Stroke

According to the stroke association: a stroke is a “brain attack” caused by a disturbance to the blood supply to the brain. There are two main types of stroke:

  • Ischaemic: caused by a clot narrowing or blocking blood vessels leading to the death of brain cells due to oxygen not reaching the cells;
  • Haemorrhagic: caused by a bursting of blood vessels, producing bleeding into the brain & causing damage.

Transient ischaemic attacks (TIA) are minor strokes where stroke symptoms resolve themselves within 24 hours. TIAs needs to be regarded as an emergency because the time necessary for effective prevention of a more serious stroke is extremely short.

Having a stroke is a long term condition - which means that survivors, their families and carers will continue to experience changes in their needs over time.

Stroke is the third largest cause of death in England and 110,000 people have a stroke each year. Stroke costs the NHS and the economy £7 billion a year in direct nursing costs, informal care and lost productivity. Statistics suggest a third of people who have had a stroke are left with a long term disability, this could include physical disability, loss of cognitive and communication skills as well as depression and other mental health problems (NHS, 2014).

The local picture

Stroke mortality is a direct measure of healthcare need. It can indicate the overall of burden on the population. By aggregating 5 years (2010-2014) of data on deaths from stroke (ICD(International classification of diseases)-60-69) we can produce age-standardised mortality ratios at ward level. These ratios compare the number of deaths in particular ward to the expected number of deaths (taking in to account the age structure of the population). Where the ratio is above 100 this indicates there are more deaths than expected from stoke and may be useful information when deciding where to provide preventative services. Standardised mortality ratios (SMR) for Calderdale are as follows:

Ward Standard Mortality Ratios 2010-2014 Lower confidence Interval Upper confidence Interval
Park 129.2 91.4 177.3
Todmorden 121.1 89.6 160.1
Rastrick 120.5 89.4 158.8
Ovenden 113.6 77.2 161.2
Skircoat 104.6 78.6 136.5
Hipperholme and Lightcliffe 95.2 68.0 129.6
Town 92.8 65.0 128.5
Calderdale 89.2 82.1 96.8
Illingworth and Mixenden 88.1 60.3 124.4
Northowram and Shelf 85.4 60.1 117.7
Luddendenfoot 81.3 54.4 116.7
Greetland and Stainland 80.6 52.2 119.0
Sowerby Bridge 80.4 54.7 114.2
Elland 76.9 51.9 109.8
Ryburn 70.9 44.5 107.4
Brighouse 67.7 45.7 96.7
Warley 59.2 37.9 88.1
Calder 54.2 33.1 83.7

(Calderdale Council, 2015)

Although a number of wards have SMRs above 100 these are not statistically significantly higher. Therefore all we can say with accuracy is that Brighouse, Warley and Calder wards have fewer deaths from stroke than would be expected.

Current provision

Accident and Emergency
Stroke patients are referred by the Accident and Emergency (A&E) department to the stroke team at Calderdale Royal Hospital. There are specialist nurses present 24/7 and they attend A&E to assess patients on arrival.

Secondary in-patient care
There is a 15 bedded Acute Stroke Unit, a 34 bedded in patient Stroke Rehab Unit and an Early Discharge service to support people back home. These services are supported by physiotherapists, occupational therapists, speech and language therapists and dieticians.

The Trust has an End of Life pathway in place with guidance for staff on hydration/nutrition, medication, pain management and on-going patient needs assessment.

Stroke Buddies
These are volunteers who have survived a stroke and go onto the Stroke Rehab Unit to talk to people about the support that is available to them when they leave hospital and offer an important peer support role at the very early stages of recovery.

The Stroke Association
This organisation is jointly contracted by the Council and CCG to deliver a community based service, the aim of the service is to improve health and social care outcomes for adults who have survived a stroke, to maximise independence and enhance quality of life of the Individual, their family and carers. Specifically, they:

  • Provide advice and information in a variety of settings;
  • Provide a link from hospital to the community with follow up calls when people return home;
  • Complete six month reviews and provide the data for the SSNAP reports;
  • Provide ongoing 1:1 support when needed;
  • Run a range of groups for peer support, carers and communication;
  • Provide appropriate support, information and signposting to stroke survivors, their family and carers at different times in their recovery whether living in their own home or in long term care;
  • Raise awareness in the wider community of the risk factors associated with stroke and what to do if you suspect someone of having a stroke;
  • Encourage user involvement in service design and delivery;
  • Manage the Stroke Buddies;
  • Produce ‘My Stroke Guide’ – A web based solution for advice information and a forum for connecting with other stroke survivors, support workers and therapists.

The Better Living Team
This service offers 1:1 (for a period of up to 12 weeks) for people recovering from a stroke who wish to pursue some form of physical exercise as part of their recovery and builds on progress begun in Community Rehabilitation. The aim is to re-enable the person to maximise their independence and it is open to adults over 18 living in Calderdale who are recovering from stroke.

At the end of the 12 week programme the person is linked in to continuing support/physical activity/health promotion service options through the community/voluntary sector or similar service provider.

User views

What people said about stroke services during the initial service review 2015:

A key theme for people was that once they knew about different services and had the right information it made a positive difference to their lives. Some of the things people said:

  • “Being able to get out of the house and meet friends for lunch at the clubs is really good and gives my partner a break”;
  • “Having someone to talk to that has been through the same experiences as you is so helpful”;
  • “Once I found out about the groups they were really helpful but I sat at home alone for a long time on my own”;
  • “I have trained as a Mentor and the training was excellent! I could not believe someone had invested in me only half a person”;
  • “I want to know what to do to stop myself from having another stroke as that really frightens me!”.

People said that if they had known about the support that was available before they left hospital and had been able to talk to someone like themselves who had been through the same experience that would have helped them a lot. Out of this consultation the Stroke Buddies project was developed with the stroke survivors, for them to work as volunteers on the stroke wards at Calderdale Royal Hospital. One person has fed back:

  • “Talking to someone who has been through the same thing and seeing how they have recovered can have a positive impact on how you feel about the future”.

Some examples of ongoing feedback from the acute stroke unit at Calderdale Royal Hospital:

  • “The care was fantastic.”;
  • “Very good communication with doctors.”;
  • “All staff very caring and helpful.”;
  • “All staff welcoming and professional. Everything well communicated.”;
  • “Lovely caring and thoughtful staff.”

Some examples of ongoing feedback from the Stroke Association:

  • “[They] gave good information regarding my Mum’s stroke. Always a phone calls away. Nothing too much to ask for, thank you”;
  • “I like the service because of the home visit. The young lady that came was very helpful, and got us the appropriate forms, and rang us on a regular basis”;
  • “I learned more about brain functions and found the review more interesting that I thought it would be.”;
  • “The reviewer was very pleasant & is to furnish some further info.”;
  • “My only comment is: I think the appointment should have been made by letter not telephone. It was a good review when the interviewer does not know you, or your circumstances, or what you were like, or did before the stroke. The interviewer could not be improved upon - he had a pleasant manner.”

Unmet needs

The Calderdale & Huddersfield NHS Foundation Trust had identified in their Annual Report some areas that need to be strengthened. In particular a key issue identified was:

Psychology services

These would support the stroke unit.

  • A third (33%) of stroke survivors experience post-stroke depression;
  • Approximately 20% of stroke survivors experience emotionalism in the first six months. This decreases to 10% in 12 months;
  • There is currently no psychology service provided in the stroke unit.

Projected future need

Age is the single most important risk factor for stroke (Stroke Association, 2016):

  • The risk of having a stroke doubles every decade after the age of 55;
  • By the age of 75, 1 in 5 women and 1 in 6 men will have a stroke.

The population is aging with currently 18% of people in Calderdale estimated to be over the age of 65. The Office of National Statistics (ONS) estimates that by 2037 that figure will rise to 25% with the prevalence rate of having a stroke being directly linked to age the number of people having a stroke is due to rise substantially (ONS, 2014).

The following areas need to be considered in future work to try to reduce the risk of stroke:

  • Improved lifestyle services;
  • Earlier detection and better management by general practice of people with hypertension;
  • Work with vulnerable and high-risk groups to reduce inequalities, specifically people living in the most deprived areas and South Asian populations;
  • Improved self-care support, both before and following a stroke

Key considerations linked to the known evidence base (what works?)

The National Stroke Strategy (Department of Health (DoH) 2007) set out 20 Quality Markers summarised into a Ten-Point Plan for Action covering the following areas:

  1. Awareness;
  2. Preventing stroke;
  3. Involvement;
  4. Acting on the warnings;
  5. Stroke as a medical emergency;
  6. Stroke unit quality;
  7. Rehabilitation & community support;
  8. Participation;
  9. Workforce;
  10. Service improvement.

These markers were set out to improve the support available to Individuals and their families following a stroke and progress against them to be evaluated.

NICE guidance CMG45 (2012) Services for the prevention of cardiovascular disease recommends that commissioners consider the following components of a high-quality service:

NICE guidance (CG162) Stroke Rehabilitation for Adults (2013):

1.1 Organising health and social care for people needing rehabilitation after stroke
1.2 Planning and delivering stroke rehabilitation
1.3 Providing support and information
1.4 Cognitive functioning
1.5 Emotional functioning
1.6 Vision
1.7 Swallowing
1.8 Communication
1.9 Movement
1.10 Self-care

Education
Recognising the signs of stroke or mini-stroke (TIA) and calling 999 for an ambulance is crucial. The quicker a patient arrives at a specialist stroke unit, the quicker they will receive appropriate treatment and the more likely they are to make a better recovery. The FAST test can help you to recognise some of the most common symptoms of a stroke:

  • Facial weakness: Can the person smile? Has their face fallen on one side?
  • Arm weakness: Can the person raise both arms and keep them there?
  • Speech problems: Can the person speak clearly and understand what you say? Is their speech slurred?
  • Time: If you see any one of these three signs, it’s TIME to call 999. Stroke is always a medical emergency that requires immediate medical attention.

References and further information

References

Further information

More information on older people can be found in the Further resources .

Authors

Angela Gardner, Commissioning Manager, Adults Health and Social Care, Calderdale Council;
John Lomas, Information & Evaluation Officer, Public Health, Calderdale Council.

January 2016.