http://jsna.hertslis.org/
Needs Assessment – Stroke and TIA
Topic Lead: Gill Catchpole
Date Last Reviewed: Feb 2015
1.
Summary
There has been focused attention on improvements to the stroke pathway over the last few years
both nationally and in Hertfordshire. This JSNA aims to take stock of the current situation in terms of
morbidity and mortality from stroke in Hertfordshire. Data is presented by Clinical Commissioning
Group (CCG) on who currently is at risk of stroke, what happens when people have strokes, the
services they can expect to receive and the likely outcomes of stroke. The document ends with
pulling together some priorities for action and future data collection to be able to continue to improve
stroke services in the future.
Key points:
- Strokes mainly affect over 65s.
- Mortality from stroke has fallen over the last 10 years for both under 75s and over 75s.
- Most people will survive a first stroke but face significant morbidity, with three quarters needing
occupational therapy or physiotherapy.
- Projections show over the next 15 years the greatest increase in numbers of people with a
longstanding health condition caused by stroke is predicted for males aged 75 and over.
- There are significant differences in the percentage of people recorded as having had a stroke
between districts in Hertfordshire. Population structures and recording practices account for
some of these differences.
- High blood pressure is the biggest avoidable risk factor for stroke. Although blood pressure in
those identified as at risk is generally managed well, only around half of those who have high
blood pressure are being identified in the community.
- Levels of diabetes, another risk factor for stroke, are rising and there is a need to improve
management of diabetes as well as decrease its spread through reduction in obesity across the
county.
Definition of Stroke / TIA and why it is an important health issue
A stroke is a serious and life threatening type of brain injury that happens when the blood supply to
a part of brain is cut off, starving those brain cells of oxygen. There are two types of stroke:
1. Ischaemic stroke caused by blood clots to the brain, this is the most common cause and
accounts for 85% of all cases;
2. Haemorrhagic stroke where a weak blood vessel in the brain busts causing by bleeding into
the brain.
A Transient Ischaemic Attack (TIA) or “mini stroke” is caused by temporary disruption of blood
supply to the brain. The effects do not last as long as a stroke although may last up to 24 hours. The
distinction between stroke and TIA is based simply on the duration of symptoms.
Stroke is the largest cause of disability in the UK, and the third most common cause of death (after
heart disease and cancer). About half of the people living in the UK with the effects of stroke
depend on others for help with everyday activities.
Stroke is a largely preventable and treatable disease. There is good evidence for effective primary
strategies to stop people having strokes and TIAs through better recognition of people at highest
risk, as well evidence for a range of interventions that are effective in reducing the effects of stroke
as long as they are implemented soon after the onset of symptoms. Guidelines for the management
of stroke and TIA have been produced nationally by NICE, the Royal College of Physicians and
regionally by the Midlands and East Stroke services review.
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2.
Who currently has strokes in Hertfordshire?
Age and sex
The total population of Hertfordshire is 1,140,700 (ONS, 2013) and 186,700 (16%) of these people
are aged 65 and over, a slightly lower proportion than across England as a whole (17%). In 2013/14
there were 18,808 people (1.5%) who had been diagnosed with a stroke or TIA in Hertfordshire
(QOF, HSCIC). That is 9,434 (1.5%) in Herts Valleys CCG (HVCCG) and 9,005 (1.5%) in East and
North Hertfordshire CCG (ENHCCG). Based upon Health Survey for England results applied to the
county, the total number of stroke cases in Hertfordshire is estimated to be around 21,190 (1.7%).
There may therefore be a moderate number of people that are undiagnosed or unrecorded as
having had a stroke or TIA in Hertfordshire.
As can be seen from Figures 1 and 2 showing the age distribution of hospital admissions for strokes
in Hertfordshire, the great majority of strokes (almost 80%) occur in people aged 65 and above.
People aged 65 and over accounted for 77% of emergency admissions for stroke in NHS Herts
Valleys CCG (1,938 out of 2,526 admissions) and 78% (1,710 out of 2,206 admissions) in NHS East
and North Hertfordshire CCG over the three year period. However there are still strokes in under
65s and a small number occurring in young people. There were five admissions for young people,
all aged between 15 to 19, in NHS Herts valleys CCG and six in East and North Hertfordshire CCG
between 2011/12 and 2013/14. As the population grows in Hertfordshire so will the number of young
people having strokes in the future, though it will still be very low.
250
250
200
200
2013/2014
50
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
0
45-49
85+
80 - 84
75 - 79
70 - 74
65 - 69
60 - 64
55 - 59
50 - 54
45 - 49
40 - 44
35 - 39
<30
30 - 34
0
2012/2013
40-44
50
2011/2012
100
35-39
100
150
<30
150
30-34
Number of admissions
Number of admissions
Figure 1: Number of stroke emergency admissions based on Health Resource Group (HRG) codes*,
by year and age, 2011/2012 to 2013/14
NHS Herts Valleys CCG
NHS East and North Hertfordshire CCG
Source: SUS data, MedeAnalytics extracted December 2014
HRG codes AA22Z, AA23Z, AA22A, AA22B
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Figure 2: Percentage of stroke emergency admissions based on Health Resource Group (HRG)
codes*, by age and sex, Hertfordshire, by CCG, 2011/2012 to 2013/14
20
18
Male %
Female %
16
14
12
10
8
6
10.0
19.0
7.3
10.1
7.4
6.3
5.6
4.9
1.2
1.3
45-49
5.5
2.9
1.0
0.9
40-44
4.4
2.8
1.0
0.7
35-39
2.8
1.3
0.4
0.9
30-34
2.3
1.4
0.2
0.6
25-29
2
0.4
0.4
4
0-24
65-69
70-74
75-79
80-84
85+
5.2
2.7
5.4
5.1
7.8
6.5
7.9
9.1
8.8
19.0
65-69
70-74
75-79
80-84
85+
60-64
3.4
1.5
60-64
55-59
3.1
1.7
55-59
50-54
2.6
1.1
0
50-54
% of all stroke emergency admissions
NHS Herts Valleys CCG
Age group
20
18
Male %
Female %
16
14
12
10
8
6
0.2
0.4
0.7
0.7
0.6
0.5
1.2
1.1
1.4
1.4
25-29
30-34
35-39
40-44
45-49
2
0.4
0.7
4
0-24
% of all stroke emergency admissions
NHS East and North Hertfordshire CCG
0
Age group
Source: SUS data, MedeAnalytics extracted December 2014
* HRG codes AA22Z, AA23Z, AA22A, AA22B
Over the three year period there were, on average, 842 emergency admissions for stroke per year
in Herts Valley CCG and 736 in East and North Herts CCG. Of these:
 52% (HVCCG) and 51% (ENHCCG) were to women;
 men made up more admissions than women between the ages of 55 to 79;
 there were twice as many admissions to women aged 85 and over compared to men (this is
because women generally live longer than men);
 28% of admissions were to people aged 85 years and over;
 1% (22 over three years in HVCCG and 15 in ENHCCG) were to people aged under 25.
 Over the same time period there were, on average, 222 emergency admissions for TIAs per
year in HVCCG and 163 in ENHCCG (based on HRG codes AA29A, AA29B, AA29Z). This
is around one quarter of the number of admissions for stroke (26% in HVCCG and 22% in
ENHCCG).
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District
GP recorded prevalence of stroke and TIA varies across districts in Hertfordshire ranging from 1.4%
in East Hertfordshire to 1.7% in Three Rivers (Figure 3). Population structures and GP recording
practices directly influence these rates. Three Rivers and North Hertfordshire have higher
proportions of people aged 65 and over and higher recorded prevalence of stroke and TIA, whilst
the proportions of stroke and TIA, as well as older people, are lower in Watford and Stevenage. It
should be noted that Royston is included in the North Herts figure below but Royston is not included
in either Hertfordshire CCG, it part of a Cambridgeshire CCG.
Figure 3: Prevalence of stroke and TIA, percentage of GP registered population, Hertfordshire by
district, 2013-14
2.0
Hertf ordshire
1.8
1.6
1.47 (2,377 patients)
1.43 (1,465 patients)
1.41 (1,300 patients)
1.40 (2,098 patients)
1.36 (1,910 patients)
Watf ord
Stevenage
St Albans
East
Hertf ordshire
1.62 (1,686 patients)
Broxbourne
Dacorum
1.65 (2,274 patients)
North
Hertf ordshire
0.2
1.71 (2,203 patients)
0.4
Hertsmere
0.6
1.73 (2,204 patients)
0.8
Welwyn Hatf ield
1.0
1.74 (1,291 patients)
1.2
Three Rivers
Percentage
1.4
0.0
District
Source: QOF, HSCIC
Ethnicity
Ethnicity was recorded in over 90% of stroke emergency hospital admissions between 2011/12 and
2013/14. The ethnic breakdown for emergency stroke admissions is compared to the CCG
population aged 65 and over in Table 1. It shows that a higher proportion of emergency admissions
for stroke are recorded as black or black British for both CCGs than might be expected in relation to
the population breakdown. The higher rate of ‘other’ in emergency admissions for stroke may
reflect a recording issue in hospitals. The resident population of HVCCG has a higher proportion of
Asian or Asian British compared to ENHCCG (2011 Census) and this is reflected in the emergency
admissions for stroke.
Table 1: Stroke emergency admissions by ethnic group, HVCCG and ENHCCG, 2011/2012 to 2013/14
HVCCG stroke admissions
ENHCCG stroke admissions
HVCCG* 2011 Census
population aged 65+
ENHCCG* 2011 Census
population aged 65+
White
Mixed
Black or
Black British
1.1%
(26)
1.7%
(35)
0.8%
Other
0.5%
(12)
0.4%
(8)
0.4%
Asian or
Asian British
3.4%
(77)
1.2%
(24)
3.4%
94.0%
(2,159)
95.0%
(1,962)
95.2%
97.0%
0.4%
1.7%
0.8%
0.2%
1.0%
(24)
1.8%
(37)
0.2%
*Aggregated using district level data
Source: SUS data, MedeAnalytics extracted December 2014; 2011 Census, ONS, July 2012
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Projections
If the prevalence of stroke and TIA remains stable then this will result in around 7,450 (40%) more
people having a stroke between 2014 and 2030 due to population increases in people aged 65 and
over. The number of people in Hertfordshire who may be left with a longstanding health condition as
a result of stroke is shown in Figure 4. All age groups and both sexes are expected to increase in
numbers though the greatest percentage increase is predicted for males aged 75 and over (62%
increase) with around 2,300 men over 75 predicted to have long standing health conditions caused
by stroke across Hertfordshire in 2030 compared to 1,436 in 2014. As the number of people living
with a long standing health condition caused by stroke dramatically increases, so too will the
demand for social care.
Figure 4: Number of people predicted to have a longstanding health condition caused by stroke, aged
65 and over by age and gender, Hertfordshire
Source: POPPI- Projecting Older People Population Information System, October 2014
3.
Who is at risk of having a stroke or TIA?
Risk factors for stroke that cannot be altered include:
- Age: the risk increases with age with 75% of strokes occurring in the over 65s. Most
Hertfordshire districts have a broadly similar age profile to that of the country as a whole. The
number of over 65s is set to increase by 22% in Hertfordshire between 2011 and 2021,
however it is still a lower proportion of the local population than over 65s are of the population of
England as a whole.
-
Ethnicity: people from Asian, African and African-Caribbean communities are more likely to
have a stroke than people from other ethnic groups. 81% of Hertfordshire’s population is White
British, there is considerable variation between the districts in the proportion of different ethnic
groups.
-
Previous history of TIA: The risk of further stroke is highest early after stroke or TIA and may be
as high as 5% within the first week and 20% within the first month. The greatest risk is in the
first 72 hours. The risk of recurrent stroke is 30 – 43% within five years.
As well as unavoidable risk factors, there are risk factors that can be changed through medication
and lifestyles changes. Avoidable risk factors for stroke include:
High blood pressure (hypertension):
High blood pressure is the single biggest treatable risk factor for stroke, causing about 50% of
ischaemic strokes and increasing the risk of haemorrhagic stroke. Reducing the number of people
with high blood pressure in Hertfordshire requires effective identification and treatment. In terms of
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identification of high blood pressure, QOF data from GP practices shows that there is a lower
prevalence of patients with recorded hypertension in East and North Hertfordshire CCG and Herts
Valleys CCG than in England as a whole (Figure 5). It is particularly lower in Herts Valleys CCG
(12.3%) compared with East and North Hertfordshire (ENH) CCG (13.2%). This could be due to
actual lower prevalence of hypertension or due to lower levels of recording hypertension across the
two areas of Hertfordshire. QOF data from GPs together with models from Public Health England
Healthier Lives provide estimates that 54.2% of hypertension has been detected in Herts Valley
CCG and 51.4% in East and North Herts CCG. This is in line with the England figure of percentage
of estimated hypertension prevalence of 54.3%. It is clear that there is a continuing need to work on
identifying patients with high blood pressure so that they can be offered treatment.
Figure 5: Prevalence of hypertension, percentage of GP registered population, Hertfordshire by
CCG, 2009-10 to 2013-14
16.0
14.0
13.5
13.4
13.6
13.7
13.7
10.0
ENHCCG
8.0
HVCCG
England
12.3 (76,061)
13.2 (76,504)
12.5
13.1
12.6
13.1
12.4
2.0
12.8
4.0
12.4 (75,499)
6.0
13.2 (75,531)
Percentage
12.0
0.0
2009-10
2010-11
2011-12
2012-13
2013-14
Year
Source: QOF, National General Practice Profiles, PHE
Figure 6: The percentage of patients with hypertension in whom the last blood pressure reading
(measured in the preceding 9 months) is 150/90 mmHg or less, Hertfordshire by CCG, 2013-14
Optimal management
ENHCCG
78.6 (60,126)
HVCCG
81.3 (61,808)
England
79.2
0%
Non optimal management
Exceptions
17.4
14.3
16.1
20%
40%
60%
80%
100%
Source: QOF, HSCIC
Where hypertension has been identified, it is generally well controlled. Figure 6 shows that 81%
of patients with recorded hypertension in HVCCG had a blood pressure below 150/90, a slightly
higher proportion than ENHCCG and national (79%). In stroke survivors, GP QOF records
indicate that the overall proportion of stroke survivors in the two Hertfordshire CCGs now have
blood pressure readings at or below the recommended level as in the rest of England (Figure
7). In 2013/14 there were differences by CCG with 84.0% of stroke survivors in ENH CCG
achieving this and 87.2% in HV CG. This compares to 85.4% in ENHCCG and 86.0% in
HVCCG in 2012/13.
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Figure 7: The percentage of patients with a history of stroke or TIA in whom the last blood
pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less, Hertfordshire
by CCG, 2013-14
Optimal management
Non optimal management
Exceptions
ENHCCG
84.0 (7,654)
11.0
HVCCG
87.2 (8,229)
8.4
England
85.5
9.7
0%
20%
40%
60%
80%
100%
Source: QOF, HSCIC
Irregular heart rhythm (atrial fibrillation):
An irregular heart beat increases the risk of blood clots and therefore strokes through blockages to
the arteries. People with atrial fibrillation have five times the risk of stroke as those without. There is
a similar prevalence of atrial fibrillation in Hertfordshire CCGS (1.5%) as in the rest of England
(1.6%) and the percentage has remained similar over the last five years (Figure 8).
Figure 8: Prevalence of atrial fibrillation, percentage of GP registered population, Hertfordshire by
CCG, 2009-10 to 2013-14
1.8
1.6
1.4
1.4
1.5
1.5
1.6
1.4
England
1.5
1.5
1.5
1.4
1.4
0.2
1.4
0.4
1.5 (9,158)
HVCCG
0.6
1.5 (8,876)
ENHCCG
0.8
1.5 (8,917)
1.0
1.5 (8,533)
Percentage
1.2
0.0
2009-10
2010-11
2011-12
2012-13
2013-14
Year
Source: QOF, National General Practice Profiles, PHE
In 2013/14 97.0% of NHS Herts Valleys CCG patients and 94.8% of NHS East and North
Hertfordshire patients with atrial fibrillation had their stroke risk assessed with CHADS2 (last 12
months) compared to 95.0% for England.
Although hypertension and atrial fibrillation are the two most significant avoidable risk factors for
stroke and TIA, there are other biological and behavioural risk factors that also increase the
likelihood, though to a smaller degree:
Diabetes:
High levels of glucose in the blood can damage the blood arteries causing them to harden and
narrow (atherosclerosis) increasing the risk of stroke. People with diabetes are twice as likely to die
of stroke as those without diabetes. There is a lower prevalence of diabetes in Hertfordshire
(estimated prevalence 6.8% in Herts Valleys CCG and 6.6% in East and North Hertfordshire CCG)
compared to the England estimated adult prevalence of 7.3%. Recorded levels of diabetes for
Hertfordshire CCGs are shown in Figure 9 and have steadily increased over the last five years to
5.0% in Herts Valleys CCG and 5.4% in East and North Hertfordshire. These increases follow the
national trend. The increased risk for people with diabetes in England of having a stroke is 34.3%.
People with diabetes in ENH CCG have a lower increased risk of stroke of 23.4% and people with
diabetes living in HV CCG have an increased risk or stroke, they are 49.7% more likely to have a
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stroke than people without diabetes. Although neither of these increased risk figures are statistical
outliers compared to the increased risk for diabetics in England as a whole, they do indicate in
particular a need for better overall control of diabetes and especially blood pressure control in
people with diabetes.
Figure 9: Prevalence of diabetes (ages 17+), percentage of GP registered population, Hertfordshire by
CCG, 2009-10 to 2013-14
7.0
6.0
5.8
5.5
5.3
6.2
6.0
4.0
ENHCCG
HVCCG
England
5.0 (485,898)
4.7
5.1
4.5
5.0
4.4
4.9
1.0
5.4 (24,959)
2.0
4.8 (23,193)
3.0
5.3 (24,277)
Percentage
5.0
0.0
2009-10
2010-11
2011-12
2012-13
2013-14
Year
Source: QOF, National General Practice Profiles, PHE
Raised cholesterol:
High cholesterol is a contributory risk factor for stroke, having more of an effect on people who
smoke or who are inactive. Reducing cholesterol levels with use of statins has been shown to
reduce the risk of stroke by 21%. 2013/14 GP QOF data in Figure 10 show that a lower proportion
of stroke survivors in ENH CCG (64.2%) and a higher proportion in HV CCG (71.0%) have optimal
cholesterol levels compared to England (68.4%). In 2012/13 the same figure was 66.3% for
ENHCCG and 68.2% for HVCCG showing that ENHCCG has slightly reduced its percentage of
optimal management whilst HVCCG has slightly improved it, however neither are significantly
different from the England average.
Figure 10: The percentage of patients with stroke shown to be non-haemorrhagic, or a history of
TIA, whose last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or
less, Hertfordshire by CCG, 2013-14
Optimal management
ENHCCG
64.2 (3,786)
HVCCG
71.0 (4,265)
England
68.4
0%
Non optimal management
Exceptions
22.9
15.7
17.9
20%
40%
60%
80%
100%
Source: QOF, HSCIC
Smoking:
Smoking doubles the risk of a stroke. The risk increases the number of cigarettes smoked such that
someone smoking 20 cigarettes a day is six times more likely to have a stroke than a non smoker.
The rates of smoking have been reducing in Hertfordshire and currently are around 19.2% but vary
between districts with the levels consistently highest, above 25%, in Stevenage. A higher
percentage of males smoke than females although this gap has reduced over the last 10 years.
Continuing work to reduce smoking levels will further help reduce the risks of stroke for people in
Hertfordshire.
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Obesity:
Obesity and low levels of physical activity both contribute to the development of high blood pressure
and Type 2 diabetes and so increase the risk of stroke. Being overweight increases the risk of
ischaemic stroke by around 22% and being obese increases the risk by 64%. More than 50% of
adults in Hertfordshire, in every district, are overweight or obese. It is of high importance that these
levels are reduced if we are to better prevent strokes.
Alcohol:
People regularly consuming a large amount of alcohol have a three fold increased risk of stroke. In
Hertfordshire more than one in five adults are estimated to be drinking alcohol in a way that is
detrimental to their health. Most districts have higher estimated rates of higher risk drinking than the
national average.
4.
What happens to people that have a stroke?
667 people died from stroke in Hertfordshire 2012, with 103 (15%) aged under 75 (data are not
available by CCG). The early mortality rate of people under 75 years old in both CCGs (Figure 11)
has fallen over the last ten years. It was 11.6 deaths per 100,000 people (50 deaths) in HV CCG
and 12.3 per 100,000 people (51 deaths) in EN CCG compared to a rate of 14.1 per 100 000 people
for the whole of England. Both CCGs have a lower earlier mortality rate than the country as a whole
which could be due to better prevention or treatment of strokes in those under 75. The later mortality
in people aged over 75 across the whole of England was 624.4 deaths per 100 000 people. This is
similar to both CCGs: 654.2 in ENH CCG and 585.5 in HV CCG.
Figure 11: Deaths from stroke, rate per 100,000 people, Hertfordshire by CCG, 2002 to 2012
NHS Herts valleys CCG
NHS East and North Hertfordshire CCG
Source: Cardiovascular disease profiles- stroke, Public Health England, August 2014
Note: SCN = East of England strategic clinical network
Most people survive a first stroke but have significant morbidity. Figure 12 shows that more than half
of people who have a stroke will return afterwards to their usual place of residence. If they came
from a care home and went back to one this is counted as having returned to their usual place of
residence.
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Figure 12: Percentage of stroke patients based on Health Resource Group (HRG) codes*, by Discharge
Destination, 2011/2012 to 2013/14, CCGs in Hertfordshire
NHS Herts Valleys CCG
Non- LA
residential
accommodation
0.3%
NHS East and North Hertfordshire CCG
LA residential
accommodation
0.8%
Other
3.0%
Non- LA
residential
accommodation
1.3%
LA residential
accommodation
2.1%
Other
1.9%
NHS nursing or
residential
accommodation
2.2%
NHS nursing or
residential
accommodation
2.2%
NHS other
hospital providerward for general
patients/ younger
physically
disabled
15.4%
NHS other
hospital providerward for general
patients/ younger
physically
disabled
23.0%
Usual place of
residence
54.5%
Usual place of
residence
60.8%
Patient died
16.2%
Patient died
16.2%
Source: SUS data, MedeAnalytics extracted December 2014
* HRG codes AA22Z, AA23Z, AA22A, AA22B
The Sentinel Stroke National Audit Programme (SSNAP) has been set up to improve the quality of
stroke care by auditing stoke services against evidence based standards, Figures 13 and 14 show
two aspects of the quality of care received by patients who had had a stoke within the CCGs. In
both cases it can be seen that the quality of care is improving with a higher proportion in both CCGs
being transferred to specialist stroke unit within 4 hours of admission and receiving thrombolysis
between in April – June 2014 compared to Jan – March 2014. Although the numbers are small,
HVCCG appears to perform particularly well on percentage of patients receiving thrombolysis at
almost double the national average (23% compared to 12%). Both CCGs were higher than the
national figures for the percentage of applicable patients who are transferred directly to a stroke unit
within 4 hours. However, this still leaves at least 30% of patients who would be eligible not being
transferred within 4 hours of admission into hospital.
England
ENHCCG
England
ENHCCG
22.8 (37 patients)
17.1 (31 patients)
12.2
11.5
66.9
(107 patients)
64.1
(116 patients)
HVCCG
Apr-Jun14
9.7 (14 patients)
Jan-Mar14
Apr-Jun14
62.0
(103 patients)
56.9
(82 patients)
58.0
57.8
Jan-Mar14
Figure 14: Percentage of all stroke patients who
receive thrombolysis (CCG OIS - C3.6),
Hertfordshire by CCG, Jan-Jun 2014
10.8 (18 patients)
Figure 13: Percentage of applicable patients who
go direct to a stroke unit within 4 hours (CCG OIS
- C3.5), Hertfordshire by CCG, Jan-Jun 2014
HVCCG
Figures 15 – 17 provide an indication of need for services. In all cases the levels of need for
HVCCG are lower than the national average in terms of percentage of patients reported as requiring
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occupational therapy, physiotherapy and speech and language therapy. They are around the
national level or slightly higher for ENHCCG. The need for speech and language therapy is less
than the need for occupational therapy and physiotherapy which are similar and can be seen in
around three quarters of patients who have suffered a stroke.
Figure 15: Percentage of patients reported as
requiring occupational therapy, Hertfordshire by
CCG, Jan-Jun 2014
Jan-Mar14
80.1 80.3
England
Figure 16: Percentage of patients reported as
requiring physiotherapy, Hertfordshire by CCG,
Jan-Jun 2014
Jan-Mar14
Apr-Jun14
78.9
84
ENHCCG
75.9 75.8
84.7 84.2
81.2 83.3
75.4 76.4
HVCCG
England
ENHCCG
HVCCG
Figure 17: Percentage of patients reported as
requiring speech and language therapy,
Hertfordshire by CCG, Jan-Jun 2014
Jan -Mar14
Apr-Jun14
Source: SSNAP,December 2014
Apr-Jun14
48.0 46.9
48.1 54.7
38.7 40.1
England
ENHCCG
HVCCG
Modified Rankin scores is a scale used for measuring the degree of disability in terms of the daily
activities of people who have suffered stroke. Figure 18 shows the modified Rankin score of stoke
patients leaving the hospitals in and around Hertfordshire. It can be seen that there appears to be a
difference across the hospitals in terms of percentages of people that are scored as having no
disabilities such that at the extremes, Barnet Hospital has recorded 13.5% of 133 stroke patients
and Princess Alexandra has recorded 62.5% of 248 stroke patients being discharged with no
symptoms or significant disabilities. This compares to a national figure of 38.3%. There are several
potential explanations for this variation, and all the variation in patterns seen amongst the hospitals,
for example it could be due to chance with small figures, difference in recording practice between
the two hospitals, more severe patients going to Barnet hospital or a higher quality of care being
provided by Princess Alexandra.
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Figure 18: Percentage of stroke patients receivng each modified Ranking scores at discharge from
inpatient care, 2013/14
5.
What do we currently do?
A Midlands and East Stroke services review was established in 2012 to review and improve the
quality of service provision. A key recommendation was that services support the whole stroke
pathway, end to end, from prevention to long term care or end of life care. The stroke pathway
consists of the components shown below, although presented in a linear manner, not all people will
pass through each element.
A) Primary
Prevention
B) PreHospital
Primary Prevention
Pre-Hospital Care
TIA
Hyper Acute Stroke Unit
(HASU)
Acute Stroke Unit (ASU)
Early Rehabilitation
C)
Acute
Phas
e
D) Community
Rehabilitation
E)
Long
Term
Care
F) Secondary
Prevention
G)
End
of
Life
Services to reduce the risk of stroke due to alcohol, smoking, obesity
and lack of physical activity. Health checks are offered to adults in
Hertfordshire aged 40 – 74 without a pre-existing condition to check
circulatory and vascular health. There are 128 out of 135 practices
signed up to deliver Health Checks in Hertfordshire. Health checks have
been running in Hertfordshire for the last 1.5 years during which time
13.7% of eligible people (44,798) have received a health check. This is
in line with the national average of 13.5% of people eligible having
received a health check. Although in Hertfordshire a lower proportion of
people were offered a health check than nationally (26.6% compared to
28.3% in England) there was a higher acceptance rate in Hertfordshire
(52.1% compared to national acceptance of 47.7%).
Ambulance services
Provides rapid diagnostic assessment and access to specialist care for
high risk patients thereby lowering the risk of a subsequent stroke.
Provides expert specialist clinical assessment, rapid imaging and the
ability to deliver intravenous thrombolysis 24/7.
Follows the hype-acute phase, usually after the first 72 hours of
admission and provide continuing specialist day and night care.
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Early Rehabilitation
In-hospital rehabilitation should begin immediately after a person has
had a stroke and continue for as long as required, to ensure the best
recovery and the minimisation of any disabilities.
Early Supported Discharge
(ESD)
Enables appropriate stroke survivors to leave hospital early through the
provision of intense rehabilitation in the community at a similar level to
that provided in hospital.
Community Support
Enables stroke survivors to develop a greater quality of life and
independence following stroke. Patients will access community
rehabilitation services following standard discharge from a stroke unit or
following ESD
Long Term Support
Provided to assist re-integration into the community and maximise the
quality of life experienced by stroke survivors, their carer/s and families.
Secondary Prevention
Includes prevention, advice and assessing individual risk factors and
giving information about possible strategies to modify lifestyle to reduce
risk of further stroke.
End of Life
Patients with stroke may enter the End of Life phase at many stages of
the Stroke Pathway, in different care settings.
See Appendix 1 for full details of each of these components of the pathway provided for people who have had
a stroke in Hertfordshire.
What do we know about user views?
The Stroke Association has worked with people across England who have had strokes to create the
Stroke Survivors’ Declaration (Appendix 2).
6.
Recommendations
Whole pathway
-
-
The NHS Midlands and East Service Specification document sets out the criteria, as
recommended by the External Expert Advisory Group, that different parts of the stroke pathway
need to meet to deliver high quality care to patients and achieve the step change improvement
sought by the Midlands and East Stroke Review. It contains the expected standards
commissioners should adopt when commissioning stroke care services. Work is underway and
should be continued with the aim of meeting these standards.
There is the need for local user views to feed into the Hertfordshire service and this JSNA.
Prevention
-
-
-
-
-
Blood pressure management is a key component of preventing stroke as it is the single biggest
avoidable risk factor. Whilst blood pressure is well controlled for those who have been identified
as having high blood pressure, there the data shows that across England as a whole, and within
Hertfordshire, only around 50% of people with high blood pressure are identified. There needs
to be continuing emphasis on increasing the proportion of people with high blood pressure who
are identified and can then be treated through testing more people and those at risk of high
blood pressure more frequently.
The numbers of people with diabetes is rising across the country and Hertfordshire figures
mirror this. The great majority of the extra cases will be Type 2 diabetes, which is largely
preventable through weight and lifestyle changes. Actions are needed to improve diabetic
control and especially control of blood pressure in people with diabetes in Herts Valley CCG,
this should be seen alongside the wider goal of reducing levels of obesity across Hertfordshire.
Further work could be done to strengthen health checks, particularly in terms of numbers of
people offered a health checks as more than half of eligible people in Hertfordshire accept a
health check when offered.
There is currently no measure of the quality of the health checks offered in Hertfordshire,
however plans to implement a GP software system and ongoing training to clinical providers
over the next year will address this.
There is the need for continued work on preventative programmes to reduce smoking, reduce
levels of obesity increase physical activity and reduce high alcohol consumption.
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7.
What we don’t know and would like to know
Further work is needed to accurately establish the number of people attending TIA clinics and of
these, who has actually had a confirmed TIA.
In terms of important hospital procedures for stroke and TIA, it would be useful to know the number
and timing of patients undergoing cerebral endarterectomy (a surgical procedure to correct the
narrowing of the carotid artery). Initial analysis suggests further work on this data is needed.
A workshop with stakeholders from the stroke services identified the need for better information on:
 Physical activity levels across Hertfordshire
 Quality of life measurements for both people suffering a stroke and their families. Potentially
questions about quality of life and return to work could be asked at the 6 months review.
 Where stroke survivors are living at 6 months (as opposed to where they are discharged to).
 Why people go back into hospital again after a stroke.
 Numbers of people referred from A and E to Luton services at the weekend that do not turn
up.
 The short and long term effectiveness of awareness campaigns such as FAST
 Who people with TIA/Stroke present first to, for example is it GP, ambulance, A and E?
 The proportion of patients that need other rehabilitation services such as dietetics and
psychology services and whether these needs are met.
 Numbers of people the ambulance services carry out FAST assessments and Stroke 60
package.
 Waiting times for services post discharge.
 Numbers of patients who are self managing.
 Numbers of patients being supported by social care and the voluntary sector.
 Numbers of stroke mimics.
 The effectiveness of the 6 week review following a stroke.
 How to combine the different risk factors to predict which districts have the greatest number
of people at high risk of stroke.
 Hertfordshire community trust is starting to collect data on stroke services provided in the
community, it would be useful to include this in further revisions of the JSNA in future.
The workshop participants also identified that:
 GPs need information on the care package of their patients. The Joint Care Package
information is currently given to patients to share with their GPs but it does not often make it
to the GP.
 People who have a TIA need information on the services available to them so they present
at the appropriate place.
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8.
Appendices.
Appendix 1
Primary
Prevention
Pre-Hospital
Care
TIA
Thrombolysing
Centre
Acute Stroke
Unit (ASU)
Early
Rehabilitation
Early
Rehabilitation
Full details of the services to reduce the risk of stroke due to alcohol, smoking, obesity and lack of physical activity are given in the relevant
Hertfordshire JSNAs.
A fast response to stroke reduces the risk of mortality and disability. People primarily present via:
 999
 Self-present at hospital
Specific TIA services provide rapid diagnostic assessment and access to specialist care for high risk patients thereby lowering the risk of a subsequent
stroke. Patients with high risk TIA should be seen in a specialist TIA clinic within 24hrs of onset, low risk within 7 days. The 3 main local hospital
providers offer 5 day TIA clinics at:
 Watford
 Lister
 Princess Alexandra Hospital Harlow
At weekends high risk TIA’s are referred to:
 Luton and Dunstable – for Watford and Lister patients
 Broomfield Hospital, Chelmsford for PAH patients
Hyper acute services provide expert specialist clinical assessment, rapid imaging and the ability to deliver intravenous thrombolysis 24/7, typically for
no longer than 72 hours after admission. At least 600 stroke admissions per year are normally required to provide sufficient patient volumes to make a
hyper acute stroke service clinically sustainable, to maintain expertise and to ensure good clinical outcomes. No local hospitals have services which
fully meet standards defined for HASU services but all have dedicated hyper-acute beds and offer thrombolysis.
 The local hospitals offering thrombolysis are:
o Watford DGH (approx 75% of HVCCG stroke activity)
o Lister DGH (approx 62% of E&NHCCG stroke activity)
o PAH DGH ( approx 24% of E&NHCCG stroke activity)
Additionally patients access London Hospitals, Addenbrookes, Buckinghamshire and Luton and Dunstable Hospital. Out of hours thrombolysis is
supported via a regional telemedicine scheme
Acute stroke care immediately follows the hype-acute phase, usually after the first 72 hours of admission. Acute stroke care services provide
continuing specialist day and night care with daily MDT rehabilitation, continued access to stroke trained consultant, access to physiological monitoring
and access to urgent imaging as required. In-hospital rehabilitation should begin immediately after a person has had a stroke. Rehabilitation services
should continue for as long as required, to ensure the best recovery and the minimisation of any disabilities.
Following stroke the broad outcomes for survivors are:
 Resolved
 Potential to benefit from rehabilitation
 Significant disability – management strategies
Inpatient rehabilitation is offered where the patient’s rehabilitation needs cannot be met in the community at their usual place of residence. All
rehabilitation is goal centred. In-patient Rehabilitation commences in the Acute Stroke, all hospitals with HASU have ASU beds. Once a patient with
on-going in-patient rehabilitation needs is medically fit, rehabilitation is stepped down to a community in-patient facility
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Early Supported
Discharge (ESD)
Community
Support
Long Term
Support
Secondary
Prevention
End of Life
Herts Valley:
 Stroke Neuro Rehabilitation Beds at Langley House, Watford (currently Holywell – Langley split but all be on one site
East & North Herts:
 Danesbury Neuro-Rehab Unit
 ICT beds primarily at Herts and Essex
All patients should be discharged with a Joint Health and Social Care Plan which outlines on-going treatment and management plans.
ESD enables appropriate stroke survivors (approx. 40%) to leave hospital early through the provision of intense rehabilitation in the community at a
similar level to that provided in hospital. An ESD service of nurses, therapists, doctors and social care staff work collaboratively as a team, with the
patient and families, providing intensive rehabilitation at home normally for up to 6 weeks thereby reducing the risk of readmission. A stroke specific
ESD service commenced in Hertfordshire in October 2014. It includes all the required therapies and access to psychology, specialist homecare and
dedicated social workers.
Stroke survivor’s rehabilitation may need to continue after the initial time spent in in-hospital rehabilitation, out in to the community. These services
enable stroke survivors to develop a greater quality of life and independence following stroke. Patients will access community rehabilitation services
following standard discharge from a stroke unit or following ESD. Community stroke rehabilitation services include health and social services, the
independent and third sectors.
Following early and intensive intervention, patients based on need, can receive community rehabilitation:
o Community neuro-rehabilitation for complex & vocational needs. The neuro-rehab service also provides access to psychology,
spasticity clinics, specialist splinting
o Intermediate Care and therapies for non-complex needs not requiring stroke specialist interventions
o Speech and Language Therapy & Dietetics where needs are not met under the above.
The stroke association are commissioned to provide the following:
o Information Advice and Support Coordination – up to a year post stroke
o Communication Support Service (Herts Valley Only). This offers telephone advice, written information, home visits, groups.
o There are a number of independent communication groups in East and North Herts
Hertfordshire has self-help stroke groups affiliated to the stroke association. Additionally there a number of communication support groups, various
exercise schemes and group rehabilitation. Carers in HERTS offer a range of support services.
Tailored support is provided to assist re-integration into the community and maximise the quality of life experienced by stroke survivors, their carer/s
and families. This includes provision of information and advice and access to reviews at 6 weeks, 6 months, 12 months and then annually. Patients are
offered a 6 week review at the hospital to which they were admitted for acute care. 6 month reviews have just been commissioned and will be provided
to all stroke survivors via the ESD service and stroke association. There are annual reviews carried out via primary care.
This includes prevention, advice and assessing individual risk factors and giving information about possible strategies to modify lifestyle to reduce risk
of further stroke. Following stroke or TIA, all patients should be placed on a primary care stroke register There are a number of self-management
support programmes. HCT offer a neurological conditions self-management, which has a stroke specific module
Patients with stroke may enter the End of Life phase at many stages of the Stroke Pathway, in different care settings.Further details are included in the
end of life JSNA.
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Appendix 2
Stroke Survivors’ Declaration
1. I can expect to be treated in a specialist stroke unit with staff who have high levels of specialist
knowledge and expertise. I have the right to dignified care and support.
2. I will be involved in decisions about my own care and have personal choices about, and control
over, the support I receive. Services will be designed around my need to live as well as possible
for as long as possible. If I have difficulties with speaking, writing or thinking, I will be able to
appoint someone to advocate on my behalf.
3. When I go home from hospital I will have specialist support.
4. I can have confidence that my health and social care teams will work effectively together so that
my care is seamless and well co-ordinated.
5. I know that my health needs will be reassessed after 6 weeks, 6 and/or 12 months, and as they
change. If I have a carer, they will be informed of their right to an assessment of their needs.
6. I will be given the information and advice I need, in the format I need, when I need it, to:
• help me understand the effects of stroke;
• tell me about the support that is available to help me adjust to life after stroke;
• help me make informed decisions about my care;
• help me explain to others the effects of my stroke.
7. My mental health and physical needs will be recognised and I will be able to access the relevant
support. My carers’ support needs will also be recognised
8. I will be given advice on the financial benefits I can claim.
9. I will be given advice on living healthily to maximise my chance of remaining
well for as long as possible.
10. The impact of my stroke on my family/ carers will be recognised. They will
have access to appropriate information and services to help them understand
and make adjustments.
11. I will have access to services that will help me manage my condition so that I can regain my
independence and confidence.
12. If I am considering moving into a care home, I can be confident that staff
have been trained to understand and recognise the needs of stroke survivors
and that I will be encouraged to live life to the full
13. My views and experiences will be heard and will be used to help shape
future services and support for stroke survivors.
14. I can expect to participate in my community, either through employment or volunteering, and
be supported in doing so. If I am of working age I will have access to rehabilitation services to
help me return to the workplace, and my employer will be able to get advice on my returning to
work, including education or training that would help me.
15. My home will be adapted for my needs as they change, and I will be provided with equipment
that helps me to retain some independence. I will have accessible transport to remain as mobile,
independent and active as possible.
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