NICE: Health organisations working to incorporate NICE recommendations into NHS care to benefit thousands of patients who have had a stroke

NICE | July 2019| Health organisations working to incorporate NICE recommendations into NHS care to benefit thousands of patients who have had a stroke

NICE has published an NHS workforce and resource impact statement designed to support commissioners and Trusts understand the potential impact on the NHS workforce and resources of implementing specific NICE guidelines.


The statement is a collaboration between NICE NHS England and NHS Improvement, NHS Clinical Commissioners, and Health Education England

The statement also highlights the initiatives underway both within and across organisations to put the NICE guideline recommendations into practice, including support by NHS England specialised commissioning for the implementation of a thrombectomy service specification across the country. These initiatives will ensure the provision of the most effective, up-to-date treatments and in doing so will improve patient care.

Read the statement from NICE

NIHR: Centralising stroke services can save lives

NIHR | June 2019 | Centralising stroke services can save lives

The National Institute of Health Research (NIHR) has published NIHR Signal to highlight the findings of a recent mixed-methods study which compared the effectiveness of the different models of stroke service centralisation implemented in London and Manchester with the rest of England.

According to the Signal, the study’s findings helps clarify what aids successful implementation. Centralised service models where all stroke patients are eligible for treatment in a hyperacute stroke unit (such as London and Greater Manchester B) seem to perform better than those with more selective admission criteria (Greater Manchester A).


Read the Signal at NIHR 

Full reference: Fulop, N. et al| 2019|Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study | Health Services and Delivery Research | Volume 7 Issue 7| Retrieved:


Background Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care and outcomes.
Objective To use formative evaluation methods to analyse reconfigurations of acute stroke services in different regions of England and to identify lessons that will help to guide future reconfigurations, by studying the following contrasting cases: (1) London (implemented 2010) – all patients eligible for Hyperacute Stroke Units (HASUs); patients admitted 24 hours a day, 7 days a week; (2) Greater Manchester A (GMA) (2010) – only patients presenting within 4 hours are eligible for HASU treatment; one HASU operated 24/7, two operated from 07.00 to 19.00, Monday to Friday; (3) Greater Manchester B (GMB) (2015) – all patients eligible for HASU treatment (as in London); one HASU operated 24/7, two operated with admission extended to the hours of 07.00–23.00, Monday to Sunday; and (4) Midlands and East of England – planned 2012/13, but not implemented.

Impact was studied through a controlled before-and-after design, analysing clinical outcomes, clinical interventions and cost-effectiveness. The development, implementation and sustainability of changes were studied through qualitative case studies, documentation analysis (n = 1091), stakeholder interviews (n = 325) and non-participant observations (n = 92; 210 hours). Theory-based framework was used to link qualitative findings on process of change with quantitative outcomes.
Results Impact – the London centralisation performed significantly better than the rest of England (RoE) in terms of mortality, resulting in an estimated additional 96 lives saved per year beyond reductions observed in the RoE, length of stay (LOS) (–1.4 days, 95% –2.3 to –0.5 days) and delivering effective clinical interventions [e.g. arrival at a Stroke Unit (SU) within 4 hours of ‘clock start’ (when clock start refers to arrival at hospital for strokes occurring outside hospital or the appearance of symptoms for patients who are already in-patients at the time of stroke): London = 66.3% ; comparator = 54.4% . Performance was sustained over 6 years. GMA performed significantly better than the RoE on LOS only. GMB (where 86% of patients were treated in HASU) performed significantly better than the RoE on LOS and clinical interventions [e.g. SU within 4 hours: GMB = 79.1%; comparator = 53.4%] but not on mortality; however, there was a significant effect when examining GMB HASUs only, resulting in an estimated additional 68 lives saved per year. All centralisations except GMB were cost-effective at 10 years, with a higher net monetary benefit than the RoE at a willingness to pay for a quality-adjusted life-year (QALY) of £20,000–30,000. Per 1000 patients at 10 years, London resulted in an additional 58 QALYs, GMA resulted in an additional 18 QALYs and GMB resulted in an additional 6 QALYs at costs of £1,014,363, –£470,848 and £719,948, respectively. GMB was cost-effective at 90 days. Despite concerns about the potential impact of increased travel times, patients and carers reported good experiences of centralised services; this relied on clear information at every stage. Planning change – combining top-down authority and bottom-up clinical leadership was important in co-ordinating multiple stakeholders to agree service models and overcome resistance. Implementation – minimising phases of change, use of data, service standards linked to financial incentives and active facilitation of changes by stroke networks was important. The 2013 reforms of the English NHS removed sources of top-down authority and facilitative capacity, preventing centralisation (Midlands and East of England) and delaying implementation (GMB). Greater Manchester’s Operational Delivery Network, developed to provide alternative network facilitation, and London’s continued use of standards suggested important facilitators of centralisation in a post-reform context.

The main limitation of our quantitative analysis was that we were unable to control for stroke severity. In addition, findings may not apply to non-urban settings. Data on patients’ quality of life were unavailable nationally, clinical interventions measured changed over time and national participation in audits varied. Some qualitative analyses were retrospective, potentially influencing participant views.Conclusions

Centralising acute stroke services can improve clinical outcomes and care provision. Factors related to the service model implemented, how change is implemented and the context in which it is implemented are influential in improvement. We recommend further analysis of how different types of leadership contribute to MSC, patient and carer experience during the implementation of change, the impact of change on further clinical outcomes (disability and QoL) and influence of severity of stroke on clinical outcomes. Finally, our findings should be assessed in relation to MSC implemented in other health-care specialties.

The full article is available here
Of interest:

Thousands more to ‘survive and thrive’ after stroke thanks to NHS specialist teams

NHS England | June 2019 | Thousands more to ‘survive and thrive’ after stroke thanks to NHS specialist teams

Rolling out  expert stroke teams across the country as part of the NHS Long Term Planwill ensure thousands more people ‘survive and thrive’, England’s top doctor announced today.

Speaking at the NHS Confederation conference, Professor Stephen Powis, NHS national medical director, revealed that the NHS has already saved hundreds more lives through the introduction of stroke networks across two major cities. Powis cited a major new study which found 170 extra lives are saved a year in London and Manchester alone thanks to the establishment of Hyper Acute Stroke Units (HASUs).

The units bring experts and equipment under one roof to provide world-class care and treatment around the clock, reducing death rates and long-term disability.



Working at the centre of a network of local hospitals, the units give patients faster access to specialist diagnosis and treatment, such as brain scans, clot-busting drugs and mechanical thrombectomy.

Patients treated at the specialist centres also spend less time in hospital, which is better for them and frees up staff and beds to care for more patients.

Professor Powis said: “Faster diagnosis, quicker access to better treatment, ongoing rehab for survivors, and 24-hour specialist units, will make the NHS even more effective at tackling strokes.

“But it’s clearly far better for everyone if we can help someone avoid having a stroke in the first place.

“For me this is a real inequalities issue – we know that people who are from disadvantaged or black or ethnic minority backgrounds are more likely to be among those who go undiagnosed and untreated, and are therefore more likely to die or be severely disabled by stroke.

“So the NHS will also take practical action to ensure that people living with the risk of stroke hanging over them will be offered the opportunity to understand and reduce that risk, and family doctors and their expanding teams, including nurses and clinical pharmacists, will be central to this.” (Source: NHS England)

Full news story from NHS England 

Of interest:

NIHR Centralising stroke services can save lives

Association Between Reported Long Working Hours and History of Stroke

Fadel, M. 2019 | Association Between Reported Long Working Hours and History of Stroke in the CONSTANCES Cohort | Stroke |

Long working hours are recognised as a risk factor for stroke.  Now French researchers have investigated the possible association in a large general population cohort.


Background and Purpose

Long working hours (LWHs) are a potential risk factor for stroke. The aim of this study was to investigate this association in a large general population cohort.


We used the French population-based cohort, CONSTANCES (Cohorte des Consultants des Centres d’Examens de Santé), to retrieve information on age, sex, smoking, and working hours from the baseline, self-administered questionnaire. Other cardiovascular risk factors and previous occurrence of stroke were taken from a parallel medical interview. We defined LWH as working time more than 10 hours daily for at least 50 days per year. Participants with primarily part-time jobs were excluded as were those with stroke before LWH exposure. We used logistic models to estimate the association between LWH and stroke, stratified by age, sex, and occupation. In additional modeling, we excluded subjects whose stroke occurred within 5 years of the first reported work exposure.


Among the 143 592 participants in the analyses, there were 1224 (0.9%) strokes, 42 542 (29.6%) reported LWH, and 14 481 (10.1%) reported LWH for 10 years or more. LWH was associated with an increased risk of stroke: adjusted odds ratio of 1.29. Being exposed to LWH for 10 years or more was more strongly associated with stroke, adjusted odds ratio of 1.45 . The association showed no differences between men and women but was stronger in white-collar workers under 50 years of age.


This large analysis reveals a significant association between stroke and exposure to LWH for 10 years or more. The findings are relevant for individual and global prevention.

Full article available from Stroke 


In the news: BBC News Long working hours ‘linked to stroke risk’

Stroke National Audit Programme – Annual Report 2019

Sentinel Stroke National Audit Programme & King’s College London| June 2019 | Sentinel Stroke National Audit Programme – Annual Report 2019

Health Quality Improvement Partnership (HQIP) has published its annual report which examines the findings of data collected during five years from April 2013 – March 2018. It aims to provide a detailed, accurate picture of the characteristics of people who have a stroke and the care that is provided to them in hospital and following discharge. The report publishes a summary of national results over five years April 2013 – March 2018 unless otherwise stated, and provides more detailed commentary on specific aspects of stroke care which are topical, pertinent and/or significantly variable in performance. 


As Sentinel Stroke National Audit Programme (SSNAP) data now covers five years, it is possible to look at changes over time, highlight those aspects of care which are improving, stagnating or deteriorating, and discuss what still needs to be done.

This is a public report on the clinical component (process of care) of the national stroke
audit, the Sentinel Stroke National Audit Programme (SSNAP). It publishes a summary of national results over five years April 2013 – March 2018 unless otherwise stated, and provides more detailed commentary on specific aspects of stroke care which are topical, pertinent and/or significantly variable in performance. It includes processes of care across the entire stroke pathway from acute interventions, assessments, rehabilitation and longer term domiciliary care, including comparisons with previous year’s results.

The findings show that in general, patients are receiving acute interventions (including urgent scanning, thrombolysis, thrombectomy and swallow screening) faster, and that stroke patients are being given more therapy to help their recovery as increasing proportions of patients are benefiting from assessments. However there is still variation between some indicators on a national level, such as in the percentage of stroke patients being admitted to a stroke unit within 4 hours (Source: Sentinel Stroke National Audit Programme & King’s College London).

Sentinel Stroke National Audit Programme – Annual Report 2019

Source: Health Quality Improvement Partnership

NICEimpact Stroke

NICE |  May 2019 | NICEimpact Stroke

NICEimpact Stroke is a report from NICE that focuses on how NICE’s evidence-based
guidance contributes to improvements in care for people who are at risk of or who have had a stroke.

Image source:

Topics covered include:

  • Stroke prevention in atrial fibrillation
  • Acute care
  • Rehabilitation
  • Spotlight on thrombectomy

NICEimpact Stroke


Lancet:Large trial says aspirin safe for brain bleed stroke patients

RESTART Collaboration | 2019| Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial | The Lancet | DOI:

A new study published in The Lancet reports that patients who experience stroke as part of a brain hemorrhage are able to take medicines such as aspirin, without raising their risk factor of experiencing another stroke.



Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events.


The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (more than or equal to 18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627).


Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years. 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy  participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy, and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy.


These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention.


Read the full article in The Lancet

In the news:

OnMedica Large trial says aspirin safe for brain bleed stroke patients