Sir John Bourn, head of the National Audit Office, reported today that the priority afforded to stroke care by the Department of Health and the wider health service can be increased, given its impact and cost. Sir John’s report shows that notable progress has been made from a low starting point. It recommends further improvements in preventing, treating and managing stroke patients, in line with recent evidence. These improvements would reduce the number of deaths, improve recovery rates, increase NHS efficiency and lead to significant financial savings.
Stroke costs about £7 billion a year. The direct cost to the NHS is about £2.8 billion a year – more than the cost of treating coronary heart disease – and annual costs to the wider economy associated with lost productivity, disability and informal care are around £4.2 billion. Stroke is one of the top three causes of death in England and a leading cause of adult disability. Approximately 110,000 strokes and a further 20,000 Transient Ischaemic Attacks (‘mini strokes’) occur in England every year. There are at least 300,000 people in England living with moderate to severe disabilities as a result of stroke.
The report’s conclusions and recommendations target areas needing attention and action:
- A fast response to stroke, including rapid access to brain scanning, reduces the risk of death and disability. However, Ambulance Trusts, Accident and Emergency departments, Radiology departments and stroke teams rarely provide an effective, integrated emergency response to stroke.
- The clinically optimal model of stroke care is care delivered in a specialised stroke unit, and 63 per cent of patients are accessing a stroke unit at some point in their hospital stay. However, what constitutes a stroke unit varies considerably between hospitals and stroke units are of insufficient size.
- Without a brain scan, treatment cannot commence safely. Research shows that scanning all stroke patients immediately is the most cost-effective strategy. Although most hospitals have the capacity to provide CT scans within 24 hours of admission, in 2004 most patients waited more than two days.
- Thrombolytic (clot busting) drugs can improve patients’ chances of recovery after a stroke, but are rarely part of acute stroke care in England. Achieving rates of thrombolysis in England in line with those being achieved in leading Australian hospitals could generate net savings to the health service of over £16 million a year, with more than 1,500 patients fully recovering from their strokes each year who would not otherwise have done so.
- Early access to rehabilitation can restore movement, improve recovery and reduce delayed discharges. However, access to professionals such as psychologist, physiotherapists, occupational and speech therapists and social workers can be patchy.
- Hospitals said that around half of patients receive rehabilitation services that meet their needs in the first six months after discharge, and this falls to around a fifth of patients in the 6-12 months after discharge. There is also a serious impact on carers which is not being addressed adequately. The lack of clarity about how responsibilities are divided between health and social care services is a barrier to the delivery of patient-centred care.
- Many people still do not realise that strokes are largely preventable and cannot list the main risk factors, or how to manage them. Over three times as many women died of stroke than of breast cancer in England and Wales in 2002, but 40 per cent more women mentioned breast cancer than mentioned stroke when asked what the top causes of death were.
- The new GPs’ contract has improved stroke prevention. Nearly all the desired GP activities, such as measuring and controlling blood pressure and cholesterol in those people who have had a previous stroke or TIA will soon be achieved, except, however, the very low referral rate for scans for people who have had a stroke or TIA.
- Some scans and interventions are being carried out after the time when they would have been of benefit. Around £1.2 million a year is being inefficiently spent on scans for patients with TIA after the critical time-period has passed. Providing carotid surgery within two weeks to eligible patients could prevent around 250 strokes, and result in a net saving to the health service of around £4 million, each year.
- All patients with suspected TIA should be assessed and investigated within seven days. However, only a third of people with TIA are seen in a TIA clinic, and the median waiting time is 14 days.