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2010 2015 The Stroke Association Manifesto 2010 to 2015 Working for a world where there are fewer strokes and all those touched by stroke get the help they need
2010 2015
A stroke is a brain attack
A stroke is what happens when the blood supply to the brain is cut and brain cells die. Because the brain controls everything we do, think and feel – things we take for granted, like being able to move, balance, speak, understand, remember, see and hear – the brain damage caused by a stroke can be devastating.
Types of stroke • An ischaemic stroke, the most common type of stroke, happens when a clot blocks an artery that supplies blood to the brain. • A haemorrhagic stroke is caused by a bleed in the brain. • A transient ischaemic attack (TIA), often called a mini-stroke, happens when the brain’s blood supply is briefly interrupted. Although the symptoms of a TIA, which are very similar to a full stroke, are temporary and disappear within 24 hours, having a TIA indicates an increased risk of a more serious stroke in the future.
Common symptoms of stroke The first signs that someone has had a stroke can include: • sudden numbness, weakness or paralysis of the face, arm or leg on one side of the body • sudden difficulty in speaking or understanding speech • sudden loss or blurring of vision, in one or both eyes • sudden severe headache with no apparent reason • sudden confusion, dizziness, unsteadiness or a sudden fall, especially with any of the other signs listed above.
The FAST stroke recognition test F – Facial weakness Can the person smile? Has their mouth or eyelid drooped? A – Arm weakness Can the person raise both arms? S – Speech problems Can the person speak clearly and understand what you say? T – Time to call 999 If you see any of these signs call 999 because stroke is a medical emergency.
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The Stroke Association
Contents
Our vision
Introduction
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We want a world where there are fewer strokes and all those touched by stroke get the help they need.
Stroke prevention
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Emergency and acute stroke care
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Our mission Our mission is to prevent strokes and achieve life after stroke by providing services, campaigning, education and research. Our values Our core values are based on professionalism, passion for our cause, innovation, respect and openness, and working together to build successful partnerships in pursuit of common goals.
Life after stroke – from the hospital into the community
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Life after stroke – long-term support
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Children and stroke
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Conclusions
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References
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Our services As well as campaigning for better stroke care across the whole of the stroke care pathway, we provide direct help to stroke survivors and their carers and families through our own range of Life After Stroke Services.
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2010 2015
Introduction
Every year in the UK over 150,000 people have a stroke or mini stroke, a transient ischaemic attack (TIA).1 That’s one stroke every five minutes.
Stroke is the biggest single cause of severe disability2 and the UK’s third biggest killer.3 Stroke cost the economy an estimated £8 billion in 2008/09 in England alone4 and it is likely that it costs proportionate amounts in the other three countries of the UK.* There is widespread public misunderstanding about stroke which may lead people to underestimate the impact of stroke on their own families, on health and social services and on society as a whole. And people don’t realise that there is a huge amount that could be done to transform the prospects for people affected by stroke. There is a wealth of evidence to show how, as a society, we could prevent tens of thousands of strokes each year, save thousands from dying from stroke, dramatically reduce the number of people with severe disabilities due to stroke, and maximise the independence of many thousands more.5 In 2005 we published The Stroke Association Manifesto, with ambitious objectives based on that evidence. Since then, our campaigning efforts, collaboration with others and the consensus for change that we have spearheaded, have all supported progress on stroke care across the UK. Virtually all of our 2005 demands are now, at least, policy commitments for the NHS in all four countries of the UK. Each of the four countries now has a strategy or action plan for stroke. In England stroke is defined as a national priority in the NHS Operating Framework. In Scotland stroke continues to be a clinical priority for the NHS and in Northern Ireland it is a key health priority. We would like to see this continue and for a similar commitment to be put in place in Wales. We welcome the inclusion of time bound targets in the Northern Ireland strategy and in Wales and would like to see similar commitments across the UK.
* This manifesto addresses issues of relevance to all four administrations of the UK – England, Northern Ireland, Scotland and Wales – as we strive to encourage improvements in stroke care across the UK. Whilst examples of existing stroke policy and practice are cited, we recognise that responsibility for change rests with each devolved administration, with the exception of reserved matters such as welfare benefits. The word country is used in this manifesto to mean a devolved administration as this reflects common usage of the term, even though devolved administrations are not countries or nations in the legal sense.
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We have started to see real improvements in stroke care in many places but we now need to see those policy commitments translated into action in every part of the UK so that everyone has speedy and equitable access to excellent stroke services. Progress is uneven and many stroke survivors are still not spending the majority of their stay in hospital on a stroke unit So there is still a long way to go. We must not be complacent and we all need to increase our efforts. Responsibility for implementation lies with local health and social care bodies. We want to see them all take up this challenge and deliver the high quality services that stroke survivors and their carers need. We would like to see the guidelines in each country on the management of stroke and TIAs fully implemented.6
Funding We believe that a continuation of ring-fenced funding for stroke in England and the introduction of ring-fenced funding in Wales, Northern Ireland and Scotland is vital to maintain momentum and ensure full implementation of stroke strategies. The amounts required are tiny considered against overall budgets, and the fact that stroke is the number one cause of long-term severe disability.
We have identified some of the key services within the care pathway where we would like to see significant improvements, but there are three key issues that will need to be addressed if these improvements are to become a reality.
Awareness We believe that national and local FAST advertising campaigns should be used in all four countries of the UK, building on the campaigns that have already been developed by the Department of Health in England and that are being proposed in Scotland7 and Northern Ireland. Continued funding is needed in order to maintain awareness of stroke symptoms. These awareness raising campaigns should also signpost people who require more information and support to The Stroke Association and other sources of support.
We have started to see real improvements in stroke care in many places but we now need to see those policy commitments translated into action in every part of the UK so that everyone has speedy and equitable access to excellent stroke services.
Research Funding for stroke research lags dangerously behind that for cancer and heart disease. The Stroke Association is committed to increasing its funding for research over the next five years. We call on government and other funding bodies to similarly increase the amount of funding available for stroke research with a particular focus on increasing stroke research capacity across the full care pathway. We would like to see a continued commitment to and expansion of funding for the UK Stroke Research Network.8
The Stroke Association’s call to action This manifesto sets out our ambitions for stroke care. We believe that over the next five years we can and should aim to: • reduce the incidence of stroke • reduce stroke mortality rates, and • reduce the levels of impairment and disability caused by stroke to that of the best in Europe.
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2010 2015
Stroke prevention
Stroke is the number one cause of long-term severe disability and the third biggest killer in the UK, but it is preventable.
The Stroke Association’s call to action
Greater attention must be given to prevention.
More effective government funded public health measures are required to significantly reduce people’s exposure to risk factors for stroke.12 Stroke should be included more prominently in existing government public health and health promotion policy and activity.13 14 15
• We could prevent 40 per cent of strokes by controlling high blood pressure across the UK.9 • We could reduce strokes by a quarter if everyone ate at least five pieces of fruit and vegetables every day.10 • Up to 15,000 strokes might be prevented every year if we diagnosed and treated TIA and atrial fibrillation quickly. • Prevention of stroke will reduce the incidence of vascular dementia because between 20 and 40 per cent of dementia is stroke related.
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Raising awareness Much more needs to be done to raise public and professional awareness of risk factors for stroke and effective primary prevention measures at individual, family, community and societal levels.11 Health promotion measures
Stroke prevention services Community based stroke prevention services should be developed in partnerships between the voluntary sector the NHS and local authorities – an example being the Stroke Prevention Service provided by The Stroke Association.16 Implementation of guidelines We need to see rapid progress in the implementation of the NICE guidelines for diagnosis and treatment of TIA and minor stroke as these measures have the potential to prevent up to 10,000 strokes per year in the UK17 and are highly cost effective.18 We also want to see continued progress on the implementation of other country-specific guidelines such as the Scottish Intercollegiate Guidance on Risk Estimation and Prevention of Cardiovascular Disease.19
Diagnosis and treatment of atrial fibrillation We would like to see improvements in the diagnosis and treatment of atrial fibrillation (AF) because appropriate anticoagulation of AF patients with a CHADS2 score of 2 or more20 would prevent approximately 4,500 strokes per year.21 The role of GPs in helping people reduce their risk of stroke
Marion Webster
We would like to see GPs encouraged to monitor and manage all those at risk of stroke and refer as appropriate to smoking cessation services, alcohol services, walking for health schemes, exercise referral schemes, and any other relevant local lifestyle initiatives - as has been proposed in the Welsh Assembly Government’s Improving Stroke Services: a Programme of Work.22
A stroke survivor benefiting from a secondary stroke prevention service. ‘The stroke was very frightening; it’s such a disabling illness. From hospital I went to a nursing home for intensive rehabilitation and was walking again after a month. Then I was referred to The Stroke Association’s Stroke Prevention Service in Hull – it’s been fantastic! ‘At the group we spend the first hour doing exercises – it’s so important in stroke recovery. We then talk about food and nutrition and how to make healthy food interesting. The Stroke Prevention Service has helped me understand about food. My husband Ted and I used to snack on pork pies. Nowadays, we eat mainly chicken and vegetables. I’ve also stopped smoking and joined a gym. ‘Without talking to other members of the group, I wouldn’t have known what stroke risk factors I had. It’s hard to believe how much more I’ve recovered.’
Up to 15,000 strokes might be prevented every year if we diagnosed and treated TIA and atrial fibrillation quickly. 7
2010 2015
Emergency and acute stroke care
Stroke costs around £8 billion a year in England alone, but we believe those costs could be reduced and outcomes improved.
The Stroke Association’s call to action
Treating stroke as an emergency and making sure that everyone who has a stroke is treated in a specialised stroke unit would reap savings in terms of bed days in hospital and reduced mortality rates. Crucially, it would also help to reduce the level of stroke-related disability, allowing thousands of people to lead more independent lives after stroke. Improvements have been made but we would like to see more, particularly in the provision of a 24/7 service for hyper-acute response.
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Emergency care All ambulance services should have agreed stroke protocols with hospitals with acute and hyper-acute stroke units.23 24 Hyper-acute stroke care Stroke should be treated as an emergency, with immediate access to brain scanning and thrombolysis where appropriate, and immediate admission to an acute stroke unit.25 26 27 28 Acute care Everyone who has a stroke should be treated in a high quality stroke unit for all of their stay in hospital.29 30 31 Stroke units All stroke units should meet the criteria set out in clinical stroke guidelines and by the British Association of Stroke Physicians.32 33 34 Skills development and training All staff working in emergency and acute care should have appropriate knowledge and skills around stroke, supported through appropriate training.35 36 37 38 39
Treating stroke as an emergency and making sure that everyone who has a stroke is treated in a specialised stroke unit would reap savings in terms of bed days in hospital and reduced mortality rates.
Nikki Camp A stroke survivor who benefited from timely hyper-acute stroke care. Daniel, Nikki’s husband, spotted her stroke and called 999 immediately. Nikki received thrombolysis and was back to work within months. ‘We were on our way back home from dropping our children at nursery. I had a headache and a kind of a fuzzy feeling in my head, I felt nauseous and a funny feeling down my left side. By the time we got home I couldn’t form words, I could barely mumble and just slumped in the corner of the car. Daniel recognised the symptoms and called 999 immediately. ‘I was taken to Good Hope Hospital where the stroke unit had been alerted, I was given a CT scan and then a clot busting drug. Very quickly after I was given that drug I was able to speak and could begin answering questions. ‘Without the clot busting drug, I wouldn’t be able to care for my children, work or enjoy our family life.’
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2010 2015
Life after stroke – from hospital into the community
Stroke can wreck people’s lives, and that of their families and friends, but with better support people can overcome more of the barriers caused by stroke.
The Stroke Association’s call to action
Making sure that every stroke survivor gets a planned discharge from hospital with all of the rehabilitation and support services already in place is the very least that is required. Integrating health and social care services is critical in achieving a smooth transition from hospital into the community. People should get as many rehabilitation services as they need for as long as they need them.40 41 Many will need continuing support for years after their stroke to meet a wide variety of urgent, long-term needs.42
Discharge planning We believe that everyone who has a stroke should be offered a care plan43 44 45 that is co-ordinated by a stroke specialist46 and have their discharge from hospital planned and implemented, preferably with ongoing support and advocacy in the community for at least the first year. We would like to see early supported discharge services encouraged in all areas. Rehabilitation and support It is essential that stroke survivors have appropriate assessment of their rehabilitation and support needs at an early stage, including physical, psychological, sensory and social needs and that rehabilitation for relatively neglected issues such as visual and cognitive impairment is improved. The English Stroke Strategy states that everyone should get the intensity of rehabilitation they need for as long as they need it.47 The Northern Ireland Stroke Strategy states that by April 2010 everyone will have access to appropriate acute and community multi-disciplinary rehabilitation services.48 In Wales, Improving Stroke Services calls for a national protocol on the referral of stroke patients to social services for community support including home adaptations to be in place by March 2010.49 We would like to see substantial progress towards these goals across the UK. Secondary prevention We would like secondary stroke prevention to be given a higher priority and for information and advice about risk factors and life style management to be given to all those who have had a stroke or TIA as this can prevent further strokes.50 GPs have a role to play in ensuring that regular assessments take place and appropriate medication is taken. GP practices should also ensure contact is made with voluntary sector organisations to establish support and continuity of secondary prevention measures for their patients and their families. Rehabilitation research We want to see more research into the benefits of different models of rehabilitation and care in the longer-term post-stroke.
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Involvement in decisions about care We believe that stroke survivors and their carers should be involved in all decisions about their own care and support.51 This includes providing information to stroke survivors and carers in a manner tailored to their individual need.52 In addition, we would like to see appropriate structures in place to ensure that stroke survivors and carers can have an effective say in the design and delivery of local services.53 Self management
Valerie Upton Valerie has been the main carer for her husband Geoff since he had his stroke in 2001. ‘When Geoff first left hospital I didn’t know what to expect. It was all new to me. I accepted all the information and rehabilitation we were given without question, it was only when I spoke to other people that I realised how much more help I needed. I felt isolated and it was very much down to me to get any help or information we required.
We want stroke survivors and their carers to have access to appropriate self management programmes to help them recover and adjust to life after stroke.54 The Scottish Government has established a Self Management Fund to support progress for long-term conditions, including stroke, and we would like to see similar developments across the UK.55 56 Carers’ needs We want to see carers encouraged to have their own needs assessed and, where agreed, the identified support should be put in place.57 58 59 60 Support and training for carers We would like to see additional stroke specific support and training for carers to help them cope with the physical, communication and cognitive impairments experienced by stroke survivors,61 62 such as that provided by The Stroke Association.
‘I was so shocked by what had happened to Geoff that I suffered panic attacks, I had to give up my job at the Post Office and looking after our grandchildren twice a week. ‘It was literally a life changing experience for both of us. Day in, day out, it does get to you. But it’s got better over the years and we just try to make the best of things.’
People should get as many rehabilitation services as they need for as long as they need them. 11
2010 2015
Life after stroke – long-term support
Meeting the long-term needs of stroke survivors is vital to maximise their independence and quality of life.
The Stroke Association’s call to action
Long-term support is just beginning to receive the attention it deserves. We would like to see it being given a higher priority and major improvements in the provision of support. Greater clarity is required in defining what is meant by high quality long-term stroke care and how it might be measured. We believe all stroke survivors should have the right to high quality services whether they are living in their own home or in residential care. Whether someone gets the services to meet their long-term needs should not be a matter of chance or geography.
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A holistic approach to long-term support Holistic, needs-based services should be available to support stroke survivors and their carers in the long-term. We would like to see all stroke survivors given information to enable them to access a range of specialist and generic support services designed with the stroke survivor at the centre.63 64 The services required will include not just health and social care but also cover employment, finance, housing, transport, education, leisure and participation in the community.65 66 67 68 This extensive range of services may be particularly important for adults of working age. Support in residential care The care and support required by those who are discharged into care homes after their stroke and those who experience a stroke while staying in residential care need to be fully recognised and addressed. We want to see the provision of appropriate stroke specific training for care home staff.69 Cognitive and psychological support All too often cognitive impairments and psychological problems such as depression and anxiety go unnoticed following stroke. More also needs to be done to prevent and manage depression following stroke.70 We would like to see the recommendations in the Northern Ireland Stroke Strategy for psychological screening and treatment, and the promotion of long-term psychological adjustment made available to all stroke survivors.71 We would also like to see the English Stroke Strategy proposals on psychological support and regular reviews fully implemented for everyone who has a stroke.72
Implementation of dementia strategies Vascular dementia is often missed because there is little awareness of the condition and a firm diagnosis cannot be made for some time after a TIA or stroke (usually at least three months).73 We want to see better recognition of vascular dementia and rapid progress in implementing government dementia strategies across the UK in order to better meet the needs of people with the condition. Information provision We believe there is an urgent need for better information about vascular dementia and other psychological problems following stroke to be available to those affected and the general public.74
Nicola Harkin A stroke survivor who is rebuilding her life with the help of long-term support services. ‘I was 22 and studying podiatry at Manchester University when I had my stroke. I lost all feeling in the right side of my body and developed aphasia. I needed support, so gave up my university place and moved back to Northern Ireland to be close to family and friends. My friends were great, they got me to draw what I wanted to say and how I felt, they even helped me enroll at an art course. ‘I had some NHS speech therapy and then I joined a Stroke Association support group which helped me further with my speech. I even became confident enough to take up studies again. I’ve completed a course in massage and aromatherapy, reflexology and a BTEC in photography, and begun an NVQ course in childcare. ‘The Stroke Association’s long-term support service has helped me find the old Nicola.’
End of life care We would like to see end of life care that takes account of needs and choices, provided by a workforce with the appropriate skills and experiences in all care settings.75 More research into long-term care Research is urgently needed to identify the best methods of delivery for long-term care. There are currently very few research groups looking into this area. We believe this needs to be addressed to ensure a firm evidence base for long-term care can be established.
We believe all stroke survivors should have the right to high quality services whether they are living in their own home or in residential care. 13
2010 2015
Children and stroke
Stroke is estimated to affect 400 children in the UK each year76 and is one of the top ten causes of childhood death.77
The Stroke Association’s call to action
However, public and professional awareness of childhood stroke is lacking and, perhaps because it is provided as part of paediatric services, stroke in children has been excluded from all stroke plans and strategies in the UK. We believe this must change.
An audit and register of stroke in children There should be an audit of stroke care for children in the UK and the introduction of a national registration system for childhood stroke. Research into childhood stroke There must be an urgent prioritisation of research into the causes and outcomes of childhood stroke and the best methods of treatment. Implementation of RCP guidelines Progress should be made towards the full implementation of the current Royal College of Physicians clinical guidance on childhood stroke. Awareness raising Increased efforts are needed to raise public and professional awareness of childhood stroke. Addressing the impact of stroke on children and families In addition we would like see more attention given to the impact of stroke in the family, particularly on children, some of whom may take on the role of carer.
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Public and professional awareness of childhood stroke is lacking and, perhaps because it is provided as part of paediatric services, stroke in children has been excluded from all stroke plans and strategies in the UK. We believe this must change.
Sam Jones The family of four-year-old Sam Jones was left devastated after he had a stroke. ‘Sam has come on in leaps and bounds since his stroke four years ago,’ says Sam’s mother, Jane. ‘If we’d known at the time that he’d make such progress it would have helped us through the dark times. ‘We were practically living in the hospital as the stroke initially left Sam with complete paralysis of his right side and communication difficulties. ‘The doctors couldn’t tell us if Sam would ever walk again, but with some very intensive physiotherapy, he climbed out of his hospital bed six weeks after his stroke and took his “first” steps. We were so proud, it was just so unexpected. ‘Sam is determined not to let his continuing physical disabilities and mobility problems get in his way. He is now back at school full time, he just doesn’t let anything beat him.’ 15
2010 2015
Conclusions
We urge you to help to reduce the devastating impact of stroke by ensuring that the needs of stroke survivors, their families and their carers are acknowledged and provided for.
Improvements to prevention, care, rehabilitation and long-term support will reduce both the social and financial cost of stroke and will help thousands of people affected by stroke to rebuild their lives. The Stroke Association believes that acting on our manifesto will help to: • reduce the number of people who are affected by stroke • reduce the number who die • increase the number who recover • improve the quality of life of those who become disabled as a result of stroke. If you would like to endorse our manifesto, register your support or comment on the issues we have raised please go to our website www.stroke.org.uk We are counting on you for your support.
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If you would like to endorse our manifesto, register your support or comment on the issues we have raised please go to our website www.stroke.org.uk
Anne Forster Anne Forster is a Professor of Stroke Rehabilitation at Bradford Royal Infirmary and the University of Leeds. ‘I’ve had a long-standing interest in stroke for over 20 years. My career began in physiotherapy which made me aware of the challenges of identifying the best way to treat stroke patients. ‘I’ve been involved in a number of community based projects and these have emphasised to me the many difficulties facing patients and their families after hospital discharge. It’s clear that we need research into improving the longer-term outcomes of stroke survivors. Such research could address improving social activities, returning to work and helping carers. ‘The Stroke Association has been absolutely fundamental to the development of stroke research. However, to build on this we need government and other funding bodies to increase the amount of funding available for research, focusing on all aspects of stroke care including prevention, diagnosis, treatment and rehabilitation.’ 17
2010 2015 References 1 National Audit Office/Department of Health, Reducing Brain Damage: Faster access to better stroke care, 2005. 110,00 strokes and 20,000 TIAs per year in England, Allender S, Peto V, Scarborough P, Boxer A, and Rayner M, 2006; Coronary Heart Disease Statistics, BHF London: 4,000 stroke in Northern Ireland and 10,000 strokes in Wales; ISD Scotland 2007: 12,500 strokes in Scotland.totalling 156,500 across the UK. 2 Adamson J, Beswick A, Ebrahim S, Is stroke the most common cause of disability? Journal of Stroke and Cerebrovascular Diseases, 2004, Volume 13, Issue 4, pages 171-177. 3 Wolfe C, Rudd T, and Beech R (eds), The Burden of Stroke. Stroke Services and Research, The Stroke Association, 1996. 4 National Audit Office Progress in improving stroke care, 2010. 5 Department of Health, Putting prevention first, Vascular Checks: risk assessment and management, 2008. 6 National Institute for Health and Clinical Excellence (NICE), Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA), NICE clinical guideline 68, 2008 (for England and Wales); Clinical Resource Efficiency Team (CREST), Guidelines for the investigation and management of transient ischaemic attack, 2006 (for Northern Ireland); Scottish Intercollegiate Guidelines Network (SIGN) guidelines for stroke (for Scotland). 7 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, paragraph 5.4. 8 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, paragraph 5.62. 9 Van Gijin J, Preventing Strokes by Lowering Blood Pressure in Patients With Cerebral Ischemia, 2002. 10 Josphipura K J, et al, Fruit and vegetables intake in relation to risk of ischaemic stroke, Journal of the American Medical Association (JAMA), 1999, Vol 282, pages 12331239. 11 Department of Health, National Stroke Strategy (for England), 2007, page 60. 12 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, paragraphs 3.7, 3.9, 3.29. 13 Department of Health, National Stroke Strategy (for England), 2007, page 18. 14 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 1, page 5. 15 Welsh Assembly Government, Welsh Health Circular WHC (2007) 082, Improving Stroke Services: A Programme of Work, page 4. 16 Department of Health, National Stroke Strategy (for England), 2007, page 17. 17 Rothwell P, et al, Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study), The Lancet, 2007, 370:9596: 1432-1442.
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18 Luengo-Fernandez R, Gray AM, Rothwell P, Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison, Lancet Neurol, 2009, 8:235-43. 19 Scottish Intercollegiate Guidance Network (SIGN), Guidance 97, Risk estimation and prevention of cardiovascular disease, 2007. 20 CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with nonrheumatic atrial fibrillation (AF), and is used to determine the degree of anticoagulation therapy required. 21 Presentation by Dr Campbell Cowan, Consultant Cardiologist and National Clinical Lead at NHS Improvement conference, 17 June 2009; also Department of Health’s Atrial Fibrillation cost benefit analysis, 2008; and The management of atrial fibrillation costing report, NICE, 2006. 22 Welsh Assembly Government, Welsh Health Circular WHC (2007) 082, Improving Stroke Services: A Programme of Work, page 3. 23 Department of Health, National Stroke Strategy (for England), 2007, page 27. 24 Welsh Assembly Government, Welsh Health Circular WHC (2007) 082, Improving Stroke Services: A Programme of Work, page 4. 25 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 7, page 26. 26 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, paragraphs 5.17, 5.20, and 5.21. 27 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Standard 1 Organisation of Stroke Services, page 8. 28 Welsh Assembly Government, Welsh Health Circular WHC (2007) 082, Improving Stroke Services: A Programme of Work, page 4. 29 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 9, page 30. 30 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, paragraph 5.23. 31 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 5, page 5. 32 British Association of Stroke Physicians (BASP), Service Development and Quality Committee, 2005. 33 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, paragraph 5.25. 34 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 5, page 5. 35 Department of Health, National Stroke Strategy (for England), Quality Marker 18, page 53. 36 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, Paragraphs 5.27, 5.61. 37 NHS Education Scotland, Stroke Core Competencies for NHS staff.
38 Stroke Training and Resources http://www.strokecore competencies.org/node.asp?id=home 39 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 13, Standard 1, pages 5, 9-10. 40 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 10 page 36. 41 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, Paragraph 5.37. 42 Department of Health, National Stroke Strategy (for England), 2007, page 38. 43 Department of Health, National Stroke Strategy (for England), 2007, page 45. 44 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, Paragraph 5.34.
60 Welsh Assembly Government, Welsh Health Circular WHC (2007) 082, Improving Stroke Services: A Programme of Work, Page 8. 61 Department of Health, National Stroke Strategy (for England), 2007, page 20. 62 Rigby H, Gubitz G, Eskes G, Reidy Y, Christian C, Grover V, Phillips S, Caring for stroke survivors: baseline and 1-year determinants of caregiver burden, International Journal of Stroke, June 2009, Volume 4, Issue 3, pages 152-158. 63 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 13 page 42. 64 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 8, Standard 5, pages 6, 19-20. 65 Department of Health, National Stroke Strategy (for England), 2007, page 42.
45 Welsh Assembly Government, Welsh Health Circular WHC (2007) 082, Improving Stroke Services: A Programme of Work, page 7.
66 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, Paragraph 5.31.
46 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 7, Standard 4, pages 6, 17.
67 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 8, Standard 5, pages 6, 19-20.
47 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 10 page 36.
68 Welsh Assembly Government, Welsh Health Circular WHC (2007) 082, Improving Stroke Services: A Programme of Work, page 8
48 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 8, Standards 1, 2 and 5, pages 8-10, 11-14 and 19-20.
69 Department of Health, National Stroke Strategy (for England), 2007, page 47.
49 Welsh Assembly Government, Welsh Health Circular WHC (2007) 082, Improving Stroke Services: A Programme of Work, page 7. 50 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 2, page 16. 51 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 12, page 41.
70 Hackett ML, Glozier NS, House AO, Moving the ambulance to the top of the cliff: reducing the burden of depressive symptoms after stroke, International Journal of Stroke, June 2009, Volume 4, Issue 3, pages 180-182. 71 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 10, Standard 1 and 5, pages 6, 10 and 20. 72 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 14, page 45.
52 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Recommendation 11, page 6.
73 O’Brien JT, Vascular cognitive impairment, American Journal of Geriatric Psychiatry, 2006, 14(9): 724-33.
53 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 4, page 21.
74 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, Paragraph 6.5.
54 Welsh Assembly Government, Welsh Health Circular WHC (2007) 082, Improving Stroke Services: A Programme of Work, page 8.
75 Department of Health, National Stroke Strategy (for England), 2007, Quality Marker 11, page 13.
55 The Long Term Conditions Alliance Scotland, Self Management Fund for Scotland http://www.ltcas.org.uk/index.php?id=47 56 NHS Scotland, Better Heart Disease and Stroke Care Action Plan, 2009, Paragraph 5.46.
76 Mallick AA, Fallon P, Ganesan V, Hedderly T, Kirkham FJ, McShane MA, Parker AP, Wassmer E, Wraige E, O’Callaghan FJK, The incidence of childhood stroke, European Journal of Paediatric Neurology, 2009;13/S1: S5-S6.
58 Community Care and Health Act (Scotland) 2002.
77 Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al. Heart Disease and Stroke Statistics 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee, 2008,117:e25-146.
59 Department of Health, Social Services and Public Safety, Improving Stroke Services in Northern Ireland, 2008, Standard 2 and 7 pages 20, 22-23.
78 Royal College of Physicians Paediatric Stroke Working Group, Stroke in childhood: clinical guidelines for diagnosis, management and rehabilitation, 2004.
57 Department of Health, National Stroke Strategy (for England), 2007, page 44.
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Every five minutes someone in the UK has a stroke. A stroke doesn’t discriminate. It can happen to anyone at any time in their life. Strokes are sudden and their consequences can be devastating. The Stroke Association is the only charity solely concerned with helping everyone affected by stroke across the UK. Our vision is to have a world where there are fewer strokes and all those touched by stroke get the help they need.
Registered office The Stroke Association Stroke House 240 City Road London EC1V 2PR Telephone 020 7566 0300 Textphone 020 7251 9096 Wales The Stroke Association Greenmeadow Springs Business Park Unit 8 Cae Gwyrdd Tongwynlais Cardiff CF15 7AB Telephone 029 2052 4400 Scotland The Stroke Association Links House 15 Links Place Leith Edinburgh EH6 7EZ Telephone 0131 555 7240 Northern Ireland The Stroke Association Graham House Knockbracken Healthcare Park Belfast BT8 8BH Telephone 028 9050 8020
The Stroke Association is a Company Limited by Guarantee, registered in England and Wales (No 61274). Registered Charity in England and Wales (No 211015) and in Scotland (SC037789). Also registered in Isle of Man (No 945) Jersey (NPO 369) and in Northern Ireland. Stroke Helpline 0303 3033 100 © The Stroke Association 2010 Designed by MGA&D
www.stroke.org.uk
