Improving long-term support for stroke survivors

National guidelines recommend structured reviews of the health and social care needs of stroke survivors and their caregivers at six months, 12 months and then annually. However, these do not always take place. University of Manchester researchers have developed the Greater Manchester Stroke Assessment Tool (GM-SAT), an evidence-based toolkit acceptable to service providers, stroke survivors and caregivers to support the delivery of these reviews.

In the UK, around 100,000 people every year have a stroke. Fortunately, many survive and live long lives, often supported by caregivers.

Over time, stroke survivors and their caregivers’ needs are likely to change, meaning that regular reviews with trained professionals are important to allow them to access advice, support, information, and rehabilitation as required. These regular reviews can improve quality of life and reduce the risk of a subsequent stroke.

Clinicians and service providers lacked appropriate guidance on how to carry out the reviews and which clinical tools to use, which was sometimes a barrier to the reviews taking place.

In Greater Manchester, GM-SAT2 has been implemented routinely across all 12 Clinical Commissioning Groups. The number of annual reviews that have taken place for stroke survivors has increased 2.5-fold since 2013, with around 1,200 now being carried out each year in the region.

The impact

Recommended in national guidance

In 2016, National Institute for Clinical Excellence (NICE) guidance included GM-SAT as an example of a suitable tool for carrying out reviews for stroke survivors. In 2017, GM-SAT was similarly recommended by the British Association of Stroke Physicians.

In 2019/20 GM-SAT2 was listed as one of the most widely used tools for supporting six-month reviews for stroke survivors in NHS England's Commissioning for Quality and Innovation Practical Guidance.

Transforming care in Greater Manchester

In Greater Manchester, GM-SAT2 has been implemented routinely across all 12 Clinical Commissioning Groups. The number of annual reviews that have taken place for stroke survivors has increased 2.5-fold since 2013, with around 1,200 now being carried out each year in the region.

National implementation into clinical practice

Since 2013, Stroke Association has used GM-SAT/GM-SAT2 for six-monthly reviews carried out by Stroke Association staff in 42 services across England, Wales and Northern Ireland. Between August 2013 and July 2019, more than 23,000 stroke survivors have now received a GM-SAT/GM-SAT2 review through the Stroke Association.

The Stroke Association said the tool is "helping our staff to work with the person to identify any unmet needs they may have and to put in place any support they need to continue to rebuild their lives after stroke".

Improving patient outcomes

From these 23,000 people who were reviewed by Stroke Association staff, 150,000 unmet needs were identified and addressed (either by Stroke Association staff or by signposting/referral to other sources of support). They included:

• 11,000 cases of atrial fibrillation, reported to allow action to reduce the risk of stroke recurrence;
• 7,000 cases with mobility needs, reported to improve independence;
• 12,000 cases with fatigue, reported to allow treatment to improve quality of life.