Monday 29th May 2017
Dr James Davies, a member of the Health Select Committee and Conservative MP for Vale of Clwyd
Stroke (or Cerebrovascular Accident) is the fourth largest cause of mortality in the UK and is also a leading cause of disability. There are over 1.2 million stroke survivors in the UK today and almost two thirds of these are living with an associated impairment.
Broadly speaking, there are two main types of stroke: 85 per cent are ischaemic (due to a blocked blood vessel in the brain) and 15 per cent are haemorrhagic (due to bleeding within or on the surface of the brain). Stroke is largely – though not exclusively – a disease of the elderly, and as our population ages, its incidence is expected to increase from the 100,000 per year cases currently recorded.
Nevertheless, stroke is potentially preventable and sometimes treatable. Prevention and treatment is important not only to tackle premature death and poor quality of life, but to address the billions of pounds of impact on the economy that is currently incurred by the condition.
Improved acute care and better control of risk factors have in recent times reduced mortality rates attributable to stroke. In particular, major strides have been made in the treatment of some ischaemic strokes, thanks to “clot-busting” drugs, but the value of these can only be realised when efficient pathways are in place for their timely administration, day or night. As for other conditions, there is a balance to be achieved between centralisation to achieve fit-for-purpose, specialist “hyperacute” stroke services (which improve outcomes and reduce hospital stay) and ensuring a safe travel time to access such services, particularly in rural areas.
Potentially controllable common risk factors for stroke include smoking, excessive alcohol intake, illegal drug abuse, poor diet, high cholesterol, lack of exercise, obesity, high blood pressure, diabetes and atrial fibrillation (AF) – an irregular heartbeat. Such risk factors are public health priorities, not least because they are all implicated in the development of other illnesses. While levels of smoking continue to show welcome levels of decline, the prevalence of obesity and diabetes sadly involves quite a different trajectory.
Success in addressing these and other risk factors is mixed. The National Audit Office found that only half of stroke survivors reported receiving information on further stroke prevention on discharge. In primary care, those with certain identified medical history receive reliable periodic review and advice thanks to the Quality and Outcomes Framework (QOF), but for those without diagnosis, the identification of stroke risk factors such as hypertension or AF may currently rely on their opting into a health check. Alternatively, risk factors may be discovered incidentally or through informal screening via the GP, following presentation with another problem.
Thromboembolic ischaemic strokes arising from AF can be largely overcome with the administration of warfarin or the newer NOAC drugs. It is striking to note that greater detection and management of patients with AF could prevent 7,100 strokes per year.
Debates will intensify over the appropriateness of introducing national screening programmes for AF, or for other rarer risk factors for stroke such as carotid artery plaques and brain aneurysms, as both screening costs and the risks involved with intervention to treat these problems reduce.
It is, of course, vital that the public can recognise and act on stroke symptoms so that prompt medical intervention can occur, thus maximising chances of recovery. The Department of Health’s ActFAST campaign promotes the recognition of stroke symptoms, focusing on facial or arm weakness and speech disturbances, as well as the need to dial 999 if stroke is suspected.
Also important are Transient Ischaemic Attacks, or “mini strokes”. Those involve the same clinical features as a stroke but resolve in full within 24 hours. TIAs were in the past sometimes dismissed as “funny turns” but it is now recognised that they can forewarn of the arrival of a full and debilitating stroke, and warrant full and rapid investigation.
UK research on stroke is significantly underfunded compared with diseases of a similar economic burden. Existing understanding of the gold standard management of stroke is outlined in guidance published by the National Institute for Health and Care Excellence (NICE) and the Royal College of Physicians (RCP) and is reflected in governmental delivery programmes across the UK. Currently, treatment of haemorrhagic strokes is a research priority, as is vascular dementia, which is thought to share significant similarities with ischaemic stroke but, generally, at the small vessel level.
It is known that the single most important intervention for stroke is the urgent admission of all cases to a dedicated Stroke Unit with specialist staff and rapid access to diagnostic tests, monitoring and treatment. That now occurs in over three-quarters of cases. Administration of a clot-busting drug, where appropriate, is most effective if given within 4.5 hours of symptom onset. That is now being achieved for 85 per cent of those eligible for it. Increasingly important in a similar setting and timescale is thrombectomy, or mechanical clot retrieval from the brain, via the femoral artery in the groin. However, that is not yet widely available, and in 2015-16, only 400 out of as many as 9,000 potentially eligible patients across the UK underwent the procedure. Other treatments involve medication to reduce the risk of further clots by “thinning” the blood, lowering blood pressure and reducing cholesterol where necessary. In addition to that, surgery may be appropriate in some cases to clip or coil any aneurysm, or to “de-fur” the carotid artery – a procedure known as carotid endarterectomy. Clearly, prompt timing is required to minimise the risk of another event in the interim.
Any significant improvements in the condition of stroke survivors tends to be made in the first six months post-event. NICE recommends that, while hospitalised, patients with relevant needs should receive at least 45 minutes of physiotherapy, occupational therapy and speech and language therapy during each of at least five days of every week. That is often not achieved at present. Early Supported Discharge, where patients with mild to moderate disability receive the same intensity of rehabilitation but as part of a community service, can reduce patient disability and dependency and save money, in part due to reduced hospital stays. Again, that practice is not yet widespread.
Long-term support needs to cater for a range of issues which may include loss of cognitive ability and mobility, communication and continence problems. Depression is often present but frequently undiagnosed, and many believe that psychologist-led care could prevent spiralling levels of need and save the health and social care systems money.
Upon discharge from hospital, patients should receive a health and social care assessment resulting in a care plan, which details what support services will be provided. Data from the Stroke Association suggests that compliance with this is patchy. NICE guidelines published in 2016 expanded on that by recommending a care review at six months and one year, then annually. Figures from the National Audit Office imply that, at discharge, the majority do not receive information on welfare benefits. In addition, three-quarters of stroke survivors of working age want to return to work but this outcome is not close to being achieved.
While it is to be welcomed that stroke care is motoring ahead in the UK, it is clear that there is still much scope for improvement, particularly in post-acute stroke care. Audits have been useful in increasing standards in acute care, and it is hoped the RCP Sentinel Stroke National Audit Programme (SSNAP) Audit may now be effective in indicating how improvements can be made further down the care pathway.