The scale and impact of stroke is staggering. According to a report from the Stroke Association, stroke is the second highest cause of death worldwide, and one of the leading causes of disability, costing the UK economy some £26bn annually in terms of lost productivity. The Stroke Association has warned that without urgent action, this figure could rise to between £61bn and £91bn by 2035. Beyond the numbers, though, think of what that means for the people who have a stroke, and their families.
While the term “game-changer” is sometimes used too freely in the medical profession, mechanical thrombectomy (MT), an emergency procedure designed to combat stroke, appears to be one of the select few treatments that lives up to the hype. An NHS commissioning paper from May 2017 noted that for “every four to six people with an acute ischaemic stroke who present with an identifiable occlusion in the anterior cerebral circulation who undergo MT, one more person will be functioning independently at three months, compared with if they had received intravenous thrombolysis [drug therapy] alone”.
The NHS approved the procedure, which involves the removal of a clot blocking blood vessels using a stent retriever to recover blood flow to a person’s brain, for nationwide rollout three years ago. There is a view to delivering a 24/7 service in the next few years. Due to myriad factors, however, including staff sizes, access to expertise, geography and, more recently, competition for attention against the backdrop of the coronavirus pandemic, that aim is still some distance from being realised.
As it stands, MT is provided by just 24 neuroscience centres in England, and 28 in the whole UK, which take on patients directly, as well as via transfer from district general hospitals. Neuroscience centres aim to provide the treatment in a “within hours” setting, but are working on expansion. Most centres in London have already got 24/7 provision, but outside of the capital this is lacking.
In November, the New Statesman and Stryker hosted a digital round table event to discuss some of these logistical barriers and how to overcome them. Sir David Amess, vice-chair of the All-Party Parliamentary Thrombosis Group and whose Southend West constituency has a specialist stroke unit at its local hospital, noted in his opening remarks that it was “vital” for the UK to improve MT provision, as it lagged behind its European counterparts.
He also stressed that strokes are not “just a medical issue at the time of the attack”, and that more needed to be done to address “life after stroke” for people who survive. Amess pointed to the correlation between stroke-related disability and poor mental health. “Seven in ten stroke survivors report feeling more anxious and depressed recently,” he said.
Speaking at the same event, Charlotte Nicholls, head of policy and public affairs at the Stroke Association, suggested it was something of a “lottery” as to whether people had access to this life-saving treatment. For a procedure with such “transformative outcomes” and that could significantly reduce the risk of post-stroke disability, she said it was disappointing that there was not more regional consistency in its provision. Dr Deb Lowe, national clinical director for stroke medicine at NHS England, described the prospect of a stroke patient leaving hospital within a day of having the procedure with no lasting side effects as like a “Lazarus moment”. Currently, the Stroke Association estimates that only 10 per cent of stroke patients in the UK are eligible to receive an MT.
While evidence from trials does show MT to be very effective, the procedure is also hugely time-dependent. One of the key concerns regarding its rollout has been over workforce capacity and expertise. A 24/7 service requires enough people to staff rotas; while the success of the procedure also depends on the technical expertise of the clinician performing it. This presents both an HR issue – clinicians and support staff should be incentivised and managed accordingly in order to ensure they are willing and able to cover anti-social hours – and a skills issue.
Dr Robert Lenthall, a consultant neuroradiologist at the Nottingham University Hospitals NHS Trust, noted during the round table that there is not currently a “centralised training process of organising training numbers for doctors that want to specialise in interventional neuroradiology and deliver MT services”. Rather, it depends on “varying levels of interest among radiology trainees”. Acknowledging this shortfall, Lenthall said, discussions had taken place between the Royal College of Radiologists and the Stroke Association about the possibility of a new “credential” to be submitted to the General Medical Council, that “could help clinicians from non-radiology backgrounds to acquire skills to participate in MT services”.
Professor Tom Robinson, professor of stroke medicine and head of the department of cardiovascular sciences at the University of Leicester, was in agreement that collaboration across specialisms could potentially help to bridge the thrombectomy skills gap. He pointed to the “world-renowned” Glenfield Hospital, known for its expertise in cardiology procedures. “And I have them in my ear quite often,” he said, “about why other specialists who have catheter skills can’t contribute to supporting delivering a thrombectomy service.”
Martin James, a consultant stroke physician based at the Royal Devon and Exeter Hospital, suggested that the UK should think “outside the box” when it came to staffing issues, and at least in the short term, could consider the “possibility of international recruitment”.
Dr Levansri Makalanda, the lead consultant in interventional neuroradiology at London’s Barts Health NHS Trust, which has a 24-hour thrombectomy service, confirmed that his hospital had taken on two new consultants from the continent. “They’re coming across from France and Greece to help with our [thrombectomy] service,” he said. Makalanda said the UK should look for “experience” as well as expertise. “[On] day one as a consultant, you’re nowhere near as good as [on] day five or ten,” he explained. Makalanda also pointed out the importance of improving stroke treatment “infrastructure”. Staffing went beyond clinicians, he said, and also encompassed radiologists and people who could perform and understand scans.
Ultimately, beyond the need for more funding for MT, Souhyb Masri, a consultant neuroradiologist at the Walton Centre in Liverpool, said that the technology’s success hinges on policymakers being “aware” of its capabilities. MT being the game-changer that it is, Masri suggested, could likely rally “enthusiasm” among the “wider public”. If MT can be marketed to the public, and people are fully aware of its capabilities, Masri argued that policymakers will sooner be convinced of its economic and social value. “A lot more needs to be done on publicising this.”
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