Policy responses and statements
- Name of organisation:
- Department of Health
- Name of policy document:
- A new ambition for stroke - a consultation on a national strategy
- Deadline for response:
- 12 October 2007
Background: This consultation document sets out the views of six working groups contributing to the development of the National Stroke Strategy, on the challenges currently facing stroke services in England and how these can be met. It invited everyone to give their views on the ideas set out in the document, as well as contribute new ideas to the debate.
The final strategy is intended to:
provide a quality framework against which local services can secure improvements to stroke services, and address health inequalities relating to stroke;
provide advice, guidance and support for commissioners, strategic health authorities (SHAs), hospitals, primary care trusts (PCTs) and social care in the planning, development and monitoring of services; and
inform the expectations of those affected by stroke and their families, by providing a guide to high-quality health and social care services.
COMMENTS ON
DEPARTMENT OF HEALTH
A NEW AMBITION FOR STROKE -
A CONSULTATION ON A NATIONAL STRATEGY
The Royal College of Physicians of Edinburgh is pleased to respond to the Department of Health on A new ambition for stroke - a consultation on a national strategy.
This document should be broadly welcomed as it attempts to address a much neglected area in our nation’s Health. Every year there are approximately 110,000 strokes in England. Stroke is the third leading cause of death and the leading cause of severe disability. The financial cost to the NHS and the economy is great and greater than coronary heart disease (National Audit Office).
GENERAL COMMENTS
The aspirations described in this document are far-reaching and very, very ambitious. Rather than a strategy they describe an “ideal” stroke service, (based on current understanding), a kind of Stroke Care “Nirvana” which would be difficult to imagine in the next 10-20 years. However, perhaps there is no major harm in aiming high! What is lacking is any realistic plan for taking the first steps towards the ideal. The only ideas on delivery are that it is in the hands of commissioners (to commission appropriately), for health providers (to provide the services) and for the latter to develop geographical networks.
What are the priorities? What are the short and medium term targets? What should be achieved by 2008, 2009, 2010, and later years?
In Scotland, our 2002 strategy focused first on setting up the structures to deliver improvements ie managed clinical networks (see below), on better access to imaging, stroke units and support after discharge in the form of stroke liaison nurses. There are targets to be taken forward at a national level (working to improve public awareness, upgrading ambulance protocols and helping to develop the workforce). Local targets can be taken forward by the proposed networks and their component commissioning and providing bodies. This strategy needs some early, important and realistic targets and a mechanism for reviewing these and setting new ones.
What mechanisms are to be put in place to advance the strategy?
The idea of geographical networks is the right one. However, investment is needed to set them up. In Scotland, each NHS Board was allocated £50,000 per annum for 2 years initially (in reality at least 3 years was required) to fully establish the networks. This paid for each to provide a network manager (often shared with CHD and diabetes networks) and an administrator. The latter is essential to help the clinicians keep the networks moving forward - to arrange meetings, to produce documents etc. After that, the hope has been that they will be sustained by NHS Boards. Networks need to have influence over planning and distribution of resources – the strategy will need to dictate where they fit into the commissioning and service delivery set up in England. In Scotland, it was required that the networks should be the principal source of advice to those planning stroke services. This is an important principle since without it networks will be ignored and clinicians, the contributing voluntary organisations and patient groups will rapidly become disillusioned in their involvement. The success of networks derives from widespread involvement of these groups.
Presumably the DoH will have the ultimate responsibility for moving the strategy forward. How will they link with the 25 (if all networks covered 2 million people) or 100 networks (for 500,000), which might have to be established? In Scotland, we have the National Advisory Committee which advises the Health Department. Several subcommittees take specific work forward. The MCN subcommittee, which first helped networks to establish themselves, is now helping each develop their services – it comprises the clinical leads and network managers. This is important so development work and good practice can be shared between networks. The IT & audit subcommitteetakes responsibility for the measurement of performance against targets and standards. IT is combined here with audit since the dream is that the data to monitor services will eventually be collected as part of routine clinical care.
How will the progress of the strategy be monitored?
The consultation document includes some loosely worded standards that stroke services should aspire to. These need to be defined far more explicitly to allow objective measurement of progress towards them. The definitions need to take account of the practicalities of collecting the monitoring data. It is no good defining a standard of care which cannot be objectively and reliably monitored in the real world. The NHSQIS standards for stroke care in Scotland provide some excellent examples of standards which can be monitored and others which cannot! A standard data collection mechanism should be planned across all networks. Without this, apparent rapid or slow progress in particular networks may simply reflect their interpretation of the standards or their method of monitoring. The national sentinel audit (in its present or a modified form) would seem the most sensible mechanism for measuring progress against standards and targets. The proposed networks would take responsibility for the data collection in the Trusts included within their area. Inevitably, some networks will advance faster than others. The DoH will need mechanisms to “encourage” slower networks to increase their rates of service improvement.
What funding will be made available to kick start the strategy?
Although it is stated that the DoH spends a lot of money on stroke services and that by providing better services we might increase effectiveness and efficiency, the strategy will fail without some pump-priming. Savings will only accrue from reducing stroke incidence (through effective prevention – primary and secondary), reducing residual disability (through better acute care and rehabilitation) and thus the need for long-term care (eg expensive social care packages and nursing home places). The savings will not occur immediately but will be delayed several years. Improvements in stroke care will require investment up front. Only then will one release the funding tied up in looking after those patients whose strokes should have been prevented and those stroke patients with ongoing care needs whose disability should have been lessened. In Scotland, £20,000,000 of new funding was made available for stroke services over 3 years for a population of about 5 million. This was vital to develop the strategy though certainly was not enough to deliver the services we aspire to. Thus, in England, it is probably unrealistic to launch a strategy without perhaps £50 million per annum for the first 3-5 years.
Networks should advise on the way this funding should be spent. However, in Scotland, the decisions about spending priorities had to be made before the networks were properly established. Ideally, networks should be established (this is bound to take a year) before larger amounts of funding are released for pump priming service improvements.
What will the impact of the stroke strategy be for other groups of patients?
The cancer targets had a detrimental effect on stroke patients. Stringent, but not necessarily evidence based, standards for imaging were imposed which led radiology departments to prioritise cancer patients over others. Stroke patients’ imaging and thus management has often been delayed. The CHD strategy focussed on the ambulance service - categorising chest pain patients as category “A”. This has increased demands on the ambulance service so that many regions are not achieving their targets. Thus other groups of patients who require very rapid transfer to hospital (eg major trauma) are likely to be suffering. It is important that the stroke strategy does not lead to worsening services for other groups of patients.
The example “cases” given are atypical.
All of the cases described involve young patients, often with communication problems. These are unrepresentative and do not provide any true insight into the nature of stroke. What about including some older patients with more diverse problems (eg with distressed families facing issues around nursing homes).
Information Technology has much to offer stroke services but features little in the draft strategy.
IT allows information to be shared and should reduce the need for duplication of effort in collecting data. It should make networking easier and reduce the impact that moving patients between units has on continuity of care and efficiency. Clinical IT systems also have the potential to improve the appropriateness of treatment by building protocols into systems so that they are more often adhered to. The current document places very little emphasis on this important area. It is fine to aspire to more and better trained staff, but the reality is that we are likely to have fewer staff in the future simply because of demographic changes. IT has some capacity to help make up the shortfall.
The Importance of Joint Working
Throughout the document there is emphasis on joint working between different NHS organisations and between Health and Social Services. Dealing adequately with the catastrophe of a stroke requires just such cooperation between different agencies. However, due to historical differences and new policies being developed there is a threat to fragment the NHS and social services. How will this initiative to develop a seamless person-centred service survive in the present culture?
SPECIFIC COMMENTS – INTRODUCTION
In Roger Boyle’s introduction he states (and it is repeated later in the document – p13) that whilst the UK spends more on stroke services than many countries, overall our outcomes are worse. In fact, the evidence does not support this statement. There are major difficulties in comparing outcomes across countries with such different populations, health and social services and population statistics. Comparable population based stroke incidence studies do not suggest that populations within the UK have higher age, sex adjusted incidence or worse case fatality than other developed countries where similar studies have been performed. There are no reliable studies comparing other outcomes after stroke. Certainly, European and North American countries provide more rapid access to acute care and especially imaging but often are severely lacking in areas of primary prevention, long-term secondary prevention, in-patient rehabilitation and longer term support. Many do not provide universal access to the services they provide. Of course, we can do much better but it is wrong to suggest that we are lagging far behind our international neighbours.
Chapter 1: Time is Brain
1 Are the recommendations from the project groups the right ones?
The RCPE welcomes the emphasis on the need to recognise stroke as a medical emergency. The College supports the importance of rapid access to stroke units for patients with a stroke or TIA. Over the years, we have seen the organisation of care for patients with acute coronary syndromes. In the same way, there should be emphasis on early assessment by trained staff and early imaging to identify patients who will benefit from thrombolysis and other acute interventions.
The National Stroke Strategy should emphasis the importance of interdisciplinary working and ensure that there are adequate staffing levels on stroke units to deliver this care.
2 Will these recommendations deliver improved services for people who experience TIA?
Patients who suffer TIAs or minor stroke and are not admitted to hospital require rapid assessment and investigation. “One stop” clinics are one way to provide this, but alternative models such as telephone “hotlines” have also been piloted and could provide alternatives. Timescales should be revised to ensure that service quality is not affected and for practical considerations, such as availability of surgical teams for endarterectomy at weekends. Investment is required to deliver appropriate imaging and ultimately more patients may be identified who will require surgical intervention (carotid endarterectomy). However, this will significantly reduce the subsequent burden of further strokes.
3 Will these recommendations help ensure stroke is treated quickly and effectively?
There will need to be a change in culture across primary and secondary care to deliver the message that “time is brain”. There does appear to be a lack of targets in this document. The milestone given of 75% of patients to a stroke unit is ultimately inadequate. Only 100% of patients receiving this care should be acceptable. Should all patients receive this care, substantial reductions in mortality and disability will occur.
This will allow units to develop pathways and networks to implement hyperacute stroke care. NHS management is driven by targets set by the government eg 4 hour casualty waits, 2 week cancer wait etc. Without adequate targets being set, NHS managers will not give this policy document the attention it deserves.
A similar target is for10% of stroke patients to have thrombolysis. This figure may be achieved in the future by units but it would be sensible to set interim targets for thrombolysis. It is suggested that patients who might be appropriate for thrombolytic treatment should go to a hospital which can provide this 24/7 (p. 19). Why? Many more hospitals will be able to provide thrombolytic treatment 9-5. This would reduce travel time, onset to treatment time and improve outcomes. It would decrease the number of displaced patients who then spend time in ambulances - time which would be better spent in a stroke unit. Continuity of care and thus efficiency is enhanced if patients do not have to move between units. Well established networks including the hospitals and the ambulance service will be able to develop the appropriate protocols. In Scotland, we are introducing telemedicine networks to increase the proportion of patients who can be treated in their local hospital which will often have a 24/7 access to scanner and a stroke unit but not a stroke specialist or radiologist.
The RCP London national Sentinel Stroke Audit has proven to be a useful driver of change in England and Wales. Permanent funding of this audit, perhaps linked to the Health Care Commission, would help deliver the strategy.
4 Are these the right recommendations to feed into an imaging strategy for TIA and Stroke?
We welcome the DoH plan to publish a separate imaging strategy for stroke. Whilst MRI is the most useful form of imaging in TIA and minor stroke not every patient will be able to have a MRI scan (pacemaker/metal fragments/claustrophobia) and therefore CT imaging should not be discarded. Availability of MRI scanners remains very variable across the country. It may not be feasible or sensible to suggest that all or even a significant proportion of such patients should have an MRI scan. Such statements usually emanate from centres with unusually easy access to such scanners. Often no brain imaging in TIA is required because the diagnostic and management yield is tiny. Sometimes CT will resolve the issue by excluding a small haemorrhage (more reliably in the acute phase than MRI) or space occupying lesion. An imaging strategy for each patient needs to be developed which will enhance their treatment. Unrealistic statements which may encourage much greater referrals for MRI risk swamping radiology departments with requests and impacting adversely on other groups of patients (both stroke and non-stroke) who would benefit more from the technique. Perhaps when MRI scanners are far more numerous then this should be included in the strategy.
5 Will this approach support continuing improvements to stroke unit care?
The College supports the need to commission services across the whole pathway of stroke care. Stroke units need adequate staffing across all grades and disciplines. Recent work from the British Association of Stroke Physicians (BASP) has demonstrated the requirements of WTEs of stroke physicians required to adequately provide a service Monday to Friday during working hours. Research has demonstrated that patients receive very little therapy, yet other research has demonstrated better outcomes with earlier and more intensive therapy. Whilst there is a common thread throughout the document with regard to team working, unless more precise specifications are made, commissioners may not deliver.
6 Do these recommendations adequately address the need for close working across first contact services…?
The DoH should support the commissioning organisations to ensure that they have the required expertise to drive the strategy of stroke care forwards.
7 Is there anything that has been missed?
A vascular risk register led by primary care and linked to a stroke register.
Chapter 2: Life after Stroke
1 Are the recommendations from the project groups the right ones?
While the recommendations made are right, there is a feeling that more specific targets should be set. Stroke is a disease that affects the patient for the rest of his/her life. But also, this illness has a major impact on the patient’s family. Stroke patients need access to long-term specialist support. The recommendations in the Stroke Strategy appear to support this life long commitment.
However, it needs to be acknowledged that patients may recover at differing rates and rehabilitation should continue until that patient has reached his/her potential. In contrast, recent documents from DoH appear to support a time limited rehabilitation period. Should patients stay longer than a certain length of time then the hospital will lose financially.
2 Will these recommendations help improve transitions from hospital to home?
Unless more specific recommendations are made for the discharge/transfer of care from hospital to community services, stroke patients will still struggle. There needs to be more integration between Health and Social Services. We are aware that geographical rehabilitation takes place eg Gateshead hospital receives patients from two areas. Gateshead patients will receive support from the community stroke team on discharge, but the other area does not have this service.
3 Do these recommendations adequately address the needs of carers?
More emphasis is required on the needs of carers. They require a great deal of appropriate information and support as they adapt to their own changed circumstances. A local directory of services compiled by Health and Social Services would help. What would be useful is a contact telephone number for a support worker who is knowledgeable about stroke and who can offer informal and formal advice. This person should have the ability to refer to appropriate specialist services if required.
4 Do these recommendations adequately address the needs of younger stroke survivors…?
The recommendations probably address the needs of the younger stroke patients. The additional challenges of vocational rehabilitation are mentioned. Unfortunately, there is presently a shortfall in specialist rehabilitation centres dealing with complex problems such as sex, and bladder and bowel problems. These areas are of significant importance to all patients and especially the younger stroke victims. For patients still working, there needs to be work done to help their transition back to work. It would appear that benefits are lost once a patient returns to any work; therefore patients may lose out financially going back part time.
5 How can services best improve access to psychological support?
Psychology services are poorly provided for stroke patients and their families. When present, the service is often stretched due to a lack of resources. There needs to be an encouragement for these services to develop and investment in providing this essential service. Members of the MDT on a stroke unit should be provided with the necessary skills for support and counselling. However, unless there are adequate numbers of experienced and trained team members on the ward, the team will fail to deliver this service for patients and their families.
6 Is there more that can be done to improve joint working across services?
The development of a clinical network across a region may help improve care for stroke patients and abolish barriers between health and social services. The development of this network will demand strong clinical leadership. Scotland has had some experience of this as alluded to above.
7 Is there anything that has been missed?
There is no mention of the need for orthotic and wheelchair services. These play a vital role in the rehabilitation of the stroke patient. Secondly, the return to driving is seen by patients as an essential part of their recovery. The DVLA regulations need to be reviewed and especially the assessment of patients post stroke. We have noted a variable standard in these assessments by doctors appointed by the DVLA to assess our stroke patients.
Chapter 3: Working together
1 Are the recommendations from the project groups the right ones?
It is appropriate to consider clinical networks to manage stroke and to increase co-operation between services. The DH needs to acknowledge that network models may vary considerably across the country depending on the geography and local infrastructure. These networks should be clinically led and this should be stated explicitly.
National standards should be set for the staffing of acute and rehabilitation units. Such standards are presently not in place and can lead to a variable skill mix on wards dealing with stroke patients. The standards should be evidence based and support the development of services such as the stroke discharge team which some areas do not have in place. The standards should look at the provision of 24/7 therapy for in-patients. All too often we hear from therapists that gains which had been made by the end of the week were lost over the weekend due to a lack of therapy.
The national tariff should be amended to be more responsive to the actual costs of stroke patients and should be used to encourage Foundation Trusts to develop their stroke services.
2 Will clinical networks drive the changes needed?
The College believes that collaborative clinical networks will prove an effective means of driving the changes required to deliver stroke services. The network as stated needs to be collaborative, clinically driven with strong leadership.
3 What are the benefits and concerns about expanding the cardiac network infrastructure?
We do not believe that the cardiac network possesses the capacity to deliver stroke medicine. Stroke services have always been the poor relation when compared to cardiology (numbers of consultants, research monies). Therefore, stroke will continue to struggle in any unequal relationship.
4 Will these recommendations support more effective local workforce planning for stroke?
There is good evidence to suggest that people with stroke should undergo as much therapy as they are willing and able to tolerate. There is growing evidence to support community stroke services. Unfortunately, in many parts of the country these services are not available. PCTs and social services try to offer generic community services/intermediate care. There is no evidence to suggest that these generic services are effective. The development of nationally recognised and quality-assured training for all levels of staff is therefore supported.
5 Are there any key gaps in research activity….?
The development of the stroke research network will help underpin the strategy for stroke patients. It will allow the development of stroke research. Historically, stroke research is under-funded and this needs to be addressed by central government.
6 Is there anything that has been missed?
The absence of time-scales for Foundation Trusts and commissioners to respond to and implement the strategy is a concern. A clear commitment to progress is essential.
Chapter 4: Everyone’s Challenge.
1 Are the recommendations from the project groups the right ones?
The College supports a programme of increased awareness and information about stroke among patients, carers and health or social professionals. The Government needs to raise this issue nationally and fund a campaign aimed at primary vascular prevention. Part of this campaign should be directed at Blood pressure lowering, either through non-drug management and or drug therapy. If the average Blood pressure in the community could be reduced by a small amount there would be a significant reduction in the prevalence of stroke.
2 Will these recommendations improve public awareness?
As mentioned above, strategies should be directed at primary prevention. However, there is a need to get a message across to the general public that a stroke is a medical emergency and not to delay in asking for help.
3 Will these recommendations improve professional awareness?
Unfortunately, there are still some professionals who do not look on stroke as an emergency. We need much higher standards of teaching at every level. This should start at medical school and continue throughout the life of a doctor. Similar comments probably apply to other disciplines also.
4 Is the right approach to improve information and advice for those who are at risk of, or have experienced a stroke?
Yes. There does need to be case finding and there have been recommendations produced by specialist societies regarding screening of adults for cardiovascular risk. Perhaps this could be included in the Quality and Outcomes Framework in Primary Care.
5 What more could be done to support primary care …?
The QOF should be used to identify patients at high risk – hypertensive, atrial fibrillation and ensure that adequate primary prevention of stroke occurs. The development of networks should enable GPs to refer quickly to their local stroke service. TIA clinics should not be part of the “Choose and Book” system which encourages late referral.
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[17 October 2007] |
