Stroke improvement plan: fairer Scotland duty summary

Stroke Improvement Plan 2023

Summary of aims and expected outcomes of strategy, proposal, programme or policy

Stroke continues to have a significant impact on people in Scotland. Over the last decade, the death rate from cerebrovascular disease (CVD), which includes stroke has decreased by 26%. However, stroke remains a leading cause of death in Scotland. There were 3,836 deaths in Scotland in 2021 where CVD, including stroke, was the underlying cause.

The Stroke Improvement Plan considers recommendations made in the Progressive Stroke Pathway, produced by the National Advisory Committee for Stroke. In addition, the Covid-19 pandemic has highlighted challenges and changed models of care across the entire health care system and this is an appropriate point to take stock and refresh our commitments on stroke.

The vision of the Stroke Improvement Plan is to support delivery of the best possible stroke care in Scotland. This means considering the entire stroke pathway, from prevention and awareness raising to the provision of rehabilitation and ongoing support.

The main outcomes we expect the plan to deliver are;

Priority 1: Prevention

We will seek to prevent as many strokes as possible, by working to improve the detection and management of underlying risk factors for stroke.

Priority 2: Awareness raising

We will work to understand current public awareness of stroke symptoms, and the action required when they occur, and support the delivery of FAST campaigns.

Priority 3: Hyperacute care

We will optimise delivery of thrombolysis and expand access to the national thrombectomy service, with the aim of a national round-the-clock thrombectomy service.

Priority 4: Early secondary prevention

We will seek to prevent as many additional strokes as possible by optimising the care of those who have suffered a stroke or TIA.

Priority 5: Rehabilitation

We will make the provision of high quality, holistic rehabilitation a cornerstone of stroke care in Scotland. Rehabilitation should be person-centred, re-accessible, delivered in the appropriate setting and patient outcomes and experiences measured.

Priority 6: Psychological care

We will ensure that the emotional and cognitive needs of those who have survived a stroke are given the same level of importance as their physical needs and recovery.

Priority 7: Collaborative implementation

We will establish a Scottish Government led forum for bringing representatives of every NHS Board stroke service, as well as third sector organisations, together. This will facilitate the sharing of best practice and identify opportunities for collaborative care across NHS Boards.

Summary of evidence

Summary of assessment findings

Evidence:

In addition to the long-term impacts of stroke, more people are living with long-term conditions such as cardiovascular disease, neurological conditions, chronic respiratory conditions and diabetes, as captured in the Scottish Burden of Disease data. Each of these conditions requires ongoing treatment and care and has a subsequent impact at each stage of the treatment of, and recovery from, stroke.

Social determinants of health have been set out in reports such as the Black report (1980). It highlights differential mortality rates with those in more deprived communities suffering higher rates of mortality with inequalities in access to health services and low rates of uptake by those groups.

The Scottish Burden of Disease Study (2016) found that the most deprived areas of Scotland have double the rate of illness or early death than less deprived areas. People living in more deprived areas are more likely to live in ill health and die prematurely.

The Scottish Burden of Disease study (2022) notes that

there is already evidence that the COVID-19 pandemic has exacerbated progress in tackling disease and risk factors

and the impact of the cost-of-living crisis is also likely to result in major health inequalities.

Homeless people are more likely to come from deprived areas and health inequalities are likely to exist between people that have experienced homelessness and those who have not. 8% of the Scottish population (as of June 2015) had experienced homelessness at some point.

In 2021/22, the death rate for CVD in the most deprived areas was 43% higher than in the least deprived areas in 2021 with mortality rates in the under-65 age category significantly above the Scottish average in the most deprived 10% of the population. This has an impact on death rates, and importantly – premature death rates.

Possible impacts:

The vision of the Stroke improvement Plan is of minimising preventable strokes and ensuring timely and equitable access to life-saving treatment. Additionally, the plan places renewed emphasis on the importance of the provision of holistic care, particularly in the approach to rehabilitation.

The evidence outlined above indicates that in order to achieve this, we will need to ensure that models of care address the barriers faced by people living in areas of socio-economic deprivation.

We will align stroke policy closely with prevention work already underway, and assess where additional input may be required to target primary prevention towards stroke and ensure these approaches are person-centred, co-designed and data driven to identify variation and inequality and to drive improvements in stroke care.

Through building on the work of the lived experience of the National Stroke Voices into the implementation of the plan, we will work to reflect the voices of people within such communities in order to better understand and address their needs and barriers they face.

Options to strengthen the strategy impact on inequalities of outcome:

Option 1:

Within Priority 1: Primary Prevention, we will seek to prevent as many strokes as possible, by working to improve the detection and management of underlying risk factors for stroke.

Pros:

Benefits are that this work is already underway, via the Scottish Heart Disease Action Plan to implement a community-based awareness, prevention and detection programme for high blood pressure and high cholesterol across Scotland. Improvements in data collection for all three conditions will support local quality improvement within primary care and data should also be made available at regional and national level to identify unwarranted variation, including on the basis of socio-economic deprivation.

Option 2:

Within Priority 5: Rehabilitation, work with Public Health Scotland to develop measures of patient experience and outcomes relating to rehabilitation, with the aim of developing these by the end of 2024.

Pros:

Key to improving stroke care is ensuring that stroke services address the challenges faced by those who have experienced a stroke. These will enable us to measure the things that are important to people in the delivery of their care, and address unwarranted variation across Scotland, including on the basis of socio-economic deprivation.

Cons:

It may be difficult to ensure data collection of measures of patient experience and outcomes if we are moving towards more effective use of routinely collected data, as opposed to relying on clinical input.

Changes to plan:

As per option 2, we have included a commitment to work with Public Health Scotland to develop measures of patient experience and outcomes relating to rehabilitation, with the aim of developing these by the end of 2024.

Our ambition is to implement measures of rehabilitation, which reflect the experiences and outcomes for those who have had a stroke.

We will work with Public Health Scotland to explore how we can capture this data and use it to inform quality improvement. This should also include capturing data reflecting the number of patients being offered six-month reviews, community rehabilitation referrals and re-engagement with services and that people from areas of socioeconomic deprivation are included in this data capture.