In May 2010, NHS Nottingham City and Nottingham City Council published their joint Strategy for Stroke Services. This was developed by a range of stakeholders from extensive review of current services, unmet needs and evidence for effective stroke prevention and care. The vision for stroke care in Nottingham City is to reduce the incidence of TIA and stroke; ensuring that when a stroke or TIA does occur patients have timely assessment and treatment in an appropriate setting, by competent and trained clinicians who link seamlessly with the community teams in order to provide comprehensive, local, personalised care packages to both patient and carer in line with the Nottingham stroke and TIA pathway illustrated below.
The following services have been mapped against the strategy’s stroke pathway to illustrate the stroke patient / carer journey.
Awareness Raising and Prevention
Across Nottingham City a range of services exist to support the prevention and early identification of cardiovascular disease, targeted towards priority areas and population groups who have the most need including stroke. These services include:
Adult Healthy Living Referral - A range of community-based services which support behavioural change to reduce lifestyle risk factors including stopping smoking, increasing physical activity, improving diet, and reducing obesity.
NHS Health Checks - A national service for cardiovascular risk assessment. In Nottingham this service was initially launched as the Happy Hearts pilot service in 2008, and is now provided through a GP Local Enhanced Service.
Change Makers for Heart Health - A community development approach which has built on an initial Healthy Communities Collaborative project. A team of volunteers from our CVD priority areas work to raise awareness of lifestyle risk factors, signs and symptoms, and signpost to support service for lifestyle changes. The volunteers promote early presentation to primary care and therefore support early diagnosis and treatment. Over the two years, teams have increased their focus on stroke and supported national awareness campaigns such as FAST.
For more details on each of these services, see the Cardiovascular Disease chapter.
The standard treatment for atrial fibrillation has been to use drugs to slow down the patient’s heart rate, so that it pumps effectively and enables them to be as active as possible, and to use anticoagulant drugs to reduce considerable the risk the blood clots caused by the AF lead to TIAs and strokes. A newer alternative is to remove or destroy very small areas of the heart that are causing the AF. This is called atrial ablation, and can be carried out using catheters introduced into the circulation via an artery in the groin, or by a more traditional operation on the chest. The procedure is now established and practice has been the subject of a national register of procedures for the last ten years, with the latest data being for 2013/14 (NICOR< 2015). Nationally, procedures have increased between 2007 and 2010, but remaining relatively steady since then. Other trends are that an increasing proportion of these procedures are for AF (now the single most common reason) and have become more complex. Research suggests, however, that more complex procedures are more likely to offer relief from the AF for several years in most patients.
This service is deemed “specialist” and is not commissioned by the Nottingham City CCG, but by NHS England’s Local Area Team for Derbyshire and Nottinghamshire. Consequently, national figures are analysed by local area team (LAT).
Data quality remains a problem (though it appears good for NUH), but the audit suggests that:
Nationally, some 17,106 procedures were carried out in 2013.
Atrial ablation is carried out less frequently in the UK than in most Western European countries.
Some 386 ablations were carried out on residents of Derbyshire and Nottinghamshire, the equivalent of 197/million population. Many other areas carried out more than 3-400/million population.
In 2013, 106 ablations were carried out on residents of Derbyshire and Nottinghamshire for AF.
The original register has been replaced with a more extensive data set from 2014, which will include patient reported outcomes (PROMs).
There appears to be a case for increased to atrial ablation procedures for the population of Derbyshire and Nottinghamshire.
NHS Nottingham City has developed a TIA specific pathway which emphasises the need to treat TIA as a medical emergency. EMAS staff are trained to assess anyone displaying signs and symptoms of TIA against the ABCD2 scale to determine their level of risk before initiating a direct referral into the specialist TIA clinic based within the Stroke Unit of Nottingham University Hospitals NHS Trust (NUH).
Since the last edition of this JSNA chapter (2013) the TIA clinic service provided by NUH has been extended from 5 to 7 days with patients admitted during the out of hour’s period. This now meets the requirements of the national Stroke Strategy.
The management of TIA patients referred to the service is governed by stringent indictors identified within the national Stroke Strategy, which include at high risk TIAs to be investigated and treatment initiated within 24 hours of presentation and are incentivise through the national best practice tariff to be implemented from April 2011.
As part of the best practice tariff for TIA to be introduced from April 2011 NUH will offer all TIA positive patients a follow up appointment at 4 weeks post discharge. Follow up will include a medication review and will promote referral to lifestyle management services to support long term prevention.
NHS Nottingham City now has a referral pathway into the Cardiac Rehabilitation service for stroke patients, providing continued access to life style management and advice. Further details on the latest national audit of cardiac rehabilitation services are in the chapter on CVD.
Acute Stroke Care
NUH Nottingham City’s acute stroke provider was awarded regional comprehensive status as part of the 2010 East Midlands Stroke and Cardiac Network exercise to develop a hyper acute Stroke Centre of the East Midlands. There is a hyper acute status, and 24/7 access to thrombolysis and telemedicine.
Community Stroke Discharge and Rehabilitation Services
Nottingham CityCare Partnership is responsible for the provision of the integrated Community Stroke Discharge and Rehabilitation Service, which includes provision of the following service elements:
Early Supported Discharge Team
The multidisciplinary team (Physiotherapists, Occupational therapists, Nurses, Mental health Nurse, Speech and Language Therapist, Stroke Rehabilitation Community Care Officers, and support workers) has been established to help and support stroke patients immediately after their discharge from hospital. The team provides intensive support for up to 7 days a week, for four to six weeks after discharge. The team facilitate and early discharge and ensure specialist rehabilitation continues at home to optimise the person’s independence and function. The rehabilitation is carried out in either the patient’s home or residential home.
Community Stroke Team – This multi-disciplinary team provides longer-term community rehabilitation services for stroke survivors, either following a period of supported discharge or for stroke survivors in the community for up to two years post-stroke. All people seen by the Community Stroke Team are required to have been through the ‘Stroke Pathway’. They can then be referred by their GP, other health care staff, or self-referral.
StrokeAbility – A community education programme for people who have had a stroke, which incorporates exercise, health education, secondary prevention advice and relaxation, over a 12 week period. The programme is delivered by health professionals, and involves input from a variety of other services, and voluntary and third-sector organisations.
Care Home Education – Following an initial three-year contract, this service has now been commissioned as part of the community service for stroke to provide a rolling programme of education to care home staff. The programme will educate care staff about what a stroke is, signs and symptoms of stroke, risk factors, primary and secondary prevention, the effects of stroke, and how to support residents following a stroke.
Stroke Review and Early Intervention Officers – Following a Reviewing Officer pilot, initially funded by a grant following publication of the national Stroke Strategy, this service has been commissioned recurrently to undertake 6 and 12 month reviews for all Nottingham City patients discharged from hospital as required by the Stroke Strategy Quality Marker 14. The review includes a holistic assessment of stroke survivors’ on-going or unmet health, psychological and social care needs, and provides signposting information for relevant services.
From January 2013 all referrals are made through the Nottingham Health and Care Point.
The following support services are also available to stroke patients and their families/carers in Nottingham City:
Family Carer Scheme - A joint project between Nottingham City Council, Nottinghamshire County Council and the Nottingham CCGs. The service became operational in January 2010. The overall purpose of the service is to provide information, emotional support and advice to people affected by stroke, their families and carers working alongside a multi-disciplinary team of professionals. The service will also have a focus on supporting families and carers from Black Minority Ethnic communities, meeting and addressing the cultural issues that affect these groups. From October 2013 there will be a new carers’ hub providing advice, support and signposting for all carers.
Long Meadow Day Centre
Stroke survivors can attend the Day Centre each week between 2 and 4 times a week (depending on their need), for specialist support. In addition to Day Care services the Long Meadow Stroke Group meets fortnightly, providing much needed support both for the person with the stroke and their carers.
Key concerns expressed by the Stroke Team within CityCare are:
A lack of commissioned rehabilitation in community settings for the most seriously affected stroke survivors, who cannot easily access services at NUH;
A recent fall in referrals, which is thought to follow from falling admissions for acute stroke at NUH;
Difficulties obtaining a timely response form social care;
Ensuring that any modifications to the tariff structure, such as ‘unbundling’ the tariff into its components, adequately meets the costs of each element;
Communication support, where additional speech and language therapist (SALT) time is a perceived need;
Psychological support – although psychological support is provided, this is mainly provided by a nurse specialist and not by a clinical psychologist. Although the local view is that this is appropriate for most cases, only support provided by a clinical psychologist is recognised in the national audit (SSNAP). There are, however, some local concerns that access to a clinical psychologist for more severe or complex cases is currently limited. The CCG commissions psychological support for patients with any long-term condition from the mental health trust, although access may be problematic for patients with mobility problems.
Until March 2016, the Nottingham City CCG and Nottingham City Council had jointly commissioned an Information, Advice and Support Service from the Stroke Association. This was decommissioned, based on the commissioners’ judgement that the ESD service provides such support to patients and carers and that there are alternative sources of information, such as the National Helpline of the Stroke Association.