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Policy responses and statements
- Name of organisation:
- Northern Ireland Department of Health, Social Services and Public Safety (DHSSPS)
- Name of policy document:
- Improving Stroke Services In Northern Ireland
- Deadline for response:
- 29 February 2008
Background: This consultation document sets out a number of proposals on the way forward for the provision of stroke services in Northern Ireland and views are being sought on 'Improving Stroke Services', which is designed to make improvements in the key areas of prevention, treatment and rehabilitation.
The Strategy aims to:
- Reduce the occurrence of stroke
- Raise awareness of the signs and symptoms of stroke
- Ensure stroke is treated as an emergency
- Ensure equitable access to evidence based care eg stroke unit care
- Provide person-centred multi-disciplinary, multi-agency care
- Ensure effective support for carers of stroke survivors
COMMENTS ON
NORTHERN IRELAND DEPARTMENT OF HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY (DHSSPS)
IMPROVING STROKE SERVICES IN NORTHERN IRELAND
The Royal College of Physicians of Edinburgh is pleased to respond to the DHSSPS on its consultation on Improving Stroke Services In Northern Ireland. Overall, this is a positive document and is warmly welcomed by the College.
There is a long history of stroke service development in Northern Ireland. For many years, and in many respects, Northern Ireland led the way in the development of such services.
Recent evidence, however, suggests that this is no longer the case in several important areas. The most recent Royal College of Physicians Sentinel Audit of Stroke has shown an alarming fall in early access to brain imaging (CT scan), and demonstrated that in several significant Northern Ireland acute hospitals, the proportion of patients treated in a stroke unit has fallen since the last audit. SITS MOST (the register of patients achieving thrombolysis in acute stroke) has shown that the UK lags well behind much of Europe in providing modern effective stroke treatment, and Northern Ireland lags very far behind the rest of the UK, particularly Scotland.
There are particular problems in the equitable delivery of services in Northern Ireland due to the concentration of population and specialist experience in the Belfast area. This underlines the importance of a regional strategic approach.
Northern Ireland has been proactive in developing specialist community-based rehabilitation services for stroke, enabling earlier and more effective discharge from hospital stroke units. A local randomised control trial has added significant evidence to the Cochrane Review which has shown effectiveness in reducing death and disability. Despite this, such teams are only available in a few areas.
No proper epidemiological review of stroke in Northern Ireland has ever been undertaken. Despite this, it is widely accepted that the incidence of stroke is likely to be high because of the significant risk factor profile in the local population. An emphasis on prevention (primary, secondary and tertiary) is therefore welcome, underpinned by the establishment of a stroke register which will provide essential information on the effectiveness of the measures proposed in the Strategy.
For all the above reasons, the Strategy is both timely and welcome. In some areas, targets could be made a little more demanding, and some could be made more clearly measurable. It is worth remembering that appropriate emphasis on the targets specified may pull resources from other areas unless accompanied by appropriate increases in funding. Overall, however, the direction is the correct one.
RECOMMENDATIONS OF NI STROKE STRATEGY
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Delivery of a regional public awareness campaign for the recognition of early signs and symptoms of TIA and stroke, and the prevention of stroke, working in collaboration where appropriate with the Cardiovascular Disease awareness campaign. (Page 14)
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By April 2011 all acute stroke patients will be appropriately assessed and, if applicable, will receive thrombolysis within 3 hours of stroke onset. (Page 16)
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That a working group will be established to bring forward proposals for the implementation of thrombolysis for acute stroke patients, where appropriate, to meet the target date in Recommendation 2 above. (Page 16)
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That by 2010 70% and by 2011 90% of all confirmed TIA patients at high risk of early stroke (ABCD2 score 6 or 7), are fully investigated in a specialist neurovascular clinic, and a plan of management put in place within a maximum of 7 days of the event. (Page 18)
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That by 2010 80% of stroke patients should spend the majority of their hospital stay in a specialist stroke unit as defined by British Association of Stroke Physicians Service Specification (at least Level 2) and with the expectation that by 2012 this should be available to all patients. (Page 20)
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That by 2009 all Trusts should have a Specialist Early Supported Discharge service in place? By April 2010 50% of all stroke patients discharged from each stroke unit and for whom Specialist Early Supported Discharge is appropriate should have access to it. Do you consider the target dates and percentage appropriate? (Page 20)
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That by April 2009 the RCP Transfer of Care Document or Northern Ireland equivalent should form the basis for the patients discharge plan? That a recognised specialist stroke co-ordinator should be available to support this process, as outlined in the Standard for Discharge Planning. (Page 21)
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That by 2010 every stroke patient should have access to stroke specialist assessment, advice, support and intervention in community settings in response to individual need. (Page 23)
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That by April 2009 75% and by April 2010 95% of all stroke/TIA patients should have undergone a Primary Care Review at 6 weeks, 6 months, and one year after onset or discharge from a Specialist Stroke Unit. (Page 24)
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That by April 2010 psychological screening and treatment for both cognitive impairment and mood disorders and promotion of long term psychological adjustment should be available for all stroke survivors and their carers. (Page 24)
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That by April 2009 each Trust should have established effective means of providing information to stroke patients and carers in a manner tailored to suit individual needs. (Page 25)
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That by April 2010 the DHSSPS should put in place a regional managed approach to the integration and delivery of stroke services to ensure equity of access across the region. (Page 26)
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That the Department of Health should work with relevant agencies to develop a competency and skills framework for stroke which will inform workforce planning for specialist stroke teams. (Page 27)
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That by April 2010 a regionally agreed fundamental hospital based stroke register should be in use across the province.
Comments on Recommendations of
Northern Ireland Stroke Strategy
Recommendation Number |
Y/N |
Comments |
1 |
Yes |
This will require collaboration with the Northern Ireland Ambulance Service. It will be vital to ensure that such a campaign coincides with a rapid service development to ensure that increased public expectations are met in practice. |
2 |
No |
This target should be met in a tighter timescale. Northern Ireland is already well behind other parts of the UK in delivery of this important treatment with proven effectiveness. The target date should be 2010, in line with many of the other targets in the Strategy. A firmer, more measurable target needs to be set for the percentage of all stroke patients who actually receive thrombolysis. |
3 |
Yes |
Agreed. |
4 |
No |
In line with recent research (Rothwell, Lancet), any patient with suspected TIA and an A,B,C,D 2 score of 6 or 7 should be treated as an acute medical emergency and an investigation, and management, plan completed in 48 hours, not 7 days. At the same time, we should be aware that the label of TIA is sometimes applied very loosely and if too many patients are channelled in
this way there may be inappropriate use of resources. |
5 |
No |
All acute trusts admitting stroke patients should have a stroke unit. At least 95% of strokes should be admitted directly to a stroke unit capable of providing modern acute stroke care (including thrombolysis), and all stroke patients who continue to need hospital care, and who have significant impairment resulting from the stroke should continue to be managed in a stroke unit capable of providing modern stroke rehabilitation. There may be scope for overlap with neurological rehabilitation services in some cases of similar need. |
6 |
No |
There is no logic in denying a treatment of proven effectiveness to 50% of patients who might benefit from it. |
7 |
Yes |
This will require resources. |
8 |
Yes |
Ease of access to specialist services following primary care review is important. This should be emphasised. Four to five years after stroke routine annual specialist review may not be cost effective. |
9 |
Yes |
See 8 above. Patients who for some reason have not been treated in a stroke unit should not be excluded. The long term and common problem of seizure disorders following stroke should not be overlooked. |
10 |
Yes |
This has been an underdeveloped area in Northern Ireland. Resources and a workforce plan will be required to deliver this target. |
11 |
Yes |
|
12 |
Yes |
Providing equitable services across a mixed rural/urban environment with very uneven population distribution will be challenging, but important |
13 |
Yes |
A significant increase in consultant medical staff trained in Stroke Medicine will be vital to the delivery of this Strategy. Northern Ireland has a recognised medical training post for training in Stroke Medicine, but this has not been funded. This should be addressed urgently. |
14 |
Yes |
This Register should be developed in collaboration with the Royal College of Physicians Sentinel Audit of Stroke. |
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
[29 February 2008] |
