Act now to deliver the stroke priorities in the long-term plan

Stroke strikes every five minutes in the UK. It’s the fourth biggest killer and is one of the leading causes of adult disability. As well as its devastating human impact, stroke has a substantial economic cost of nearly £26 billion each year. Yet, we know what interventions can reduce stroke-related mortality, improve quality of life for stroke survivors and reduce costs to the system – it’s a case of making them happen.

Newly published reports into acute care (‘20-’21) and the provision of post-acute services from the Sentinel Stroke National Audit Programme (SSNAP) lay bare the wide nature of the challenges that are threatening stroke survivors’ recoveries in England, Wales and Northern Ireland.

Stroke units and staff across the care system have been under enormous pressures since the start of the Covid-19 pandemic. We’re incredibly grateful for their tremendous determination working in such challenging times, continuing to deliver stroke prevention, treatment and care to those who need it. This new data highlights that their sustained efforts need to be matched by strong national and local leadership and commissioning to improve stroke care in the long-term.

The reports show that there have been some significant improvements in stroke care in recent years, such as decreases in hospital mortality rates and an increase in Early Supported Discharge (ESD) (specialist stroke rehabilitation provided to the same dose and intensity in the community as in hospital). Frustratingly, however, we are not seeing positive change elsewhere.

One of the greatest areas for concern is thrombectomy treatment, currently available to a mere 2.2% of patients, far below the 10% target set out in the NHS Long Term Plan for 2022. It’s a crying shame that we have only inched towards this target. Thrombectomy dramatically reduces the severity of disability caused by stroke. It’s also highly cost-effective, saving the NHS £47,000 per patient over five years, and the associated cost of disability-related care. Yet despite the miracles of this treatment, it is still only available to around a fifth of those eligible.

Since the last post-acute audit in 2015, many areas of treatment and care have stalled or even gone backwards. We know stroke survivors have complex ongoing needs – both physical and mental, following a stroke. Stroke survivors’ recoveries shouldn’t stop when they leave hospital, yet worryingly few are getting vital community rehabilitation and psychological support within target referral times.

Whilst an expansion of ESD is to be celebrated, it is only effective when co-ordinated by a multidisciplinary team and met with timely access to rehabilitation and support. Otherwise, it can contribute to common feelings of abandonment post-hospital. It’s vital that stroke patients receiving ESD feel ready to be discharged and can access quality rehabilitation quickly afterwards. Currently only 41% of teams meet referral times for ESD. Just one third (33%) of community rehabilitation teams meet treatment time targets, and almost half (43%) have waits of 15 days or more.

This latest data also highlights that stroke survivors wait an average of 10 weeks to see a psychologist. Like Phil Woodford from Catterall, who didn’t receive support to deal with his suicidal thoughts. “I had never had bad or negative thoughts before but I started feeling suicidal. I couldn’t cope. I was scared, angry, upset and frightened.” Phil’s referral for mental health support was rejected. “I was told to adjust my anti-depressants instead. I think psychological support and rehab should start as soon as a stroke is diagnosed.”

It’s shocking that the mental health effects of a stroke are not provided for, demonstrating the continued lack of parity between mental and physical therapies. Stroke is a sudden brain attack. It changes lives in an instant. It can rob stroke survivors of their ability to walk, talk and do every day activities. For many, like Phil, it can cause depression and anxiety. Ten weeks to see a psychologist isn’t good enough when we know that at least 16% of stroke survivors have considered suicide.

The NHS Long Term Plan stroke commitments and the creation of 20 Integrated Stroke Delivery Networks (ISDNs) are our biggest opportunity to turn stroke care around. After this difficult winter is behind us, we must see a renewed focus on commissioning the right evidence-based interventions to deliver better acute and post-stroke care. Local service reconfigurations, efficient referral pathways, appropriate staffing levels and universal commissioned support for people to live well after stroke are essential to ensure that stroke survivors have the best possible chance of rebuilding their lives.

We must see urgent action both nationally and locally to roll out thrombectomy and drive up thrombolysis rates, renewing efforts to achieve universal access for all patients who could benefit. This requires meaningful capital investment in workforce training, imaging equipment, and establishing and refurbishing thrombectomy centres. Crucially, it also requires a recognition from the wider system about the enormous individual and societal gains to be made by targeting investment in this area.

ISDNs are the key vehicle for stroke transformation regionally, bringing together stroke clinicians, providers, commissioners, charities and others to drive improvements across the full pathway. ISDNs should pay special attention next year to increasing timely ESD services, and improving provision of stroke rehabilitation, including quicker access to vital psychological rehabilitation and emotional support for people like Phil.

We know that the Covid-19 pandemic has exacerbated existing system-wide pressures, but achievements in other parts of the system highlight the possibility for advances. Health and social care leaders, commissioners, stroke networks and charities all share a responsibility to give the best possible outcomes to stroke survivors. We must act together to deliver on the priorities outlined in the NHS Long Term Plan, to work towards universal access to stroke treatment and high quality care.