National Report (2021)
Source: data.gov.uk (2023-09-06)

Sentinel Stroke National Audit Programme (SSNAP) - Acute Organisational Audit 2021. The SSNAP acute organisational audit is a snapshot audit which runs on a biennial basis and reports on the structure and organisation of acute stroke services in England, Wales and Northern Ireland. The results of the 2021 acute organisational audit contain national and hospital level findings on the organisation of stroke services, in particular acute care organisation, staffing levels and skill mix, provision of stroke treatments, TIA (mini stroke) services, engagement with patients and carers, and pathway at discharge. The results reflect the organisation of stroke services as of 1 October 2021. 100% of eligible hospitals in England, Wales and Northern Ireland participated in the audit.

The full results portfolio of named hospital results, available to download below, describes the performance for all 157 participating sites in England, Wales and Northern Ireland. All participating sites were measured against 10 key indicators of acute stroke service organisation enabling hospitals to compare their performance with others and benchmark themselves against national standards and results.

Full Results Portfolio: A very detailed file showing hospital level results for the 10 key indicators of acute stroke service organisation as well as every data item benchmarked against the national average.

National report: Includes national level results for the 2021 acute organisational audit. Includes national performance against 10 key indicators and many important aspects of acute stroke service organisation, clinical commentary, changes over time and country comparisons

Sentinel Stroke National Audit Programme 
(SSNAP) 
 
Acute Organisational Audit 2021 
Reporting the organisation of stroke services in England, Wales and 
Northern Ireland on 1 October 2021 
 
 
 
 
 
 
 
June 2022 
Prepared by  
King’s College London, Sentinel Stroke National Audit Programme on behalf of the 
Intercollegiate Stroke Working Party  

 
The Sentinel Stroke National Audit Programme (SSNAP) is led by the School of Life Course and 
Population Sciences at King’s College London, on behalf of the Intercollegiate Stroke Working Party 
(ICSWP).  
The SSNAP is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of 
the National Clinical Audit and Patient Outcomes Programme (NCAPOP). HQIP is led by a consortium 
of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices. Its aim 
is to promote quality improvement in patient outcomes, and in particular, to increase the impact 
that clinical audit, outcome review programmes and registries have on healthcare quality in England 
and Wales. HQIP holds the contract to commission, manage, and develop the National Clinical Audit 
and Patient Outcomes Programme (NCAPOP), comprising around 40 projects covering care provided 
to people with a wide range of medical, surgical and mental health conditions. The programme is 
funded by NHS England, the Welsh Government and, with some individual projects, other devolved 
administrations and crown dependencies (https://www.hqip.org.uk/national-programmes/). 
© 2022 Healthcare Quality Improvement Partnership 
This report was prepared by the SSNAP project team on behalf of the ICSWP: 
SSNAP Project Team 
Mr Edward Barrett, Project Officer 
Dr Ajay Bhalla, Associate Clinical Director 
Ms Jennifer Butt, Stroke Programme Manager (Acting, June 2021-January 2022) 
Ms Isobel Cabraal, Project Officer 
Ms Louise Clark, Associate Director 
Mr Nahuel Durante, Project Officer 
Dr Rebecca Fisher, Associate Director 
Mr Artur Ganeev, Data Scientist  
Professor Martin James, Clinical Director 
Ms Evelina Käld, Data Analyst 
Dr Andrew Lewis-Smith, Senior Data Analyst 
Ms Ellie McMullen, Senior Operations Officer 
Ms Sabrina Ralph, SSNAP Programme Manager 
Ms Anisa Rothman, Project Officer 
Ms Tijana Savic, Data Analyst 
Ms Kaili Stanley, Stroke Programme Manager 
Please cite as: 
Intercollegiate Stroke Working Party; SSNAP Acute Organisational Audit Report 2021. London: King’s 
College London, 2022. 
 
 
 
 
i

 
Title 
SSNAP 2021 Acute Organisational Audit report 
Document 
purpose 
To disseminate the results of the SSNAP 2021 Acute Organisational Audit of stroke 
services in acute trusts. 
Target 
audience 
Multi-disciplinary stroke teams, managers, medical directors and trust executives of 
sites that participated in the 2021 acute organisational audit. Health and social care 
professionals and healthcare management organisations including commissioners. 
General public and stroke survivors and their carers. NHS England, Wales and 
Northern Ireland. 
Description 
This is the fifth acute organisational audit report published under the auspices of the 
Sentinel Stroke National Audit Programme (SSNAP). It publishes national level 
findings on the organisation of stroke services, including acute care organisation, 
staffing and pathway at discharge. It reflects the organisation of stroke services as of 
1 October 2021. It should be read alongside the continuous clinical audit which 
reports on the care delivered by these hospitals every 3 months.  
Trusts can use this report to benchmark their performance against national level 
findings and compare themselves with national standards.  
It gives a comprehensive picture of current services, and the style of the report 
should allow lay people as well as experts to read it and extract relevant 
information.  
The report presents key recommendations, an executive summary, an in-depth look 
at the 10 Key Indicators of the report followed by other key findings from the 
organisational audit. The aspects of service organisation are presented in tables, 
graphs and maps, along with clinical commentary.  
A full results portfolio (excel file) of all data items by named hospital is available.  
Supersedes 
SSNAP Acute Organisational Audit 2012, 2014, 2016 and 2019 
National Sentinel Stroke Audit – Organisational Report (2010, 2009, 2008, 2007, 
2006, 2004 and every 2 years since 1998) 
Related 
publications 
National Clinical Guideline for Stroke 5th edition (Royal College of Physicians, 2016). 
Published October 2016: https://www.strokeaudit.org/Guideline/Full-Guideline.aspx 
The Healthy NHS Board, A review of guidance and research evidence, 2010: 
https://www.leadershipacademy.nhs.uk/wp-content/uploads/2013/06/NHSLeadership-
HealthyNHSBoard-2010-LiteratureReview.pdf  
NICE Guideline NG128, 2019: https://www.nice.org.uk/guidance/ng128  
NICE Clinical Guideline CG138, 2012: https://www.nice.org.uk/guidance/cg138  
NICE Quality Standard QS2, 2016: https://www.nice.org.uk/guidance/QS2  
NICE Quality Standard QS15, 2019: https://www.nice.org.uk/guidance/QS15  
SSNAP Clinical Audit Quarterly reports: https://www.strokeaudit.org/results/clinical-
audit/national-results.aspx  
The Foundations of Good Governance, NHS Providers 2015: 
https://nhsproviders.org/media/1738/foundations-of-good-governance-web-file.pdf 
Contact 
xxx@xxx.xx  
 
ii

 
Table of Contents 
Foreword 
1 
Executive Summary 
2 
Ten Key Recommendations 
5 
Results 
7 
Key Indicators of Acute Stroke Organisation 
7 
Summary of Key Indicators .................................................................................................................. 9 
1.  Staffing/Workforce .......................................................................................................................11 
2.  Seven Day Working .......................................................................................................................14 
3.  Access to Specialist Treatment and Support ................................................................................19 
4.  Patient and Carer Engagement .....................................................................................................21 
5.  TIA Service .....................................................................................................................................23 
6.  Quality Improvement and Leadership ..........................................................................................24 
Other Key Findings 
25 
A  Type and Number of Stroke Unit Beds ..........................................................................................25 
B  Access to Specialist Treatment and Support .................................................................................25 
C  Telemedicine ..................................................................................................................................26 
D  Specialist Stroke Consultant Ward Rounds ...................................................................................27 
E  Nurse Staffing .................................................................................................................................27 
F  Therapy staffing .............................................................................................................................30 
G  Consultant Workforce and Training ..............................................................................................32 
Key Indicators by country 
34 
Glossary 
42 
References 
45 
Acknowledgements 
46 
 
 
 
iii

 
Foreword 
There is a wealth of high-quality evidence about how to reduce case fatality, recurrent vascular 
events and long-term disability after acute stroke. Implementation of this evidence requires 
appropriate resources, reconfiguration of care pathways, and leadership within organisations to 
support change. Ten Key Performance Indicators (KPIs) for acute stroke care have been developed 
from national clinical guidelines and policy documents. These KPIs enable stroke services in England, 
Wales, Northern Ireland and Isle of Man to monitor and improve their stroke care.  
Despite the COVID-19 pandemic, there have been important improvements in KPIs and against key 
recommendations since 2019.  Access to thrombectomy is improving, though only a fifth of 
Thrombectomy Centres currently provide 24 hours per day, 7 days a week thrombectomy. More 
services provide 7 day therapy input (42% versus 38% in 2019). Furthermore, more services (76% 
versus 63% in 2019) fulfil the KPI for early supported discharge and for magnetic resonance imaging 
as first line in people with transient ischaemic attack (49% of services versus 33% in 2019). 
Engagement with senior management has held steady. These data almost certainly reflect the 
efforts of stroke service staff to improve delivery of evidence-based care.  
However, reconfiguration of existing resources can only go part of the way to improve quality of 
care; it is crucial that services are properly staffed. The data for acute stroke unit staffing are 
concerning. There has been a shift from trained to untrained nursing staff on acute stroke units: only 
46% of services now meet the minimum requirement for trained nursing staff. Only 26% of stroke 
teams are routinely pre-alerted to patients with possible strokes before their arrival in hospital.  
Only 9% of services have appropriate access to clinical psychology. The number of sites with at least 
one unfilled stroke consultant vacancy has risen further to 52%. As of September 2021, there were 
at least 105 vacant posts across 81 sites – an average of 1.3 per site. And yet, at the same time, 
existing stroke services are delivering more clinical care than ever before-meaning that existing staff 
are becoming more overstretched.   
As we emerge from the pandemic, I would encourage acute stroke services to reflect with pride on 
these advances in stroke care, continue to work with senior leadership within organisations to 
ensure that stroke remains high priority, enlist support of patients and public, and to consider 
innovative ways to bring about further improvements in care. And all of us involved in stroke care 
should continue to make the case for additional resources, so that everyone who has an acute stroke 
or TIA has equitable, rapid access to high quality evidence-based stroke care.  
 
 
 
 
 
Professor Gillian E Mead 
President, British and Irish Association of Stroke Physicians 
1

 
Executive Summary 
This report on the biennial SSNAP Acute Organisational Audit (AOA) provides an overview of the 
organisation of acute stroke services on the census date of 1 October 2021, with comparative 
information on the provision of services in 6 domains (Workforce, Seven-day Working, Access to 
Specialist Treatment, Patient and Carer Engagement, TIA Services and Quality Improvement/ 
Leadership) distilled into Ten Key Indicators (see Page 8), with each team scored out of 10.   
Introduction and Methodology  
182 acute stroke services are included – 158 in England, 15 in Wales, 8 in Northern Ireland and one 
in the Isle of Man (see Appendix 1), representing 157 trusts/providers. As in previous AOAs, there 
was 100% participation among eligible acute providers. Data were collected via a web-based audit 
proforma (Appendix 2), with inbuilt validations to ensure data accuracy. A full introduction and 
methodology is available in Appendix 3.  
Organisation of the Audit 
Governance oversight of the AOA is provided by the Intercollegiate Stroke Working Party, a multi-
disciplinary stroke expert group (see Appendix 4). The audit is run by the Stroke Programme at the 
School of Life Course and Population Sciences at King’s College London. 
Key findings 
The key findings in each of the 6 domains across 4,707 acute stroke beds in those 182 hospitals and 
the significant changes in services described by the AOA since the previous audit round in 2019, are 
summarised in the two infographics below. 
 
 
2

ACUTE STROKE SERVICES
ENGLAND, WALES & NORTHERN IRELAND
acute stroke admissions 
in the preceding year
85,000
1 IN 2 SITES HAVE AN UNFILLED STROKE 
CONSULTANT POST
157
157
participating
participating
sites
sites
Quality of acute hospital stroke care 2021
7-day working
have responsibility for audit results 
taken at management level
have the presence of a clinical psychologist 
(qualified) per 30 beds
have an out of hours stroke specialist 
nurse
meet the minimum establishment of band 
6 and band 7 nurses per 10 beds 
49% 
provide MRI** as first line of brain imaging 
for TIA*** patients
61%
76%
46%
have access to a specialist (stroke/
neurological specific) early supported 
discharge (ESD*) team 
have the minimum number of nurses on 
duty at 10am weekends
23%
9%
undertake a formal survey seeking patient/
carer views on stroke services
40%
receive a pre-alert for suspected stroke 
patients
26% 
76%
15% of sites achieved 7 out of 10 Key Indicators
Patient & carer 
engagement
TIA service
offer at least two types of therapy 7 days 
a week†
42%
4,707
BEDS ON STROKE 
UNITS
808 
HYPERACUTE BEDS
ON STROKE UNITS
% of sites
Staffing/Workforce
Access to specialist 
treatment & support
Quality improvement
& leadership
*ESD Early Supported Discharge
**MRI Magnetic Resonance Imaging
***TIA Transient Ischemic Attack
† Includes occupational therapy, physiotherapy and speech and language therapy
3

KI 3 have an out of hours stroke 
specialist nurse
ACUTE STROKE SERVICES
ENGLAND, WALES & NORTHERN IRELAND
Quality of acute hospital stroke organisation 
2019-2021 (% of sites)
Getting better
Plateauing
Getting worse
KI 5 offer at least two types of therapy 7 
days a week
KI 7 have access to a specialist (stroke/
neurological specific) early supported 
discharge (ESD) team
KI 9 provide MRI as first line of brain 
imaging for TIA patients
KI 2 have the presence of a clinical 
psychologist (qualified) per 30 beds
KI 10 have responsibility for audit results 
taken at management level
KI 4 have the minimum number of 
nurses on duty at 10am weekends
KI 1 meet the minimum establishment of 
band 6 and band 7 nurses per 10 beds
KI 8 undertake a formal survey seeking 
patient/carer views on stroke services
2019
2021
2019
2021
2019
2021
Note: 9 of the 10 Key Indicators are calculated in the same way as in the 2019 Acute Organisational Audit, these are displayed above. 
Please note that whilst comparisons can be made for these indicators, there have been significant changes in participating sites since 
the last organisational audit, so please exercise caution in making any comparisons between these data. 
The criteria for KI6 have changed since 2019, see page 19 for further details.
38%
42%
63%
76%
33%
49%
7%
9%
71%
76%
63%
61%
58%
46%
30%
23%
56%
40%
+4%
+13%
+16%
-12%
-7%
-16%
+2%
+5%
-2%
4

 
Improvements have been seen in the implementation of the 2016 National Clinical Guideline 
recommendations for 7-day therapy (42% of services now offer at least two types of rehabilitation 
therapy 7 days/week) and in access to stroke specialist early supported discharge teams (up to 76% 
of services). The use of MRI as first-line imaging for TIA patients has increased substantially to 49%, 
in line with 2019 NICE Clinical Guideline NG128. 
Areas with a lack of progress, or going backwards, are mainly relating to workforce/staffing and 
specialist skills. Access to clinical psychology remains as poor as in previous rounds of the AOA, and 
nurse staffing on stroke units has deteriorated, with significantly fewer sites meeting 
recommendations for senior nursing supervision of acute stroke beds (down 12% to 46%). 
Medical staffing, already a serious issue threatening the viability of many services, has deteriorated 
over the last two years, with over half of sites (52%) now reporting at least one vacancy at 
consultant grade, and with posts lying vacant for an average of 18 months.  
Overall, only 15% of sites (24 sites) achieved 7 or more Key Indicators, fewer than in 2019 (16% (27 
sites)). It is now incumbent on Trust Directors, and all those who provide and commission stroke 
services, to identify the key areas for improvement in their own stroke services and implement an 
appropriately resourced improvement plan in conjunction with other key reviews such as their 
2019 Getting It Right First Time (GIRFT) report (GIRFT National Stroke Report), which in many sites 
may have been side-lined by the COVID-19 pandemic. 
The key points for intervention are summarised in the Ten Key Recommendations from this report 
(see below), along with their ‘line of sight’ to the underpinning evidence or policy. Some of these Key 
Recommendations reflect the imperative to reverse a deteriorating position with acute care over 
the time course of the COVID-19 pandemic (e.g., access to rapid, round-the-clock specialist 
expertise, and admission to an appropriately staffed acute stroke unit within 4 hours of hospital 
arrival). Now is the time to restore performance in these key indicators that are linked through 
direct evidence to cost-saving care and better outcomes for people with acute stroke. 
Ten Key Recommendations 
1.  All hospitals providing hyperacute stroke care should ensure that they are providing sufficient 
specialist nursing staff on their hyperacute stroke unit – at least 3 registered nurses per 10 beds, all 
of whom have received training in swallowing assessments. Patients with acute stroke should be 
admitted to such an appropriately staffed unit within 4 hours of hospital arrival. 
Evidence/policy links: Paley et al, 2018; Bray et al, 2014; RCP National Clinical Guideline for Stroke 
2016; NICE Quality Standard QS2, 2016; NHS England National Stroke Service Model, 2021 
2.  All hospitals providing hyperacute stroke care should have a system for the pre-alert of cases of 
suspected stroke by pre-hospital clinicians directly to the stroke team who should rapidly assess 
patients in the emergency department. This assessment should include rapid, round-the-clock access 
to diagnostics, assessment for reperfusion treatments and direct admission to a specialist stroke 
unit. 
Evidence/policy links: RCP National Clinical Guideline for Stroke 2016; NICE Guideline for Stroke and 
transient ischaemic attack in over 16s: diagnosis and initial management, NG128, 2019  
5

 
3.  All hospitals providing stroke rehabilitation should provide at least two types of qualified 
therapy for 7 days/week. Those that presently do not should examine their traditional working 
practices and learn from centres that have successfully implemented 7-day working. 
Evidence/policy links: RCP National Clinical Guideline for Stroke 2016; Clarke et al, 2018  
4.  All hospitals providing stroke rehabilitation should have access to clinical psychology as a 
member of the multidisciplinary rehabilitation team – at least 1 whole time equivalent qualified 
psychologist per 30 stroke unit beds. 
Evidence/policy links: RCP National Clinical Guideline for Stroke 2016; NICE Quality Standard QS2, 
2016; NHS England National Stroke Service Model, 2021 
5.  All comprehensive stroke services should provide access to specialist stroke rehabilitation at 
home, including access to an early supported discharge team with full coverage of the population. 
Evidence/policy links: RCP National Clinical Guideline for Stroke 2016; NICE Quality Standard QS2, 
2016 
6.  All stroke services and networks should regularly seek feedback from patients and carers about 
the experience of using their services and respond to those views. The active participation of 
patients, carers and advocacy groups in planning and strategic decision-making for stroke services 
and networks should be supported.  
Evidence/policy links: NICE Clinical Guideline CG138, 2012; NICE Quality Standard QS15, 2019 
7.  All services for people with suspected TIA and minor (non-hospitalised) stroke should provide a 
diagnostic service that includes same-day access to specialist assessment and MRI scanning including 
diffusion-weighted and blood-sensitive sequences. 
Evidence/policy link: NICE Clinical Guideline NG128, 2019 
8.  All comprehensive stroke services should include appropriate governance oversight of the 
service, including as a minimum regular review of comparative national audit (SSNAP) reports by an 
individual with board-level responsibility for stroke governance. All services providing stroke care 
should have a member of their board with specific responsibility for stroke. 
Evidence/policy links: The Healthy NHS Board, A review of guidance and research evidence, 2010; The 
Foundations of Good Governance, NHS Providers 2015 
9.  All local health systems and stroke networks should work urgently to improve access to 
reperfusion treatments for acute ischaemic stroke for their population, by reducing variation in the 
delivery of thrombolysis and extending out-of-hours coverage of regional thrombectomy services. 
Evidence/policy links: NICE Clinical Guideline NG128, 2019; RCP National Clinical Guideline for Stroke 
2016; Bray et al, 2013; NHS England National Stroke Service Model, 2021 
10.  Postgraduate deaneries and national training bodies should take urgent action to reverse the 
decline in training in stroke medicine, as one step to rectify a situation in which over half of all stroke 
services are now carrying a vacant consultant post for a median of 18 months. Without immediate 
action to increase the senior specialist workforce, the continuation of some services will be 
jeopardised by the absence of consultants to lead and deliver the service. 
Evidence/policy links: Meeting the Future Consultant Workforce Challenges 2019-22; NHS England 
National Stroke Service Model, 2021 
6

 
Results 
Key Indicators of Acute Stroke Organisation 
Table 1.1 on the following page defines each Key Indicator and the criterion required to meet it and 
reports the national performance against each. The Key Indicators are broken down into 6 different 
categories: 
1. Staffing/Workforce 
2. Seven day working 
3. Access to specialist treatment and support 
4. Patient and carer engagement 
5. TIA Service 
6. Quality improvement and leadership 
 
More detailed information and results for each Key Indicator can be found in Section 2 of this report. 
Each Key Indicator is presented in order along with relevant contextual data, information on the 
standards for the Key Indicator and clinical commentary.  
 
7

 
Table 1.1 National performance against 10 Key Indicators of acute stroke 
organisation 
KI 
Key Indicator (Criterion for indicator) 
National results* 
Staffing/Workforce 
1. 
Minimum establishment of band 6 and band 7 nurses per 10 beds 
Criterion: Sum of band 6 and 7 (WTE) nurses per 10 stroke unit beds is equal to/above 
2.375 per 10 beds for ALL stroke beds**. 
46% (72/157) of sites 
meet KI 1 
2. 
Presence of a clinical psychologist (qualified) 
Criterion: Presence of at least one (WTE) qualified clinical psychologist per 30 stroke unit 
beds 
9% (14/157) of sites 
meet KI 2 
7-day working 
3. 
Out of hours presence of stroke specialist nurse 
Criterion: Met if there is out of hours presence of a stroke specialist nurse to undertake 
assessments of suspected stroke patients in ED 
76% (101/133) of 
sites meet KI 3 
4. 
Minimum number of nurses on duty at 10am weekends*** 
Criterion: Met if have 3.0 WTE nurses per 10 type 1 and 3 beds (average number of nurses 
on duty on type 1 and type 3 beds) † 
23% (30/133) of sites 
meet KI 4 
5. 
At least two types of therapy available 7 days a week  
Criterion: Met if 7-day working for at least two types of qualified therapy. Includes 
occupational therapy, physiotherapy and speech and language therapy 
42% (66/157) of sites 
meeting KI 5 
Access to specialist treatment and support 
 
6. 
Stroke team receives a pre-alert for suspected stroke patients 
Criterion: Met if a pre-alert is received for all types of strokes and if the call is made to 
stroke specialist nurse, stroke consultant on call or stroke junior doctor on call 
26% (34/133) of sites 
meeting KI 6 
7. 
Access to a specialist (stroke/neurological specific) early supported discharge (ESD) team  
Criterion: Met if they have access to at least one stroke/neurology specific ESD team AND 
at least 66% of patients have access to at least one of the teams if needed 
76% (119/157) of 
sites meet KI 7 
Patient and carer engagement 
8. 
Formal survey undertaken seeking patient/carer views on stroke services 
Criterion: Met if at least one a year 
40% (63/157) of sites 
meet KI 8 
TIA service 
9.  
First line of brain imaging for TIA patients is MRI 
Criterion: Met if MRI is first line brain imaging for suspected TIA AND investigations are 
completed within 2 days  
49% (77/157) of sites 
meet KI 9 
Quality improvement and leadership 
 
10.  Management level that takes responsibility for audit results  
Criterion: Met if Executive on the Board, Non-executive on the Board, or Chair of Clinical 
Governance takes responsibility for the follow-up of stroke audit results 
61% (95/157) of sites 
meet KI 10 
* Sites assigned the performance of the site that treats their patients in the first 72 hours have not been included in the 
national results. 
** The national median in 2016 for the total establishment of both these bands of nurses was 2.375 per 10 stroke beds. 
This was used to set a minimum standard of WTE band 6 and 7 nurses. 
***If a site has both type 1 and type 3 beds an average of Saturday and Sunday per 10 type 1 and 3 beds. 
† Type 1 beds are beds used solely for pre-72 hour care. Type 3 beds are beds used for pre and post-72 hour care. 
 
 
8

 
Summary of Key Indicators 
Figure 1: Distribution of Key Indicators achieved* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Please see table 1.1 above for full description of each Key Indicator.  
Overall, the average number of Key Indicators (KIs) achieved by the 157 participating sites in the 
2021 audit is 5 – unchanged from 2019. Fewer sites achieved 8 or more KIs in 2021 than in 2019, and 
none achieved all ten. The proportion of sites achieving each of the evidence-based Key Indicators is 
shown in figure 2. The ‘difficult’ standards remain much the same as in 2019, and in previous audits 
before that - with nurse staffing on stroke units and clinical psychology provision remaining 
prominent. 
Figure 2: National Key Indicator performance*  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Please see table 1.1 above for full description of each Key Indicator.  
 
9

 
Figure 3: Site-level Key Indicators comparison between 2019 and 2021 
 
 
 
London 
No change 
Improved 
Deteriorated 
Site-level comparison demonstrating whether the number of Key Indicators achieved by a site 
has increased, decreased or remained the same between 2019 and 2021 
10

 
1.  Staffing/Workforce 
KI.1 Nursing 
Key Indicator 1 
Minimum Establishment of band 6 and band 7 nurses per 10 beds 
2016 
2019 
2021 
51% (90/178) 
of sites meet Key Indicator 
58% (98/169) 
of sites meet Key Indicator 
46% (72/157) 
of sites meet Key Indicator 
Key Indicator achieved if: 
Sum of band 6 and 7 (WTE) nurses per 10 stroke unit beds is equal to/above 2.375 per 10 beds 
 
Standard 
2016 RCP National Clinical Guideline for Stroke, 5th Edition 
Recommended staffing levels for stroke units (table 2.1) 
  
Physiotherapist 
 WTE per 5 beds                      
Nurse 
WTE per bed 
Hyperacute 
Stroke Unit 
0.73 
2.9 
(80:20 registered: unregistered) 
Acute 
Stroke Unit 
0.84 
1.35 
(65:35 registered: unregistered) 
 
There has been a steady fall in the establishment of the sort of senior and experienced nurses 
necessary to provide clinical leadership in nursing on an acute stroke unit in an Acute Stroke Centre 
(ASC) or Stroke Recovery Unit (SRU). Most acute sites have insufficient senior nurse establishment to 
ensure that there is at least one of them present on the acute stroke unit on every shift, leaving the 
unit in the care of junior and less experienced band 5 nurses. Overall, there has been an erosion of 
registered nurse staffing at band 5 and above in all types of stroke unit over the last 5 years, which is 
a cause for concern given the evidence behind trained, skilled nursing in the prevention of 
complications after acute stroke. 
There is clear multi-professional guidance regarding nurse staffing on acutely-admitting stroke units 
laid out in the 2016 National Clinical Guideline for Stroke, so hospitals should be well aware of the 
staffing levels and competencies required to maximise the patient and organisational benefits of 
specialist stroke care. 
Figure 4: Total establishment of registered nurses whole time equivalents (WTE) per 10 beds all 
Stroke Unit (SU) beds 
 
 
 
 
Band 5 
Band 6 
Band 7 
11

 
Table 1.2: Total establishment of registered nurses whole time equivalents (WTE) per 10 beds all 
Stroke Unit (SU) beds, and by type of SU bed  
Total establishment of nurses 
(Bands 5-8a) for all stroke beds 
(Q2.7, 2.12 & 2.19) Median 
(IQR) 
Total stroke unit 
beds 
Type 1 beds 
Type 2 beds 
Type 3 beds 
2016 (178 sites) 
2016 (73 sites) 
2016 (92 sites) 
 2016 (105 sites) 
2019 (169 sites) 
2019 (86 sites) 
2019 (105 sites) 
2019 (81 sites) 
2021 (157 sites) 
2021 (83 sites) 
2021 (98 sites) 
2021 (73 sites) 
Band 5 
Nurses 
2016 
Total WTE 
18.4 (12.8-28.9) 
7.9 (4.6-13.0) 
14.3 (11.3-20.1) 
14.2 (10.4-18.7) 
WTE / 10 
beds 
7.3 (5.9-8.8) 
10.7 (7.6-14.8) 
7.0 (5.7-8.0) 
7.0 (5.6-8.1) 
2019 
Total WTE 
17.7 (12.4-24.6) 
7.0 (4.1-13.2) 
12.9 (9.7-17.0) 
14.1 (9.0-18.3) 
WTE / 10 
beds 
7.0 (5.6-8.2) 
9.1 (6.0-13.9) 
6.5 (4.8-7.8) 
6.6 (5.2-7.6) 
2021 
Total WTE 
18.2 (12.6-26.2) 
6.9 (4.1-13.3) 
12.9 (9.4-17.4) 
13 (8.6-19.3) 
WTE / 10 
beds 
6.6 (5.4-8.7) 
8.9 (5.0-12.9) 
6.2 (4.7-7.7) 
6.4 (5.0-7.7) 
Band 6 
Nurses 
2016 
Total WTE 
4.4 (2.0-7.7) 
3.0 (1.0-6.6) 
2.8 (2.0-4.0) 
3.0 (2.0-5.0) 
WTE / 10 
beds 
1.7 (1.0-2.5) 
4.2 (1.7-7.4) 
1.3 (0.8-1.7) 
1.3 (0.8-2.2) 
2019 
Total WTE 
5.3 (3.0-8.8) 
3.4 (2.0-6.0) 
3.0 (2.0-4.1) 
3.8 (2.0-6.0) 
WTE / 10 
beds 
1.9 (1.4-2.9) 
3.8 (2.5-6.9) 
1.4 (0.9-2.0) 
1.7 (1.1-2.9) 
2021 
Total WTE 
5.2 (3.0-8.0) 
3.0 (1.0-6.2) 
3.0 (1.9-4.6) 
3.5 (2.0-6.0) 
WTE / 10 
beds 
1.7 (1.2-2.7) 
3.1 (1.6-5.9) 
1.3 (0.9-1.8) 
1.7 (1.0-2.8) 
Band 7 
Nurses 
2016 
Total WTE 
2.0 (1.0-2.4) 
1.0 (0.4-1.4) 
1.0 (1.0-1.4) 
1.0 (1.0-2.0) 
WTE / 10 
beds 
0.6 (0.4-0.9) 
1.1 (0.5-1.8) 
0.5 (0.4-0.6) 
0.6 (0.4-1.0) 
2019 
Total WTE 
1.5 (1.0-2.0) 
1.0 (0.2-1.4) 
1.0 (1.0-1.0) 
1.0 (0.9-1.5) 
WTE / 10 
beds 
0.5 (0.4-0.8) 
0.8 (0.4-1.7) 
0.5 (0.4-0.6) 
0.5 (0.3-0.7) 
2021 
Total WTE 
1.0 (1.0-2.0) 
0.6 (0.2-1.0) 
1 (0.6-1.0) 
1.0 (1.0-1.4) 
WTE / 10 
beds 
0.5 (0.4-0.6) 
0.6 (0.3-1.0) 
0.4 (0.3-0.5) 
0.4 (0.3-0.7) 
Band 
8a 
Nurses 
2016 
Total WTE 
0.0 (0.0-0.5) 
0.0 (0.0-0.0) 
0.0 (0.0-0.1) 
0.0 (0.0-0.1) 
WTE / 10 
beds 
0.0 (0.0-0.1) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.1) 
2019 
Total WTE 
0.0 (0.0-0.8) 
0 (0.0-0.2) 
0.0 (0.0-0.3) 
0.0 (0.0-0.2) 
WTE / 10 
beds 
0.0 (0.0-0.2) 
0.0 (0.0-0.3) 
0.0(0.0-0.1) 
0.0 (0.0-0.1) 
2021 
Total WTE 
0.0 (0.0-0.9) 
0.0 (0.0-0.3) 
0.0 (0.0-0.5) 
0.0 (0.0-0.0) 
WTE / 10 
beds 
0.0 (0.0-0.2) 
0.0 (0.0-0.2) 
0.0 (0.0-0.1) 
0.0 (0.0-0.0) 
 
12

 
KI.2 Clinical Psychology  
Key Indicator 2 
Presence of a qualified clinical psychologist 
2016 
2019 
2021 
6% (10/178) 
of sites meet Key Indicator 
7% (12/169) 
of sites meet Key Indicator 
9% (14/157) 
of sites meet Key Indicator 
Key Indicator achieved if: 
Presence of at least one (WTE) qualified clinical psychologist per 30 stroke unit (SU) beds 
 
Standard 
NICE Quality Statement  
Statement 3: Adults who have had a stroke have access to a clinical psychologist with expertise in 
stroke rehabilitation who is part of the core multi-disciplinary stroke rehabilitation team. 
[New 2016] 
 
2016 RCP National Clinical Guideline for Stroke, 5th Edition 
2.12.1 
A: Services for people with stroke should have a comprehensive approach to delivering 
psychological care that includes specialist clinical neuropsychology/clinical psychology input 
within the multi-disciplinary team. 
B: Services for people with stroke should offer psychological support to all patients regardless of 
whether they exhibit specific mental health or cognitive difficulties and use a matched care model 
to select the level of support appropriate to the person’s needs. 
C: Services for people with stroke should include specialist clinical neuropsychology/clinical 
psychology provision for severe or persistent symptoms of emotional disturbance, mood or 
cognition. 
 
There remains a persisting problem with access to Clinical Psychology in acute inpatient settings, 
with very little progress registered in the organisational audit over the last 5 years. This effectively 
means that the NICE Quality Statement regarding access to clinical psychology is being achieved in 
little more than a handful of places, and the number of sites with any access at all has fallen by 
nearly a third. For many years access to clinical psychological rehabilitation for cognitive and mood 
disorders in stroke rehab has proved resistant to change, ‘baked in’ by workforce supply and 
financial issues. Yet feedback from patients and their carers consistently reflects their need for 
support with adjusting to the enormous changes that sudden physical and cognitive disabilities force 
on their lives, and these latest data indicate that very little progress has been made in addressing 
these widespread needs. A fresh approach is required – perhaps using the same approach to the 
imaginative use of psychological wellbeing practitioners that has underpinned the NHS Improving 
Access to Psychological Therapies programme. People with stroke certainly need their access to 
psychological therapies to be improved. 
 
 
 
13

 
Table 1.3: Access to qualified clinical psychologists 
Sites with access to qualified clinical 
psychologists (Q5.2) 
National 2014 
183 sites 
% (n) 
National 2016 
178 sites 
% (n) 
National 2019 
169 sites 
% (n) 
National 2021 
157 sites 
% (n) 
Presence of at least one whole time equivalent 
(WTE) qualified clinical psychologist per 30 
stroke beds (Key Indicator 2) 
N/A 
6% 
(10/178) 
7% 
(12/169) 
9% 
(14/157) 
Presence of at least one qualified clinical 
psychologist 
54% (98) 
57% (101) 
51% (86) 
43% (68) 
Median (IQR) WTE of qualified clinical 
psychologist 
0.1 (0.0-0.5) 
0.1 (0.0-0.4) 
0.1 (0.0-0.4) 
0.0 (0.0-0.4) 
Median (IQR) WTE per 10 beds of qualified 
clinical psychologists 
0.0 (0.0-0.2) 
0.0 (0.0-0.1) 
0.0 (0.0-0.1) 
0.0 (0.0-0.1) 
Percentage of sites with qualified clinical 
psychologists working 7-days a week 
1% 
1/98 
2% 
2/101 
0% 
0/86 
0% 
0/68 
 
2.  Seven Day Working 
KI.3 Out of Hours Access to Stroke Specialist Nursing 
Key Indicator 3 
Out of hours presence of stroke specialist nurse 
2016 
2019 
2021 
N/A 
71% (101/142) 
of sites meet Key Indicator 
76% (101/133) 
of sites meet Key Indicator 
Key Indicator achieved if: 
Out of hours presence of a stroke specialist nurse to undertake assessments of suspected stroke 
patients in ED.   
 
Standard 
2016 RCP National Clinical Guideline for Stroke, 5th Edition 
2.4.1 
C: A hyperacute stroke unit should have immediate access to:  
• 
specialist medical staff trained in the hyperacute and acute management of people with 
stroke, including the diagnostic and administrative procedures needed for the safe and 16 
timely delivery of emergency stroke treatments. 
• 
specialist nursing staff trained in the hyperacute and acute management of people with 
stroke, covering neurological, general medical and rehabilitation aspects. 
• 
stroke specialist rehabilitation staff. 
E: An acute stroke unit should provide: 
• 
specialist medical staff trained in the acute management of people with stroke. 
• 
specialist nursing staff trained in the acute management of people with stroke, covering 
neurological, general medical and rehabilitation aspects. 
• 
stroke specialist rehabilitation staff. 
 
 
 
14

 
People with acute stroke need immediate access to skilled specialist nursing staff at whatever hour 
they arrive at hospital, and this standard is clearly laid out in the National Clinical Guideline 6 years 
ago. It seems quite hard to believe that 32 acutely-admitting sites are still attempting to provide a 
specialist stroke service without appropriately trained nursing staff immediately available for up to 
half of their admissions (i.e., those that occur outside office hours). This identifies the need for those 
organisations to prioritise the role of skilled nursing in delivering specialist acute stroke unit care – a 
key aspect emphasised in the published evidence (Paley et al, 2018). 
 
With half of all acute stroke admissions occurring outside conventional weekday office hours, teams 
should be scrutinising their organisation and standards of care out of hours to ensure that they 
match the access to diagnostics and clinical expertise available during the working week. One useful 
approach is to ask the question: ‘What would our SSNAP rating be if we were assessed purely on our 
out-of-hours service?’ 
 
KI.4 Weekend Nurse Staffing 
Key Indicator 4 
Minimum number of nurses on duty at 10am weekends 
2016 
2019 
2021 
21% (32/156) 
of sites meet Key Indicator 
30% (42/142) 
of sites meet Key Indicator 
23% (30/133) 
of sites meet Key Indicator 
Key Indicator achieved if: 
3.0 nurses per 10 type 1 and 3 beds (average number of nurses on duty on type 1 and type 3 beds) 
 
Table 1.4: Registered nurses on duty at 10am weekends: Type 1 beds  
Registered nurses usually on 
duty at 10am weekends 
(Q2.4(i)) 
% (n) in category 2014 
(75 sites) 
% (n) in category 2016 
(73 sites) 
% (n) in category 2019 
(86 sites) 
% (n) in category 2021 
(83 sites) 
Sites with 3 or more nurses 
(Key Indicator 4) 
N/A 
56% (41) 
49% (42) 
48% (40) 
Sites with 2-2.9 nurses 
N/A 
33% (24) 
28% (28) 
35% (29) 
Sites with fewer than 2 nurses 
N/A 
11% (8) 
19% (16) 
17% (14) 
National median (IQR) per 10 
beds 
3.3 (2.5-5.0) 
3.3 (2.5-4.2) 
3.3 (2.5-4.8) 
2.9 (2.3-3.8) 
 
 
Table 1.5: Registered nurses on duty at 10am weekends: Type 3 beds  
Registered nurses usually on 
duty at 10am weekends 
(Q2.16(i)) 
% (n) in category 2014 
(109 sites) 
% (n) in category 2016 
(105 sites) 
% (n) in category 
2019 (81 sites) 
% (n) in category 
2021 (73 sites) 
Sites with 3 or more nurses 
(Key Indicator 4) 
N/A 
3% (3) 
6% (5) 
1% (1) 
Sites with 2-2.9 nurses 
N/A 
34% (36) 
17% (14) 
32% (23) 
Sites with fewer than 2 nurses 
N/A 
63% (66) 
77% (62) 
67% (49) 
National median (IQR) per 10 
beds 
1.7 (1.5-2.1) 
1.8 (1.6-2.1) 
1.7 (1.5-2.1) 
1.8 (1.7-2.1) 
 
 
15

 
Table 1.6: Median number of nurses on duty at 10pm weekends: Type 1 and 3 beds 
Registered nurses 
usually on duty at 10pm/10 stroke beds 
(Q2.6(i) & Q2.18(i)) 
Median (Interquartile range) 
Total stroke units 
Type 1 beds 
Type 3 beds 
2014 (183 sites) 
2014 (75 sites) 
2014 (109 sites) 
2016 (178 sites) 
2016 (73 sites) 
2016 (105 sites) 
2019 (169 sites) 
2019 (86 sites) 
2019 (81 sites) 
2021 (157 sites) 
2021 (83 sites) 
2021 (73 sites) 
Saturdays 
2014 
Number per 10 
beds 
1.3 (1.0-1.7) 
3.0 (1.7-3.9) 
1.2 (0.9-1.5) 
2016 
Number per 10 
beds 
1.4 (1.2-1.7) 
2.5 (2.2-3.9) 
1.3 (1.0-1.5) 
2019 
Number per 10 
beds 
1.4 (1.2-1.8) 
2.5 (2.0-4.0) 
1.2 (1.1-1.7) 
2021 
Number per 10 
beds 
1.5 (1.2-1.8) 
2.5 (2.0-3.8) 
1.3 (1.1-1.7) 
Sundays / 
Bank 
Holidays 
2014 
Number per 10 
beds 
1.3 (1.0-1.7) 
3.0 (1.7-3.9) 
1.2 (0.9-1.5) 
2016 
Number per 10 
beds 
1.4 (1.2-1.7) 
2.5 (2.2-3.9) 
1.3 (1.0-1.5) 
2019 
Number per 10 
beds 
1.4 (1.2-1.8) 
2.5 (2.0-4.0) 
1.2 (1.1-1.7) 
2021 
Number per 10 
beds 
1.4 (1.2-1.8) 
2.5 (2.0-3.8) 
1.3 (1.1-1.7) 
 
Table 1.7: Median number of nurses on duty at 10am trained in swallow screening 
Nurses trained in swallow screening usually 
on duty at 10am 
(Q2.5(i) & Q2.17(i)) 
Median (Interquartile range) 
Total stroke units 
Type 1 beds 
Type 3 beds 
2014 (183 sites) 
2014 (75 sites) 
2014 (109 sites) 
2016 (178 sites) 
2016 (73 sites) 
2016 (105 sites) 
2019 (169 sites) 
2019 (86 sites) 
2019 (81 sites) 
2021 (157 sites) 
2021 (83 sites) 
2021 (73 sites) 
Weekdays 
2014 
Number per 10 
beds 
1.4 (0.9-1.9) 
2.5 (1.7-3.3) 
1.4 (0.9-1.9) 
2016 
Number per 10 
beds 
1.5 (0.9-1.9) 
2.5 (2.1-4.0) 
1.6 (0.9-1.8) 
2019 
Number per 10 
beds 
1.5 (1.1-2.1) 
2.5 (2.0-4.3) 
1.6 (0.9-1.8) 
2021 
Number per 10 
beds 
1.4 (0.9-1.9) 
2.5 (1.7-3.8) 
1.4 (0.9-1.8) 
Saturdays 
2014 
Number per 10 
beds 
1.4 (0.8-1.7) 
2.5 (1.7-3.3) 
1.3 (0.8-1.8) 
2016 
Number per 10 
beds 
1.3 (0.8-1.7) 
2.5 (1.7-3.8) 
1.4 (0.8-1.7) 
2019 
Number per 10 
beds 
1.4 (0.9-2.0) 
2.5 (2.0-4.0) 
1.4 (0.8-1.8) 
2021 
Number per 10 
beds 
1.3 (0.8-1.8) 
2.5 (1.7-3.7) 
1.2 (0.8-1.8) 
16

 
Nurses trained in swallow screening usually 
on duty at 10am 
(Q2.5(i) & Q2.17(i)) 
Median (Interquartile range) 
Total stroke units 
Type 1 beds 
Type 3 beds 
2014 (183 sites) 
2014 (75 sites) 
2014 (109 sites) 
2016 (178 sites) 
2016 (73 sites) 
2016 (105 sites) 
2019 (169 sites) 
2019 (86 sites) 
2019 (81 sites) 
2021 (157 sites) 
2021 (83 sites) 
2021 (73 sites) 
Sundays / 
Bank 
Holidays 
2014 
Number per 10 
beds 
1.3 (0.8-1.7) 
2.5 (1.7-3.3) 
1.3 (0.8-1.8) 
2016 
Number per 10 
beds 
1.3 (0.8-1.7) 
2.5 (1.7-3.8) 
1.4 (0.8-1.7) 
2019 
Number per 10 
beds 
1.4 (0.9-2.0) 
2.5 (2.0-4.0) 
1.4 (0.8-1.8) 
2021 
Number per 10 
beds 
1.2 (0.8-1.8) 
2.5 (1.7-3.7) 
1.2 (0.8-1.8) 
 
Given the strong observational evidence that the ratio of registered nurses to patients on an acutely-
admitting stroke unit is a determinant of early survival for people with stroke (Bray et al, 2014; Paley 
et al, 2018), we have used the same methodology over the last 7 years to track nurse staffing in 
acute stroke units. Rather as with KI1 this indicator has shown a steady erosion of registered nurse 
staffing over that time. Overall, fewer acute sites are now meeting this standard, and there are over 
100 sites that are still failing to achieve it. This appears to particularly affect the 83 sites providing 
type 1 beds for patients in those critical first 72 hours after stroke, at least during the daytime.  
Fortunately, these sites have remained relatively stable in their availability of nurses trained in 
swallow screening (for the importance of this, see Paley et al, 2018), but there has been a significant 
decline across the week in the number of nurses with this skill in combined type 3 beds. It is 
important for hospitals to avoid redeploying skilled stroke nurses and safeguard nurse staffing for 
acute stroke in the same way that they do in other directly-admitting specialist areas such as 
coronary care. 
KI.5 Seven Day Therapy Access 
Key Indicator 5 
At least two types of therapy available 7 days a week 
2016 
2019 
2021 
31% (55/178) 
of sites meet Key Indicator 
38% (65/169) 
of sites meet Key Indicator 
42% (66/157) 
of sites meet Key Indicator 
Key Indicator achieved if: 
7 day working for at least two types of qualified therapy. Includes occupational therapy, 
physiotherapy and speech and language therapy 
 
Standard 
NICE Quality Statement 
Statement 2: Adults having stroke rehabilitation in hospital or in the community are offered at 
least 45 minutes of each relevant therapy for a minimum of 5 days a week.  
[2010, updated 2016] 
 
17

 
2016 RCP National Clinical Guideline for Stroke, 5th Edition 
2.11.1 
A: People with stroke should accumulate at least 45 minutes of each appropriate therapy every 
day, at a frequency that enables them to meet their rehabilitation goals, and for as long as they 
are willing and capable of participating and showing measurable benefit from treatment. 
 
Table 1.8: National breakdown of qualified therapy staff disciplines working 7 days with 
participating sites 
Combinations of qualified therapy types working 
7 days 
(Q5.2) 
2016 National 
(178 sites) 
% (n) 
2019 National 
(169 sites) 
% (n) 
2021 National 
(157 sites) 
% (n) 
All three types of therapy 
6% (11) 
9% (15) 
10% (15) 
Occupational therapy and physiotherapy 
25% (44) 
29% (49) 
31% (49) 
Speech and language therapy and physiotherapy 
0% (0) 
1% (1) 
1% (2) 
Physiotherapy only 
9% (16) 
8% (13) 
9% (14) 
Speech and language therapy only 
0% (0) 
1% (1) 
1% (1) 
No types of therapy available 7 days a week 
60% (107) 
53% (90) 
48% (76) 
Further detail is available in Table 1.29 
The last 5 years have seen a steady increase in the proportion of ASCs and SRUs providing therapy at 
weekends to the highest value we have seen at 42% (representing one more site than in 2019). This 
is a welcome development and suggests that these sites are taking a fresh approach to accelerated 
early inpatient rehabilitation, as weekend therapy is more likely to also be able to involve family 
members and is less likely to be interrupted by other, less productive but fatiguing activity (at least 
from the patient’s point of view e.g., ward rounds and investigations). Weekend therapy represents 
a genuine opportunity to intensify and accelerate recovery, and SSNAP has produced evidence at the 
2021 UK Stroke Forum to show that services providing 7 day therapy are delivering higher levels of 
treatment rather than simply spreading 5 days’ worth of therapy over more days (Cabraal et al, 
2021). There is further to go to improve this quality indicator but sites reaping the benefits of 
weekend therapy should be persuading their ‘late adopter’ network colleagues to do likewise, 
particularly in sites not involved in the first 72 hours of hyperacute care, where 7-day therapy is 
much less commonly provided. 
Table 1.9: Number of sites providing two types of therapy 7 days a week by service type  
Number of sites providing two types of therapy (qualified) 7 days a week 
(Q5.2) 
2021 National 
157 sites 
% (n/N) 
Treat all patients in first 72h 
46% (57/125) 
Treat some patients in first 72h 
25% (2/8) 
Treat no patients in first 72h 
29% (7/24) 
All sites 
42% (66/157) 
 
 
 
18

 
3.  Access to Specialist Treatment and Support 
KI.6 Stroke Team Alerted Before Arrival at Hospital (Pre-Alert) 
Key Indicator 6 
Stroke team receives a pre-alert for suspected stroke patients 
2016 
2019 
2021 
N/A 
38% (54/142)* 
of sites meet Key Indicator 
26% (34/133) 
of sites meet Key Indicator 
Key Indicator achieved if: 
Site pre-alert is received for all types of stroke and if the call is made to a stroke specialist nurse, 
stroke consultant on call or junior stroke doctor on call 
*Criteria for Key Indicator 6 has changed since 2019, so data are not directly comparable. In 2021, teams had to select one 
recipient for the pre-alert. 
 
Standard 
2016 RCP National Clinical Guideline for Stroke, 5th Edition 
3.1.1 
C: The pre-hospital care of people with suspected stroke should minimise time from call to arrival 
at hospital and should include a hospital pre-alert to expedite specialist assessment and 
treatment. 
 
Table 1.10: Key Indicator 6: Pre-alert relevant member of the stroke team 
Key Indicator 6: Stroke team receives a pre-alert for 
suspected stroke patients (Q1.11) 
National 2019 
(142 sites)  
% (n) 
National 2021 
(133 sites)  
% (n)  
Do the stroke team receive a pre-
alert (telephone call) from your 
ambulance crews for thrombolysis 
candidates only 
Yes 
80% (113) 
74% (98) 
No 
11% (16) 
17% (22) 
Sometimes 
9% (13) 
10% (13) 
Do the stroke team receive a pre-
alert (telephone call) from your 
ambulance crews for all FAST 
positive 
Yes 
69% (98) 
67% (89) 
No 
11% (15) 
14% (18) 
Sometimes 
20% (29) 
20% (26) 
Do the stroke team receive a pre-
alert (telephone call) from your 
ambulance crews for all other 
suspected strokes 
Yes 
37% (52) 
41% (55) 
No 
15% (22) 
20% (27) 
Sometimes 
48% (68) 
38% (51) 
 
Table 1.11: Key Indicator 6 recipient of pre-alert 
Key Indicator 6: Stroke team receives a pre-alert for suspected stroke patients 
(Q1.12) 
National 2021 
121 sites 
% (n)  
Pre-alert call made to: 
Stroke Specialist Nurse 
32% (39) 
Stroke Junior Doctor on call 
4% (5) 
Stroke Consultant on call 
1% (1) 
 
19

 
This is the only Key Indicator in which we have ‘raised the bar’ this year compared to the 2019 audit, 
by specifying that pre-alerts should be made directly to a member of the stroke team (as opposed to 
a more general pre-alert to the ED) for all patients, at least ‘sometimes’. These changes may account 
for some, but not all, of the drop in achievement of the Key Indicator we observe between the two 
audits. Modern paramedic training encompasses stroke presentations that are potentially FAST-
negative, especially those in the posterior circulation, so a pre-alert for these patients is clinically 
appropriate even if the proportion of mimics is likely to be higher than in the FAST-positive group.  
Direct interaction between paramedics and receiving stroke teams, using telemedicine or video-
triage, may improve the appropriate selection of patients for reperfusion and help to identify 
mimics. Pre-alerting has consistently been shown to be a key component of reducing door-to-needle 
times, so a relentless focus on reducing time to treatment for both thrombolysis and thrombectomy 
inevitably requires an inclusive policy of acute assessment for all cases of suspected stroke at the 
front door – even if this includes a higher ‘mimic rate’. Even now, 12 sites in the UK are attempting 
to provide reperfusion therapy for acute stroke without any form of pre-alert directly to the stroke 
team – these sites urgently need to review their practices to implement the best available evidence 
for expediting reperfusion treatment and delivering more benefit to patients. Using a huge sample 
of SSNAP patients over three years, it has been shown using machine learning that reducing the 
typical door-to-needle time to 30 minutes in the UK would increase the overall population benefit 
from thrombolysis by 26% even if the thrombolysis rate itself remains unchanged (Allen et al, 2022). 
KI.7 Specialist Early Supported Discharge (ESD) 
Key Indicator 7 
Access to a specialist (stroke/neurological specific) early supported discharge team 
2016 
2019 
2021 
N/A* 
63% (107/169) 
of sites meet Key Indicator 
76% (119/157) 
of sites meet Key Indicator 
Key Indicator achieved if: 
Hospital has access to at least one stroke/neurology specific early supported discharge 
multidisciplinary team AND at least 66% of patients have access to at least one of the teams if 
needed 
*Criteria for Key Indicator 7 has changed since 2016, so data are not directly comparable. From 2019, teams must have 
access to at least one specialist early supported discharge team AND have a coverage of at least 66% of their catchment 
population.  
 
Standard 
NICE Quality Statement 
Statement 4: Adults who have had a stroke are offered early supported discharge if the core 
multi-disciplinary stroke team assess that it is suitable for them. 
[New 2016] 
 
2016 RCP National Clinical Guideline for Stroke, 5th Edition 
2.7.1  
A: Hospital inpatients with stroke who have mild to moderate disability should be offered early 
supported discharge, with treatment at home beginning within 24 hours of discharge. 
 
 
20

 
Table 1.12: Access to specialist early supported discharge (ESD) 
Access to specialist early supported 
discharge (Q6.1(a) & (b)) 
National 2014 
183 sites 
% (n) 
National 2016 
178 sites 
% (n) 
National 2019 
169 sites 
% (n) 
National 2021 
157 sites 
% (n) 
Site has access to at least one specialist 
early supported discharge (ESD) team 
74% 
(135) 
81% 
(145) 
85% 
(143) 
90%  
(141) 
 
Median, interquartile range (IQR) and n/N 
Percentage of patients at the site which 
have access to at least one specialist 
early supported discharge (ESD) team 
100% 
85-100% (IQR) 
91/135 with 100% 
100%  
80%-100% (IQR) 
83/145 with 100% 
100% 
67%-100% (IQR) 
85/143 with 100%   
100% 
94%-100% (IQR) 
100/141 with 100% 
 
Overall, 90% of ASCs and SRUs have access to at least one specialist (stroke/neurology-specific) early 
supported discharge team, up from 74% in 2014. Most of these have full population coverage, but 
there is still a significant proportion of services where ESD provision is determined not by the 
patient’s needs, but by where they live – 22 sites have ESD provision that covers less than two thirds 
of their catchment population. The evidence indicates that patients without ESD will not recover as 
well (and will stay in hospital longer) than their near-neighbours who are fortunate enough to live in 
an area with access to such a service. The cost-effectiveness of ESD is robust, but in some places this 
alone appears insufficient to ensure that it is commissioned – as if such services are required to 
achieve a higher standard of proof than an equivalently effective pharmaceutical intervention. 
In the meantime, the evidence and policy have moved on, and in the future these services will be 
expected to be reformed into Integrated Community Stroke Services (ICSS) providing a needs-based, 
not time-limited, seamless transition from facilitating early discharge from hospital for patients at all 
levels of disability through to supporting community reintegration and return to work (NHS England, 
2021). The current proportion of needs-based ESD services is static at 20%. This year represents the 
last time that the quality of discharge support will be measured purely on the presence of partial 
coverage for earlier discharge for a subset of patients – expectations for a supported transfer home 
from hospital will be raised to the higher standard of comprehensive and seamless ICSS provision. 
4.  Patient and Carer Engagement 
KI.8 Formal Survey Undertaken Seeking Patient/Carer Views on Stroke Services 
Key Indicator 8 
Formal survey undertaken seeking patient/carer views on stroke services 
2016 
2019 
2021 
61% (108/178) 
of sites meet Key Indicator 
56% (95/169) 
of sites meet Key Indicator 
40% (63/157) 
of sites meet Key Indicator 
Key Indicator achieved if: 
Formal survey undertaken seeking patient/carer views on stroke services at least once a year 
 
Standard 
2016 RCP National Clinical Guideline for Stroke, 5th Edition 
2.8.1 
D: The views of people with stroke and their family/carers should be actively sought when 
evaluating service quality and safety, and when planning service developments. 
21

 
NICE Quality Standard 15 
Statement 4: People using adult NHS services experience care and treatment that is tailored to 
their needs and preferences. [2012, updated 2019] 
 
Table 1.13: Seeking patient/carer views on stroke services 
Patient views on stroke services  
National 2016 
National 2019 
National 2021 
178 sites 
169 sites 
157 sites 
% (n) 
% (n) 
% (n) 
Frequency of a formal 
survey seeking 
patient/carer views on 
stroke services. (Q9.7) 
(Key Indicator 8) 
Continuous (every patient) 
31% (56) 
25% (42) 
16% (25) 
More than 4 times a year 
10% (17) 
8% (14) 
5% (8) 
3-4 times a year 
3% (5) 
4% (6) 
3% (4) 
1-2 times a year 
17% (30) 
20% (33) 
17% (26) 
Less than once a year 
28% (49) 
23% (39) 
29% (46) 
Never 
12% (21) 
21% (35) 
31% (48) 
Representation on stroke strategic group  
National 2016 
National 2019 
National 2021 
164 sites 
148 sites 
131 sites 
% (n) 
% (n) 
% (n) 
Representation on 
stroke strategic group 
(Q9.2) 
Ambulance trust representative 
50% (82) 
51% (76) 
44% (58) 
Clinician 
99% (163) 
100% (148) 
100% (131) 
Patient representative 
54% (88) 
45% (67) 
45% (59) 
Commissioner 
66% (109) 
62% (92) 
41% (54) 
Social Services 
45% (73) 
28% (42) 
14% (18) 
Stroke Network representative 
56% (92) 
53% (78) 
66% (86) 
Trust board member 
47% (77) 
42% (62) 
36% (47) 
 
Service quality and safety is only incompletely evaluated if the views of patients and their families 
are not also taken into consideration. Perhaps rather inevitably over the last two years of severe 
disruption, reaching out beyond the service to those who use it has fallen to its lowest level – 40% 
lower than five years ago. In general, the frequency of consultation with service users has fallen 
across the board, and stakeholder representation on groups locally responsible for strategy and 
planning has significantly weakened, particularly through a dramatic reduction in engagement from 
service commissioners, social services and ambulance trusts. Much of the last two years has 
inevitably been about preserving stroke services in the context of severe pandemic pressures on 
other acute areas, but the necessary process of recovery and restoration will be hampered without 
the correct stakeholders ‘in the room’ (or in the Teams meeting). 
This reduction in service user engagement, maintained over the medium to longer term, will weaken 
services and reduce their responsiveness and accountability. Proper patient and public engagement 
should not be regarded as an optional add-on, to be set aside when times get tough, but should be 
at the core of service evaluation and planning for all stroke services and networks. Hearing the voice 
of people with stroke is notoriously difficult to do properly and requires proper resourcing at 
provider and network level, but those who put in the effort to do so consistently report its value in 
shaping services that are patient-centred rather than service-centred. All NHS services should be 
tailored to the needs and preferences of the people who use them, and the only way to do this 
reliably is through an active two-way process of consulting with those who are receiving such 
services, and responding to their feedback. 
22

 
5.  TIA Service 
KI.9 First Line of Brain Imaging for TIA Patients 
Key Indicator 9 
First line of brain imaging for TIA patients is MRI 
2016 
2019 
2021 
N/A 
33% (56/169) 
of sites meet Key Indicator 
49% (77/157) 
of sites meet Key Indicator 
Key Indicator achieved if: 
MRI is first brain imaging for suspected TIA AND investigations are completed within 2 days (Next weekday, the 
next day, the same day (5 days a week), or the same day (7 days a week)).   
 
Standard 
Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, NICE NG128  
1.2.2 
After specialist assessment in the TIA clinic, consider MRI (including diffusion weighted and blood-
sensitive sequences) to determine the territory of ischaemia, or to detect haemorrhage or alternative 
pathologies. If MRI is done, perform it on the same day as the assessment. [2019] 
 
Table 1.14: First line brain imaging most frequently used for suspected TIAs 
Key Indicator 9: First line of brain imaging for TIA patients is MRI 
AND investigations are completed within 2 days (Next weekday, 
the next day, the same day (5 days a week) or the same day (7 
days a week)) 
National 2019 
169 sites 
% (n) 
National 2021 
157 sites 
% (n) 
First line brain imaging used 
(type) (Q4.10(a)) 
 
Computed Tomography 
50% (85) 
36% (56) 
Magnetic Resonance Imaging 
45% (76) 
60% (94) 
Rarely image TIAs 
5% (8) 
4% (7) 
 
Table 1.15: Timescale for investigating and initiating treatment 
Key Indicator 9: First line of brain imaging for TIA patients is 
MRI AND investigations are completed within 2 days (Next 
weekday, the next day, the same day (5 days a week) or the 
same day (7 days a week)) 
National 2019 
160 sites  
% (n) 
National 2021 
151 sites  
% (n) 
Timescale taken to 
investigate and initiate 
treatment for ALL 
outpatients (Q7.11) 
The same day (7 days a week) 
31% (50) 
26% (40) 
The same day (5 days a week) 
26% (41) 
26% (39) 
The next day 
14% (23) 
18% (27) 
The next weekday 
8% (13) 
8% (12) 
Within a week 
19% (31) 
19% (29) 
Within a month 
1% (2) 
2% (3) 
Longer than a month 
0% (0) 
1% (1) 
 
The 2021 acute organisational audit is a welcome opportunity to report on significant progress 
towards the implementation of NICE Clinical Guideline NG128, with half of all acute sites now 
reporting the availability of MRI as first-line investigation within one working day for all outpatients 
referred. Further progress should now be made to ensure that the clinical guideline is fully 
implemented across the UK, replacing CT as first-line imaging (and thus reducing duplicate imaging) 
in all TIA clinics. 
23

 
6.  Quality Improvement and Leadership 
KI.10 Management Level that Takes Responsibility for Audit Results 
Key Indicator 10 
Management level that takes responsibility for audit results 
2016 
2019 
2021 
N/A 
63% (106/169)  
of sites meet Key Indicator 
61% (95/157)  
of sites meet Key Indicator 
Key Indicator achieved if: 
Executive on the Board, Non-executive on the Board or Chair of Clinical Governance take 
responsibility for the follow-up of stroke audit results. 
 
Table 1.16: Level of management responsible for reviewing SSNAP results 
Key Indicator 10: Management level that takes responsibility for audit 
results 
National 2019 
169 sites 
% (n) 
National 2021 
157 sites 
% (n) 
Management level that takes 
responsibility for the follow-up of 
the results and recommendations 
of the Sentinel Stroke Audit (Q9.1) 
Executive on the Board 
58% (98) 
50% (78) 
Non-executive on the Board 
17% (28) 
15% (24) 
Chair of Clinical Governance (or 
equivalent) 
25% (43) 
36% (57) 
 
Achieving continuous quality improvement in complex healthcare is demanding for any organisation 
and requires sustained commitment at the highest level. Given the enormous pressures and 
disruption to organisations’ ‘business as usual’ over the last two years, it is encouraging to see that, 
for the large part, senior managers have remained engaged with stroke audit results and 
interpretation to a similar extent as prior to the pandemic, with half of all acute sites identifying a 
board-level executive with responsibility for implementing the audit recommendations. 
However, although a prerequisite for quality improvement, this is insufficient on its own to effect 
the necessary change. Foy and colleagues highlight the other essential components for audit 
programmes to lead to transformational change: applying what is already known about making audit 
more effective, attending to the whole audit cycle, getting the right message to the right recipients, 
making the most of the available data, embedding an incremental approach and engaging with 
patients and the public (Foy et al, 2020). Continuous quality improvement over the medium term 
requires a sustained organisational commitment and visibility at executive level and the consistent 
application of evidence-based approaches. The remaining 62 acute providers that are lacking this 
visibility have a ready explanation for why they are struggling to improve their services, and they 
need to be brandishing this report (and others like it, such as their trust-specific Getting It Right First 
Time (GIRFT) Report, which contains site-specific and region-wide quality improvement 
recommendations) at senior level within their organisation in order to get the process of quality 
improvement started again and building momentum. 
 
 
24

 
Other Key Findings 
A  Type and Number of Stroke Unit Beds 
The process of rationalisation and centralisation of acute stroke services in England (a process less 
pronounced in Wales and Northern Ireland) has continued with a further reduction in acute sites to 
157 – 15% fewer than seven years ago. Overall, there has been a slight shift towards hyperacute 
(first 72-hour or type 1) beds through this centralisation, within an overall reduction in acute stroke 
beds of 10% over the same period. 
Table 1.17: Type and number of stroke unit (SU) beds 
Type and number of 
stroke unit (SU) beds 
(Q2.1) 
Total N of beds 
2014 
Total N of beds 
2016 
Total N of beds 
2019 
Total N of beds 
2021 
n Site level 
n 
Median 
(IQR) 
Beds solely used for 
patients in first 72 
hours after stroke 
(type 1 beds) (Q2.1c) 
National 
183 sites 
National 
178 sites 
National 
169 sites 
National 
157 sites 
681 
601 
774 
808 
83 
8 
(6-12) 
Beds for pre- and 
post-72 hour care 
(type 3 beds) (Q2.1e) 
2381 
2349 
1759 
1588 
73 
22 
(14-28) 
Beds solely used for 
patients beyond 72 
hours (type 2 beds) 
(Q2.1d) 
National 
183 sites 
National 
178 sites 
National 
171 sites 
National 
157 sites 
2178 
2169 
2314 
2311 
98 
22 
(16-28) 
Total number of beds 
5250 
5119 
4847 
4707 
 
B  Access to Specialist Treatment and Support 
Unsurprisingly, the overall number of thrombectomy-capable centres (in England now termed 
Comprehensive Stroke Centres (CSCs)) is unchanged, with one each in Wales and Northern Ireland 
and 24 in England. 5 acutely-admitting sites still do not have access to thrombectomy. 
Access hours for thrombectomy are steadily improving – 14 sites now offer a weekend service (up 
from only 6 two years ago), and only 11 remain restricted to weekday office hours only.  
Table 1.18: Current days and hours of thrombectomy service 
Thrombectomy centre service hours 
(Q3.7) 
2021 National 
(26 sites) 
% (n) 
24 hours a day, 7 days a week 
19% (5) 
Extended hours including weekends 
27% (7) 
Office hours including weekends 
8% (2) 
Monday-Friday, extended hours 
4% (1) 
Monday-Friday, office hours 
42% (11) 
 
 
 
 
25

 
Standard 
2016 RCP National Clinical Guideline for Stroke, 5th Edition 
3.5.1 
G: Patients with acute ischaemic stroke should be considered for combination intravenous 
thrombolysis and intra-arterial clot extraction (using stent retriever and/or aspiration techniques) 
if they have a proximal intracranial large vessel occlusion causing a disabling neurological deficit 
(National Institutes of Health Stroke Scale [NIHSS] score of 6 or more) and the procedure can 
begin (arterial puncture) within 5 hours of known onset. 
 
Table 1.19: Patient access to intra-arterial (thrombectomy) treatment 
Use of intra-arterial 
(thrombectomy) treatment to 
treat patients with acute stroke 
(Q3.3 & 3.5) 
National 2014 
167 sites 
% (n) 
National 2016 
158* sites 
% (n) 
National 2019 
144* sites 
% (n) 
National 2021 
134* sites 
% (n) 
Sites whose patients 
have access to intra-
arterial 
(thrombectomy) 
treatment 
Yes, 
on-site 
13% (21) 
18% (28) 
18% (26*) 
19% (26*) 
Yes, 
by referral 
42% (70) 
50% (79) 
75% (108) 
77% (103) 
No 
46% (76) 
32% (51) 
7% (10) 
4% (5) 
* In 2016 and 2019, there were 2 sites that have patients referred to them for intra-arterial treatment, but do not have an 
acute service on site. In 2021, this was 1 site. They submitted information on their thrombectomy service only 
C  Telemedicine 
The use of telemedicine remains substantially limited to decision-making in thrombolysis, despite 
this not necessarily being the most complex area of hyperacute practice. For supporting remote or 
precariously staffed services, networks should be re-examining the potential for telemedicine, 
particularly as decision-making for thrombectomy (and the interpretation of advanced imaging) 
progressively extends beyond standard working hours when a local stroke physician may not be 
available. 
Table 1.20: Use of telemedicine to allow remote access for management of acute stroke 
Groups of patients assessed 
using telemedicine (Q1.20) 
National 2016 
105 sites 
% (n) 
National 2019 
93 sites 
% (n) 
National 2021 
89 sites 
% (n) 
All patients 
9% (9) 
13% (12) 
21% (19) 
Some patients 
30% (32) 
33% (31) 
29% (26) 
Only patients eligible for 
thrombolysis 
61% (64) 
54% (50) 
49% (44) 
 
 
 
26

 
D  Specialist Stroke Consultant Ward Rounds 
There are still eight hyperacute units (type 1 beds) which do not have a ward round 7 days a week – 
this is an important area to address for these few remaining units. 
Standard 
2016 RCP National Clinical Guideline for Stroke, 5th Edition 
2.4.1 
C: A hyperacute stroke unit should have immediate access to:  
• 
specialist medical staff trained in the hyperacute and acute management of people with 
stroke, including the diagnostic and administrative procedures needed for the safe and 16 
timely delivery of emergency stroke treatments; 
• 
specialist nursing staff trained in the hyperacute and acute management of people with 
stroke, covering neurological, general medical and rehabilitation aspects;  
• 
stroke specialist rehabilitation staff. 
E: An acute stroke unit should provide: 
• 
specialist medical staff trained in the acute management of people with stroke; 
• 
specialist nursing staff trained in the acute management of people with stroke, covering 
neurological, general medical and rehabilitation aspects; 
• 
stroke specialist rehabilitation staff. 
 
Table 1.21: Specialist consultant led ward rounds (type 1 beds) 
Stroke consultant ward 
rounds (type 1 beds) 
(Q2.3) 
National 2016 
Type 1 beds 
73 sites 
% (n) 
National 2019 
Type 1 beds 
86 sites 
% (n) 
National 2021 
Type 1 beds 
83 sites 
% (n) 
Specialist consultant-led 
ward round at least once a 
day (7 days per week) 
84% (61) 
90% (77) 
90% (75) 
 
E  Nurse Staffing 
The steady shift of skill mix from registered to unregistered staff described in previous editions of 
this audit over the last 7 years has continued, and as reported in Key Indicators 1 and 4, there has 
been an erosion of the sort of senior nursing leadership and skills present on acute stroke units of all 
kinds across the week – particularly but not exclusively in type 1 hyperacute beds. The development 
of new roles for unregistered nursing staff need not be an unwelcome or detrimental process as long 
as skills are maintained, which does require a commitment to the training and education of staff of 
all grades to be given appropriate priority. Although funding remains available for external courses 
for both nurses and therapists in 90% of sites, similar to 2 years ago, the median number of training 
sessions attended in the last 12 months at 14 (IQR 3-40) appears inadequate to maintain or develop 
the specialist skills required across the entire nursing and therapy establishment of a stroke unit – 
and the median number of external training sessions relating to psychological skills was zero. 
 
27

 
Registered nurses (Have trained as a nurse and been awarded a degree (or previously a diploma) in 
nursing and are registered as a practising nurse with the UK Nursing and Midwifery Council (NMC)) 
Table 1.22: Total establishment of whole time equivalents (WTE) for registered nurses 
Total establishment of nurses 
(bands 5-8a) for all stroke beds 
(Q2.7, 2.12 & 2.19) Median (IQR) 
Total stroke 
unit beds 
Type 1 beds 
Type 2 beds 
Type 3 beds 
2014 (183 sites) 
2014 (75 sites) 
2014 (99 sites) 
2014 (109 sites) 
2016 (178 sites) 
2016 (73 sites) 
2016 (92 sites) 
2016 (105 sites) 
2019 (169 sites) 
2019 (86 sites) 
2019 (105 sites) 
2019 (81 sites) 
2021 (157 sites) 
2021 (83 sites) 
2021 (98 sites) 
2021 (73 sites) 
Band 5 
Nurses 
2014 
Total WTE 
18.0 (13.3-27.2) 
9.8 (4.5-14.4) 
14.0 (10.3-17.8) 
14.8 (10.9-18.0) 
WTE / 10 beds 
7.3 (5.9-8.7) 
10.3 (7.5-16.5) 
6.8 (5.2-7.9) 
6.9 (5.8-8.2) 
2016 
Total WTE 
18.4 (12.8-28.9) 
7.9 (4.6-13.0) 
14.3 (11.3-20.1) 
14.2 (10.4-18.7) 
WTE / 10 beds 
7.3 (5.9-8.8) 
10.7 (7.6-14.8) 
7.0 (5.7-8.0) 
7.0 (5.6-8.1) 
2019 
Total WTE 
17.7 (12.4-24.6) 
7.0 (4.1-13.2) 
12.9 (9.7-17.0) 
14.1 (9.0-18.3) 
WTE / 10 beds 
7.0 (5.6-8.2) 
9.1 (6.0-13.9) 
6.5 (4.8-7.8) 
6.6 (5.2-7.6) 
2021 
Total WTE 
18.2 (12.6-26.2) 
6.9 (4.1-13.3) 
12.9 (9.4-17.4) 
13.0 (8.6-19.3) 
WTE / 10 beds 
6.6 (5.4-8.7) 
8.9 (5.0-12.9) 
6.2 (4.7-7.7) 
6.4 (5.0-7.7) 
Band 6 
Nurses 
2014 
Total WTE 
3.0 (2.0-6.0) 
2.5 (0.7-5.4) 
2.0 (1.0-3.0) 
2.0 (1.0-4.0) 
WTE / 10 beds 
1.2 (0.7-2.0) 
2.7 (0.9-6.7) 
0.9 (0.6-1.3) 
0.9 (0.6-1.7) 
2016 
Total WTE 
4.4 (2.0-7.7) 
3.0 (1.0-6.6) 
2.8 (2.0-4.0) 
3.0 (2.0-5.0) 
WTE / 10 beds 
1.7 (1.0-2.5) 
4.2 (1.7-7.4) 
1.3 (0.8-1.7) 
1.3 (0.8-2.2) 
2019 
Total WTE 
5.3 (3.0-8.8) 
3.4 (2.0-6.0) 
3.0 (2.0-4.1) 
3.8 (2.0-6.0) 
WTE / 10 beds 
1.9 (1.4-2.9) 
3.8 (2.5-6.9) 
1.4 (0.9-2.0) 
1.7 (1.1-2.9) 
2021 
Total WTE 
5.2 (3.0-8.0) 
3.0 (1.0-6.2) 
3.0 (1.9-4.6) 
3.5 (2.0-6.0) 
WTE / 10 beds 
1.7 (1.2-2.7) 
3.1 (1.6-5.9) 
1.3 (0.9-1.8) 
1.7 (1.0-2.8) 
Band 7 
Nurses 
2014 
Total WTE 
1.0 (1.0-2.0) 
0.5 (0.0-1.0) 
1.0 (0.5-1.0) 
1.0 (0.8-1.0) 
WTE / 10 beds 
0.4 (0.4-0.6) 
0.6 (0.0-1.3) 
0.4 (0.3-0.5) 
0.4 (0.3-0.6) 
2016 
Total WTE 
2.0 (1.0-2.4) 
1.0 (0.4-1.4) 
1.0 (1.0-1.4) 
1.0 (1.0-2.0) 
WTE / 10 beds 
0.6 (0.4-0.9) 
1.1 (0.5-1.8) 
0.5 (0.4-0.6) 
0.6 (0.4-1.0) 
2019 
Total WTE 
1.5 (1.0-2.0) 
1.0 (0.2-1.4) 
1.0 (1.0-1.0) 
1.0 (0.9-1.5) 
WTE / 10 beds 
0.5 (0.4-0.8) 
0.8 (0.4-1.7) 
0.5 (0.4-0.6) 
0.5 (0.3-0.7) 
2021 
Total WTE 
1.0 (1.0-2.0) 
0.6 (0.2-1.0) 
1.0 (0.6-1.0) 
1.0 (1.0-1.4) 
WTE / 10 beds 
0.5 (0.4-0.6) 
0.6 (0.3-1.0) 
0.4 (0.3-0.5) 
0.4 (0.3-0.7) 
Band 
8a 
Nurses 
2014 
Total WTE 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
WTE / 10 beds 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
2016 
Total WTE 
0.0 (0.0-0.5) 
0.0 (0.0-0.0) 
0.0 (0.0-0.1) 
0.0 (0.0-0.1) 
WTE / 10 beds 
0.0 (0.0-0.1) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.1) 
2019 
Total WTE 
0.0 (0.0-0.8) 
0.0 (0.0-0.2) 
0.0 (0.0-0.3) 
0.0 (0.0-0.2) 
WTE / 10 beds 
0.0 (0.0-0.2) 
0.0 (0.0-0.3) 
0.0 (0.0-0.1) 
0.0 (0.0-0.1) 
2021 
Total WTE 
0.0 (0.0-0.9) 
0.0 (0.0-0.3) 
0.0 (0.0-0.5) 
0.0 (0.0-0.0) 
WTE / 10 beds 
0.0 (0.0-0.2) 
0.0 (0.0-0.2) 
0.0 (0.0-0.1) 
0.0 (0.0-0.0) 
28

 
Unregistered nurses (Have not undertaken nurse training and NMC registration, they are often 
referred to as nursing assistant or healthcare assistant, but this is not a ‘registered qualification’).  
Table 1.23: Total establishment of whole time equivalents (WTE) for unregistered nurses 
Total establishment of nurses 
(bands 2-4) for all stroke beds 
Median (IQR) 
Total stroke 
unit beds 
Type 1 beds 
Type 2 beds 
Type 3 beds 
2014 (183 sites) 
2014 (75 sites) 
2014 (99 sites) 
2014 (109 sites) 
2016 (178 sites) 
2016 (73 sites) 
2016 (92 sites) 
2016 (105 sites) 
2019 (169 sites) 
2019 (86 sites) 
2019 (105 sites) 
2019 (81 sites) 
2021 (157 sites) 
2021 (83 sites) 
2021 (98 sites) 
2021 (73 sites) 
Band 2 
Nurses 
2014 
Total WTE 
12.1 (8.6-17.5) 
3.5 (1.5-7.0) 
10.0 (6.0-13.0) 
10.8 (6.1-14.0) 
WTE / 10 beds 
4.6 (3.7-5.8) 
5.3 (1.6-6.7) 
4.6 (3.7-5.7) 
4.8 (3.6-6.2) 
2016 
Total WTE 
13.7 (8.2-18.9) 
3.0 (1.0-7.2) 
12.1 (7.5-16.1) 
11.5 (6.2-15.4) 
WTE / 10 beds 
5.2 (3.8-6.5) 
4.7 (1.7-6.8) 
5.4 (4.2-7.4) 
5.1 (3.7-6.4) 
2019 
Total WTE 
15.7 (10.0-19.8) 
3.6 (0.7-4.0) 
13.6 (9.0-17.2) 
12.3 (6.8-16.4) 
WTE / 10 beds 
5.7 (4.5-7.1) 
4.7 (0.2-6.6) 
6.0 (4.1-8.1) 
5.6 (4.5-6.8) 
2021 
Total WTE 
15.8 (10.0-22.0) 
4.2 (1-7.5) 
13.0 (7.0-16.7) 
12.6 (5.4-17.0) 
WTE / 10 beds 
6.0 (4.4-7.5) 
5.5 (1.5-7.3) 
5.8 (3.6-7.9) 
5.9 (3.7-7.3) 
Band 3 
Nurses 
2014 
Total WTE 
1.0 (0.0-3.0) 
0.0 (0.0-1.0) 
0.0 (0.0-2.0) 
1.0 (0.0-3.0) 
WTE / 10 beds 
0.4 (0.0-1.2) 
0.0 (0.0-0.9) 
0.0 (0.0-1.1) 
0.5 (0.0-1.2) 
2016 
Total WTE 
0.9 (0.0-3.0) 
0.0 (0.0-0.8) 
0.0 (0.0-3.0) 
0.6 (0.0-2.0) 
WTE / 10 beds 
0.3 (0.0-1.2) 
0.0 (0.0-1.1) 
0.0 (0.0-1.3) 
0.3 (0.0-1.0) 
2019 
Total WTE 
1.0 (0.0-3.7) 
0.0 (0.0-1.1) 
0.9 (0.0-3.0) 
0.8 (0.0-3.0) 
WTE / 10 beds 
0.4 (0.0-1.5) 
0.0 (0.0-1.6) 
0.4 (0-1.6) 
0.4 (0-1.4) 
2021 
Total WTE 
1.0 (0.0-4.0) 
0.0 (0.0-1.0) 
0.4 (0.0-2.6) 
1.0 (0.0-3.6) 
WTE / 10 beds 
0.4 (0.0-1.5) 
0.0 (0.0-0.8) 
0.2 (0.0-1.2) 
0.8 (0.0-1.9) 
Band 4 
Nurses 
2014 
Total WTE 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
WTE / 10 beds 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
0.0 (0.0-0.0) 
2016 
Total WTE 
0.0 (0.0-1.0) 
0.0 (0.0-0.6) 
0.0 (0.0-0.0) 
0.0 (0.0-0.8) 
WTE / 10 beds 
0.0 (0.0-0.3) 
0.0 (0.0-0.7) 
0.0 (0.0-0.0) 
0.0 (0.0-0.3) 
2019 
Total WTE 
0.0 (0.0-1.0) 
0.0 (0.0-0.7) 
0.0 (0.0-1.0) 
0.0 (0.0-1.0) 
WTE / 10 beds 
0.0 (0.0-0.5) 
0.0 (0.0-0.7) 
0.0 (0.0-0.4) 
0.0 (0.0-0.4) 
2021 
Total WTE 
0.4 (0.0-2.0) 
0.0 (0.0-0.6) 
0.0 (0.0-1.8) 
0.0 (0.0-2.0) 
WTE / 10 beds 
0.1 (0.0-0.7) 
0.0 (0.0-0.6) 
0.0 (0.0-0.5) 
0.0 (0.0-0.7) 
 
 
 
 
29

 
F  Therapy staffing 
Therapy staffing levels on acute and rehabilitation stroke units are holding steady over the last 5 
years, with a welcome increase in physiotherapy staffing levels. Levels of Support Worker staffing 
have also remained stable, and these figures are reassuring given the pressures on acute services 
since the 2019 audit. Teams should always be looking at improving their efficiency and the delivery 
of at least 45 minutes of each relevant therapy each day, including at weekends to achieve 
accelerated rehabilitation and discharge. All hospitals providing stroke rehabilitation should provide 
at least two types of qualified therapy for 7 days/week, and those that do not should be examining 
their traditional working practices and learning from centres that have successfully implemented 
increased therapy delivery and 7-day working (RCP National Clinical Guideline for Stroke 2016; 
Clarke et al, 2018).   
Registered Therapists (all disciplines)  
Table 1.24: Total establishment of whole time equivalents (WTE) for registered therapy staff 
Total establishment of the multi-disciplinary team 
 for all stroke beds (Q5.2) 
Median (IQR) 
Total stroke unit beds 
2016 (178 sites) 
2019 (169 sites) 
2021 (157 sites) 
Occupational 
therapist 
(Registered) 
2016 
Total WTE 
3.3 (2.0-4.7) 
WTE / 10 beds 
1.3 (1.0-1.6) 
2019 
Total WTE 
3.7 (2.7-5.0) 
WTE / 10 beds 
1.4 (1.1-1.6) 
2021 
Total WTE 
4.0 (3.0-5.5) 
WTE / 10 beds 
1.4 (1.1-1.8) 
Physiotherapist 
(Registered) 
2016 
Total WTE 
3.8 (2.6-5.0) 
WTE / 10 beds 
1.4 (1.1-1.7) 
2019 
Total WTE 
4.0 (3.0-5.8) 
WTE / 10 beds 
1.5 (1.2-1.8) 
2021 
Total WTE 
4.5 (3.0-6.2) 
WTE / 10 beds 
1.6 (1.2-1.9) 
Speech and 
language therapist 
(Registered) 
2016 
Total WTE 
1.6 (1.0-2.2) 
WTE / 10 beds 
0.6 (0.4-0.8) 
2019 
Total WTE 
1.8 (1.0-2.8) 
WTE / 10 beds 
0.7 (0.5-0.8) 
2021 
Total WTE 
2.0 (1.5-3.2) 
WTE / 10 beds 
0.7 (0.6-1.0) 
Dietitian 
(Registered) 
2016 
Total WTE 
0.5 (0.3-1.0) 
WTE / 10 beds 
0.2 (0.1-0.3) 
2019 
Total WTE 
0.6 (0.2-1.0) 
WTE / 10 beds 
0.2 (0.1-0.3) 
30

 
Total establishment of the multi-disciplinary team 
 for all stroke beds (Q5.2) 
Median (IQR) 
Total stroke unit beds 
2016 (178 sites) 
2019 (169 sites) 
2021 (157 sites) 
2021 
Total WTE 
0.6 (0.4-1.0) 
WTE / 10 beds 
0.2 (0.1-0.3) 
Pharmacist 
(Registered) 
2016 
Total WTE 
0.5 (0.3-1.0) 
WTE / 10 beds 
0.2 (0.1-0.3) 
2019 
Total WTE 
0.6 (0.3-1.0) 
WTE / 10 beds 
0.2 (0.1-0.3) 
2021 
Total WTE 
0.8 (0.3-1.0) 
WTE / 10 beds 
0.2 (0.1-0.4) 
 
Unregistered Therapists and Support Workers (all disciplines) 
Table 1.25: Total establishment of whole time equivalents (WTE) for unregistered therapy staff 
Total establishment of the multi-disciplinary team for all 
stroke beds (Q5.2) 
Median (IQR) 
Total stroke unit beds 
2016 (178 sites) 
2019 (169 sites) 
2021 (157 sites) 
Occupational 
therapist 
(Support worker) 
2016 
Total WTE 
1.0 (0.6-1.7) 
WTE / 10 beds 
0.4 (0.3-0.6) 
2019 
Total WTE 
1.0 (0.7-2.0) 
WTE / 10 beds 
0.4 (0.3-0.6) 
2021 
Total WTE 
1.0 (0.8-2.0) 
WTE / 10 beds 
0.5 (0.3-0.7) 
Physiotherapist 
(Support worker) 
2016 
Total WTE 
1.1 (0.9-2.0) 
WTE / 10 beds 
0.5 (0.3-0.7) 
2019 
Total WTE 
1.5 (1.0-2.0) 
WTE / 10 beds 
0.5 (0.4-0.7) 
2021 
Total WTE 
1.3 (1.0-2.1) 
WTE / 10 beds 
0.5 (0.4-0.7) 
Speech and 
language therapist 
(Support worker) 
2016 
Total WTE 
0.2 (0.0-0.6) 
WTE / 10 beds 
0.1 (0.0-0.2) 
2019 
Total WTE 
0.4 (0.0-0.8) 
WTE / 10 beds 
0.2 (0.0-0.3) 
2021 
Total WTE 
0.4 (0.0-0.9) 
WTE / 10 beds 
0.1 (0.0-0.3) 
Pharmacist 
(Support worker) 
2016 
Total WTE 
0.3 (0.0-0.5) 
WTE / 10 beds 
0.1 (0.0-0.2) 
31

 
Total establishment of the multi-disciplinary team for all 
stroke beds (Q5.2) 
Median (IQR) 
Total stroke unit beds 
2016 (178 sites) 
2019 (169 sites) 
2021 (157 sites) 
2019 
Total WTE 
0.2 (0.0-0.5) 
WTE / 10 beds 
0.1 (0.0-0.2) 
2021 
Total WTE 
0.2 (0.0-0.6) 
WTE / 10 beds 
0.1 (0.0-0.2) 
 
G  Consultant Workforce and Training 
The well-documented workforce pressures within the medical subspecialty of stroke medicine have 
continued since 2019, and the number of sites with at least one unfilled consultant vacancy has risen 
further to over half (52%). As of September 2021, there were at least 105 vacant consultant posts 
across 81 sites – an average of 1.3 per site (median number of programmed activities covered by 
vacant posts: 10 (IQR 10-14)). What is more, these posts are lying vacant for longer – up this year to 
a median of 18 months (IQR 10-24 months). In Northern Ireland 2 hospitals have posts that have 
been unfilled for an average of 4.5 years (median number of months posts have been funded but 
unfilled: 54 (IQR 51-57)). At the same time, the number of programmed activities in stroke being 
delivered by the existing workforce has risen sharply – up 11% in the last two years – appropriately 
reflecting our greater ability to intervene, but also falling on an already-stretched workforce that 
over the last two years has also been responding to additional emergency pressures outside stroke 
medicine. Notably, the effect of the rationalisation of services mentioned earlier (15% fewer acutely-
admitting sites over the last 7 years) has done little to offset the shortages in the remaining sites – 
the workforce will not or cannot move with the patients. This scenario is a source of serious concern, 
not simply for the existing medical workforce, but also it raises the very real prospect of some 
acutely-receiving sites being unable to provide a specialist stroke physician at all in the near future. 
SSNAP’s latest Annual Report ‘2020-21: A Year Like No Other’ documented some concerning trends 
in clinical quality, hyperacute treatment and access to specialist care for people with acute stroke, 
including the lowest-ever figures for 4-hour stroke unit access and ‘90% stay’ that SSNAP has 
reported since its inception in 2013. Whilst understandably considered to be a direct effect of the 
unique pressures on the acute hospital sector over the pandemic period, the changes documented 
here in senior medical and nursing staffing, and in hospitals’ commitment to quality improvement, 
will leave the specialty struggling to embark on the renewed process of recovery and restoration 
that is required to return just to pre-pandemic levels of staffing and quality. Many severe challenges 
remain and many sites are already lacking the key clinical leaders that will be needed to overcome 
those challenges to achieve the ambitions we all share for our services and our patients. 
 
 
 
 
 
 
32

 
Table 1.26: Consultant workforce, unfilled, existing and planned posts 
Site has at least one accredited specialist registrar in post 
for stroke speciality training (Q8.1) 
National 2014 
(183 sites) 
% (n) 
National 2016 
(178 sites) 
% (n) 
National 2019 
(169 sites) 
% (n) 
National 2021 
(157 sites) 
% (n) 
Yes 
29% (53) 
31% (56) 
26% (44) 
29% (45) 
Unfilled stroke consultant posts (Q8.4) 
National 2014 
(183 sites) 
% (n) 
National 2016 
(178 sites) 
% (n) 
National 2019 
(169 sites) 
% (n) 
National 2021 
(157 sites) 
% (n) 
Number of sites with any unfilled stroke consultant posts 
26% (48) 
40% (72) 
48% (81) 
52% (81) 
If yes: 
National 2014 
(48 sites) 
National 2016 
(72 sites) 
National 2019 
(81 sites) 
National 2021 
(81 sites) 
Number of programmed activities (PAs) 
these posts cover (Q8.4a) 
Median 
(IQR), 
Total 
10 (6-11), 
454 
10 (8.5-11.9), 
804 
10 (8.0-12.0), 
950 
10 (10-14), 
1052 
Number of months these posts have been 
funded but unfilled (Q8.4b) 
Median 
(IQR) 
8 (2-19) 
15 (6-24) 
12 (5-24) 
18 (10-24) 
Existing stroke consultant posts (Q8.5) 
National 2014 
(183 sites) 
National 2016 
(178 sites) 
National 2019 
(169 sites) 
National 2021 
(157 sites) 
Number of programmed activities (PAs) for 
stroke consultant physicians per site 
Median 
(IQR), 
Total 
22 (14-34) 
4671 
22 (13-41) 
5122 
28.2 (20-48) 
5,794 
34.2 (20-60), 
6431 
Number of consultants (individuals) 
programmed activities (PAs) are divided 
between (Q8.5a) 
Median 
(IQR), 
Total 
3 (2-4) 
656 
3 (2-5) 
676 
4 (2-6) 
730 
4 (3-7), 
763 
Number of programmed activities (PAs) 
which are allocated to direct clinical care 
(DCC) (Q8.5b) 
Median 
(IQR), 
Total 
17 (10-27) 
3588 
19 (11-31) 
3907 
20 (14-35) 
4,274 
25 (15-45), 
4763 
 
Future planned stroke consultant posts (Q8.6) 
National 
2014 
(183 sites) 
% (n) 
National 
2016 
(178 sites) 
% (n) 
National 
2019 
(169 sites) 
% (n) 
National 
2021 
(157 sites) 
% (n) 
Number of sites with new/additional posts for stroke 
consultant physicians 
48% (87) 
46% (81) 
41% (70) 
50% (79) 
If yes: 
National 2014 
(87 sites) 
National 2016 
(81 sites) 
National 2019 
(70 sites) 
National 2021 
(79 sites) 
Number of programmed activities (PAs) planned 
for new/additional stroke consultant physicians 
(Q8.6) 
Median 
(IQR), 
Total 
10 (5-10) 
829 
0 (0-10) 
881 
0 (0-10) 
938 
2 (0-10), 
966 
Number of new/additional consultants 
(individuals) these programmed activities (PAs) are 
divided between (Q8.6a) 
Median 
(IQR), 
Total 
1 (1-2) 
118 
1 (1-2) 
130 
1 (1-2) 
118 
1 (1-2), 
137 
Number of new/additional programmed activities 
(PAs) for direct clinical care (DCC) for stroke 
(Q8.6(b)) 
Median 
(IQR), 
Total 
7 (4-9) 
653 
7 (4-9) 
670 
8 (5.2-12) 
676 
8 (6.0-10.7), 
768 
 
 
 
33

 
Key Indicators by country 
This section compares national figures for the organisation of stroke care in England, Wales and 
Northern Ireland at 1 October 2021.   
Denominators vary within tables because of differing site characteristics. 157 sites participated in 
the audit across England (136), Wales (12), Northern Ireland (8) and Islands (1). There are 24 sites in 
England which do not provide care to patients in the first 72 hours. These sites are excluded from 
the analysis of measures relating to this phase of acute care.  
The national column reflects the national figures including the results from the Isle of Man. 
However, the regional breakdowns relate to results from England, Wales and Northern Ireland only.  
Table 1.27: Key Indicators summary by country 
Key Indicator 
summary by 
country 
National 
157 sites 
% (n) 
England 
136 sites 
% (n) 
Wales 
12 sites 
% (n) 
Northern Ireland 
8 sites  
% (n) 
Total Key Indicators Achieved 
0 
1% (1) 
1% (1) 
0 
0 
1 
3% (5) 
1% (1) 
25% (3) 
13% (1) 
2 
10% (16) 
9% (12) 
17% (2) 
25% (2) 
3 
18% (28) 
16% (22) 
25% (3) 
25% (2) 
4 
17% (27) 
15% (21) 
33% (4) 
25% (2) 
5 
19% (30) 
21% (29) 
0 
13% (1) 
6 
17% (26) 
19% (26) 
0 
0 
7 
11% (17) 
13% (17) 
0 
0 
8 
4% (6) 
4% (6) 
0 
0 
9 
1% (1) 
1% (1) 
0 
0 
Post 72hrs sites receive points from KIs 3,4, and 6 from their main acute site 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
34

 
Key Indicators: England 
 
Figure 5: Distribution of Key Indicators achieved in England  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 6: National Key Indicator performance in England 
 
 
 
35

 
Key Indicators: Wales 
 
Figure 7: Distribution of Key Indicators achieved in Wales 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 8: National Key Indicator performance in Wales 
 
 
 
 
36

 
Key Indicators: Northern Ireland 
 
Figure 9: Distribution of Key Indicators achieved in Northern Ireland 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 10: National Key Indicator performance in Northern Ireland 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
37

 
Table 1.28: Staffing/Workforce 
Key Indicators by country 
National 
157 sites 
% (n) 
England 
136 sites 
% (n) 
Wales 
12 sites 
% (n) 
Northern Ireland 
8 sites  
% (n) 
Key Indicator 1: Minimum 
establishment of band 6 and band 7 
nurses per 10 beds 
46% (72) 
49% (67) 
8% (1) 
38% (3) 
Band 6 nurses WTE per 10 beds Median 
(IQR) 
1.7 (1.2-2.7) 
1.9 (1.3-2.7) 
0.9 (0.7-1.4) 
1.6 (1.2-2.3) 
Band 7 nurses WTE per 10 beds Median 
IQR) 
0.5 (0.4-0.6) 
0.5 (0.4-0.6) 
0.5 (0.4-0.6) 
0.5 (0.4-0.7) 
Key Indicator 2: Presence of a clinical 
psychologist (qualified) 
9% (14) 
10% (14) 
0% (0) 
0% (0) 
Clinical psychologist WTE per 30 beds 
(qualified) Median (IQR) 
0.0 (0.0-0.3) 
0.0 (0.0-0.4) 
0 (0-0) 
0 (0-0) 
 
Table 1.29: 7-day working 
Key Indicators by country 
National 
133 sites 
% (n) 
England 
112 sites 
% (n) 
Wales 
12 sites 
%(n) 
Northern Ireland 
8 sites 
% (n) 
Key Indicator 3: Out of hours presence 
of stroke specialist nurse 
76% (101) 
82% (92) 
50% (6) 
25% (2) 
Key Indicator 4: Minimum number of 
nurses on duty at 10am weekends 
23% (30) 
24% (27) 
8% (1) 
25% (2) 
Nurses per 10 type 1 beds 10am 
Saturdays Median (IQR) 
2.9 (2.3-3.8) 
3.0 (2.3-3.8) 
2.5 (1.8-2.5) 
5.0 (4.4-5.0) 
Nurses per 10 type 1 beds 10am Sundays 
Median (IQR) 
2.9 (2.3-3.8) 
2.9 (2.3-3.8) 
2.5 (1.8-2.5) 
5.0 (4.4-5.0) 
Nurses per 10 type 3 beds 10am 
Saturdays Median (IQR) 
1.8 (1.7-2.1) 
1.7 (1.6-2.0) 
1.7 (1.7-1.8) 
2.5 (2.1-2.7) 
Nurses per 10 type 3 beds 10am Sundays 
Median (IQR) 
1.8 (1.7-2.1) 
1.7 (1.6-2.0) 
1.7 (1.7-1.8) 
2.5 (2.1-2.7) 
Key Indicator 5: At least two types of 
therapy available 7 days a week 
National 
157 sites 
% (n) 
England 
136 sites 
% (n) 
Wales 
12 sites 
% (n) 
Northern Ireland 
8 sites  
% (n) 
42% (66) 
47% (64) 
17% (2) 
0% (0) 
(e) Occupational therapy 
(qualified) available 5, 6 or 7 
days per week 
5 
days 
40% (63) 
34% (46) 
83% (10) 
75% (6) 
6 
days 
19% (30) 
20% (27) 
8% (1) 
25% (2) 
7 
days 
41% (64) 
46% (63) 
8% (1) 
 
(g) Physiotherapy (qualified) 
available 5, 6 or 7 days per week 
5 
days 
34% (54) 
28% (38) 
75% (9) 
75% (6) 
6 
days 
15% (23) 
16% (22) 
 
12% (1) 
7 
days 
51% (80) 
56% (76) 
25% (3) 
12% (1) 
38

 
(i) Speech & Language Therapy 
(qualified) available 5, 6 or 7 
days per week 
 
National 
151 sites 
% (n) 
England 
133 sites 
% (n) 
Wales 
12 sites 
% (n) 
Northern Ireland 
5 sites  
% (n) 
5 
days 
75% (113) 
73% (97) 
92% (11) 
80% (4) 
6 
days 
13% (20) 
14% (19) 
 
20% (1) 
7 
days 
12% (18) 
13% (17) 
8% (1) 
 
 
Table 1.30: Access to specialist treatment and support 
Key Indicators by country 
National 
133 sites 
% (n) 
England 
112 sites 
% (n) 
Wales 
12 sites 
%(n) 
Northern Ireland 
8 sites 
% (n) 
Key Indicator 6: Stroke team receives a 
pre-alert for suspected stroke patients 
26% (34) 
29% (33) 
8% (1) 
0% (0) 
1.11. Do the stroke team receive a pre-
alert (telephone call) from your 
ambulance crews for suspected stroke 
patients? 
 
 
 
 
Thrombolysis candidates only 
Yes 
74% (98) 
74% (83) 
83% (10) 
50% (4) 
No 
17% (22) 
 15% (17) 
8% (1) 
50% (4) 
Sometimes 
10% (13) 
11% (12) 
8% (1) 
0% (0) 
All FAST positive 
Yes 
67% (89) 
65% (73) 
58% (7) 
100% (8) 
No 
14% (18) 
15% (17) 
8% (1) 
0% (0) 
Sometimes 
20% (26) 
20% (22) 
33% (4) 
0% (0) 
All other suspected strokes 
Yes 
41% (55) 
42% (47) 
17% (2) 
62% (5) 
No 
20% (27) 
21% (24) 
17% (2) 
12% (1) 
Sometimes 
38% (51) 
37% (41) 
67% (8) 
25% (2) 
1.12. If the stroke team receive a pre-
alert, who is the call usually made to? 
 
 
 
 
Stroke Specialist Nurse 
32% (39) 
37% (37) 
18% (2) 
0% (0) 
Stroke Junior Doctor 
4% (5) 
5% (5) 
0% (0) 
0% (0) 
Stroke Consultant 
1% (1) 
1% (1) 
0% (0) 
0% (0) 
Key Indicator 7: Access to a specialist 
(stroke/neurological specific) early 
supported discharge (ESD) team 
National 
157 sites 
% (n) 
England 
136 sites 
% (n) 
Wales 
12 sites 
% (n) 
Northern Ireland 
8 sites  
% (n) 
76% (119) 
80% (109) 
33% (4) 
75% (6) 
6.1. Do you have access to at least one 
stroke/neurology specific early 
supported discharge multidisciplinary 
team? 
90% (141) 
96% (130) 
42% (5) 
75% (6) 
6.1 (b) What percentage of your patients 
has access to at least one of these teams 
if needed? % (IQR) 
100  
(94-100) 
100  
(91-100) 
100  
(90-100) 
100  
(100-100) 
 
 
 
 
39

 
Table 1.31: Patient and carer engagement 
Key Indicators by country 
National 
157 sites 
% (n) 
England 
136 sites 
% (n) 
Wales 
12 sites 
% (n) 
Northern Ireland 
8 sites  
% (n) 
Key Indicator 8: Formal survey undertaken 
seeking patient/carer views on stroke 
services 
40%  
(63) 
40%  
(54) 
33%  
(4) 
50%  
(4) 
9.7. How often is there a formal survey 
seeking patient/carer views on stroke 
services? (This does not include the Friends 
and Family Test) 
 
 
 
 
Never 
31% (48) 
32% (44) 
33% (4) 
0% (0) 
Less than once a year 
29% (46) 
28% (38) 
33% (4) 
50% (4) 
1-2 times a year 
17% (26) 
17% (23) 
8% (1) 
25% (2) 
3-4 times a year 
3% (4) 
3% (4) 
0% (0) 
0% (0) 
More than 4 times a year 
5% (8) 
5% (7) 
0% (0) 
12% (1) 
Continuous (every patient): 
16% (25) 
15% (20) 
25% (3) 
12% (1) 
 
Table 1.32: TIA Service 
Key Indicators by country 
National 
157 sites 
% (n) 
England 
136 sites 
% (n) 
Wales 
12 sites 
% (n) 
Northern Ireland 
8 sites  
% (n) 
Key Indicator 9: First line of brain 
imaging for TIA patients is MRI 
49%  
(77) 
52%  
(71) 
17%  
(2) 
50%  
(4) 
4.10. Which imaging modality do you 
most frequently use in your 
neurovascular clinic for suspected 
TIAs? 
 
 
 
 
(a) First line brain imaging 
Computed Tomography 
35% (56) 
33% (45) 
75% (9) 
25% (2) 
Magnetic Resonance Imaging 
60% (94) 
62% (85) 
25% (3) 
62% (5) 
Rarely image TIAs 
4% (7) 
4% (6) 
0% (0) 
12% (1) 
7.11. Within what timescale can you 
see, investigate and initiate treatment 
for ALL your TIA patients? 
 
 
 
 
Outpatient 
100% 
(151/151) 
100% 
(131/131) 
100% (12/12) 
100% (7/7) 
Outpatient timescale 
 
National 
151 sites 
% (n) 
England 
131 sites 
% (n) 
Wales 
12 sites 
% (n) 
Northern Ireland 
7 sites  
% (n) 
The same day (7 days a week) 
26% (40) 
30% (39) 
8% (1) 
0% (0) 
The same day (5 days a week) 
26% (39) 
24% (32) 
25% (3) 
57% (4) 
The next day: 
18% (27) 
21% (27) 
0% (0) 
0% (0) 
The next weekday 
8% (12) 
6% (8) 
8% (1) 
43% (3) 
Within a week 
19% (29) 
18% (23) 
42% (5) 
0% (0) 
Within a month 
2% (3) 
2% (2) 
8% (1) 
0% (0) 
Longer than a month 
1% (1) 
0% (0) 
8% (1) 
0% (0) 
 
 
40

 
Table 1.33: Quality improvement and leadership 
Key Indicators by country 
National 
157 sites 
% (n) 
England 
136 sites 
% (n) 
Wales 
12 sites 
% (n) 
Northern Ireland 
8 sites  
% (n) 
Key Indicator 10: Management level 
that takes responsibility for audit 
results 
61% (95) 
60% (81) 
92% (11) 
38% (3) 
9.1. What level of management takes 
responsibility for the follow-up of the 
results and recommendations of the 
Sentinel Stroke Audit? 
 
 
 
 
Executive on the Board 
50% (78) 
47% (64) 
92% (11) 
38% (3) 
Non-executive on the Board 
15% (24) 
16% (22) 
17% (2) 
0% (0) 
Chair of Clinical Governance (or 
equivalent) 
36% (57) 
40% (54) 
25% (3) 
0% (0) 
 
 
41

 
Glossary 
Acute Stroke Centre 
(ASC) 
Provides hyper-acute, acute and inpatient rehabilitation, but excluding 
thrombectomy and neurosurgery (in England).  
Carer 
A person (commonly the patient’s spouse, a close relative or friend) who 
provides on-going, unpaid support and personal care at home. 
Commissioners 
Funding bodies of NHS services in England. 
Comprehensive 
Stroke Centre (CSC) 
Provides hyper-acute, acute and inpatient rehabilitation including 
thrombectomy and neurosurgery (in England).  
CT scan 
A CT scan (computerised tomography) of the head. A CT scan X-rays the 
body from many angles. The X-ray beams are detected by the scanner and 
analysed by a computer. The computer compiles the images into a picture 
of the body area being scanned. These images can be viewed on a monitor 
or reproduced as photographs. 
Direct clinical care 
(DCC) 
Refers to direct patient contact and/or management. DCC is work directly 
related to preventing, diagnosing or treating illness, including emergency 
work carried out during or arising from on‐call work. 
Getting It Right First 
Time (GIRFT) 
A national programme designed to improve medical care within the NHS 
by reducing unwarranted variations. By tackling variations in the way 
services are delivered across the NHS, and by sharing best practice 
between trusts, GIRFT identifies changes that will help improve care and 
patient outcomes, as well as delivering efficiencies such as the reduction of 
unnecessary procedures and cost savings. 
https://gettingitrightfirsttime.co.uk/. 
You can read the GIRFT National Stroke Report here.  
Hyperacute Stroke 
Unit (HASU) 
Some stroke services designate the most intensive treatment as 
hyperacute. This would be where patients are initially treated and usually 
for a short period of time (i.e., up to three days). 
Integrated 
Community Stroke 
Services (ICSS) 
A multidisciplinary team that offers stroke rehabilitation at a range of 
intensities – from ESD to less-intensive rehabilitation courses. 
Intracerebral 
haemorrhage (ICH) 
A type of stroke caused by bleeding within the brain tissue itself. 
Ischaemic stroke 
The most common type of stroke. They occur when a blood clot blocks the 
flow of blood and oxygen to the brain. 
Large artery 
occlusive stroke 
A stroke subtype where there is a blockage in one of the brain’s larger 
blood supplying arteries such as the carotid or middle cerebral artery.   
Magnetic resonance 
imaging (MRI) 
A type of scan that uses strong magnetic fields and radio waves to produce 
detailed images of the inside of the body. 
Multi-disciplinary 
A team or service which is composed of staff from different healthcare 
professions with specialist skills and expertise. The members work 
together to ensure patients receive comprehensive, coordinated 
treatment. 
National Institutes 
of Health Stroke 
Scale (NIHSS) 
A validated international tool used by healthcare professionals to 
objectively quantify (measure) the impairment caused by stroke. 
42

 
National Clinical 
Guideline for Stroke 
(2016) 
A National evidence based guideline for stroke care published by the 
Intercollegiate Working Party for Stroke fifth edition 2016 
https://www.strokeaudit.org/Guideline/Guideline-Home.aspx 
Neurovascular Clinic 
An outpatient clinic for patients with transient ischaemic attacks (TIA) or 
minor stroke for further investigation. 
Out of hours 
In hours is between 08.00-18.00 Monday to Friday. Out of hours is all days 
and times outside this range. 
Per 10 (30) stroke 
beds 
A method of calculating ratios of staff to every 10-stroke unit beds. The 
whole-time equivalents (WTE) for each staffing discipline in a service 
divided by the total number of beds used by stroke patients multiplied by 
10. This enables comparison between services of different sizes. 
The same rule applies for per 30 beds in terms of Key Indicator 2 but 
multiplied by 30. 
Pre-Alert 
Information given to a receiving hospital about a critically ill or injured 
patient’s condition. 
Programmed 
activities (sessions) 
A 4-hour unit of time (one half-day), 10 of which comprise a consultant’s 
work week. In contrast to supporting professional activities, programmed 
activities are dedicated to direct clinical care. 
Sessions 
A term used to describe a junior doctor's time. One session represents half 
a day. 
Service 
centralisation 
The reorganisation of many stroke services into fewer, highly specialised 
hospitals that focuses on acute stroke care. For example, London and 
Greater Manchester have a centralised stroke service which means a 
stroke patient will be taken to a dedicated specialist stroke unit rather 
than their nearest hospital.   
Specialist early 
supported discharge 
(ESD) team 
A stroke specific service delivered by specialist professionals within a 
multi-disciplinary team to provide rehabilitation and support in a 
community setting with the aim of reducing the duration of hospital care 
for stroke patients and enabling them to return home quicker. 
Stroke Recovery 
Unit (SRU) 
Provides acute and inpatient rehabilitation only (in England).  
Stroke specialist 
senior nurses 
Nurses at band 6 level or above with specialist training and experience in 
stroke medicine. 
Swallow screening 
A process which broadly identifies the safety of a patient's swallow ability. 
This screening process, which may be performed by any member of the 
team trained to do this, acts to establish whether the patient requires 
further formal assessment regarding the patient’s ability to swallow (either 
fluids or solid foods). 
Thrombectomy 
The surgical removal of a thrombus (blood clot) from a blood vessel.  
Thrombolysis 
The use of drugs to break up a blood clot. 
Transient ischaemic 
attack (TIA) 
Less severe than a stroke in that all the symptoms disappear within a day 
(and often last for less than half an hour). It is also referred to as ‘mini 
stroke’. 
43

 
Trusts 
In the context of the UK National Health Service (NHS), trusts are 
organisational units, e.g., hospital trusts, community trusts, primary care 
trusts or combinations thereof. In this report it usually refers to hospitals. 
Type 1 beds 
Stroke unit beds solely for patients in first 72 hours after stroke. 
Type 2 beds 
Stroke unit beds solely for patients beyond 72 hours after stroke. 
Type 3 beds 
Stroke unit beds used for both pre and post-72-hour care. 
Whole time 
equivalent (WTE) 
The number of hours staffing disciplines are contracted to work within a 
typical working week. For example, a WTE number of 1.0 means that the 
person is equivalent to a full-time worker (and works e.g., 37.5 hours per 
week); while a WTE of 0.5 signals that the worker is half-time (and works 
18.75 hours). This should not be confused with the number of individuals, 
which is the number of people (bodies) a service has to deliver those 
hours. 
 
44

 
References 
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simulation and machine learning to identify key levers for maximising the disability benefit of 
intravenous thrombolysis in acute stroke pathways NIHR Journals Library - Health and Social 
Care Delivery Research (in press) 
 
2. Bray BD, Campbell J, Cloud GC, Hoffman A, et al, 2013. Bigger, faster? Associations between 
hospital thrombolysis volume and speed of thrombolysis administration in acute ischemic 
stroke. Stroke, 44, 3129-35. 
https://www.ahajournals.org/doi/pdf/10.1161/STROKEAHA.113.001981 
 
3. Bray BD, Ayis S, Campbell J, Cloud GC, et al, 2014. Associations between stroke mortality and 
weekend working by stroke specialist physicians and registered nurses: prospective multicentre 
cohort study. PLoS Medicine, 11(8), e1001705. 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4138029/pdf/pmed.1001705.pdf 
 
4. Cabraal I, Kald E, Ralph S, Clark L, et al, 2021. Does 7-day therapy working deliver more therapy 
overall? Data from the national stroke audit for England, Wales and Northern Ireland (SSNAP). 
https://www.strokeaudit.org/SupportFiles/Documents/Research/UKSF-poster-SSNAP-5v7-day-
therapy.aspx    
 
5. Clarke DJ, Burton LJ, Tyson SF, Rodgers H, et al, 2018. Why do stroke survivors not receive 
recommended amounts of active therapy? Findings from the ReAcT study, a mixed-methods 
case-study evaluation in eight stroke units. Clinical Rehabilitation 2018. 1-14. 
https://journals.sagepub.com/doi/pdf/10.1177/xx-xxxx-xxxx 
 
6. Foy R, Skrypak M, Alderson S, Ivers, N.M, et al, 2020. Revitalising audit and feedback to improve 
patient care. BMJ, 368  https://www.bmj.com/content/368/bmj.m213  
 
7. Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke. 5th ed. London, UK: 
Royal College of Physicians; 2016. 
https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-
Guideline-for-Stroke-5t-(1).aspx 
 
8. Meeting the Future Consultant Workforce Challenges 2019-22. https://www.biasp.org/wp-
content/uploads/2022/03/BASP-Stroke-Medicine-Workforce-Requirements-Report-FINAL.pdf  
 
9. National Institute for Health and Care Excellence, 2019. Clinical Guideline 128: Stroke and 
transient ischaemic attack in over 16s: diagnosis and initial management 
https://www.nice.org.uk/guidance/ng128 
 
10. National Institute for Health and Care Excellence, 2012. Clinical Guideline 138: Patient 
experience in adult NHS services: improving the experience of care for people using adult NHS 
services https://www.nice.org.uk/guidance/cg138 
 
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https://www.nice.org.uk/guidance/QS2  
 
12. National Institute for Health and Care Excellence, 2019. Quality Standard QS15:  Patient 
experience in adult NHS services https://www.nice.org.uk/guidance/QS15 
 
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13. NHS England, 2021. National Stroke Service Model – Integrated Stroke Delivery Networks. 
https://www.england.nhs.uk/wp-content/uploads/2021/05/national-stroke-service-model-
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14. NHS Providers. The Foundations of Good Governance. London: NHS Providers, 2015. 
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Acknowledgements 
King’s College London and the Intercollegiate Stroke Working Party (Appendix 4) thank all who have 
participated in the piloting and development of the audit since the first round in 1998.  
The web-based data collection tool was developed by Netsolving Ltd (www.netsolving.com).  
Thanks are due to the many people who have participated in the SSNAP 2021 acute organisational 
audit. It is recognised that this has involved many individuals spending time over and above an 
already heavy workload with no financial recompense. 
Thanks are due to many team members who contributed to organising the collection and retrieval of 
data including audit staff, IT and coding staff in addition to members of the clinical teams. 
Thanks to Professor Gillian Mead FRCP (Ed), President of The British and Irish Association of Stroke 
Physicians, for her insightful Foreword.   
The programme is funded by NHS England, the Welsh Government and, with some individual 
projects, other devolved administrations and crown dependencies. 
https://www.hqip.org.uk/national-programmes/ 
Published by SSNAP [June, 2022].  
 
46