The following is a letter from the British Association of Stroke Physicians to the Health Secretary Jeremy Hunt about an NHS National Stroke Strategy:
Dear Mr Hunt,
We are writing to you in response to your recent media appearances highlighting stroke as an important condition requiring high quality multi-disciplinary care seven days a week, and we call upon you to renew the government’s commitment to improve stroke care by working with stroke clinicians and stroke survivors to produce an updated NHS National Stroke Strategy in England.
The British Association of Stroke Physicians (BASP) is concerned about the quality of multidisciplinary care received by stroke patients at weekends, but we cannot identify any contemporary evidence supporting a link between levels of junior doctor staffing and excess mortality for people with stroke admitted on Saturday or Sunday.
Furthermore, we are very concerned by any message given to the public which risks discouraging people with symptoms that may indicate a stroke from seeking help at weekends.
BASP has listened carefully to recent discussions about the ‘weekend effect’ on stroke mortality, and we have been back to the key original UK research papers which compare the process of care and outcomes for people with stroke who were admitted on weekdays with those admitted at weekends (1-3).
A recent study has demonstrated an increased mortality for patients who were admitted at weekends (1).
This excess mortality persisted when adjusted for stroke severity and other factors, and is attributable to reduced access to stroke unit care at weekends. Stroke unit care has been shown decisively to reduce mortality and disability from stroke. Stroke units are the cornerstones of high quality stroke care and patients should be admitted to a stroke unit as soon as possible after the onset of symptoms.
The Sentinel Stroke National Audit Programme has shown that the quality of stroke care is lower at weekends. This comprehensive and contemporary audit of stroke care has clearly demonstrated an excess mortality associated with low weekend staffing by registered nurses – one excess death per 25 admissions. The adjusted 30-day mortality risk was 15.2% for stroke units with 1.5 nurses per 10 beds at a weekend compared to 11.2% for units with 3.0 nurses per 10 beds – an absolute difference of 4% and relative difference of 26% (2).
Importantly, no similar link was found between the number of weekend stroke consultant ward rounds and mortality.
Nevertheless, BASP regards seven day consultant ward rounds on hyperacute and acute stroke units as best practice, as outlined in our own professional standards.
We are not aware of any research which has looked at levels of junior doctor staffing at weekends and stroke mortality.
A number of dedicated hyperacute stroke units are now providing excellent 24/7 care, but there still remains unacceptable geographical variation in the quality of in-patient stroke services across England.
We strongly believe that stroke patients should receive high quality care regardless of the time of hospital admission. Immediate access to a stroke unit is vital in reducing both mortality and disability following stroke. The intensity of weekend nursing staffing really matters, and the low levels of registered nurses on stroke units at weekends needs to be addressed as a matter of urgency.
NHS National Stroke Strategy
There have been major improvements in stroke services since the introduction of England’s first ever NHS National Stroke Strategy in 2007. However, further improvement is essential, and BASP is calling for a renewal of the Government’s commitment to improve the care of people with stroke, by working with the professions and stroke survivors to produce an updated National Stroke Strategy for the next ten years.
BASP is particularly keen to work with the National Clinical Director for Stroke and NHS England to look at implementing evidence-based improvements to stroke care on weekdays, weeknights and weekends, to reduce the enormous burden of stroke on individuals, families and society.
We look forward keenly to hearing your plans for taking these matters forward.
Professor Helen Rodgers MB ChB FRCP
Clinical Professor of Stroke Care, Newcastle University
President, British Association of Stroke Physicians
On behalf of the BASP National Executive
Stroke patients admitted within normal working hours are more likely to achieve process standards and to have better outcomes.
- Bray BD, Ayis S, Campbell J, Cloud GC, James M, Hoffman A, Tyrell PJ, Wolfe CDA, Rudd AG.
Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: prospective multicentre cohort study. PLoS Medicine 2014;11:e1001705
- Roberts SE, Thorne K, Akbari A, Samuel DG, Williams JG.
Mortality following stroke, the weekend effect and related factors: record linkage study. PLoS One. 2015;10:e0131836