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Getting Research into Practice (GRiP) Stroke Rehabilitation

Stroke represents a condition which is responsible for the consumption of a large proportion of the NHS budget; about 4% is spent each year on cerebrovascular disease, and the biggest part of that is on the aftermath of stroke.

The size of the problem

A district with a population of 250,000 will have 500 first-ever and 100 recurrent stroke cases each year (in total about 0.25% of the population). Most strokes occur in over-65s, and about 20% of stroke victims die in the first four weeks, with a further 10% dying within a year. Stroke deaths account for 12% of deaths from all causes in England and Wales.

The typical district of 250,000 is likely to devote about 30 beds to the care of stroke victims who have recently had a stroke, (about 12% of beds on general medical wards).

The typical district will have around 1500 stroke survivors living in the community, of which half (750, 0.3% of the population) will have a significant level of disability. Half of stroke survivors have some significant disability.

Effective rehabilitation?

One important question is whether rehabilitation after stroke is effective. This has been well reviewed in an Effectiveness Bulletin from the University of Leeds in March 1992. This bulletin examined 17 major studies; important lessons could be drawn, despite their comment that there were few well designed studies that assess the effectiveness of rehabilitation after stroke.

Organisation saves lives

Organised stroke care can, however, save lives. Langhorne and colleagues published a statistical overview of randomised controlled studies reported between 1962 and 1993 in which the management of stroke patients in a specialist unit was compared with that in general wards. The overview covered 1568 stroke patients, with 766 in special units and 820 in general wards.

The conclusions were that patients treated in stroke units showed a reduction in mortality of 28% after four months, and 21% over one year.

Death is an objective outcome: morbidity is not. A detailed analysis of functional outcomes was hampered by lack of consistent recording. However, nine of the ten studies reported functional gains in stroke units, and one reported very similar outcomes.

Northampton's GRiP

In Northamptonshire, as part of the GRiP initiative, they have a stroke project whose basic aim is to answer the question "can we put evidence derived from research into clinical practice". While research evidence often provides provision of the best possible care, this has to be viewed in relation to the resources available to produce a pragmatic solution which is acceptable and achievable at the local level.

Specialty Liaison Groups

Services for stroke survivors are provided by many professionals and agencies, whose behaviour may need to be changed. To have an impact on behaviour change, the 'target audience' needs to be receptive, and the message needs to be timely and credible.

Northamptonshire is developing a particular interest and expertise in the use of small groups of peers spanning primary and secondary care. The SLG system, where hospital consultants talk directly to GPs and other professionals, with the involvement of DHA purchasers and public health, can act as a lever for change of professional practice when driven by research evidence.

Clinical guidelines (including a referral protocol) are being designed to improve stroke care in hospitals and in the community, by recommending good clinical practice based on research evidence, and with an emphasis on the primary/secondary care interface, and integrating rehabilitation services.


Unless credibility has been established in the minds of clinicians, then the prospect of useful change is poor.

Northamptonshire tackled this issue by commissioning its own detailed review of stroke rehabilitation, clearly presented.

Northamptonshire held its own local Stroke Conference, with local and guest speakers, and with attendance across professional groups.

Northamptonshire decided that the project would have few administrative meetings, but with clear agendas and more action between meetings.


The main levels for change are the quality of information between clinicians in provider organisations and purchaser HAs, and the clinical audit.

Retrospective audits formed the prior baseline to the project, with ongoing audit to monitor effectiveness of change on an ongoing basis.

Clinical guidelines and contracts

The steering group is examining brief checklists or 'pathways', backed up with short reference documents summarising diagnostic criteria, treatment options, indications for referral and discharge, arrangements for follow up, information for patients and points for audit. Evaluation forms will also be designed with each guideline.

These guidelines are being developed in a process that entails participation by key groups in a full consultation process, maintaining credibility and 'ownership' of the process.

Guidelines will, of course, be open to update when new evidence is available, or based on the experience of operating the system. Guidelines will form a basis for future contracts.

Effectiveness in action

The Northamptonshire GRiP project on stroke rehabilitation is drawing on an extraordinary breadth of experience. Public health, consultants, GPs, therapy services, social services, community nursing, purchasers and finance are all represented on the steering group.

The project is based on effectiveness, and its aim is to get that evidence of effectiveness into action.


Effectiveness Bulletin on Stroke Rehabilitation, University of Leeds, March 1992.
Langhorne et al, Lancet 1993 342: 395-8.
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