Are the NHS reforms holding back stroke care?
The sweeping changes in the NHS and financial pressures are having a negative impact, argues Dr Matthew Fay
Two significant reports have driven the prevention of stroke and the care of people who suffer it – the 2007 National Stroke Strategy and the 2008 NICE clinical guidelines for acute stroke and transient ischaemic attack.
Since then, we have seen a six-fold improvement in public and professional awareness of stroke as a treatable medical emergency and a doubling of the proportion of people with stroke accessing specialist units. Patients are spending the majority of their admission on such units and there has been an increase in thrombolysis rates from less than 1% to 5% of all stroke.
Recently completed trials have increased treatment options for primary and secondary prevention and stroke has remained high on the political agenda despite a change in administration.
However, it's questionable whether any of this has made any difference to how stroke is treated in primary care, and the upheaval in the NHS and restriction of finance may have hurt stroke improvement plans in a way that didn't happen to the cardiac initiative a few years ago.
Despite the clear recommendation that a person suffering a transient ischaemic attack should be rapidly assessed by a stroke specialist in a dedicated outpatient facility, the Sentinel Stroke Audit of 2010 revealed that only 10% of centres provided a seven-day specialist service.
And although there has been a reduction in people with TIA in hospital, 63% of those admitted with high-risk TIA are managed in non-specialist stroke beds. Almost half of centres admit low-risk TIA, resulting in increased bed use and wasted resource. Suggestions that TIA referrals should move to the Choose and Book system would degrade the ability to ensure a patient is seen in 24 hours.
Even in areas where we see a rapid response to the clinical emergency of a TIA, problems are observed in the treatment options. A person who suffers a TIA who is found to be, or has previously suffered from, atrial fibrillation requires rapid anticoagulation. Problems have emerged in commissioning decisions for provision of anticoagulation, resulting in an unacceptable delay from referral to these services and initiation of therapy.
This could be resolved with stronger contracting tools or the greater use of oral anticoagulants. The use of these agents is restricted around the country due to cost concerns, with some areas banning their use entirely pending final NICE approval.
Stroke remains high on the political agenda, but service provision remains patchy, with limited integration between primary and secondary care. While many important elements of the pathway, particularly in acute care, have been established or strengthened in recent years, clinical commissioning groups need to prioritise the commissioning of the entire pathway of care. In so doing, not only can we achieve the goals laid out in the National Stroke Strategy,1 but we will also realise the savings we need to make.
Dr Matthew Fay is a GP in Shipley, North Yorkshire, and national clinical lead for the stroke improvement programme
Dr Fay would like to acknowledge the help of Dr Damian Jenkinson, a consultant stroke physician at Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and a national clinical lead for stroke, in writing this article
1 Salva O, McGuire A and Wolfe C. Cost of stroke in the UK. Age and Ageing 2009;38:27-329
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