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The British Geriatrics Society (BGS) is the only professional association, in the United Kingdom , for doctors practising geriatric medicine. The 2,200 members worldwide are consultants in geriatric medicine, the psychiatry of old age, public health medicine, general practitioners, allied health professionals, and scientists engaged in the research of age-related disease. The Society offers specialist medical expertise in the whole range of health care needs of older people, from acute hospital care to high quality long-term care in the community.

Geriatric Medicine
Geriatric Medicine (Geriatrics) is that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness of older people. Their high morbidity rates, different patterns of disease presentation, slower response to treatment and requirements for social support, call for special medical skills. The purpose is to restore an ill and disabled person to a level of maximum ability and, wherever possible, return the person to an independent life at home.

The Society is delighted to be given the opportunity to contribute to this debate and would comment as follows:

Chapter 1- Time is brain

1. Are the recommendations from the project groups the right ones?
In general, yes. Many clinicians find that duplex ultrasound is more reliable than MRA for detecting carotid stenosis. Is the recommendation that patients with TIA should have both?

The recommendations will require substantial extra resources. TIA is a common condition and a large hospital will see about one per day. This would require 1-2 slots of MRI per working day. Many hospitals will need extra ultrasound slots. Currently many hospitals only see patients once, a follow-up visit will require double the clinic time. This is a massive increase over present provision particularly for MRI. In many hospitals TIA is currently managed as an outpatient condition. Even if patients stay only 24h, the recommendations would lead to an average of one extra medical bed being occupied at any time in each hospital over the whole NHS.

The needs of patients in whom a stroke is just one part of a complex medical situation should be specifically mentioned. It is neither necessary nor in the best interests of some patients with chronic disabling or life-limiting disease to have scans which will not change management. Some such patients may also not benefit from Stroke Unit care and are better managed on specialist wards for older people or in the community.

2. Will the recommendations deliver improved services for people who experience TIA?
Yes if accompanied by extra resources. Again, the avoidance of unnecessary imaging in patients with chronic disabling or life-limiting disease needs to be specifically mentioned.

3. Will the recommendations help to ensure that stroke is treated quickly and effectively?
Yes

4. Are these the right recommendations to feed into an imaging strategy for TIA and stroke?
Yes but see (1) above

5. Will this approach support continuing improvements to stroke unit care?
Yes but… As shown in your scenario “Getting to the Stroke Unit” the changes made in Aintree resulted in only 3% of patients being thrombolysed. It is important that energy and investment targeted towards thrombolysis should not in any way reduce the energy and investment that is needed for rehabilitation. The BGS feels that there is a risk that emphasis on acute treatment may divert attention from the clear deficiencies in the later part of the stroke pathway. See comments in 2(1) below.

6. Do the recommendations adequately address the need for close working across first contact services, ambulance services and hospitals?
Yes

7. Is there anything that has been missed?
There is no timescale for any of the recommendations to be implemented. Without this we feel that many organisations will defer their responsibilities indefinitely.

Chapter 2 – Life after a stroke
1. Are the recommendations from the project groups the right ones?
In general, yes. Para 5 correctly identifies the huge gulf between the level of rehabilitation presently available and that supported by the evidence. The BGS agrees with this analysis. There is at present a severe shortage of funded posts in all the rehabilitation professions. We wonder how the investment to achieve evidence based levels of rehabilitation is to be achieved. Without it the present difficulties experienced by stroke survivors will continue.

There is still, for most districts a considerable gap between the level of rehabilitation available to in-patients and that available in the community. Until this gap is closed there will be reluctance to move towards early discharge

The paper should be clear as to what “the third sector” referred to in para12 actually means. We are not familiar with this term.

2. Will the recommendations help improve transitions from hospital to home?
Yes

3. Do the recommendations adequately address the needs of carers?
Yes

4. Do the recommendations adequately address the needs of younger stroke survivors, who may face additional challenges?
Yes. However there is an even greater lack of specialist therapists trained to work with this age group. This particularly applies to those with cognitive and psychological problems who often have to wait months for suitable rehabilitation programmes.

We note that most of the case histories in the document are of ‘younger’ patients. This does not reflect the reality as stroke is predominantly a disease of the elderly. This misleading emphasis on the young should be changed in the final document.

5. How can services best improve access to psychological support?
In many districts there is currently no psychological support. Fully trained clinical psychologists are expensive and in short supply. Clinical psychology assistants and trained counsellors could probably do some of this work but are also virtually unavailable. If the Government wishes to make this service more widely available it needs to employ and train the people who can provide it.

Regional and sub-regional rehabilitation units often have long waiting lists and idiosyncratic admission policies. They are often unresponsive to the needs of patients and DGH teams and fail to provide timely assessment and support. This is largely due to under-resourcing.

6. Is there more that can be done to improve joint working across services?
No

7. Is there anything that has been missed?
The major weakness in the chapter is that it does not fully deliver on the proposed title of the report: “A new ambition for stroke: a consultation on a national strategy”. The “ambition” component is described but there is only a rudimentary “national strategy.”

The chapter essentially provides a listing and review of services known to be helpful to patients recovering from a stroke – both in hospital, during the transfer of care period, and in the longer-term. The ambition is that more stroke patients will more easily access these services in the future. But no genuine implementation strategy is presented or developed describing how the ambition will be realised. What should be done, who should do it, how will it be done and by when – none of these questions are addressed. What is needed in the next version is some practical implementation guidance. Should there be a lead PCT person responsible for commissioning stroke recovery services? Should there be a district–wide multi-agency group established to progress stroke care? Virtually no mention has been made of the role and involvement of the primary care team, or the possibility of modifying the QoF to encourage regular reviews of stroke patients in accord with other long-term conditions. The NSF for Older People recommends a new post – that of the Stroke Care Co-ordinator – to help support stroke patients and their families in the longer-term. This post does not now appear to be part of our proposed national stroke strategy.

There is no timescale for any of the recommendations to be implemented. Without this we feel that many organisations will defer their responsibilities indefinitely.

There is little reference to the management of those in whom stroke causes predominantly cognitive problems. These patients and their carers need greater access to clinical psychology support and counselling.

Chapter 3 – Working together
1. Are the recommendations from the project groups the right ones?
Broadly yes

2. Will clinical networks drive the changes needed?
Because of the acknowledged resource implications it will be important for Commissioners to be part of the process.

3. What are the benefits and concerns about expanding the cardiac network infrastructure?
We have a number of concerns.

• Those prescribing thrombolysis for stroke need to be able to take an accurate medical history, do a reliable and complete neurological examination and interpret CT scans for subtle changes. This needs a different level of training to that required in acute coronary syndrome and we do not anticipate these skills being as easily acquired as those needed to interpret simple changes on an ECG.
• The risk/benefit ratio of anti-thrombotic treatment is quite different in stroke and MI. Cardiologists to date have failed to recognise this.
• Hyperacute stroke care needs to be multidisciplinary. There is no point in thrombolysing a patient who then aspirates because of poor swallow screening or fails to mobilise early because of inadequate physiotherapy assessment.
• Most hospitals now have stroke specialists. They are best qualified to have input at the earliest stage. It seems odd to give this responsibility to a different specialist group who already have a heavy workload and significant waiting times in may areas.
• There are potential disadvantages in thrombolysing patients in non-local centres. Discharge planning in stroke requires knowledge of and immediate access to local community services. Transferring patients between centres always leads to delays and this significantly disadvantages older and more dependant patients. The hazards of this have not been quantified but are likely to be significant.

4. Will the recommendations support more effective local workforce planning for stroke?
Yes but only if adequate resources are provided.

5. Are there any key gaps in research activity which need to be addressed to support the implementation of this strategy?
This document has not addressed research priorities at all. Transfer of stroke patients between hospitals may bring significant hazards (see above) and should not be implemented without piloting and monitoring closely to identify both risks and benefits before major systems changes are introduced.

6. Is there anything that has been missed?
No

Chapter 4 – Everyone’s Challenge
1. Are the recommendations from the project groups the right ones?
Yes

2. Will the recommendations improve public awareness?
Yes

3. Will the recommendations improve professional awareness?
Yes

4. Is this the right approach to improve information and advice for people at risk of a stroke or who have experienced a stroke?
Yes

5. What more could be done to support primary care in recognising and reducing people’s risk of stroke? Focus on stroke education as described but ensure that local services are funded before raising expectations

6. Is there anything that has been missed?
No

Professor Peter Crome MD PhD FRCP FFPM
President
For and on behalf of British Geriatrics Society
14 September 2007