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Stroke patients across the Midlands and East regions to benefit from improvements to local stroke services

The NHS across the Midlands and East is proposing to transform the care people receive when they suffer a stroke or transient ischemic attack (TIA) by introducing an improved system of care across the region.

Whilst we already have a network of stroke specialists who are committed to improving the lives of stroke survivors evidence tells us that we can do even better.

We know that there have been significant improvements in stroke services, which include stroke, transient ischemic attacks (TIAs) and rehabilitation services, across the NHS Midlands & East over the past four years, however there is still room for significant improvement.

By working together the NHS and its partners aim to improve stroke services.  By building on the knowledge and expertise of our workforce and services we can bring significant benefits to our patients by:

  • Increasing survival rates

  • Improving quality by reducing disability and shortening recovery times

  • Improving patient experience

 

Our work will reflect the whole pathway of care; ensuring that patients suffering a stroke receive the best care possible at all stages of their stroke journey; giving them the best chances of survival and the fullest recover possible.

 

Sally Standley, Programme Lead for the review says: “This work is a major priority across the region, and it is encouraging to see the commitment and interest of partner organizations in stepping up to tackle this challenge.  Wherever possible we will build on existing good practice in the region, rather than starting with a blank sheet of paper; and will work with and through local organizations to ensure that they have the opportunity to shape the future.”

Professor Tony Rudd, Stroke Review Chair and Royal College of Physicians Stroke Lead agreed saying: "Stroke care has improved considerably in the UK over the last 10 years and certainly compared to many other countries in Europe and elsewhere we already have services of which we can be proud. However there are still inequalities in the standards of care people might receive depending upon where they have their stroke and what time of day or day of the week it happens. We have to ensure that everyone has access to the highest quality of care and I am delighted to have been asked to chair the project board for this really important piece of work.”

“The reorganisation of stroke care in London has been a major success but I know full well that the solutions we used in London are not going to be directly transferrable to the Midlands and East of England. We have to ensure that we find systems that are appropriate to the regions and build on existing high quality services. I also want to emphasise how important it is that we work on the whole stroke pathway, both in hospital and the community. This work is not just about getting more patients thrombolysed; that is perhaps the least important outcome of all. We need to see all patients at all stages of their illness getting the best quality care.”

 

For more information/documentation about this review visit the Stroke Review webpages. 

Read the Stroke Services Review newsletter

 

Our vision

We want people in the East Midlands who have a stroke to get the best possible treatment. We want to widen access to specialist care, and to make sure as many people as possible benefit from the latest drug treatments.

A stroke happens when the blood supply to the brain is disturbed. If brain cells go for too long without a proper supply of blood, they start to die. Most strokes happen when a blood clot gets stuck in an artery and blocks the flow of blood to the brain.

  • A less common type of stroke happens when a blood vessel bursts, causing bleeding in or around the brain. It's also possible to have a 'mini stroke' (a transient ischaemic attack, or TIA). This happens when a blood clot blocks a vessel leading to your brain for a short time, before clearing on its own.

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How stroke is treated

It’s extremely important to be correctly diagnosed and treated quickly by a team of stroke specialists.

Strokes caused by a blood clot can be treated with clot-busting drugs (thrombolysis). These drugs help restore blood flow to the brain. They have to be given within three hours of the stroke to have the best chance of working. These drugs can only be given within three hours of symptoms starting.

Mini strokes also need rapid treatment to reduce the risk of a second, potentially major stroke.It's important for stroke specialists to carry out urgent tests before treatment, such as brain scans, to diagnose the type and severity of the stroke.

 

Why we need to change services

Strokes can have devastating and long-lasting effects on people who have them, and on their families. Just over 6,000 people in the East Midlands have a stroke each year, and around 1,500 people are admitted to hospital with a 'mini stroke' (also called a transient ischaemic attack, or TIA).

Strokes are treatable, but they're not always recognised or treated quickly enough. Staff in local Accident and Emergency (A&E) departments and general hospital wards don't always have the skills, experience and equipment needed by patients in the early stages of a stroke.

Some treatments for stroke, like clot-busting drugs (thrombolysis), need to be given urgently, and can only be administered after doctors have done a brain scan. Specialist hospitals will have 24-hour access to scans, and will be able to make sure that all eligible patients are treated with thrombolysis.

What the research says

Compared with a general ward, care in a specialist stroke centre means people are more likely to survive their stroke, leave hospital sooner and are less likely to be dependent on others for long-term care.

In studies looking at nearly 5,000 people:

  • After five years, 60 percent of people receiving ordinary care had died. This fell to 52 percent among people who got specialist care.

  • The proportion of people alive and living independently, as opposed to in a care home, was 22 percent with specialist care, compared with 14 percent for ordinary care.

 

Treatment with clot-busting drugs (thrombolysis) can also help prevent disability. In a group of 1,000 stroke patients treated with thrombolysis, compared with people who didn’t have this treatment, 50 to 60 more people will have less disability and be able to live independently, rather than needing care in a nursing home. However, treatment must be given quickly if it's to work, and also to minimise the risk of potentially severe side effects.

 

How we're changing services

To make sure the highest number of people get the best quality care for a stroke, we're changing the way strokes are treated in the East Midlands.

We are accrediting some hospitals to specialise in treating strokes. These hospitals will have the skills, experience and equipment to offer treatment as an emergency, 24 hours a day. Ambulance crews will be trained to recognise stroke patients and take them straight to a specialist centre.

Following a robust programme to identify the best model for the East Midlands, specialist stroke centres are now being developed throughout the region so all patients benefit from the best care in line with their needs.

A regional ‘comprehensive’ tertiary centre, at Nottingham University Hospitals NHS Trust, now provides the full range of specialist services including complex neurological and neuro-radiological care.

‘Primary’ centres offering 24-hour a day specialist treatment including thrombolysis are being developed at University Hospitals Leicester NHS Trust, United Lincolnshire Hospitals NHS Trust, Derby Hospitals NHS Foundation Trust, Chesterfield Royal NHS Foundation Trust, Sherwood Forest Hospitals NHS Foundation Trust and Northampton General Hospital NHS Trust. All will be fully operational over the course of the next 12 months.

For some kinds of stroke, clot-busting drugs (thrombolysis) can reduce the risk of being severely disabled. However, treatment must be given within three hours of getting symptoms. Our proposals will make sure eligible patients have access to thrombolysis in time to benefit.

People will be taken by ambulance directly to the nearest specialist stroke centre rather than their local A&E. For most people, this should be within a 60-minute journey by ambulance. On arrival, patients will be assessed by a specialist, have access to a brain scan, and receive thrombolysis if appropriate. This will usually be within an hour of admission. Although not everyone will need thrombolysis, they can still benefit from faster access to specialist services.

Patients will usually stay in the specialist stroke centre for the first 72 hours, or until they are stable. They will then be transferred to a dedicated local stroke unit in the same hospital or closer to their home, where they will receive rehabilitation. Care in a local stroke unit will significantly improve a person’s chances of recovering from a stroke.

We are also introducing quicker and better treatment for people who have a 'mini stroke' (a transient ischaemic attack, or TIA). All patients who have a TIA will be assessed and see a specialist within 24 hours (for high-risk patients) or within seven days (for low-risk patients).

[ Zoom ]
stroke pathway

Journey times

If someone is having a stroke, the first three hours are the most important. clot-busting treatment using thrombolytic drugs can only be given during this time. We need to make sure pateints reach a specialist hospital and get treated within this time limit. 

It takes time to realise someone has had a stroke and call for help. Once in hospital, doctors need time to do tests and start treatment. We've allowed for a 60-minute journey time, and for 60 minutes spent in hospital being examined and having tests. So our plans should allow us to reach the three-hour goal.

To calculate journey times, we've taken into account the real experiences of ambulance drivers who make these journeys every day. We've looked at records of journeys in rural and urban areas, which give details of how quickly ab ambulance can travel down particular roads with its siren on and lights flashing.

The East Midlands Public Health Observatory then took these average speeds and used sophisticated software to predict how long journeys to individual hospitals would take.

We've used this information to help us plan where specialist stroke centres should go, giving everyone the best chance of reaching one within 60 minutes. We've also taken into acocunt different levels of traffic at different times.

For some people it might be quicker to go to their local A&E. However, this might not mean the best stroke care. Treating a stroke needs a team of skilled and experienced staff with access to sophisticated equipment. Specialist teams also need to treat several hundred patients each year to hone their skills and get the best results. Not all hospitals are able to provide this level of care or see enough patients, so it's worth traveklling further to a hospital that can.

 

Benefits for patients

The NHS in the East Midlands can reduce the devastation caused by strokes by providing specialist care. There’s good research showing that people are more likely to survive with less disability if they're treated in a specialist unit, rather than a general hospital ward.

Treatment with clot-busting drugs (thrombolysis) can also help prevent disability after a stroke. However, thrombolysis has side effects, so the risks and benefits of this treatment are finely balanced. People must be treated very soon after a stroke if they are to benefit.

Specialist care

According to the research, for every 1,000 people admitted straight to a specialised stroke unit rather than an ordinary ward, 60 to 80 more people will be alive and living independently after five years.

Thrombolysis

People treated with thrombolysis also have a better chance of being able to live independently, rather than requiring full-time care in a nursing home. However, thrombolysis can cause dangerous bleeding as a side effect.

In a group of 1,000 stroke patients treated with thrombolysis, compared with people who didn’t have this treatment:

  • 50 to 60 more people will have less disability and be able to live independently

  • 30 more people will die in the first three to six months, because of the side effects of thrombolysis

  • 40 to 60 more people will have bleeding in their brain, as a side effect of thrombolysis.

 

Treating 'mini strokes'

If someone has a transient ischaemic attack (TIA) or minor stroke there's a danger of going on to have a major stroke. In one trial, quick, aggressive treatment for a TIA or minor stroke cut the risk of a second stroke by 80 per cent.

 

How we made our decisions

In a major review during 2007, as part of a national review of the NHS, NHS East Midlands asked around 4,500 members of the public and 500 health and social care staff about the healthcare issues that mattered to them. There was strong support for specialised services dealing with heart attacks and strokes.

The details of our proposals  were developed with local doctors and the people responsible for commissioning healthcare. A clinical summit was held in September 2008 to review current stroke and heart attack services across the region, and to discuss the development of a new service model. Clinical Advisory Groups were set up as a result of this summit, and met regularly to develop the service model and the minimum standards of care that should be on offer.

We also sought views on the proposed changes from patients, carers and their representatives during a series of small workshops in November and December 2008. During the summer and autumn of 2009 we held a series of engagement events around the region to seek the views of patients and the public on our more detailed proposals.

How we decided which hospitals should offer specialist stroke care

We collected data on past strokes, where and when they tend to happen, and the population in each area, to help us anticipate how many people will need care across the region. We also looked at how long ambulance journeys take in different areas, and we reviewed the strengths and weaknesses of current services.

Our sources included East Midlands Ambulance Service, East Midlands Public Health Observatory, the performance intelligence unit of the Strategic Health Authority (SHA), and the Nottingham Stroke Unit. The accuracy of this data was checked with the health community.

In July 2009, all NHS hospitals in the East Midlands that offer emergency care were invited to apply to provide a specialist PPCI centre and/or a level of care for heart attacks and chest pain that meets new quality guidelines.

A panel of independent experts, including doctors from within and outside of the region, have now assessed these proposals. They visited each hospital to review the care they provide at the moment and discussed with clinicians and managers how they would deliver the new services.

We then put together our final recommendations for creating our new regional system of care for stroke, including where the specialist centres should go. In February 2010, these recommendations were presented to our local primary care trusts (PCTs) who  are responsible for commissioning the new services for the people in their area. They agreed to fund the new specialist centres.

The hospitals which have been accredited as specialist centres are now working hard to implement the new services as quickly as possible so patients start to get the benefits.

brain scan

Other useful links:

For more information/documentation about this review visit the Stroke Review webpages. 

Read the Stroke Services Review newsletter

Your views about stroke care

Check out how well our stroke services are performing on quality through the East Midlands Quality Observatory

NHS Improvement - STROKE

Developing rapid access to surgery for mini strokes in Leicester 

East Midlands Cardiac and Stroke Network

Look out for the signs of stroke

FAST stroke awareness logo

We want the public to know what a stroke looks like, and to call for help quickly if they see one happening. To recognise the signs of a stroke, you can use the FAST test:

Face – Has their face fallen on one side?Can they smile?

Arm – Can they raise both arms and keep them there?

Speech – Is their speech slurred?

Time to call 999. If you see any single one of these signs.