NHS England Long Term Plan and the National Stroke Programme

Nine in every ten strokes are preventable and associated with a number of potentially modifiable risk factors. 5 million people in England have undiagnosed hypertension and of those diagnosed, 40% have poorly controlled blood pressure.

Atrial fibrillation (AF) - associated with the most devastating strokes - is undetected in 30% of those it affects and over half of those who are diagnoses are poorly controlled. Yet we know lowering blood pressure prevents strokes and appropriate treatment such as anticoagulation prevents two-thirds of strokes in people with AF.

Most people at increased risk, including those at risk of having further strokes, can be identified and managed effectively within primary care and other services through a population health approach. Identifying and managing people at risk of stroke also helps prevent a range of other cardiovascular events such as heart attacks and kidney disease.

Working with Public Health England, community services and others, we will:

• Improve the detection and management of atrial fibrillation, high blood pressure and high cholesterol through working with pharmacists, specialist nurses and others to reduce the burden on GPs, and promote the NHS RightCare CVD pathways.
• Consider a new national CVD audit.
• Increase access to blood pressure, AF and cholesterol testing devices, and increase public awareness of these conditions and their link to stroke and other CVDs.
• Target awareness-raising in harder to reach communities such as some BAME communities and those less advantaged.
• Improve the use of genetic testing when detecting and diagnosing CVD conditions.

Despite significant progress over the last decade, the quality and availability of hospital and pre-hospital stroke services still varies greatly. Work needs to be done in particular to drive up the numbers of patients receiving highly effective treatments such as thrombolysis and thrombectomy.

Before reaching hospital, patients need to be assessed and triaged using the latest technology, taken to the most appropriate hospitals for their diagnosis and treatment in an appropriate timeframe to give the greatest opportunity for the best possible treatment.

Reconfigurations - the reconfiguration of hyper-acute stroke services into fewer units delivering specialist treatment and care - in Northumbria, London and Greater Manchester have successfully achieved life-saving results by reducing the number of stroke units admitting stroke patients.

Elsewhere, however, stroke service reconfigurations are incomplete, delayed or have not yet started, meaning many stroke patients are still not able to access the full range of evidence-based treatment as recommended by national guidelines. It is important to recognise that reducing the number of hyper-acute units admitting and treating stroke patients within the first few days after stroke will not necessarily reduce the number of overall hospitals providing a local stroke service.

We will support the creation of new Integrated Stroke Delivery Networks (ISDNs), with the aim of increasing the number of stroke patients accessing hyper-acute stroke units and game-changing stroke treatments. These ISDNs will involve all relevant agencies, including ambulance services and providers of early supported discharge, and all units receiving stroke patients will meet crucial 7-day standards for stroke care.

The stroke programme will support STPs and ICSs to fully reconfigure local acute stroke services so that all stroke patients are taken directly to a hyper-acute stroke unit, where they will receive the best treatment and care. These changes will save thousands of lives, reduce disability, decrease bed days and save the NHS tens of millions of pounds. To support STPs and ICSs, the stroke programme will:

• Develop national service specifications for acute stroke care.
• Develop an evidence base on the case for nationwide stroke service reconfiguration, with the results and next steps going out for public consultation.
• Establish a stroke programme delivery board, chaired by a senior clinical expert, to oversee and support the proposed changes, and, working with the Getting It Right First Time (GIRFT) programme, focusing on existing planned reconfigurations that may have stalled or delayed.
• Undertake new modelling work to link in with the existing thrombectomy roll-out programme to set out the benefits of ISDNs.
• Ensure NHS England and the Stroke Association work together to share best practice, challenges and ideas through the professional stroke community.
• Promote the use of technologies to support this work, such as new apps for ambulance staff to help with triaging patients and telemedicine for improved pre-hospital care and decision-making. ISDNs will also investigate the use of technology to help select patients eligible for thrombolysis and thrombectomy.

Stroke causes a wide range of physical, communication, emotional and cognitive difficulties, and more than half of survivors report fatigue, memory and concentration difficulties, anxiety or low mood. On average, stroke survivors receive less than half the amount of rehabilitation recommended by national guidelines and many report feeling 'abandoned' after leaving hospital.

Making improvements in this part of the pathway is a clear priority for stroke survivors and carers, and where we have seen the least progress over the last decade.

This workstream is focusing on inpatient rehabilitation, ESD, increased provision of 6-month reviews and community-based ongoing support.

The stroke programme will work to establish a number of rehabilitation pilots (locations TBC) to test, demonstrate and evidence the opportunities and benefits of person-centred stroke rehabilitation. These will again be driven by STPs and ICSs, and will also focus on increasing the use of technology. The pilots will work across the whole rehabilitation journey and will include:

• Developing standard service specifications to give clarity for teams and commissioners on how to deliver recommended service levels.
• Supporting the nationwide implementation of the RightCare Stroke and Rehabilitation pathways, as well as the 2016 Rehabilitation Commissioning Guidance.

Psychological support

• Better access to psychological rehabilitation, including neuropsychology with specialist supervision from stroke neuropsychologists where needed.
• Enabling access to the new Improving Access to Psychological Therapies Programme for Long Term Conditions for people recovering from stroke.
• Better access to vocational or back to work rehabilitation, which will link to the Department for Work & Pensions and Department of Health & Social Care Improving Lives: The Future of Work, Health and Disability programme.

Technology and information

• Using technology such as the Stroke Association's online support tool, My Stroke Guide, and tools for professionals such as the Q global platform.
• Developing a stroke 'passport' to help survivors and carers with self-management and navigation.
• Reviewing SSNAP data collections to help develop a revised service specification, with a particular focus on post-acute care.
• Supporting and sharing best practice through the new community network set up by the Stroke Association.

Early Support Discharge (ESD)

• Further developing NHS RightCare's Intelligence products, including a high impact intervention product for ESD
• Implementing Discharge to Assess approaches by ESD teams.

Longer-term support

• The Stroke Association developing a national life after stroke initiative, drawing on successful models such as 'Living With and Beyond Cancer' to create person-centred ongoing practical, social and emotional support.

40% of hospitals have at least one unfilled stroke consultant post, with the length of time posts remain unfilled rising from 8 to 15 months between 2014 and 2016. While acute service reconfigurations go some way to easing the situation by making most efficient use of staff and resources, more needs to be done if we are to deliver the most impactful interventions to all those who are eligible.

We need more specialists trained to deliver mechanical thrombectomy and more stroke specialist nurses, and must work to fill skills gaps across the whole pathway. But workforce modernisation is not just about filling vacancies and upskilling. It's also about working in a more creative way with the resources we have.

Working with Health Education England and professional organisations such as the Royal Colleges, the stroke programme will:

• Promote the implementation of the stroke skills and competency framework and ensure the framework is kept updated.
• Identify areas of best practice that add skills and competencies to already existing roles, for example upskilling more health professionals to be able to perform mechanical thrombectomy procedures.
• Ensure that the rehabilitation pathway pilot areas promote and draw on flexible multi-disciplinary working and competency-based practice.
• Ensure the pilot areas work to increase their staffing levels in both stroke specialist and general roles.
• Developing a standardised skills and capability framework to support improved care and improve cross-organisational and cross-boundary working in post-acute and community care.
• Increase the use of technologies to develop skills and competencies.
• Promote existing third sector support, such as Stroke Association peer support groups.

This work is underpinned throughout by improvements in the available modelling, research, financial levers and data. It will ensure the availability of the evidence needed to drive patient-centred improvements and improve outcomes for stroke survivors in England.

This will include coordination of data and research needs and responses to these, including updates to the national audit programme, SSNAP. It will also include provision of health economics evidence to support the case for change, showing both the benefits to patients and the financial viability of making the needed changes.