Commissioning a service for the diagnosis and initial management of acute stroke

Suspected stroke is a medical emergency, and an urgent response saves lives and reduces long-term disability. Rapid diagnosis, immediate brain imaging, appropriate use of thrombolysis and direct admission to an acute stroke unit all contribute to better outcomes for stroke patients. Each year in England approximately 110,000 people have a first or recurrent stroke. More than 900,000 people are living with the effects of stroke, with half of these people being dependent on others for help with everyday activities. Stroke represents a substantial health and resource burden costing the NHS £2.8 billion per year in direct costs and £2.4 billion per year in informal care.

The National Stroke Strategy describes stroke as a disturbance to the blood supply to the brain. Brain scanning is needed to differentiate between an ischaemic stroke (approximately 85% of all strokes) and a stroke caused by a primary intracerebral haemorrhage. Thrombolysis (clot-busting drugs) given to a person who has had a primary intracerebral haemorrhage would be fatal. However, thrombolysis for ischaemic stroke given within 3 hours of symptom onset can save lives and reduce dependency. Thrombolysis should only be administered where specialist medical and nursing care is always available.

NICE clinical guideline CG68 on stroke recommends that all people with suspected stroke should be admitted directly to a specialist acute stroke unit following initial assessment. Brain imaging should be performed immediately (in the next slot and definitely within 1 hour) for people with acute stroke who meet the criteria in NICE clinical guideline CG68 on stroke and for all other people with acute stroke as soon as possible (within 24 hours).

The 2008 National Sentinel Stroke Audit found that although the number of thrombolysis services in the UK is increasing rapidly, the number of units offering a 24-hour, 7-day a week (24/7) service and the number of patients receiving thrombolysis remains low. The National Audit Office estimated the cost of thrombolysis for 9% of patients with acute ischaemic stroke to be £9.9 million and the saving in care costs to be £26.4 million.

The NHS in England: operational plans 2008/9-2010/11 requires all PCTs to implement the recommendations in the National Stroke Strategy and performance is monitored against the target to ensure that patients spend at least 90% of their time in an acute stroke unit.

The National Stroke Strategy identifies stroke networks as a clear lever for change. The Department of Health has set up the stroke improvement programme to support the development of local stroke care networks. Stroke networks can support commissioners with service redesign to ensure that appropriate urgent care is available for people with stroke and transient ischaemic attack.

Benefits

The potential benefits of robustly commissioning an effective service for the diagnosis and initial management of acute stroke include:

• improving clinical outcomes and increasing the number of people who remain non-institutionalised and independent following a stroke
• reducing deaths and dependency through rapid diagnosis and appropriate treatment
• improving performance and patient-centred clinical care through implementing the recommendations outlined in NICE clinical guideline CG68 on stroke
• reducing length of hospital stay
• improving processes of care, partnership working, patient experience and engagement
• better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an effective acute stroke service are:

• ensuring that all front-line staff are trained and competent in recognising stroke symptoms
• ensuring that appropriate care and referral pathways are in place and that people are transported by 999 call to a centre with a 24/7 acute stroke service and the ability to deliver thrombolysis
• accurately assessing and diagnosing all people with suspected stroke in healthcare settings and in the community
• providing effective and efficient clinical care in line with NICE clinical guideline CG68 on stroke
• ensuring that acute stroke services are integrated with other services for people with a stroke to ensure continuity of care
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning an acute stroke service include:

• World class commissioning.
• The NHS in England: The operating framework for 2009/10.
• National service framework for coronary heart disease: Modern standards and service models, National service framework for long-term conditions and National service framework for older people.
• National clinical guidelines for stroke: Royal College of Physicians Intercollegiate stroke working party.
• The Care closer to home initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• Commissioning framework for health and well-being.
• Considering the impact of patient choice.
• The Expert patients programme.
• A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with Standards for better health.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.