Are stroke services in the NHS still improving?

The Sentinel Stroke National Audit Programme (SSNAP) has today launched findings from its 2016 Acute Organisational Audit showing that the way that care is provided for people with acute stroke continues to improve with more provision of weekend therapy and better access to early supported discharge (ESD) teams.

However, the SSNAP Acute Organisational Audit report highlights concerns about staffing levels, particularly consultants, with 40% of sites now with an unfilled stroke consultant post, increasing from 26% in 2014. Consultants are needed more rather than less as new treatments are developed and acute care becomes more complex. Although the overall number of consultants in post and consultant time (programmed activities (PAs)) in stroke has increased since 2014, this highlights a growing consultant workforce issue which could undermine recent improvements in care.

Results also show that patient engagement is inadequate with almost 40% of hospitals carrying out formal surveys of patient and carer experience of stroke services less than once a year or not at all, and nearly half of stroke strategy groups not having patient or carer representation. Shared decision making with service users is a key tenet of NHS England’s strategy for healthcare improvement. Patients and their carers bring a unique insight, and therefore an essential voice, to service development and have been at the forefront of recent service changes at strategic and local levels.

SSNAP is commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), and run by the Clinical Quality Improvement Department (CQID) of the Royal College of Physicians.

Other headline results from the 2016 acute organisational audit include:

  • Lack of essential psychology provision: very few hospitals (6%) achieve the standard of one whole time equivalent (WTE) qualified clinical psychologist for every 30 stroke unit beds.
  • Lack of nurse staffing particularly at weekends: only 20% of acute hospitals are meeting the standard for weekend nurse staffing levels. There should be at least three registered nurses on duty at all times during the day per 10 stroke beds. Fewer nurses than this at weekends is associated with more hospital deaths.
  • There continues to be a reassuring increase in many areas of acute stroke organisation:
    • all hospitals now have a designated stroke unit
    • 7-day access to occupational and physiotherapy has increased to 31% and 40% of hospitals, however only 6% can provide speech and language therapy 7 days a week
    • 99% of hospitals are able to give their patients access to thrombolysis 24 hours a day, 7 days a week
    • 68% provide intra-arterial (thrombectomy) treatment on-site or by referral off-site
    • 81% of hospitals have specialist early supported discharge (ESD) available to them meaning that patients can return home sooner and receive specialist post-acute care.

Professor Pippa Tyrrell, associate director for stroke for the RCP’s Clinical Quality Improvement Department, said: 

Stroke care has improved beyond recognition in the last 20 years. Patients are almost routinely being admitted to specialist stroke units where, in general, they receive high quality care, they stay in hospital for a very much shorter period of time, and are often discharged to early supported discharge (ESD) services where rehabilitation continues at home. Thirty-day mortality has dropped significantly, and people leave hospital with less disability than they did in the past.

However, we still have marked variation of services and patient outcomes across the UK. Some patients cannot access acute stroke units rapidly, and are therefore denied treatment such as thrombolysis or thrombectomy. Seven-day working is improving, but access to speech and language therapy at weekends remains extremely low.

It is only by measuring the quality of our services that we know how well we are providing them, and we congratulate all of those dedicated staff who work so hard to provide and check data for both the organisational and clinical audits, which provide so much very detailed information about individuals who have strokes, the processes of care they receive and their eventual outcome.

The Acute Organisational Care Audit is available from the SSNAP website

Please see also the RCP media release Stroke in the UK: Mind the Gap! - the latest annual Sentinel Stroke National Audit Programme (SSNAP) report reveals further improvement in stroke care is needed.

Notes to editors

The SSNAP Acute Organisational Audit measures structure, staffing levels and resources in every hospital that provides acute inpatient care throughout England, Wales and Northern Ireland. All 178 eligible trusts took part in the audit and results are based on a snapshot date of 1 July 2016. It complements the continuous SSNAP clinical audit which measures processes of care and clinical outcomes of individual patients and reports on this cyclically every 4 months and annually.

The SSNAP Acute Organisational Audit is a two-yearly, evidence based audit, using standards and evidence from the RCP’s National Guideline for Stroke, NICE Quality Standards and the NHS England Urgent and Emergency Care review. The last audit took place in 2014.

Information on HQIP, the National Clinical Audit Programme, and how it is funded

The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement and, in particular, to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the National Clinical Audit Programme, comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands.