Kent Joint Strategic Needs Assessment (Kent JSNA)
Kent ‘Stroke and TIA’ JSNA Chapter Summary Update
‘2014/15’
Contact: [email protected]
Website: www.kpho.org.uk
Stroke and TIA Kent JSNA – 2014/15
Introduction
Stroke is one of the diseases of the arteries – these are known collectively as
cardiovascular disease (CVD).
A stroke happens when the blood supply to part of the brain is cut off. This can happen
in two ways:
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Through a blockage of an artery cutting off oxygen to parts of the brain
(ischaemic stroke) – this type is most common (88% of all strokes, BHF 2009)
Bleeding from an artery in the brain (primary inter-cerebral heamorrhage).
A Transient Ischemic Attack (TIA) or ‘mini stroke’ is caused by a brief delay in blood
supply to a particular area of the brain. Neurological dysfunction lasts for less than 24
hours, but this is often an important warning sign of a more serious stroke, heart attack
or other vascular event.
Stroke is the third biggest cause of death in England (11%) and the largest single cause
of severe disability (DH, 2007):
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There are an estimated 111,000 first strokes in the UK every year (BHF 2009)
300,000 people in England live with moderate to severe disability as result of
stroke. The effects can include physical disability, aphasia (language
impairment), loss of cognitive and communication skills, and depression (DH
2007).
It is estimated that stroke costs the UK economy around £7billion per year £2.8bn in direct costs to the NHS, £2.4bn in costs for informal social care, and
£1.8bn in income lost due to productivity and disability (DH 2007)
The death rate from stroke for men under 65 years is three and a half times
higher in the most deprived 20th of England and Wales (BHF 2009)
Latest QOF data indicated that in Kent & Medway, 30,500 people were recorded as
having a Stroke or TIA. This is a prevalence of 1.7% across Kent and Medway (same as
the national average). The lowest prevalence of stroke was seen in Medway with just
1.3% of the population appearing on a stroke register, the highest prevalence of 2.1% is
seen in South Kent Coast CCG area.
Thanet CCG area has the second highest prevalence with 2.0%, followed by Canterbury
& Coastal CCG (1.9%), Ashford CCG (1.8%), DGS CCG (1.6%) and Swale CCG (1.4%).
The national prevalence from the quality and outcomes framework (QOF) is 1.7%. Latest
PHE figures show national comparison of premature mortality and prevalence for stroke
/ TIA and other risk factors in which Kent has been rated better than average for most
except Atrial Fibrillation.
Who’s at Risk and Why?
Modifiable risk factors for stroke

Hypertension is one of the most important risk factors for stroke because it
weakens the artery walls. People with high blood pressure have a four-fold
increased risk of having a stroke (BHF 2009).
 Atrial Fibrillation is a significant risk factor for stroke. People with atrial fibrillation
have a five-fold greater risk of stroke and thromboembolism (NICE 2006).
 People with diabetes are two times more likely to die from a stroke (BHF 2009)
glycaemic control in patients with Diabetes Mellitus may reduce the risk of
cerebral vascular diseases
 Smoking: A person who smokes 20 cigarettes a day has six times the risk of
stroke compared with a non-smoker (BHF 2009).
 Alcohol: People who regularly consume a large amount of alcohol have a threefold increased risk of stroke (BHF 2009)
 Cholesterol: high cholesterol contributes to the development of atherosclerosis,
which increases the risk of stroke (BHF 2009)
 Obstructive Sleep Apnoea: identificiation of patients with OSA and their treatment
reduce the risk of cerebral vascular diseases.
Other risk factors include obesity, low levels of physical activity and a diet high in salt
and saturated fat, as they all contribute to the development of high blood pressure
and atherosclerosis (BHF 2009).
The below images show population prevalence percentages for hypertension, atrial
fibrillation and diabetes mellitus, across the South East Coast:
Fixed risk factors for stroke
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Age: risk increases with age – 75% of strokes occur in people over 65 years (DH
2007)
Those with a family history of stroke are more likely to have a stroke than the
average population (Stroke Association, 2009).
Ethnicity: People from Asian, African and African-Caribbean communities are
more likely to have a stroke than other ethnic groups (Stroke Association 2009).
For example, men born in Bangladesh have a stroke mortality rate three times
higher than those born in England or Wales (BHF 2009)
10–20% of those who have had a TIA will go on to have a stroke within a month.
The greatest risk is within the first 72 hours. The risk of a recurrent stroke is 30–
43% within five years. (Stroke Association 2006).
The Level of Need in the Population
Latest QOF data shows that in Kent & Medway 30,511 people were recorded as having
a stroke or TIA. This is a prevalence of 1.7% across Kent and Medway (equal to the
national prevalence).
The lowest prevalence of stroke was seen in Medway with just 1.3% of the population
appearing on a stroke register, the highest prevalence of 2.1% is seen in South Kent
Coast CCG area. Thanet CCG area has the second highest prevalence with 2.0%,
followed by Canterbury & Coastal CCG (1.9%), Ashford CCG (1.8%), DGS CCG (1.6%)
and Swale CCG (1.4%).
Current Service Provision in Kent & Medway
Awareness and Prevention
FAST campaign
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The national FAST campaign was launched in spring 2009. ‘FAST’ is a simple
way to remember 3 specific symptoms of stroke: Facial weakness; Arm
weakness; Speech problems; Time to call 999.
A number of events were organized across Kent and are ongoing, to help project
the FAST message.
The campaign was successful in raising national awareness of stroke and TIA,
and was repeated in November 2009.
Acute treatment for strokes
TIA clinics
All areas of Kent now have rapid access TIA clinics where high risk patients are able to
be seen within 24 hours and all patients are seen within a week. Although the majority of
the trusts across the South East Coast are performing well, there is some variation
regarding the timeframes in which both HIGH and LOW risk patients can be seen,
investigated and treated for both HIGH and LOW risk TIA.
Acute stroke unit
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All stroke patients require high-dependency care on an acute stroke unit for the
first 24 hours of the illness. Every district general hospital in Kent offers
thrombolysis (early clot bursting drugs) and dedicated acute stroke care.
All areas have access to dedicated Stroke Rehabilitation Units (SRU) when inpatient stroke rehabilitation is needed.
Community Services for those who have had a stroke
Early Supported Discharge Team (ESDT)
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These services offer early discharge (typically within 10 days) and rehabilitation
in the patient’s own home; about 30% of patients are suitable for this model of
care. Although there is variation and not all areas have access to these teams,
ESD teams operate in Medway and West Kent.
Community Stroke Team (CST)
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This multi-disciplinary team (Physiotherapists, Occupational therapists, Mental
Health Nurse, Speech and language Therapist and support workers) provides
longer-term community rehabilitation services for stroke survivors. As with ESD
teams, there is variation across the South East Coast, and not all stroke patients
in Kent & Medway have access to a CST.
Sentinel Stroke National Audit of Stroke Programme (SSNAP)
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The Sentinel Stroke National Audit Programme (SSNAP) aims to improve the
quality of stroke care by auditing stroke services against evidence based
standards, and national and local benchmarks. Building on 15 years of
experience delivering the National Sentinel Stroke Audit (NSSA) and the Stroke
Improvement National Audit Programme (SINAP), SSNAP is pioneering a new
model of healthcare quality improvement through near real time data collection,
analysis and reporting on the quality and outcomes of stroke care.
https://www.rcplondon.ac.uk/projects/sentinel-stroke-national-audit-programme
Projected Service Use and Outcomes in 3-5 years and 5-10 years
Evidence of What Works
NICE
Stroke Pathway Published 09/05/2011
QS2 Stroke: quality standard Published 01/06/2010
CG162 Stroke rehabilitation: NICE guidance Published 12/06/2013
NICE Atrial Fibrillation guidelines updated June 2014
Royal College of Physicians of London
National clinical guideline for stroke : fourth edition Published 26/09/2012
Diagnosis and initial management of transient ischaemic attack: Concise guidelines
Published 01/04/2010
Scottish Intercollegiate Guidelines Network
Guideline 119: Management of patients with stroke: dysphagia - Full guideline
Published 01/06/2010
Guideline 118: Management of patients with stroke: rehabilitation, prevention and
management of complications, and discharge planning - Full guideline
Published 14/03/2011
CVD profiles
Key information on stroke and cardiac issues now available
http://www.sepho.org.uk/NationalCVD/docs/29_CVD%20Profile.pdf
Stroke Statistics Update (Dec 2012) http://data.gov.uk/dataset/stroke_statistics_update
Strokes and TIA (from Clinical Knowledge Summaries 2009)
https://www.evidence.nhs.uk/topic/stroke?pa=3
Engagement
Strategic Clinical Networks (SCNs) provide an organisational model through
which multiple professionals, clinicians, organisations and patient/carers and their
representatives will come together to improve patient outcomes and benefit population
health across a range of boundaries.
SCNs will assure commissioners that they are commissioning services from providers
who are actively engaged in the SCNs, developing and delivering their services in line
with evidenced based practice and audit / assurance processes. They will enable
commissioners to achieve:
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their core purpose of quality improvement;
the metrics in the Commissioning Outcomes Framework;
evidence provision to support authorisation and annual assessment
Engagement in SCNs will enable providers to develop and deliver services in line with
the requirements of the terms and conditions of contract, best practice tariffs and CQUIN
payments.
The South East Coast Cardiovascular (SEC CVD) SCN Stroke Clinical Advisory Group
(CAG) is made up of representation from provider and commissioning organisations
across Kent, Surrey and Sussex alongside patient, carer and third sector members. It
will provide a forum for bringing together and agreeing the stroke component of the
overarching CVD SCN strategic work programme. In conjunction the purpose of the
group will be to influence and advise on the commissioning of stroke and TIA services
which address the whole patient pathway and deliver the required patient outcomes.
Key Issues, unmet need and service gaps
After a comprehensive data review and taking into consideration national priorities,
quality standards and local commissioning needs, the following areas have been
identified by the SEC CVD SCN as key improvement areas across the South East
Coast:
 Improving detection rates for Atrial Fibrillation, and optimising anticoagulation for
existing patients
 Ensuring that the existing acute models for stroke care meet the required quality
standards, and are fit for the future
 Consistency of access to Six Month Reviews for stroke patients
 Ensuring life after stroke services are fit for purpose
 Commissioning against the South East Coast Integrated Service Specification
Recommendations for Commissioning
The South East Coast Cardiovascular Strategic Clinical Network (SCN) have
recommended:
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All acute and community providers should be recording, completing and returning
the Sentinel Stroke National Audit Programme (SSNAP) data as this is the only
national standardised stroke audit system to enable benchmarking and recording
of quality of services.
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CCGs to review existing stroke models of care, in line with the work currently
being undertaken within Surrey and Sussex, to ensure that the existing model of
care (District General Hospitals, linked by Telemedicine) is cost effective,
sustainable, meets quality standards, and offers the best possible patient
outcomes.
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The Integrated Stroke Service Specification (ISSS), which was developed by the
previous county wide Stroke Networks for Kent, Surrey and Sussex and contains
best practice guidance for stroke services, should be used as the basis for
commissioning stroke services.
Cardiovascular Commissioning Guidance 2015/16
The purpose of this paper is to provide commissioners of healthcare services across the
South East Coast (Kent & Medway, Surrey and Sussex) with some strategic
commissioning guidance in relation to cardiovascular disease and the specific areas of
heart, stroke, renal and diabetes. This is intended to support the production of CCG
2015/16 commissioning intentions and is based on the CVD SCN strategic work
programme which was developed during 2014/15 to support both Clinical
Commissioning Groups (CCGs) and direct commissioning.
South East Coast Cardiovascular Commissioning Guidance 2015/16
Key Contacts
Oena Windibank, Quality Improvement Lead, South East Coast Cardiovascular Strategic
Clinical Network ([email protected])
Mark Trickey, Quality Improvement Lead, South East Coast Cardiovascular Strategic
Clinical Network ([email protected])
Abraham George, Consultant in Public Health, Kent County Council
([email protected])
References
BHF (2009) Stroke Statistics 2009 edition. British Heart Foundation. www.heartstats.org
[Accessed 02 February 2010]
DH (2007) National Stroke Strategy. Department of Health.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGui
dance/DH_081062 [Accessed 02 February 2010]
DH (2009) Achieving the 2010 Life Expectancy Target: Modelling required mortality
reductions and potential deaths averted through evidence-based interventions. National
Support Team for Health Inequalities
NICE Atrial Fibrillation guidelines updated June 2014
http://www.nice.org.uk/guidance/CG180
NICE (2006) The Management of Atrial Fibrillation (CG36) National Institute of Clinical
Excellence. http://guidance.nice.org.uk/CG36 [Accessed 02 February 2010]
POPPI Projecting Older People Population Information System. www.poppi.org.uk
[Accessed 02 February 2010]
Stroke Association (2006) Stroke Statistics. www.stroke.org.uk [Accessed 02 February
2010]
Stroke Association (2009) www.stroke.org.uk [Accessed 02 February 2010]