PLATFORM PIECE by Dr Ivan Wiggam, Clinical Director of Stroke Services, Belfast Health & Social Care Trust
FEW medical conditions are more feared than acute stroke which remains one of the leading causes of death and disability.
We have known for many years that organised stroke care reduces the risk of death and dependency after stroke. In Northern Ireland, dedicated teams of stroke professionals seek to deliver stroke unit care in most of our acute hospitals, bringing huge benefits to those affected.
But stroke care has moved on. The process of care now includes a number of key interventions which, if delivered consistently, are associated with better outcomes.
Research from several countries suggests that centralisation of care in fewer highly specialised centres can improve the process of care, allowing more patients to benefit from treatments such as clot-busting therapy.
The quality of stroke care in England, Wales and Northern Ireland is routinely measured in the Sentinel Stroke National Audit Programme. It is notable that areas such as London and Manchester which have centralised services are able to consistently deliver world-class care, whereas other regions, including Northern Ireland have not been able to achieve this.
It would appear that our expertise is spread too thinly across too many centres, preventing us achieving the highest standards of care for all of our patients. This is not insignificant.
Treating more patients in centralised hyperacute stroke units (HASUs) in both London and Manchester has been associated with reduced mortality. In order to provide specialised HASU care for all patients with acute stroke in Northern Ireland, we need to move to fewer more specialised centres.
There is another important reason why change is needed. We now have a revolutionary new treatment for stroke known as thrombectomy which involves physically removing the clot from the brain.
This procedure is carried out in the Royal Victoria Hospital by a small number of highly specialised doctors known as interventional neuroradiologists.
The treatment is only applicable when a large artery is blocked and the brain tissue is not irreversibly damaged. Specialist brain imaging and expertise is required to pick out the patients who will benefit from thrombectomy.
Going forward, it is essential that all centres providing acute stroke care have the necessary expertise to identify patients who need immediate transfer to Belfast for this life-changing intervention. It is vitally important that this treatment is not denied or delayed because of lack of specialist imaging or expertise at a local stroke centre.
Thrombectomy services remain limited in many countries due to lack of available expertise. In Northern Ireland we are very fortunate to have one of the most active centres in the UK, with results that are comparable to the best centres in the world.
However, we are not yet in a position to provide a 24/7 service. Given the impact of this treatment on patient outcomes we want to expand the service so that we can offer this intervention to all who will benefit. This will require both investment and reorganisation of services.
As someone involved in provision of stroke services in Northern Ireland for almost two decades I have seen very significant improvements over the years, largely achieved by the dedication and hard work of stroke professionals across the province.
However we have now come to a point when hard work and dedication cannot deliver what is required. We should not be content to accept services that are second best, compared to London or Manchester.
All patients with acute stroke should have access to world class stroke care, not just a few. Significant reorganisation of services will be necessary to achieve this.
Change is never easy but I believe it will be worth it. I strongly welcome the public consultation on acute stroke services and hope that positive changes will follow.