Annual Report Apr22-Mar23
Source: data.gov.uk (2024-05-10)

Sentinel Stroke National Audit Programme Clinical results 22/23. 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.

SSNAP Annual Report 2023
SSNAP
Sentinel Stroke National Audit Programme
Stroke care received between April 2022 to March 2023
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
Isobel Cabraal, Project Officer
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
© 2023 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, 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. 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, CG162; 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 can be
accessed by going to: www.strokeaudit.org > Results > Clinical audit > National > Annual.
This report presents data from more than 91,000 patients admitted to hospitals between April 2022 and
March 2023 and submitted to the audit, representing over 90% of all admitted strokes in England, Wales and
Northern Ireland. This data is summarised in key messages for both those who provide and those who
commission stroke care in hospitals and the community, and presented in tables and charts.
10 years of SSNAP
2022 marked 10 years since the inception of SSNAP as the national clinical audit for stroke and this year
(2022/23) marks the tenth complete year of data collection. Many graphs in this report include all 10 years
of data to show how key measures have changed since inception of the audit. Key messages and national
recommendations focus on the current performance of stroke care.
Figures 1 and 2 show the continued and increasing participation in SSNAP over the past 10 years.
Changes in inpatient SSNAP scores over time (2014-2023)
Figure 1: Proportion of inpatient teams achieving the ratings of A-E based on a summary of their performance. The
grey bar shows the proportion of teams that entered data onto the minimum dataset during the first COVID-19 wave
and received a report but did not receive a score for that period.
1

Number of records submitted to SSNAP by community teams (2013-2023)
Figure 2: The number of records submitted and locked by community teams between 2013 and 2023.
Key messages from 2022/23
1.
The proportion of patients accessing timely specialist stroke care continues to decline: 40.2%
patients directly admitted to a stroke unit within 4 hours in 2022/23 compared to 44.4% in 2021/22,
and 72.9% patients spending at least 90% of their stay on a stroke unit in 2022/23 compared to
76.5% in 2021/22. These figures compare to 54.9% and 83.2% respectively for 2019/20.
2.
Reperfusion treatment rates have improved: the proportion of all patients receiving thrombolysis has
increased from 10.4% in 2021/22 to 10.7% in 2022/23, and 3.1% of all patients received
thrombectomy in 2022/23 compared to 2.5% in 2021/22.
3.
Intracerebral haemorrhage patients now have better access to specialist care (76% patients directly
admitted to a stroke unit in 2022 compared to 66% in 2013), which is associated with reduced
in-hospital mortality rates compared with 10 years ago (29% in 2022 compared to 33% in 2013).
4.
The transition to integrated community stroke services has begun with 49% of community providers
now identifying as a combined ESD-CRT service. 61% of patients were discharged to an ESD (Early
Supported Discharge) and/or CRT (Community Rehabilitation Team) service in 2022/23 compared to
40.7% in 2013/14.
5.
SSNAP now collects data on return to work at 6 months after a stroke. The proportion of patients
working full-time 6 months after stroke is 6.1% compared to 14.5% working full-time before stroke.
National recommendations
1.
Reverse the recent decline in hyperacute specialist access for stroke. For action by: Acute trusts,
Local Health Boards (LHBs), Regional Medical Directors (RMDs) and Integrated Stroke Delivery
Networks (ISDNs).
2.
Increase the proportion of patients receiving the appropriate imaging immediately on arrival at
hospital, to accelerate the identification of patients eligible for reperfusion treatments. For action by:
Acute trusts, LHBs, RMDs, Radiology Networks and ISDNs.
3.
Increase the proportion of days on which people recovering from stroke receive rehabilitation
therapy, both inside and outside hospital. For action by: Acute and community trusts and LHBs.
4.
Increase the proportion of patients accessing stroke/neuro ESD and/or CRT. For action by: LHBs,
acute and community trusts, supported by ISDNs and regional SQuIRe (Stroke Quality Improvement
Rehabilitation) leads.
5.
Reverse the recent decline in the proportion of stroke survivors who receive formal follow-up 6
months after their stroke. For action by: Acute and community trusts and Integrated Care Board (ICB)
and LHB commissioners, supported by ISDNs and regional SQuIRe leads.
A full line of sight table, linking national recommendations to report findings, is available online.
2

Summary of results for people admitted to hospital with stroke
High Quality Specialist Stroke Care
73%
of patients spent at least 90% of
hospital stay on a specialist
stroke unit
↓(77% 2021/22)
89%
of patients received stroke
specialist nursing assessment
within 24hrs of admission
↓(90% 2021/22)
72%
of applicable patients received
swallow screening within 4hrs of
admission
= (72% 2021/22)
Seven Day Priority Clinical Standards of Stroke Care
40%
of patients were directly admitted
to a stroke unit within 4hrs of
hospital arrival
↓(44% 2021/22)
83%
of patients were assessed by a
stroke specialist within 24hrs of
admission
↓(84% 2021/22)
57%
of patients received brain
imaging within 1hr of hospital
arrival
↑(55% 2021/22)
Reperfusion Treatment
54 minutes
median time from arrival at
hospital to thrombolysis
treatment
↑(53 minutes 2021/22)
10.7%
of all stroke patients received
thrombolysis
↑(10.4% 2021/22)
3.1%
of all stroke patients underwent a
thrombectomy
↑(2.5% 2021/22)
Delivery of Inpatient Rehabilitation
% of applicable patients receiving the equivalent of 45 minutes of therapy 5 days a week
25%
physiotherapy
↓(27% 2021/22)
30%
occupational therapy
↓(32% 2021/22)
14%
speech and language therapy
↓(15% 2021/22)
Community Rehabilitation
61%
of patients discharged to a
stroke/neurology specific
community rehabilitation service
↑(60% 2021/22)
49%
of community rehabilitation
services registered as a
combined ESD-CRT services
↑(26% 2021/22)
6%
of patients were working full-time
6 months after stroke compared
with 15% prior to stroke
= (6% and 14% 2021/22)
Longer Term Outcomes
37%
of applicable patients received a
6 month follow-up
↓(41% 2021/22)
17%
of patients at 6 months reported
moderate or severe anxiety or
depression
↓(18% 2021/22)
3%
of patients had a recurrent stroke
within 6 months
↑(2.8% 2021/22)
3

Patient characteristics
91,162 patients were admitted to hospital with a stroke in 2022/23, compared to 92,054 in 2021/22 and
85,480 in 2020/21. Table 1 summarises the key characteristics of those patients admitted in 2022/23,
highlighting the complex nature of this disease requiring a skilled multidisciplinary specialist team across
the patient’s entire journey.
Total stroke admissions
91,162
Ethnicity
Infarction
79,161 (86.8%)
White
76,194 (83.6%)
Intracerebral haemorrhage
11,604 (12.7%)
Black
1,761 (1.9%)
Not known
397 (0.4%)
Asian
3,495 (3.8%)
Age (median, IQR)
76 [65-85]
Mixed
456 (0.5%)
Age (over 80 years)
32,827 (36.0%)
Other
1,503 (1.6%)
Gender (female)
42,596 (46.7%)
Not stated/Not known
7,753 (8.5%)
Comorbidities before stroke
IMD quintile (England only)
Congestive heart failure
5,295 (5.8%)
1 - most deprived
15,848 (19.5%)
Hypertension
51,331 (56.3%)
2
15,781 (19.4%)
Diabetes
22,220 (24.4%)
3
16,988 (20.9%)
Previous stroke/TIA
21,884 (24.0%)
4
16,989 (20.9%)
Atrial fibrillation (AF)
17,109 (18.8%)
5 - least deprived
15,557 (19.2%)
Dementia
6,385 (7.0%)
Table 1: Casemix of patients admitted with stroke in England, Wales and Northern Ireland. IMD = Index of Multiple
Deprivation, English patients only.
Reperfusion treatment
Proportion of all patients receiving thrombolysis (2019-2023)
Figure 3: Proportion of patients (out of all strokes) receiving thrombolysis, comparing 2019/20, 2020/21, 2021/22
annual data with 2022/23 quarterly data.
4

The proportion of patients receiving thrombolysis has increased from 10.4% in 2021/22 to 10.7% in 2022/23
(fig. 3), however this is still below pre-pandemic levels of 11.7% in 2019/20. Innovative methods using
machine learning can help identify locally-important means of improving thrombolysis rates (Allen et al.,
2022; Pearn et al., 2023) and as evidence for increasing eligibility for thrombolysis grows, the measurement
of these metrics will become even more significant.
Proportion of all patients receiving thrombectomy (2015-2023)
Figure 4: Proportion of patients (out of all strokes) receiving thrombectomy between 2015 and 2023.
The proportion of patients undergoing treatment with mechanical thrombectomy (MT) has increased to
3.1% in 2022/23 (fig. 4) however the growth and trajectory is still slow. Increasing the number of
thrombectomy centres operating 24 hours a day, seven days per week with the appropriate workforce will
improve the number of patients undergoing this procedure. As some centres of excellence achieve
treatment levels for local patients similar to those seen elsewhere in Europe, eradicating geographical
variation in access to MT has become all the more important.
A full annual thrombectomy portfolio can be accessed by going to: www.strokeaudit.org > Results > Clinical
audit > National > Annual.
Thrombolysis
Thrombectomy
National
10.7%
National
3.1%
England
10.5%
England
3.2%
Wales
13.7%
Wales
0.5%
Northern Ireland
13.9%
Northern Ireland
3.9%
Table 2: Proportion of patients receiving reperfusion treatment nationally and in England, Wales and Northern Ireland.
Thrombectomy proportions based on location of thrombectomy centre.
5

Intracerebral haemorrhage
Outcomes for intracerebral haemorrhage patients (2013-2022)
Figure 5: Changes in outcomes for patients admitted with intracerebral haemorrhage between 2013 and 2022.
Outcomes for patients with intracerebral haemorrhage (12% of all stroke admissions) have improved over
the past 10 years, including a fall in in-hospital mortality from 33% in 2013 to 29% in 2022 (fig. 5), occurring
in parallel with an increase in the proportion of these patients directly admitted to a stroke unit from 66% in
2013 to 76% in 2022 (ESOC 2023: Have outcomes for intracerebral haemorrhage in the UK improved?).
Access to interventions to control physiological parameters such as blood pressure, temperature, glucose
and anticoagulant reversal are important to improve survival and recovery (Ma et al., 2023) and SSNAP has
shown small improvements in the implementation of blood pressure lowering in the UK over the last 5 years
(Holloway et al., 2023).
Access to specialist stroke care
Proportion of patients receiving brain imaging within 1 hour of arrival (2013-2023)
Figure 6: Proportion of patients receiving brain imaging within 1 hour of arrival between 2013 and 2023.
The proportion of patients receiving brain imaging within 1 hour of arrival has increased to 56.9% in 2022/23
(fig. 6). A key priority is to ensure that the appropriate sequence of brain imaging is undertaken at the first
sitting, with adoption of artificial intelligence to expedite decision making for acute treatments (National
optimal stroke imaging pathway [NOSIP]). Following publication of new evidence extending eligibility of late
6

presenting patients for MT, it is anticipated that more patients will require advanced imaging in a timely
fashion to accommodate the new guidance.
Proportion of patients directly admitted to a specialist stroke unit within 4 hours of arrival (2013-2023)
Figure 7: Proportion of patients directly admitted to a stroke unit within 4 hours of arrival between 2013 and 2023.
The proportion of patients directly admitted to a stroke unit within 4 hours of admission has declined from
44.4% in 2021/22 to 40.2% in 2022/23 (fig. 7), well below the pre-pandemic level of 54.9% in 2019/20. A
renewed approach to optimising inpatient flow through the hospital is critical to preserve stroke unit
capacity commencing at the front door and facilitating early supported discharge, particularly at weekends
with prompt access to integrated community stroke rehabilitation services and enhanced social care.
Proportion of patients spending at least 90% of their stay on a specialist stroke unit (2013-2023)
Figure 8: Proportion of patients spending at least 90% of their stay on a stroke unit between 2013 and 2023.
The proportion of patients spending at least 90% of their inpatient length of stay on a stroke unit has
declined from 76.5% in 2021/22 to 72.9% in 2022/23 (fig. 8). This metric has highlighted that services are
still challenged in optimising patient flow efficiently on stroke units and a whole system collective approach
across the entire stroke pathway is required to improve access for patients to specialist care and stroke
rehabilitation.
7

Inpatient rehabilitation
Percentage of days on which therapy is received (2013-2023)
Figure 9: Proportion of days (out of total days therapy was required) on which therapy was received, per discipline,
between 2013 and 2023.
There has been a fall in 2022/23 in the percentage of inpatient days a patient requires therapy on which
therapy was received across each therapy discipline (fig. 9). This may be driven by a combination of
workforce pressures and slow adoption of seven day working. In parallel, there has also been a reduction in
the standards of receiving 45 minutes of therapy five days per week. Appropriately resourced seven day
working across therapy disciplines will offer an opportunity to enhance the intensity of rehabilitation. The
provision of psychology still remains low despite mood and cognitive issues being common, and further
increasing the intensity and dose of rehabilitation inside and outside hospital is a priority.
Community rehabilitation
Proportion of patients discharged to a stroke/neurology specific service (2013-2023)
Figure 10: Proportion of patients discharged to a stroke-specific ESD and/or stroke-specific CRT service between 2013
and 2023.
In April 2023, 49% of community services were identified as a combined ESD-CRT service (table 3). This is in
line with the National service model for an integrated community stroke service (ICSS), recognising that a
wider group of stroke patients require ongoing rehabilitation, beyond ESD, in an integrated fashion according
to need. The increase in complexity of patients discharged from hospital will require a responsive,
appropriately resourced and flexible approach in delivering stroke rehabilitation at a similar intensity and
dose to that which would be delivered in hospital. The NHS England National stroke rehabilitation pilots
demonstrated implementation of the ICSS model in different geographical contexts.
8

April 2022
April 2023
Standalone ESD
104 (46%)
Standalone ESD
64 (31%)
Standalone CRT
63 (28%)
Standalone CRT
42 (20%)
Combined ESD-CRT
59 (26%)
Combined ESD-CRT
102 (49%)
Table 3: Number and proportion of community teams registered per team type, before and after engagement with
services in March 2023.
Employment status before and at 6 months after stroke (2021-2023)
Figure 11: Comparison of employment status of stroke patients before stroke and at 6 months after stroke, between
July 2021-March 2022 and April 2022-March 2023. This only includes those patients that had a 6 month review (36.9%
of applicable patients in 2022/23).
10.6% of patients have been supported to continue working either full-time or part-time at 6 months after
stroke compared to 18.8% of patients working before stroke in 2022/23 (fig. 11). Vocational rehabilitation is
a key component of a comprehensive community stroke service to facilitate return to work, remain in work
or leave in a supported way, and NHS England have developed a new vocational rehabilitation toolkit to
support clinicians, commissioners and leaders to maximise the chances of people returning to work after a
stroke.
6 month follow-up
Proportion of patients receiving a 6 month assessment (2013-2023)
Figure 12: Proportion of patients receiving a 6 month assessment after stroke, by follow-up method, between 2013 and
2023.
9

There has been a reduction in the proportion of patents receiving a 6 month stroke review from 40.7% in
2021/22 to 36.9% in 2022/23, albeit with an increase in the proportion receiving face to face assessment
(fig. 12). Commissioning stroke reviews are critical in assessing long term needs including secondary
prevention, disability management and patient outcomes. For example, quality of life measures have
highlighted that just under one fifth of patents have mood issues that require ongoing assessment and
management (fig. 13). COVID-19 necessitated a move to telephone reviews, however the best approach to
delivery of 6 month reviews must be reviewed with patients to ensure their needs and preferences are met.
EQ5D-5L at 6 months after stroke
Figure 13: EQ5D-5L at 6 months after stroke for those having a follow-up assessment between April 2022 and March
2023. EQ5D-5L is a patient reported outcome measure.
Concluding thoughts
The delivery of specialist stroke care both in hospital and in the community is crucial to accelerate recovery
from stroke and there are improvement opportunities for services through innovative and creative methods.
This can range from pre-hospital video triage for timely diagnosis to methods for increasing the intensity of
stroke rehabilitation in the patient’s own home. The fundamental tenets of organised stroke care need to be
retained including rapid transfer to specialist stroke units, coordinated transfers of care and provision of
specialist stroke rehabilitation in hospital and in the community.
Although we are seeing incremental improvements in the delivery of reperfusion therapy, ongoing quality
improvement will be required to maximise their benefit at a population level, particularly through eradicating
geographical variation in access to treatments. Deploying an able, flexible, proactive multidisciplinary
workforce is fundamental to delivering high quality specialist stroke rehabilitation inside and outside
hospital, as well as meeting the longer term needs of patients at 6 months and beyond.
SSNAP provides an essential vehicle to monitor performance and drive quality improvement across the
entire stroke pathway. Further developments to the national stroke audit over the next 12 months will
increase our ability to understand how and where to deliver greater quality improvement and better
outcomes for people with stroke.
10

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.
Sandra Aina, stroke survivor and artist, who has 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: Marney Williams and Danny Lloyd, 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 for continuing to participate in SSNAP. Their participation and
commitment to the audit ensures that quality, rich and robust data is available which can be used to improve
stroke services.
Cover art provided by: Sandra Aina
My stroke happened in May 2015. I didn’t know. In fact, if I had died, I
wouldn’t have known. I spent one month in Plymouth hospital, one month
in Basildon Hospital and six weeks at Brentwood recovery service. I came
out initially not using a wheelchair but then a dear friend who also had
had a stroke, gave me hers, and it changed my life. I had good care,
especially from Brentwood but I could not get over the devastation of
losing my physical and mental being. I cried every day for 18 months and
then one evening my in-law called from Nigeria. My hubby gave me the
phone, and through my tears I explained to her how I felt. I don’t really
remember what she said to me, but I just felt better afterwards. I’m more
or less back to my old self now. The painting you’re looking at is my
representation of the scream. That is how I felt. This represents just how
I felt in those early days. I hope you like my copy.