Introduction

This quality standard covers diagnosis and initial management, acute‑phase care, rehabilitation and long‑term management of stroke in adults (aged over 16 years). For more information see the stroke topic overview.

This quality standard has been updated. This topic was identified for update following the annual review of quality standards in 2014. The review identified that there had been changes in the areas for improvement for stroke. For further information about the update, see update information. Statements from the 2010 quality standard that are no longer national priorities for improvement but are still underpinned by current accredited guidance are included after the updated statements in the list of quality statements.

Why this quality standard is needed

Stroke is defined by the World Health Organization as a clinical syndrome consisting of 'rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin'.

Stroke is a major health problem in the UK. The Stroke Association's report, State of the Nation, highlighted that stroke accounted for around 40,000 deaths in the UK in 2015, which represents 7% of all deaths. Each year there are approximately 152,000 cases of stroke in the UK, of which about 25–33% are recurrent strokes. Most people survive a first stroke, but often have significant morbidity. About 1.2 million people in the UK live with the effects of stroke, and over a third of these are dependent on other people.

The State of the Nation highlights that stroke is estimated to cost the UK economy around £9 billion a year. This comprises direct costs to health and social care of £4.38 billion, costs of informal care of £2.4 billion, costs because of lost productivity of £1.33 billion and benefits payments totalling £841 million.

Development of stroke services, and particularly access to acute stroke care on a stroke unit, has resulted in improvements in mortality and disability outcomes post stroke. However, many people who have a stroke need long‑term support to help them manage any difficulties they have, participate in society and regain their independence. Stroke rehabilitation aims to help people to restore or improve their physical and mental functioning, adapt to any loss of function and work towards regaining a meaningful role for the individual. It involves many different specialists for different areas of care depending on the person's needs.

The quality standard is expected to contribute to improvements in the following outcomes:

  • mortality rates of adults who have a stroke

  • long‑term disability of adults who have a stroke

  • patient experience of stroke services

  • experience of carers looking after people who have had a stroke.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – safety, experience and effectiveness of care – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015/16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults

1b Life expectancy at 75

i Males ii Females

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease (PHOF4.4*)

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions (ASCOF 1A**)

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Improving functional ability in people with long‑term conditions

2.2 Employment of people with long‑term conditions (ASCOF 1E**,PHOF 1.8*)

Enhancing quality of life for carers

2.4 Health‑related quality of life for carers (ASCOF 1D**)

3 Helping people to recover from episodes of ill health or following injury

Overarching indicators

3b Emergency readmissions within 30 days of discharge from hospital (PHOF 4.11*)

Improvement areas

Improving recovery from stroke

3.4 Proportion of stroke patients reporting an improvement in activity/lifestyle on the Modified Rankin Scale at 6 months

Helping older people to recover their independence after illness or injury

3.6 i Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation service (ASCOF 2B[1]*)

ii Proportion offered rehabilitation following discharge from acute or community hospital (ASCOF 2B [2]*)

4 Ensuring that people have a positive experience of care

Overarching indicators

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

ii Hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to inpatients' personal needs

Improving people's experience of accident and emergency services

4.3 Patient experience of A&E services

Improving the experience of care for people at the end of their lives

4.6 Bereaved carers' views on the quality of care in the last 3 months of life

Improving people's experience of integrated care

4.9 People's experience of integrated care (ASCOF3E**)

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Deaths attributable to problems in healthcare

5b Severe harm attributable to problems in healthcare

Improvement areas

Reducing the incidence of avoidable harm

5.1 Deaths from venous thromboembolism (VTE) related events

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 2 The Adult Social Care Outcomes Framework 2015/16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life (NHSOF2**)

Outcome measures

People manage their own support as much as they wish, so they are in control of what, how and when support is delivered to match their needs

1B Proportion of people who use services who have control over their daily life

1C Proportion of people using social care who receive self‑directed support, and those receiving direct payments

Carers can balance their caring roles and maintain their desired quality of life

1D Carer‑reported quality of life (NHSOF 2.4**)

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation

1I Proportion of people who use services and their carers, who reported that they had as much social contact as they would like

2 Delaying and reducing the need for care and support

Overarching measure

2A Permanent admissions to residential and nursing care homes, per 100,000 population

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help them manage their care needs

Earlier diagnosis, intervention and reablement means that people and their carers are less dependent on intensive services

2B Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services (NHSOF 3.6 [1]*)

Placeholder 2E The effectiveness of reablement services

When people develop care needs, the support they receive takes place in the most appropriate setting and enables them to regain their independence

2C Delayed transfers of care from hospital, and those which are attributable to adult social care

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services

3A Overall satisfaction of people who use services with their care and support

3B Overall satisfaction of carers with social services

Placeholder 3E The effectiveness of integrated care

Outcome measures

Carers feel that they are respected as equal partners throughout the care process

3C The proportion of carers who report that they have been included or consulted in discussions about the person they care for

People know what choices are available to them locally, what they are entitled to, and who to contact when they need help

3D The proportion of people who use services and carers who find it easy to find information about support

People, including those involved in making decisions on social care, respect the dignity of the individual and ensure support is sensitive to the circumstances of each individual

This information can be taken from the Adult Social Care Survey and used for analysis at the local level

Alignment with NHS Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 3 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

Indicators

1.8 Employment for those with long‑term health conditions including adults with a learning disability or who are in contact with secondary mental health services (NHSOF 2.2*, ASCOF 1E**)

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.3 Mortality rate from causes considered preventable (NHSOF 1A**)

4.4 Under 75 mortality rate from all cardiovascular diseases (including heart disease and stroke) (NHSOF 1.1*)

4.11 Emergency readmissions within 30 days of discharge from hospital (NHSOF 3b*)

4.13 Health‑related quality of life for older people

Alignment with Adult Social Care Outcomes Framework and/or NHS Outcomes Framework

* Indicator is shared

** Indicator is complementary

Safety and people's experience of care

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to stroke in adults.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE Pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to people using services. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect people's experience of using services and are specific to the topic are considered during quality statement development.

A number of NICE quality standards are relevant to the safe care of adults who have a stroke. In particular the NICE quality standard for venous thromboembolism in adults: reducing the risk in hospital covers prophylaxis for venous thromboembolism.

Coordinated services

The quality standard for stroke specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole stroke care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults who have a stroke.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality stroke service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health and social care practitioners involved in assessing, caring for and treating adults who have a stroke should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults who have a stroke. If appropriate, health and social care practitioners should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.