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Written evidence submitted by The Stroke Association

 

The Stroke Association welcomes the opportunity to provide evidence to the Public Accounts Committee on access to urgent and emergency care.

 

About the Stroke Association 

The Stroke Association is the UK’s largest charity for people affected by stroke. We're here to support people to rebuild their lives after stroke. We provide specialist support, fund critical research and campaign to make sure people affected by stroke get the very best care and support to rebuild their lives.

There are over 100,000 new strokes every year, and over 1.3 million stroke survivors in the UK today. And these numbers are only set to grow. Stroke is the fourth biggest killer in the UK. And the cost of stroke to our society is around £26 billion a year. Sadly, we know stroke causes a greater range of disabilities than any other condition. Almost two-thirds of stroke survivors leave hospital with a disability. However, thanks to improvements in stroke care, you are now twice as likely to survive a stroke compared to 20 years ago.  

Our visionis for there to be fewer strokes, and for people affected by stroke to get the help they need to live the best life they can.  

 

In summary

 

  1. The current state of the accessibility of urgent and unplanned services

1.1      Stroke requires a timely category 2 ambulance response. For every minute a stroke goes untreated, 1.9 million brain cells die.[1]

1.2    Pressure on the urgent and emergency care system in England is resulting in ambulance delays and further transfer delays between different hospitals. This is making it harder for patients to access timely stroke care and game-changing treatments like thrombectomy and thrombolysis, which is harming patients and leading to unnecessary deaths and cases of disability. According to the Association of Ambulance Chief Executives 160,000 patients are harmed because of handover delays each year.[2]

1.3    Although recent ambulance response times have shown welcomed improvement, pressures on the ambulance service are well known. In April, the average response time to Category 2 emergencies like stroke was 28 minutes and 35 seconds. This is outside the 18-minute target for category 2 calls.[3] Furthermore, the previous winter has seen response times that are regularly double or triple the 18-minute target, endangering the lives of stroke patients.[4]  

1.4   In 2021, the Association of Ambulance Chief Executives also found that an average of 190,000 handovers have missed their targets each month at emergency departments across England since 2018.[5] This means that valuable ambulance resources are unable to be used by other patients having stroke emergencies.  

1.5   Thrombectomy is a game changing treatment for some stroke patients and 24/7 access to thrombectomy is essential to reducing disability after stroke. However, there is also unacceptable conveyance to thrombectomy centres. For example, the Walton Centre NHS Foundation trust has a conveyance time of 22 minutes while the Nottingham University Hospitals NHS Trust has an average of 4 hours and 5 minutes.[6] According to guidance, ambulance crews should wait while the patient is being scanned as per the National Optimal Stroke Imaging Pathway.[7] Thrombectomy inter-hospital transfers need to be prioritised to avoid harmful delays.

1.6   Stroke has not been immune to well-known and immense pressures in the health and care system over the last few years. This has reversed much over the progress made over the last 6/7 years. According to the most recent stroke statistics available, the average time it took for stroke patients in England to arrive at a stroke unit was 11 hours and 30 minutes. It also to 5 hours and 12 minutes for suspected stroke patients to have a brain scan.[8] 44% of stroke patients are not being scanned within one hour of arrival at hospital.[9]

 

  1. The main operational constraints

2.1      There are several operational constraints across the health care system which have had an impact on stroke patients’ ability to access urgent and emergency care. Workforce constraints are impacting the ability to provide timely, quality urgent and emergency stroke care. Governments across the UK need to urgently address NHS staffing issues within ambulance services, hospitals, and social care services.

2.2    The number of paramedics in England that left the ambulance service exceeded the number that joined in the year to June 2022. One of the common reasons given for poor staff retention is low job satisfaction. 1 in 4 ambulance workers have said that they would leave their role as soon as they could secure another job.[10]

2.3    Ambulance support staff reported the highest sickness absence rate at 9.5% - a lot higher than the overall sickness absence rate in England of 5.6%.[11]

2.4   Hospitals are also at their limit and, like the ambulance service, are experiencing issues with a lack of available staff. Over half of acute stroke units (52%) have at least one vacancy at consultant grade, and these posts are lying vacant for an average of 18 months.[12]

2.5   Hospitals have been unable to discharge patients due to a lack of social care packages available for them. This disrupts the flow of patients into and out of hospital and contributes to pressure on ambulances and access to urgent and emergency care. In England, bed occupancy rates increased from 88% in 2010-11 to 93% 2019-20.[13]

2.6   In England, each thrombectomy service has different funding needs and some centres in England need urgent infrastructure improvements, while others need equipment to expand their hours and have a 24/7 service.[14]

2.7    There are also geographical disparities in thrombectomy access with nearly 10% of stroke patients receive a thrombectomy in London, compared to only 0-3%* in other areas.[15] This has created a postcode lottery.

2.8   Innovations have huge potential to improve access to urgent and emergency stroke care. However, there is variation in which ambulance services are making use of these technologies as part of their day-to-day operations. For example, AI-powered imaging software with image sharing capability can support fast and efficient imaging processes. It acts as a decision-support tool to allow consultants to quickly decide if a patient is suitable for thrombectomy and enables the rapid transfer of images. Although most stroke units are now using AI-powered imaging software, some still do not have this in place.[16]

2.9   Other technologies such as video-triage where paramedics can access rapid real time support from a stroke specialist can also improve pre-hospital care and speed up decision making on how and where to treat a patient. There have been pilots across England, and it is vital for technologies such as this to be quickly adopted.[17]

 

  1. Plans to address these challenges.

3.1   The UEC Recovery Plan, published on 30th January introduced a system-wide approach to addressing these system pressures, which we welcomed.[18] However, delivery of this plan hinges on the upcoming Workforce Plan, which needs to be published urgently to address the staffing issues.

3.2 Delivery of the UEC Recovery Plan also needs NHS England and ICSs to make concerted efforts ahead of next winter when pressures and demand on the system are likely to be high.

3.3 Ambulance services and ISDNs should also agree to prioritise stroke calls and those eligible for thrombectomy through segmenting category 2 calls as necessary following successful pilots in London and the Midlands.

3.4 Within their plans, ICBs need to work with and alongside other ICBs to support their ISDNs to prioritise 24/7 access to thrombectomy and act on recommendations within the Quality Review. 

 

June 2023

5

 


[1] Saver, Jeffrey L (2006) Time is Brain- Quantified https://doi.org/10.1161/01.STR.0000196957.55928.abStroke. 2006; 37:263–266

[2] AACE (December 2022) Delayed hospital handovers: Impact assessment of patient harm

[3] https://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/ambulance-quality-indicators-data-2023-24/

[4] https://www.england.nhs.uk/statistics/statistical-work-areas/ambulance-quality-indicators/ambulance-quality-indicators-data-2022-23/

[5] The Association of Ambulance Chief Executives (2021) Delayed hospital handovers: Impact assessment of patient harm

[6] Sentinel Stroke National Audit Programme, SSNAP Portfolio for Oct- Dec 2022 admissions and discharges: Country results portfolio.

[7] NHS (2021) National Stroke Service Model: Integrated Stroke Delivery Networks

[8] Sentinel Stroke National Audit Programme, SSNAP Portfolio for Oct- Dec 2022 admissions and discharges: Country results portfolio.

[9] Sentinel Stroke National Audit Programme, SSNAP Portfolio for Oct- Dec 2022 admissions and discharges: Country results portfolio.

[10] Nuffield Trust (December 2022) Ambulance staff strikes: facts and figures on the ambulance workforce

[11] NHS Digital (2023) NHS Sickness Absence Rates, October 2022.

[12] Sentinel Stroke National Audit Programme (2021) Post –acute Organisational Audit Report.

[13] https://www.nuffieldtrust.org.uk/resource/hospital-bed-occupancy#background

[14] Stroke Association (2022) Saving Brains

[15] Stroke Association (2022) Saving Brains

[16] Stroke Association (2022) Saving Brains

[17] https://www.ucl.ac.uk/epidemiology-health-care/research/applied-health-research/research/health-care-organisation-and-management-group/photonic

[18] https://www.stroke.org.uk/newsroom#/pressreleases/stroke-association-response-to-nhses-plan-to-recover-urgent-and-emergency-care-services-3230749