Commissioning a service for the diagnosis and initial management of transient ischaemic attack and non-disabling stroke

NICE clinical guideline CG68 on stroke defines a transient ischaemic attack (TIA) as stroke symptoms and signs that resolve within 24 hours. A non-disabling stroke is defined as a stroke with symptoms that last for more than 24 hours but later resolve, leaving no permanent disability. Some people who have had a stroke or TIA have narrowing of the carotid artery that may require surgical intervention (carotid endarterectomy). Carotid imaging is required to define the extent of carotid artery narrowing. A TIA or non-disabling stroke is a medical emergency and an urgent response can save lives and reduce the risk of someone having a full stroke.

The National Stroke Strategy recommends that there should be care pathways in place to ensure that patients with suspected TIA and non-disabling stroke are immediately referred for appropriately urgent specialist assessment and investigation so that a secondary prevention management plan can be put in place.

NICE clinical guideline CG68 on stroke estimates that 20,000 people will have a TIA each year. More recent data suggest that in England the annual incidence of TIA is around 0.5 per 1000 people, equivalent to about 25,777 cases per year^[1]. Providing carotid surgery within 2 weeks to patients who need it could prevent around 250 strokes, and result in a net saving to the health service of around £4 million each year. Therefore it is reasonable to assume that investing in services for people with TIA would save money in the future by avoiding future strokes^[2].

The NHS in England: operational plans 2008/9-2010/11 requires all primary care trusts (PCTs) to implement the recommendations in the National Stroke Strategy and their plans for this will be centrally monitored and performance managed by strategic health authorities. In addition, PCTs are monitored against the vital signs target to measure the percentage of higher‑risk TIA patients receiving treatment within 24 hours.

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 networks. Stroke networks can support commissioners with service redesign to ensure appropriate urgent care is available for people with stroke and TIA.

Benefits

The potential benefits of robustly commissioning an effective TIA service include:

• decreasing the delay in time before people seek medical input by raising public awareness of the signs and symptoms of TIA and stroke
• reducing the risk of further TIAs and stroke through rapid access to specialist assessment, investigations and treatment for people following a TIA or stroke
• improving performance and patient-centred clinical care by implementing the recommendations outlined in NICE clinical guideline CG68 on stroke
• improving clinical outcomes
• reducing the number of admissions for stroke
• reducing inequalities and improving access to immediate treatment
• increasing patient choice, and improving partnership working, patient experience and engagement
• better value for money, by providing timely carotid surgery and reducing the number of strokes per year, resulting in savings to health and social care.

Key clinical issues

Key clinical issues in providing a TIA service are:

• ensuring that all front-line staff are trained and competent to recognise TIA and stroke symptoms
• accurately assessing and diagnosing all people presenting with suspected TIA and non-disabling stroke
• ensuring that at all points of access appropriate referral pathways are in place
• providing effective and efficient clinical care in line with NICE clinical guideline CG68 on stroke
• ensuring that the service is integrated with other services for people with TIA/stroke to ensure continuity of care
• providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a TIA service include:

• World class commissioning.
• The NHS in England: The operating framework for 2009/10
• The NHS in England: operational plans 2008/9-2010/11
• 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 prepared by the Royal College of Physicians Intercollegiate Stroke Working Party.
• Atrial fibrillation (NICE clinical guideline CG36).
• 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.
• 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.

References

1. Department of Health (2007) Impact Assessment: a new ambition for stroke. London: Department of Health.

2. National Audit Office (2005) Reducing brain damage: faster access to better stroke care. London: The National Audit Office.