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    Northumberland covers a large area and contains a mix of rural and urban populations.  This can make it difficult for stroke patients to receive timely and appropriate care. Early assessment, diagnosis and treatment of strokes by specialist teams can limit further damage to the brain and aid the recovery process.  This not only benefits patients and their families, but also has a positive impact upon cost of care.


    Northumbria designed an integrated stroke service that provided a much more holistic, joined up and coherent approach for patients.

    Care is delivered by a specialist stroke team which research shows as being the single biggest factor in improving stroke recovery.   Stroke patients receive rapid assessment and initial intervention at a specialist emergency hospital, then ongoing treatment and longer term rehabilitation at general hospitals.  Intensive follow on rehabilitation takes place at community hospitals, and importantly, in patients’ own homes.

    In the hospital: patients are transported by ambulance to the emergency specialist hospital where 24/7 consultant led services enable fast diagnosis and intervention. Diagnostics such CT, MRI and blood tests are used to  ensure that the right emergency treatment is given.  As soon as patients are stable, the integrated stroke team initiates the rehabilitation programme which continues in general hospitals.

    A multidisciplinary team approach enables the patient to be discharged safely with fully integrated community support, to regain as much independence as possible. A unique, multidisciplinary ‘Hospital to Home’ discharge service that considers a patient’s discharge at the point of admission, helpspeople to regain independence and avoid readmissions. Intensive interventions are also provided to get patients home quicker.

    Leaving hospital: The team agrees a discharge plan so that patients know what services and support they will receive, and who will be coming to see them. This could include ongoing physiotherapy, home modifications, extra caring support at home, and/ or telecare and telehealth.

    Followup care: The whole patient journey is supported by access to an individual patient’s record  across the pathway.   After discharge, patients are seen by their GP,  a practice nurse or district nurse, and are reviewed in a stroke review clinic at six weeks and six  months after the stroke.  Annual assessments and reviews are provided by their GP. Virtual clinics enable patients in rural, hard to reach areas, to be directly connected with specialist consultants and physicians. Specialist and community nurses and multi-disciplinary allied health teams are deployed as required.  They promote health, safety, well-being, reablement and rehabilitation to patients who have been discharged from hospital.


    • This integrated clinical service has:
    • Halved  the length of time of hospital stay;
    • Increased patient satisfaction;
    • Improved recovery rates; and
    • Ensured hospital beds are freed up for urgent and elective patients, ultimately saving money and increasing access.

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