What is the data telling us?

Prevalence - trends and forecasts

There are approximately 110,000 strokes and 20,000 Transient Ischaemic Attacks (TIAs) per year in England. Of these a third will be left with a long term disability and one in four people will go on to die as a direct result of their stroke. For those who have already had a stroke there is a 30-40% risk of recurrent stroke within five years of the first event.
 
Over the period between 2006 and 2008, there were an average of 42 deaths per year from stroke in people under the age of 75 years in Newcastle.  The death rate in Newcastle is above the national average for both males and females, but not significantly so (Figure 1).
 
Trend data relating to death rates from stroke in the under 75 age group are presented in Figures 2 and 3 below.  These demonstrate

• a consistent national and regional decline in the death rate from stroke over the period 1993 -2008 for both males and females;
• that although rates can fluctuate substantially from year to year Newcastle's rate has been generally downwards for both males and females.

 
 
 
Prevalence of stroke rises with age and deprivation, from 0.1% in 16-34 year olds to 11.6% for over 75 year olds. Nationally 25% of strokes occur in people under the age of 65 years. In the over 75 age group prevalence varies according to gender with 13.1% of men and 10.7% of women affected by the condition, although more women than men over the age of 75 die as a direct result of a stroke.
Those of African or Caribbean ethnicity are at higher risk of stroke. Incidence rates, adjusted for age and sex are twice as high in Black people compared to Caucasian people.
People, who have an abnormal heart rhythm such as Atrial Fibrillation and are overweight or obese, have a higher risk of stroke, particularly if they suffer from high blood pressure and have a high cholesterol level. Guidance from the National Institute for Health and Clinical Excellence (NICE) on the appropriate treatment of patients with Atrial Fibrillation suggests that around 4,500 strokes and 3,000 deaths per year could be avoided.
The prevalence of diagnosed stroke in an area can be ascertained from data collected as part of the monitoring arrangements for the Quality and Outcome Framework (QOF). This data (Table 1) illustrates that prevalence in Newcastle is lower than the regional average, but higher than the national average.
 
 
A prevalence model developed to estimate the number of people with stroke suggests a significant gap between actual and measured (or diagnosed) levels (Table 2).  Comparing QOF data for 2009/10 (5,434) with the model estimate for 2009 (7,511) suggests that there may be over 2,000 people who potentially have had a stroke and are not recorded by GP practices.
 

 
Diagnosis and treatment
Current evidence shows that effective management in the early stages of a stroke can have a major impact on the outcome for some patients. There is substantial evidence to demonstrate that people suspected of having had a stroke should receive a brain scan within 24 hours of the event.  The scan will facilitate confirmation of an early diagnosis and ensure that the most appropriate treatment is commenced.  Up to 1,000 people a year could have the potential to regain independence if they have the opportunity to receive this level of care.  Therefore prompt access to an acute stroke unit is essential to reduce death and increase the number of individuals who achieve a positive outcome.
A National Audit Office report acknowledged the volume of work that has been undertaken in improving the level of acute stroke care nationally. All hospitals across England now have a stroke unit in place and the proportion meeting key clinical requirements has risen from 73% in 2008 to 82% in 2009. In 2008, 59% of stroke patients spent 90% of their stay on a stroke unit. However, in the same year only 17% reached the stroke unit within the recommended four hour time frame from the point of their arrival at hospital.
In 2008 all hospitals provided access to scans. However, only 59% of patients were given a brain scan within 24 hours. Access to weekend and evening scans is significantly more limited.
The North of Tyne Strategic Plan for 2010/14 sets out as one of its seventeen key priorities the Delivery of the National stroke strategy. The National Stroke Strategy has twenty sets of quality indicators. NHS North of Tyne selected two key indicators which focus on the quality of care patients receive in both the immediate and long term stages. It is these two Vital Signs indicators that will be used to measure achievement of this initiative. The two selected indicators are:
1. Percentage of patients that spend at least 90% of their time on a stroke unit.
2. Percentage of high risk TIA cases who are treated within 24hrs.
The local data to monitor achievement of these two indicators is currently extracted from the acute stroke unit which is based in the Royal Victoria Infirmary, part of the Newcastle Hospitals Foundation Trust.
  The 2009/10 data for the first indicator is set out in Table 3 and demonstrates that:

• Newcastle performance improved substantially in the fourth quarter of 2009/10 and in this quarter it exceeded the regional, network and national average.
• Newcastle's performance for the fourth quarter exceeded the national target as set at 80% by 2011.
• In three of the four quarters of 2009/10 Newcastle's performance has been higher than the national average but lower than the regional average.

  

The 2009/10 data against the second indicator is presented in Table 4 and demonstrates that:

• Newcastle had a significantly lower level of achievement for this indicator in the first half of the year when benchmarked against the other two Primary Care Organisations (PCOs) North of Tyne, but performance increased substantially in the second half of the year.
• Newcastle's performance in quarter four exceeded the regional, network and national achievements.
• Newcastle's performance for quarter four exceeded the 60% target set for April 2011.

Evidence suggests the most effective way to reduce the human and economic impact of stroke is through prevention. Targeted management of at-risk patients, i.e. those with high blood pressure or cholesterol levels, is essential. Data collected as part of the monitoring arrangements for the Quality and Outcome Framework (QOF) provides an insight into current achievement by primary care against these target areas for stroke patients. 2009/10 data are presented in Figure 4 and Table 5 and demonstrate that:

• Newcastle has performed consistently better across all indicators when compared to the other North of Tyne PCOs, the North East overall and to England.   

What is the story behind the data?

Stroke is one of the three major causes of death and the largest cause of adult disability in England. The cost to the NHS amounts to £7 billion a year - £2.8 billion in direct costs to the NHS and a further £2.4 billion on informal care costs. In addition to costs to the service are the individual losses in terms of income and independence. Approximately 110,000 people a year are affected by a stroke in the UK and a third of these will be left with a long-term disability.

The aim of implementing the National Stroke Strategy is to reduce the incidence of stroke by primary prevention strategies, including vascular checks, early diagnosis, treatment and management of high risk groups.

Newcastle has a number of areas of high deprivation, coupled with the highest Black and Minority Ethnic (BME) community North of Tyne, both of which are key factors associated with an increased prevalence of stroke.  In an effort to reduce the inequalities gap, a particular focus should be taken to work with those groups most at risk of stroke:

• People who live in deprived communities;
• Black and minority ethnic (BME) groups;
• Patients with pre-disposing vascular disease/coronary heart disease; and
• Patients who are overweight /obese and also suffering from hypertension.

As part of the development of the National Stroke Strategy (2007) a formal national pubic consultation exercise was undertaken.  One of the key issues highlighted during the consultation, was the lack of awareness of stroke as a significant health problem.  The feedback indicates that the public did not appear to be aware of the symptoms of a stroke or have an understanding that it is largely a preventable disease.  As a consequence the Department of Health in February 2009 launched an awareness campaign titled "Stroke act FAST".  This campaign was designed and delivered nationally through a range of media, posters and leaflets.  Potentially this campaign could be used as part of a social marketing strategy aimed at the at-risk groups in the local population.

What are the gaps in data?

• More detailed analysis required of patient outcomes at both the acute and long term rehabilitation stage.
• Analysis of the effectiveness of the rehabilitation services to identify a cost effective model of delivery.

What are the national and local drivers?

• National Service Framework for Older People 2001 included a standard that aimed to reduce the incidence of stroke in the population and ensure that those who have had a stroke have prompt access to integrated stroke care services.

 

• National Service Framework for Long Term conditions 2005 aimed to promote quality of life and independence for people with long term neurological conditions by ensuring they receive co-ordinated care and support that is planned around their needs and choices.

 

• Royal College of Physicians, National Sentinel Stroke Audit Report 2004 aims to assess the quality of care for people who have had a stroke and help trusts use audit as a means of quality improvement.

 

• National Audit Office, Department of Health: Reducing Brain Damage: Faster access to better stroke care 2005 recommended further improvements in preventing stroke and in the effective management of those who have had a stroke

 

• Department of Health, Mending Hearts and Brains 2006 emphasised the need for stroke patients to receive sophisticated diagnostic and monitoring facilities in a 24/7service.

 

• National Institute for Health and Clinical Excellence guidance:  

         Stroke 2008

         Atrial Fibrillation 2006

 

• Improving Stroke Service: A Guide for Commissioners 2006 was designed to help commissioners review existing services and identify where investment needs to be made in the future.

 

•  Putting prevention First: Vascular checks, risk assessment and management.

 

• Care Quality Commission, Review of services for people who have had a stroke and their carers - Guidance, 2010 aims to look at the longer term care after people have left hospital from both a health and social care perspective.

 

At a local level NHS North of Tyne has agreed, in the Strategic Plan, to focus its actions on the following key areas:

• Further development of Transient Ischaemic Attack (TIA) and hyper acute stroke services to include consideration of the current funding that supports this work; and
• Development of a community stroke rehabilitation pathway.

What is currently working here or elsewhere?

The Department of Health recommended that a network approach be used as a lever to deliver the National Stroke Strategy. North of Tyne is part of the North of England Cardiovascular network that has been leading the development of stroke services in line with the strategy. The group have, to- date, initiated regional standards for Hyper Acute care,TIA management and stroke rehabilitation.

Nationally the Department of Health has launched the NHS health checks programme which is currently being introduced across North of Tyne. The programme is available for all eligible individuals aged 40-74 years of age and aims to identify and manage people at risk of heart disease, stroke, diabetes and kidney disease. It is anticipated that this primary prevention programme will have the potential to identify early, individuals at risk of stroke and through proactive management and lifestyle intervention provide significant benefits to their future health. This programme is still in the early stages of implantation North of Tyne and therefore it will take some time to establish what outputs are being achieved.

Locally North of Tyne and Newcastle are fortunate to have good, well- established local stroke services across the whole stroke pathway. Newcastle Hospitals Foundation Trust has recently reorganised its in-patient stroke services and moved them to a new unit at the Royal Victoria Infirmary (RVI). The unit is sited close to the Neurology services and allows access to brain scanning 24/7 as recommended in the National Stroke Strategy. From the statistical evidence it would appear that the relocation of this service has facilitated a much improved provision for the assessment and treatment of stroke patients. In addition, the Accident and Emergency department has relocated to the RVI in June of this year which should enable more patients to reach the stroke unit within the recommended four hour time frame.

The rehabilitation services are currently provided by Newcastle and North Tyneside Community Health, through a consultant led, multi disciplinary team based at Walkergate Hospital. The service provides supported discharge to patients following a stroke and actively works with patients to achieve maximum independence. Social services play a key role in the discharge planning of stroke patients and to facilitate this work a dedicated social worker is part of the multi disciplinary team.

Newcastle currently has a Stroke Health Improvement group, which meets monthly and has membership from provider services, commissioning, the North East Cardio Vascular Network and public health. The focus of the group is to support and develop local stroke acute and rehabilitation services in line with the National Stroke Strategy. 

What should we be doing next?

• Develop a service specification which aims to achieve the quality markers set out in the National Stroke Strategy.
• Continue to work with the acute stroke services to achieve the targets.
• Support QOF validation teams from the primary care commissioning arm of the PCT, to review and assess data, and support those practices with the lowest levels of achievement in relation to QOF indicators, in order to ensure effective management of patients at risk of stroke.
• Work with primary care to ensure that all appropriate stroke patients are recorded on the practice registers.
• Ensure the model of delivery enables improved uptake of the service by easy to overlook groups e.g. BME communities.