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Tuesday 25th October 2016

Stroke services for improvement

26th June 2007

The Department of Health is reviewing stroke services and will be publishing a new strategy in the next few months. Here we look at the progress that has been made since guidelines were first published for England in 2000, and what the picture is across the rest of Europe.


Good stroke care

The annual cost to the NHS of the 110,000 strokes that are suffered by patients each year is around £2.8bn. Roughly speaking one third will make a good recovery, one third will be left disabled, and one third will die. Stroke is the third largest killer in the UK and across Europe after heart disease and cancer.

Research has shown that outcomes are better if patients receive specialist stroke care from the onset of their symptoms. The main elements of a specialist stroke service are:

  • Emergency administration of clot-busting drugs (thrombolysis) when indicated.
  • Early scanning to assess the stroke.
  • Acute and rehabilitation care on a dedicated stroke unit staffed by multi-disciplinary specialists in stroke care.
  • Access to ongoing rehabilitation and care after discharge from hospital, including advice on secondary prevention.
  • Rapid access to outpatient assessment for patients who have had a trans ischaemic attack (TIA), often a precursor to a full stroke.
  • Primary prevention in primary care for those with risk factors including heart disease, diabetes and obesity.

The government has a target to reduce deaths from stroke and heart disease in the under 75s by at least 40% by 2010 compared to 2000 levels. National Clinical Guidelines for the care of stroke patients in England were first published in 2000 by the Intercollegiate Working Party on Stroke. The National Service Framework for Older People, published the following year, set out clear targets for stroke services in the NHS in England. Similar guidelines did not follow in Wales until just last year. The Intercollegiate Working Party updated its clinical guidelines in 2004. In early 2006, following a National Audit Office report, the Department of Health embarked on an 18 month work programme to update the national strategy to modernise stroke services. A draft for consultation is expected in the next few weeks. In December last year the Department of Health published the ASSET 2 toolkit to help PCTs to commission effective local stroke services.

How do services in England and Wales measure up?

Official figures show that death rates from stroke in the under 65s have fallen by a quarter in the last decade, and certainly services are better organised now than ever before. The National Sentinel Stroke Audit Programme has been the main way of assessing how stroke services in England and Wales have been fairing since 1998 when the programme started. The audit, run by the Royal College of Physicians on behalf of the Intercollegiate Working Party, has been funded by the Department of Health, and more recently by the Healthcare Commission.

The fifth audit was published in April this year and showed that stroke care is still something of a lottery around the country. It found amongst other things that:


  • Only 12% of hospitals have arrangements with ambulance services for emergency treatment and transfer of patients who have had a stroke.
  • Only one in five hospitals offers thrombolysis for stroke patients, and even with this number only a fraction of patients who would benefit from it are receiving it.
  • Less than 10% are scanned within 3 hours, and only 42% are scanned within 24 hours of their stroke – a drop from 59% in the 2004 audit, although the criteria have changed between the years. The figure was only 28% in Wales.
  • 91% of hospitals now have specialist stroke units, but still only about 50% of patients make it on to one during their admission. Only around 10% of patients are admitted directly to a stroke unit and only 15% make it to the stroke unit on their first day in hospital.
  • A third of patients with swallow disorders are not assessed within 72 hours by a speech and language therapist. Nearly 30% of those with motor disorders are not seen by a physiotherapist within 72 hours. Figures for assessment by occupational therapists and social workers are even worse.
  • There has been a large increase in recent years in the number of stroke units offering specialist rehabilitation.
  • Only 35% of patients referred to TIA clinics are seen within seven days.

The audit report concluded that the profile of stroke still needs to be raised as a medical emergency akin to heart attack where patients are picked up, thrombolysed and admitted to specialist coronary care units without delay. The situation in Wales was found to be particularly poor with urgent action called for to implement recently published guidelines.

In terms of post-discharge care, the Stroke Association reported in November last year that there were still significant problems with people being “abandoned? after discharge from hospital. Many were not being given advice on secondary prevention, medication, benefits or rehabilitation.

The picture across Europe

There are considerable disparities in incidence of and mortality rates from stroke across Europe. For example, there has been a downward trend in death rates from stroke in the UK, whereas death rates have continued to rise in Eastern Europe.

There is also considerable variation in how stroke services are organised in different European countries, including availability of specialist stroke units, staffing levels, access to scanning and thrombolysis, availability of ongoing rehab and follow up, levels of patient and carer involvement, and access to voluntary sector support bodies.

Austria and Germany were the first nations to establish acute stroke units with a similar ethos to intensive care or coronary care units. Austria now has a network of stroke units such that transport times to one from anywhere in the country is less than 45 minutes. It thrombolyses 41% of patients and 50% are scanned within 30 minutes of arrival in hospital. Northern European nations (Sweden, Norway, and Finland for example) have developed more combined stroke units incorporating rehabilitation as well as care for the early acute phase. The UK tends to have a mixture of acute and combined stroke units. In Russia, models of stroke care are still developing and specialist services tend to be centralised at regional tertiary hospitals.

It follows that spending on stroke services varies widely across European nations, with Eastern European nations spending the least, and Denmark spending the most. But across all nations, proportion of spend on outpatient and community services is small compared to spend on hospital based care.

A number of pan-European collaborations (including BIOMED I and II, and the European Registry of Stroke – EROS – project) have tried to link outcomes to service organisation and levels of investment. Studies that have linked mortality with investment suggest there is at least a minimum level of investment that is required to start to turn the corner on mortality figures. Eastern European nations are not achieving these levels. But after a certain level of investment, there is no clear link between proportion of spend and outcomes.

Researchers have concluded that social and health risk factors may be as much to blame for outcome differences. Across European nations there are differences in the prevalence of risk factors such as heart disease and diabetes. There are also differences in how these risk factors are managed, including thresholds for intervening with blood pressure, blood glucose levels and temperature. Studies in both Europe and the US have shown that incidence of stroke is higher in certain ethnic groups including black African, Afro-Caribbean, and Hispanic populations. Exposure to different risk factors, including smoking, diet and exercise, are thought to account for much of these differences.

Because of the financial and social burden of stroke across Europe from loss of earnings and disability, there is considerable collaboration between nations to improve outcomes. The Helsingborg Declaration is a pan-European consensus on stroke management made between leading national and European stroke organisations and the World Health Organisation. First made in 1995 and recently updated in 2006, it sets standards for stroke care across Europe and targets for improvement. The Declaration has set the following aims to be achieved across Europe by 2015:

  • All patients will have access to a continuum of care from organised stroke units to appropriate rehabilitation and secondary prevention measures.
  • 85% of stroke patients will survive the first month post–stroke.
  • 70% will be independent in their activities of daily living by three months.
  • There will be a 20% reduction in stroke mortality rates compared to 2005 levels.
  • There will be action to reduce smoking and hypertension across Europe.

Still, funding for research on stroke across Europe remains tiny compared to that on heart disease and cancer.

For more information on stroke services in the UK and across Europe go to:





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