Should stroke services be centralised to improve care?

A BMJ study funded by the National Institute of Health Research has concluded that NHS reforms and consolidation of stroke units would benefit a majority of stroke patients.

The Stroke Association suggested the number of acute stroke units could be reduced from 127 to 80 specialist units, including 30 neuroscience centres and 50 hyper-acute stroke units (HASUs). This could form part of the NHS long-term plan to ‘reconfigure stroke services into specialist centres’.

In London, centralisation of stroke care has lessened the economic burden on the NHS, increased the number of patients receiving thrombolysis treatment, and reduced mortality. Centralisation elsewhere is also likely to improve care; the study observed that patients admitted to centralised HASUs had better access to services such as brain scans and quicker direct admission to a stroke unit.

The study by the BMJ assessed an HASU model of care with the main measures being travel distance, time, and the number of patients attending HASUs with at least 600 admissions per year. The study found that it would be possible for most patients to visit an HASU with at least 600 admissions per year, a figure which currently stands at just 56%.

The HASU model described in the paper estimates that only 1.5% of the population would not benefit from centralisation, i.e. those located more than 1 hour from a reconfigured HASU. Furthermore, the number of patients within 30 minutes of HASUs would be reduced from 90% to 80–82%, with 95% and 98% lying within 45 and 60 minutes travel time, respectively.

Analysis of the study by the Health Service Journal suggests that centralisation will involve:

  • increasing the number of neuroscience centres from 24 to an estimated 30
  • remodelling the current 102 stroke units into 50 HASUs, each aiming to admit at least 600 patients per year.

The NHS has made no comment on the expected scale of centralisation that will occur but states that the reconfiguration will achieve ‘amongst the best performance in Europe for delivering thrombolysis’ by 2025, as well as increase the proportion of stroke patients receiving thrombectomy from 1% to 10%.