London Strategy for Life after
Stroke
Tony Rudd
Story so far
New acute model of care
999
30 min
LAS journey*
HASU
SU
After 72 hours
HASUs
• Provide immediate response
• Specialist assessment on arrival
• CT and thrombolysis (if appropriate)
within 30 minutes
• High dependency care and
stabilisation
• Length of stay less than 72 hours
2
Community
Rehabilitation
Services
Discharge from
acute phase
Stroke Units
• High quality inpatient rehabilitation
in local hospital
• Multi-therapy rehabilitation
• On-going medical supervision
• On-site TIA assessment services
• Length of stay variable
1 year outcomes
% of patients spending 90% of their time on a dedicated SU
90
85
80
% achievement
75
70
London
65
England
60
Target
55
50
45
40
Q1
Q2
Q3
2009/10
Q4
Q1
2010/11
1 year outcomes
Average length of stay
20
18
16
14
12
10
8
6
4
2
0
Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2009/10
2010/11
Jul
Aug
1 year outcomes
Thrombolysis rates
16%
14%
14%
12%
12%
10%
10%
8%
6%
4%
2%
3.5%
0%
Feb-July 2009
Aim
Feb-July 2010
Jan-March 2011
Improvements in Community
Services
 Many more areas now have early supported
discharge teams
 Some increase in longer term stroke
rehabilitation teams
 We are reviewing in-patient rehabilitation
services
London Stroke Survival vs Rest of
England
Hazard ratio for survival in London
0.72 95%CI 0.67-0.77 p<0.001
The Stroke Association
UK Stroke Survivor Needs Survey
Christopher McKevitt
Reader in Social Science & Health
King’s College London
Aims
1. To estimate levels of self reported long term
need in stroke survivors (1-5 years)
2. To compare levels of need between stroke
survivors in England, Scotland, Wales &
Northern Ireland
Results
• 51% reported having no unmet needs
• Of those reporting unmet needs, total number
per respondent ranged from 1-13, median 3
Information
•
•
•
54%: more information about stroke
No differences by age, gender, ethnicity, disability level
or time since stroke
Significantly different by nation (p=0.009):
Northern Ireland=66%
Wales=65%
England=54%
Scotland=49%
Unmet health needs
N reporting
problem
(weighted %)
Mobility
321 (58.4)
Falls
265 (43.9)
Incontinence 217 (37.2)
Pain
249 (39.5)
Emotional
244 (38.4)
Speech
194 (34.3)
Sight
212 (37.2)
Need unmet
(%)
25
21
21
15
39
28
26
Need met to
some extent
(%)
43
47
40
51
34
33
39
Other unmet needs
N reporting
problem
(weighted %)
Fatigue
Concentration
Memory
Reading
301 (51.7)
260 (44.7)
260 (42.8)
148 (23.2)
Need unmet
(%)
43
43
59
34
Need met to
some extent
(%)
36
41
25
43
Changes in social
participation
• 52% unable to return to work or reduced
hours
• Significantly higher in Black and other ethnic groups
compared to Whites (p=0.006, population registers)
• 67% reported loss in leisure activities
• Significantly higher in Black and other ethnic groups
compared to Whites (p=0.012, population registers)
Impact on finances
• 18% of those working at time of stroke
reported a loss of income since stroke
• 31% reported increased expenses
• 16% (25% population registers) reported
need for benefits advice
Family
• 42% reported a negative change in
relationship with partner
• 26% reported negative changes in family
relationships
Groups at higher risk?
• No differences by
• age
• gender
• time since stroke
• Higher unmet need:
• disability, including communication disability
• ethnic minority stroke survivors
• people living in poorest areas
Stroke survivors in London ‘denied
recovery’ says new report calling for
better coordination and support
‘Stroke survivors across London say they are being
denied the chance to make their best recovery
because of a lack of patchy post hospital care and
confusion between health and social care services,
states a new national report published today
(Tuesday May 1st 2012) by the Stroke Association.’
Stroke Association Survey
Findings
•85% of stroke survivors say that the impact of
stroke is not understood
•Six out of ten (59%) said that health and social
care services did not work well together resulting
in families and carers having to take
responsibility for coordinating care.
•Almost a third (31%) reported services being
reduced or withdrawn even though their needs
had stayed the same or had increased.
Stroke Association Survey Findings
 38% felt they did not receive enough support
from NHS services
 Almost a third (31%) reported services being
reduced or withdrawn even though their
needs had stayed the same or had increased.
 77% are unable to get out as much since they
had their stroke.
Life After Stroke Commissioning
Guide
London stroke strategy – where this
fits
London stroke
strategy (2008)
Public consultation
(2008/09)
Rehab commissioning
guide (2009)
Life after stroke
(2010)
Principles
 Active citizenship
 Quality of life
 Empowerment
Scale of need
6,000
Sum of stroke and TIA patients in a GP register in 2008/9
5,000
4,000
3,000
2,000
1,000
• Prevalence ranges from 1.6% to 0.8% of registered GP population
• 88,000 people across London on GP registers have had a stroke or TIA
Diverse needs
 15% have on-going
continence problems
 25% of nursing home
residents have had a stroke
 33% of stroke survivors
report depressive symptoms
 20% “silent stroke” –
underlying cognitive
problems
Regular review
 Needs change over time
 Recognise variability of needs and aspirations
 National guidance – 12 monthly review
Structured
social group
Social
care
Therapist
Stroke
survivor
GP
Stroke
navigator
Information
 Stroke care navigator





Single point of contact
Direct role in delivering care
Coordinate care packages
Training stroke survivors and carers
Work across different sectors
 London stroke directory
www.londonstrokedirectory.org.uk
Engaging with community life
 Stroke survivors do not
get out of the home as
much as they would like
 Building confidence
 Addressing practical
issues
 Community/social
groups have benefits
beyond primary purpose
Peer support & peer-led services
Improve
emotional
wellbeing
Build capacity
Source of
information
Sense of
purpose
Confidence
Range of
functions
Peer
support
Improve
functional
status
Carers and families
 Carers have a right to
their own needs
review
 Training and education
should be provided
 Local authority and
charitable sector
support is available
Conclusions
 Stroke care is better in London as a result of the
stroke reorganisation
 BUT......
 Still failing to meet longer terms needs of people after
stroke
 There is no additional money for changing these services
 Need to persuade commissioners that these are services
that are worth investing in for both clinical and economic
reasons
 Major concerns that government cuts will negatively affect
the resources available to people for longer term support