Annual Report Apr23-Mar24
Source: data.gov.uk (2025-05-23)

Sentinel Stroke National Audit Programme Clinical results 23/24. The clinical component of SSNAP prospectively collects a minimum dataset for every stroke patient since December 2012 to measure processes of acute care, rehabilitation and care in the community. SSNAP also collects outcome measures at 6 months. The aim is to improve the quality of stroke care by auditing stroke services against evidence based standards.

The latest SSNAP periodic report presents national and named team results for the entire inpatient stroke care pathway. It is based on patients admitted or discharged from hospital in the most recent 3-monthly time period.

This report contains results for important measures of inpatient stroke care including stroke unit care, thrombolysis, therapy assessments and intensity, timings of interventions, and discharge standards. It also provides comparisons where appropriate against the previous 4 periodic reports to show changes over time.

A SSNAP scoring system has been derived to enable hospitals to compare their performance against other hospitals and benchmark against the national result. This summary of performance is based upon results for 44 key indicators which are grouped into 10 domains covering key aspects of stroke care. An overall score is calculated from domain scores adjusted for case ascertainment and audit compliance. Please see technical guidance for details about how the SSNAP scores are calculated.

Extremely high standards have been set with the aim of stimulating hospitals to identify where improvements are needed and drive change. Nowhere else in the world has set as stringent standards and the results should be read in this context.

SSNAP Summary Results: This excel file contains summary information by named team for 44 key indicators within 10 domains of care in addition to measures of overall performance based on the SSNAP scoring system.

Full Results Portfolio: This is a very detailed file containing results for every stroke measure collected by SSNAP. It is intended as a reference document for those who wish to drill-down in more detail than the summary results.

State of the Nation Report 2024
SSNAP
Sentinel Stroke National Audit Programme
Stroke care received between April 2023 to March 2024
Commissioned by

 
 
The Sentinel Stroke National Audit Programme (SSNAP) is led by the School of Life Course and Population 
Sciences at King’s College London.  
 
The report was prepared by the SSNAP team: 
Alex Iordache, Project Officer 
Anita Segilola, Project Officer 
Artur Ganeev, Data Scientist 
Ellie McMullen, Programme Manager (SSNAP Operations) 
Evelina Käld, Senior Data Analyst 
Kaili Stanley, Stroke Programme Manager 
Kevin Vasquez, Data Scientist 
Maude Holloway, Project Manager 
Youssef Hbid, Research Associate 
 
SSNAP Clinical and Associate Directors 
Dr Ajay Bhalla 
Ms Louise Clark 
Dr Rebecca Fisher 
Professor Martin James 
 
© 2024 Healthcare Quality Improvement Partnership (HQIP) 
 
Healthcare Quality Improvement Partnership 
The Sentinel Stroke National Audit Programme (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, and the Royal College of 
Nursing. 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. www.hqip.org.uk/national-programmes.  
 
School of Life Course and Population Sciences 
The School of Life Course & Population Sciences unites over 400 experts in women and children’s health, 
diabetes, nutritional sciences, population health and the molecular genetics of human disease. Our research 
links the causes of common health problems to life’s landmark stages, treating life, disease and healthcare 
as a continuum. We use this expertise to teach the next generation of health professionals and research 
scientists. www.kcl.ac.uk/slcps  
 
Sentinel Stroke National Audit Programme (SSNAP) 
T: xx-xxxx-xxxx 
E: xxx@xxx.xx  
www.strokeaudit.org  
 
 
i

 
 
Introduction 
SSNAP measures the quality and organisation of stroke care across England, Wales and Northern Ireland. 
The overall aim of SSNAP is to provide timely information to clinicians, commissioners, patients, and the 
public on how well stroke care is being delivered. Processes of care are measured against evidence-based 
quality standards referring to the interventions that any patient may be expected to receive. These standards 
are laid out in the latest clinical guidelines including the National Clinical Guideline for Stroke (2023) and 
NICE guidelines (Stroke and TIA, NG128; Stroke rehabilitation, NG236; and Quality standard for stroke), as 
well as national policy documents including the NHS Long Term Plan, the National Stroke Service Model, the 
National service model for an integrated community stroke service and the Quality statement for stroke. 
 
Further information on the programme including data analysis and methodology, full datasets, and reports 
produced are available on the SSNAP website: www.strokeaudit.org. The full annual results portfolio and 
annual thrombectomy portfolio can be accessed by going to: www.strokeaudit.org > Results > Clinical audit 
> National > Annual.  
 
Throughout the report, five key messages are shown in green boxes and five national recommendations in 
pink boxes. A full line of sight table, linking national recommendations to report findings, is available online.  
 
Patient characteristics 
95,222 patients were admitted to hospital with a stroke in 2023/24, compared to 92,134 in 2022/23 and 
92,067 in 2021/22. Table 1 summarises the key characteristics of those patients admitted in 2023/24, 
highlighting the complex nature of this disease requiring a skilled multidisciplinary specialist team across 
the patient’s entire journey.  
 
Total stroke admissions 
95,222 
Ethnicity 
     Infarction 
82,484 (86.6%) 
     White 
77,575 (81.5%) 
     Intracerebral haemorrhage 
12,387 (13.0%) 
     Black 
1,819 (1.9%)  
     Not known 
351 (0.4%) 
     Asian 
3,775 (4.0%) 
Age (median, IQR) 
76 [65-84] 
     Mixed 
501 (0.5%) 
Age (under 65 years) 
22,719 (23.9%) 
     Other 
1599 (1.7%) 
Gender (female) 
44,188 (46.4%) 
     Not stated/Not known 
9953 (10.5%) 
 
 
Comorbidities before stroke 
IMD quintile (England only) 
     Congestive heart failure 
6,037 (6.3%)  
     1 - most deprived 
16,334 (19.7%) 
     Hypertension 
54,532 (57.3%) 
     2 
16,005 (19.2%) 
     Diabetes 
23,635 (24.8%) 
     3 
17,303 (20.7%) 
     Previous stroke/TIA 
23,014 (24.2%) 
     4 
17,400 (20.8%) 
     Atrial fibrillation (AF) 
18,329 (19.2%) 
     5 - least deprived 
16,416 (19.7%) 
    Dementia 
6,590 (6.9%) 
 
 
Table 1: Casemix of patients admitted with stroke in England, Wales and Northern Ireland. IMD = Index of Multiple 
Deprivation, English patients only. 
 
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Summary of results for people admitted to hospital with stroke
Arrival at hospital
26.5%
of patients received brain imaging 
within 20 minutes of hospital arrival
24.9% 2022/23
Hyperacute assessment
Acute interventions
4h00m
median time from onset to arrival 
at first hospital
3h55m 2022/23
22.5%
of patients were assessed by a 
stroke specialist consultant within 
1 hour of hospital arrival
19.3% 2022/23
11.6%
of all stroke patients received 
thrombolysis
10.7% 2022/23
3.9%
of all stroke patients received 
a thrombectomy
3.1% 2022/23
Hyperacute intervention for intracerebral haemorrhage: for patients on 
anticoagulants eligible for reversal, given reversal agents within 1hr of 
arrival OR for patients with elevated systolic blood pressure (>150mmHg) 
on admission, given anti-hypertensives within 1hr of arrival. 
24.9%
of eligible patients received 
hyperacute intervention for 
intracerebral haemorrhage within 1 
hour of hospital arrival
22.8% 2022/23
6 month follow-up
38.8%
of applicable patients received 
a 6 month follow-up
38.7% 2022/23
46.7%
of patients were directly admitted 
to a stroke unit within 4 hours of 
hospital arrival
40.2% 2022/23
Specialist pathway
75.9%
of patients spent at least 90% of 
their hospital stay on a specialist 
stroke unit
72.8% 2022/23
63.4%
of patients were discharged to a 
stroke/neurology specific 
community rehabilitation service
61.1% 2022/23
22.9%
of patients were discharged to a 
stroke/neurology specific combined 
ESD-CRT service
Discharge to a combined ESD-CRT service can only be measured for the 2023/24 year and so there is no comparative data for 2022/23.
From 2024/25, a new metric for the proportion of patients assessed by a stroke-skilled clinician within 1hr of arrival will be reported. In this report, the 
proportion of patients assessed by a stroke specialist consultant within 1hr of arrival has been used. 
95,222
stroke admissions
250
hospitals
195
community services
184
6 month follow-up 
providers
Click here to see 
country rates
Click here to see 
country rates
Stroke care providers
Key: green icons show improvement against previous year, orange no change, and red worsening. Technical guidance on metrics available here. 
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Arrival at hospital 
Onset to arrival time
 
Figure 1: Median time (in minutes) from onset of stroke to arrival at hospital between 2013 and 2024. 
 
There has been a continued increase in stroke onset to hospital arrival time (fig. 1), and data from the last 4 
years (2019-2023) show that all component timings of the pre-hospital pathway have significantly increased 
(ESOC 2024: Pre-hospital timings for emergency stroke presentations in the UK), highlighting opportunities 
for quality improvement. Collaboration between stroke networks and ambulance providers is a pressing 
priority to ensure efficient practices are adopted to reduce delays, including a renewed approach in using 
the Face Arm Speech Test (FAST) for the public, and other innovations such as pre-hospital video triage. 
 
Recommendation 1 
Collaborate in regional networks to reduce the time from stroke onset to hospital and subsequently to 
specialist care on a stroke unit. For action by: Integrated Stroke Delivery Networks (ISDNs) and Local Health 
Boards (LHBs). 
 
Hyperacute assessment 
Access to initial brain imaging 
 
Figure 2: Proportion of patients receiving brain imaging within 1 hour of arrival and within 20 minutes of arrival 
between 2013 and 2024. 
 
The proportion of patients receiving brain imaging within 1 hour of arrival has increased to 59.5% in 
2023/24, and the proportion scanned within 20 minutes of arrival is 26.5% (fig. 2). A key priority is to ensure 
that the appropriate sequence of brain imaging is undertaken at the first sitting as rapidly as possible, with 
adoption of Artificial Intelligence (AI) to expedite decision making for acute reperfusion therapies (National 
optimal stroke imaging pathway [NOSIP]). Data suggests that there is still considerable scope to simplify 
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and extend the use of advanced imaging (UKSF 2023: Advanced imaging implications of new national 
guidelines for thrombolysis beyond 4.5 hours).  
 
Recommendation 2 
Increase the proportion of patients receiving the appropriate imaging immediately on arrival at hospital, to 
accelerate the identification of patients eligible for hyperacute interventions. For action by: ISDNs, LHBs and 
Regional Radiology Networks. 
 
Assessment by Stroke Clinician within 1 hour 
 
Figure 3: Proportion of patients assessed by a stroke consultant within 14 hours of arrival and within 1 hour of arrival 
between 2013 and 2024. 
 
The proportion of patients receiving a consultant assessment within 1 hour and 14 hours has increased to 
22.5% and 61.8% respectively (fig. 3). Diagnostic and therapeutic assessment of patients with suspected 
stroke by a trained and skilled clinician is key to the delivery of reperfusion and hyperacute treatments for 
ICH, and critical to the patient’s progress through the pathway to specialist care on a stroke unit, reinforcing 
the maxim that ‘time is brain’. Assessment of all acute medical admissions within 14 hours has been an 
objective since the 2017 Seven day services clinical standards, and reporting the assessment by a stroke-
skilled clinician within 1 hour is a new performance metric that will help to drive improvements in hyperacute 
specialist care. 
 
Acute interventions 
Thrombolysis rate 
 
Figure 4: Proportion of patients (out of all strokes) receiving thrombolysis between 2013 and 2024. 
 
The proportion of patients receiving thrombolysis has increased from 10.7% in 2022/23 to 11.6% in 2023/24 
(fig. 4), recovering to pre-pandemic levels. Understanding the sources of variation in thrombolysis practice is 
important for quality improvement and novel methods using machine learning can help identify locally 
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important means of improving thrombolysis rates (Pearn et al., 2023). As the evidence for thrombolysis 
eligibility expands with increasing population benefit, the measurement of thrombolysis rates compared 
with bespoke site-specific targets will become even more significant. 
 
Thrombectomy rate 
 
Figure 5: Proportion of patients (out of all strokes) receiving thrombectomy between 2016 and 2024.  
 
Although the rates of mechanical thrombectomy (MT) are lower than the European average, the proportion 
of patients undergoing treatment has increased to 3.9% in 2023/24 (fig. 5) with a 30% increase in the 
number of thrombectomies from the previous year. As the evidence continues to advance significantly, it is 
likely that up to 15% of patients may be eligible for MT. Approaching this ambition will require improvements 
in availability of services and workforce, equity of geographical coverage and early identification of patients 
suitable for MT using advanced imaging. Thrombectomy networks are important in supporting 
comprehensive and acute stroke centres so that higher volumes of MT can be managed as efficiently as 
possible, for example through improved repatriation. 
 
Key message 
Reperfusion treatment rates have improved: the proportion of all patients receiving thrombolysis has 
increased from 10.7% in 2022/23 to 11.6% in 2023/24, and 3.9% of all patients received thrombectomy in 
2023/24 compared to 3.1% in 2022/23.  
 
Hyperacute interventions for intracerebral haemorrhage 
 
Figure 6: Proportion of eligible patients diagnosed with intracerebral haemorrhage given anticoagulant reversal agents 
within 1 hour OR given antihypertensives within 1 hour of arrival between 2018-2024.  
 
Outcomes for patients with intracerebral haemorrhage (13% of all stroke admissions) have improved over 
the past 10 years, including a significant fall in in-hospital mortality associated with an increase in the 
proportion of ICH patients directly admitted to a stroke unit. Better specialist access for ICH supports the 
delivery of quality improvement bundles of care including rapid anticoagulant reversal and blood pressure 
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lowering (fig. 6), critical to preventing deterioration and to improving survival and disability outcomes (Ma et 
al., 2023; Parry-Jones et al., 2023).  
 
Key message 
The proportion of eligible patients receiving an appropriate hyperacute intervention has increased since 
SSNAP started collecting this data, from 18.9% in 2018/19 to 24.9% in 2023/24.  
 
Specialist pathway 
Access to stroke unit within 4 hours 
 
Figure 7: Proportion of patients directly admitted to a stroke unit within 4 hours of arrival between 2013-2024.  
 
The proportion of patients directly admitted to a stroke unit within 4 hours of admission has improved from 
40.2% in 2022/23 to 46.7% in 2023/4 (fig. 7). This partial recovery reflects the organisational priority for 
acute stroke care that is needed to ensure timely interventions and key multidisciplinary assessments. A 
refreshed whole systems approach to optimising inpatient flow through the hospital is critical to preserve 
stroke unit capacity according to demand. Such approaches should include early access to needs-based, 7-
day rehabilitation at all stages of the pathway, which will provide earlier discharge and improve hospital 
capacity and flow.  
 
90% stay on a stroke unit 
 
Figure 8: Proportion of patients spending at least 90% of their stay on a stroke unit between 2013-2024.  
 
The proportion of patients spending at least 90% of their inpatient stay on a stroke unit has improved from 
72.8% in 2022/23 to 75.9% in 2023/24 (fig. 8), but not yet returned to pre-pandemic levels. This metric 
highlights that despite a partial recovery in access to organised stroke care, services are still challenged in 
optimising patient flow efficiently on stroke units. A collective approach across the entire stroke pathway is 
required to improve access for patients to specialist care and stroke rehabilitation consistently. 
 
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The Stroke Rehabilitation Spotlight Report focusses on the performance of stroke rehabilitation across the 
pathway.  
 
Key message 
Timely access to specialist acute stroke care has partly recovered this year: 46.7% patients were directly 
admitted to a stroke unit within 4 hours in 2023/24 compared to 40.2% in 2022/23, and 75.9% patients spent 
at least 90% of their stay on a stroke unit in 2023/24 compared to 72.8% in 2022/23..  
 
Recommendation 3 
Restore timely access to hyperacute specialist inpatient care for stroke. For action by: Integrated Care 
Boards (ICBs) and LHBs. 
 
 
Access to stroke/neurology specific ESD and/or CRT services 
 
Figure 9: Proportion of patients discharged to a stroke-specific ESD and/or stroke-specific CRT service between 2013 
and 2024.  
 
The proportion of patients discharged to a stroke/neurology specific community rehabilitation service has 
increased to 63.4% in 2023/24 (fig. 9). There are currently 106 (47.5%) community teams registered as 
combined ESD-CRT services and 22.9% of patients were transferred to a combined ESD-CRT service on 
discharge from hospital in 2023/24. This reflects the ongoing commitment to continued implementation of 
the National service model for an integrated community stroke service (ICSS) across England. The NHS 
England National stroke rehabilitation pilots demonstrated the feasibility of implementation of the ICSS 
model in different geographical contexts. 
 
Key message 
The transition to integrated, needs-based community stroke services continues with 47.5% of community 
providers identifying as a combined ESD-CRT service. 63.4% of patients were discharged to an ESD (Early 
Supported Discharge) and/or CRT (Community Rehabilitation Team) service in 2023/24 compared to 40.7% 
in 2013/14.  
 
Recommendation 4 
Support the shift to leaving hospital much sooner and at an earlier stage in rehabilitation by providing 
equitable access to needs-based integrated 7-day rehabilitation along the whole pathway. For action 
by: ICBs and LHBs. 
 
 
 
 
7

 
 
6 month follow-up 
Access to 6-month follow-up 
 
Figure 10: Proportion of patients receiving a 6 month assessment after stroke, by follow-up method, between 2013 and 
2024.  
  
The proportion of patients receiving a 6-month stroke review has remained stable at 39% between 2022/23 
and 2023/24 (fig. 10). An increase in face-to-face assessments likely reflects the restoration and recovery of 
the review process following the COVID pandemic, and however it is delivered, a personalised approach to 6-
month reviews is important to ensure that the full range of patients’ needs are identified and met. For 
example, patient-reported outcome measures (EQ5D-5L) have highlighted that approximately one fifth of 
patients have mood and pain issues that require ongoing management (Patient Outcomes Spotlight Report). 
 
Key message 
Personalised review of people with stroke 6 months after the event remains patchy and is only available to a 
minority of stroke survivors, with 39% of applicable patients receiving a 6-month review.  
 
Recommendation 5 
Respond to the need for ongoing support and regular review when recovering from the life-changing effects 
of acute stroke and ensure that all stroke survivors receive formal follow-up 6 months after their stroke, with 
further support made available for those identified with ongoing needs. For action by: ICBs and LHBs. 
 
 
Conclusion 
Implementation of this report’s five national recommendations will lead to better outcomes for patients and 
will also improve patients’ experience of stroke services. Restoring access to specialist care in hospital to 
levels considered typical before the COVID pandemic must remain a high priority for hyperacute stroke 
services. 2023 saw the publication of major updates to national guidance for stroke treatment and 
rehabilitation (National Clinical Guideline for Stroke [2023]), and in turn 2024 has seen major revisions to the 
measurement of the intensity and frequency of rehabilitation in SSNAP, along with the refreshed set of 
performance metrics laid out in this report. As the ageing of the UK’s population ensures that the prevalence 
of stroke-related disability and the cost to society increases, reducing the population burden of physical and 
cognitive disability after stroke will need to remain the unrelenting focus for services in the years to come. 
 
 
8

 
 
We would like to express our thanks to the following people and organisations for their invaluable 
contribution in producing this report: 
 
SSNAP Clinical and Associate Directors: Dr Ajay Bhalla, Consultant Stroke Physician, Ms Louise 
Clark, Stroke Consultant Therapist, Dr Rebecca Fisher, Programme Manager - Stroke, NHS England, and 
Professor Martin James, Consultant Stroke Physician. 
 
Carol Parsons, stroke survivor and an artist who provided us with the artwork featured in this report. Our 
patient representatives on the Intercollegiate Stroke Working Party (ICSWP), for their continued support of 
the programme: Danny Lloyd, Emily Toplis and Marney Williams, and our Patient and Public Voice 
Representation group. Their valuable contribution keeps the patient voice at the heart of what we do as a 
programme. 
 
The hospitals and community teams and ambulance trusts for continuing to participate in SSNAP. Their 
participation and commitment to the audit ensures that high quality, rich and robust data is available which 
can be used to improve stroke services. 
 
 
 
 
 
Cover art provided by: Carol Parsons  
 
Carol has always been an artist so her recovery from stroke in 
2018 has been about learning how to continue with her work. 
She is also a trained tutor and has run workshops, courses, 
demonstrations and painting holidays for over twenty years. 
She has work in private collections in Australia, Canada, 
France, USA and the UK.