In January 2019, NHS England announced its Long Term Plan, in which stroke has been named as a new national priority.
It also includes sections on stroke care as well as cardiovascular disease. The plan is ambitious for both of these areas and milestones have been set out around how the programme will support improvements to prevention, treatment and care. This work will be led by new Integrated Stroke Delivery Networks.
The National Stroke Programme
The National Stroke Programme has been developed jointly by NHS England and the Stroke Association in consultation with clinical experts and people affected by stroke.
Building on the work of the 2007-17 National Stroke Strategy, the programme supports the health and care system to deliver better prevention, treatment and care for the 80,000 people who have a stroke in England each year, and meet the ambitions set out in the Long Term Plan. To get the latest details on the programme’s actions and ambitions, please see our FAQs below.
What does the programme aim to achieve?
Over the course of the Long Term Plan we aim to achieve:
- Over 10,000 strokes prevented through better treatment for the nearly 100,000 people with known atrial fibrillation (a type of irregular heartbeat which increases risk of stroke).
- 3.6 million patients with improved management of high blood pressure and cholesterol.
- Better public awareness of stroke, including its symptoms and risk factors.
- A reduction in avoidable dementia cases given the strong link between stroke and dementia.
- Reduced health inequalities, particularly associated with socioeconomic status and race.
- 90% of stroke patients receiving specialist stroke unit care.
- Twice as many patients receiving clot-busting thrombolysis treatment, ensuring 20% of stroke patients receive it by 2025 – the best performance in Europe.
- At full roll out, ten times as many people receiving clot-removing mechanical thrombectomy procedures, from less than 1% of patients now to 10%, saving thousands of lives and allowing 1,600 more people to be independent after their stroke over the next decade.
- All eligible patients getting person-centred therapies through Early Supported Discharge (ESD) from hospital.
- Three times as many patients receiving 6 month reviews of their recovery and needs.
- More support with self-management and navigation post-stroke for patients and carers.
- An enhanced national stroke audit to identify need and drive improvements.
- More stroke survivors returning to work.
- Millions of pounds saved through more strokes prevented, improved efficiency and joining up of services, and reduced disability post-stroke.
What is the role of ICSs and STPs?
Integrated care systems (ICSs) and sustainability and transformation partnerships (STPs) are expected to lead stroke improvement in their area. The Long Term Plan puts them as key vehicles for delivery of improved and transformed services across wider population areas.
Because it is both a medical emergency and a long-term condition, stroke embodies the need for integrated, joined-up health care and community services. Only with this approach can local systems embed and achieve the stroke programme’s ambitions, ensuring stroke survivors and their families experience tangible improvements.
What should commissioners be doing to implement the stroke programme?
Commissioners should be putting plans in place to ensure local delivery of the ambitions set out in the Long Term Plan as part of their immediate and longer term planning, They should ensure that they are engaging their local communities around the opportunity to improve patient outcomes.
Local NHS organisations, working together as part of systems with their local authority counterparts and other partners, are being asked to develop their own STP/ICS level strategies for the next five years, which set out how they intend to translate the plan’s contents into local action. Services should be commissioned which meet those recommended in the RightCare pathways and clinical guidelines.
If local areas have examples of best practice they believe could be replicated elsewhere, please get in touch with the stroke programme at firstname.lastname@example.org
We would like you to be part of our growing community of best practice so we can take a collaborative approach to improving stroke care. If you want to be part of the community, please get in touch with us at email@example.com
What is the quality improvement offer from the Stroke Association?
Alongside NHS England, the Stroke Association is supporting service improvement across the stroke pathway through working with ICSs and STPs. This includes:
- Support for freeing up local clinical leaders to help shape clinical pathways and services.
- Supporting acute service reconfigurations to ensure that patients’ voices are firmly embedded.
- Facilitating stroke survivors’ involvement in local service development, and supporting local initiatives including piloting the stroke passport.
If you are part of an ICS or STP and would like to discuss the support the Stroke Association can provide to support service improvement, please contact Helen Southwell, Stroke Programme Manager at firstname.lastname@example.org.
View additional guidance for our quality improvement support offer.
What is expected to happen over the next 12 months?
The first year of the Long Term Plan will provide the opportunity for wider engagement and consultation, and planning as each system prepares for improvements to their stroke services, preparing to implement an Integrated Stroke Delivery Network in each area, which will involve relevant agencies, including ambulance services through to early supported discharge.
We expect a national consultation to take place this year and for momentum to build as each area realises the impact that evidence-driven improvements to their patient pathways and services, delivered in an integrated and networked way, can have on the lives of stroke survivors.
Will there be additional funding?
ICSs seeking to establish Integrated Stroke Delivery Networks (ISDNs) will be encouraged to develop capital funding bids where appropriate, drawing on the ICS/STP capital fund from 2020 onwards. Once established, ISDNs are expected to receive increased income via existing payment mechanisms which are designed to reward delivery of best practice patient care.
Funding has also been allocated from the recent funding settlement to drive specific improvements, focussing on increased rehabilitation, with key priorities being psychological and vocational support, with initial pilot plans due to be further developed shortly.
We expect funding for workforce development to be decided on by Health Education England subsequent to the upcoming spending review.
How will the stroke programme run?
A short slide set that sets out the key aims of the programme and a timeline of activity and milestones is available on the Stroke Association’s website. This is also available on request by emailing email@example.com
How are people affected by stroke involved in this work?
Stroke survivors and carers have been campaigning for improvements in the way stroke is prevented and treated, particularly around rehabilitation and longer term support. That’s why we have been working with them every step of the way to ensure their voice is heard.
Stroke survivors are part of the governance structure around the stroke programme, meaning they are part of the decision-making process.
The Stroke Association’s leadership role across the stroke programme also means that the changes we want to encourage are based on the needs and experiences of those affected by stroke. As part of this, stroke survivors are being directly involved in the development of key deliverables within the programme such as the stroke passport and the national stroke survivor initiative, details of which are set out in the appendix.
What other resources are available?
- RCP Stroke Guideline
- RightCare CVD pathway
- NHSLong Term Plan
- Getting It Right First Time stroke
- A New Era for Stroke
- Sentinel Stroke National Audit Programme (SSNAP)
- Webinar: Transforming stroke services across the whole patient pathway, September 2018. A recording of this webinar is available by request. Please email firstname.lastname@example.org.
- The NHS RightCare Stroke Pathway was published in October 2017 to support local commissioners responsible for stroke to improve services for patients in their area.
- The Stroke Specific Education Framework outlines core competencies for a range of professionals working with stroke survivors.
- 7 day rehabilitation service case study from Torbay and Southern Devon Health and Care NHS Trust.
- NHS Improvement’s Guidance on Psychological Support after Stroke provides guidance to support the establishment and development of services for psychological care of people following stroke.
- See an example of using computer modelling to improve acute stroke care in the South West.
- Achieving successful system change – Lessons from stroke reconfiguration in London and Greater Manchester.
- Ending the postcode lottery of stroke care – blog by Stroke Association CEO Juliet Bouverie.
Detail of each stroke programme workstream
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.
Urgent and emergency care
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 which 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.
Rehabilitation and ongoing care
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 least progress over the last decade.
This work stream 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.
- 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 which 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.
Data, research & finance
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.
We are so proud that the work we carried out as part of our A New Era for Stroke campaign helped to ensure that stroke was included in this new plan. We will continue working with local health leaders and on the National Stroke Programme to make sure that stroke is a priority both locally and nationally.
Find out more
- For more information, please take a look at our news article or our list of FAQs.
- Read more about our A New Era for Stroke campaign in our full report.
- You can also read on overview of our Stroke Delivery plan.
- If you would like to get involved with our campaign please join the campaigns network or email email@example.com.