feeling about the need to improve stroke services, driven by local clinicians - which was a big plus. Setting up the unit also coincided with a more general review of how we managed emergency access at the hospital, ' she explains.

'Though we haven't done the figures on this yet, I am sure we'll be able to demonstrate improvements in terms of lower readmission rates, and probably in speed of discharge.'

Case study: Sheffield Teaching Hospitals trust

Ask any stroke expert for an example of good practice and Sheffield Teaching Hospitals trust will not be far from the top of the list.

Since 2001 there has been a strong push at the trust to make stroke care more co-ordinated, both within the trust - which now covers the whole city - and through closer working with primary care, community rehabilitation teams and social services.

The trust admits 1,000-1,500 stroke patients a year and has an 84-bed stroke unit - one of the biggest in the country. It employs five specialist stroke nurses who track patients through the hospital system and help manage their transition into the community. Savings from bed closures in one of the trust's hospitals have been reinvested in extra resources for community rehabilitation teams.

The trust has also worked with the four PCTs in the area to encourage better preventive work in primary care and has introduced a dedicated stroke phoneline for GPs, which provides a single point of access to expert advice and a rapid stroke assessment service.

Stroke nurse consultant Amanda Jones says the focus has been on 'redesigning care by looking at the whole care pathway, from before a stroke occurs, through treatment to home-based care and regular follow-ups'.

Length of stay has plummeted by 50 per cent, with patients now spending an average of four weeks in hospital. 'At£400 a day per bed, That is a big saving, ' says Ms Jones.