S7E1 - The Stroke Pathway in Focus: Improving Access, Outcomes and Equity

This episode of AXREM Insights focuses on the current state of the UK stroke pathway, featuring insights from Michelle Dalmacio of the Stroke Association. The discussion highlights the scale of the challenge, with over 100,000 strokes each year and growing demand placing pressure on services. While effective treatments such as thrombectomy can significantly improve recovery and reduce disability, access remains inconsistent, with only a small percentage of eligible patients receiving it and limited 24/7 availability across centres. The conversation explores how workforce shortages, regional inequalities, and gaps in community rehabilitation continue to impact patient outcomes, reinforcing the need for coordinated national action.

Alongside these challenges, the episode emphasises the opportunity for innovation to transform stroke care. Advanced imaging, AI-driven decision-making, and tele-radiology are presented as key tools to support faster diagnosis, better triage, and more equitable access to specialist treatment. The importance of the full care pathway is a central theme, particularly the role of rehabilitation and community support in long-term recovery. The episode also underlines the importance of public awareness, encouraging recognition of stroke symptoms through the FAST test and stressing that stroke is a medical emergency where rapid action can save lives and improve outcomes.

View our State of the Stroke Pathway paper here

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Transcript

Disclaimer: This transcript was produced using AI transcription software. It may contain errors, misspellings or inaccuracies and has not been fully edited for verbatim precision. It is intended to accompany the podcast audio and should not be relied upon as a standalone or definitive record of the discussion. 

Hello and welcome to AXREM Insights Stroke Pathway Podcast.
I'm Sally Edgington and I'm here with Paige Ward,
AXREM Future Leaders Representative
and Clinical Product Manager at Ag for Healthcare.
Today we have the pleasure to be speaking
to Michelle Dalmacio,
Associate Director of the Stroke Association.
So welcome Michelle and thank you for being
on our show today.
Let's start by handing over to you to tell us
about yourself, your career so far
and what led you to the Stroke Association.
Ah, thank you for having me.
Now I'm quite excited to be here.
So I have worked for the Stroke Association for 11 years
and I don't know if you can tell by my accent
but I am not originally from here, I'm actually Canadian.
And 28, I found myself in a situation
where I was at risk of redundancy
and I took a trip to Europe
and that inspired me to continue traveling.
So I moved to England with the intention
of only living here for a year,
but then 21 years later I'm still here.
And when I started working in England,
my first job was in charity.
So I had kind of my whole time living in England,
I have always worked with charities,
previously supporting disabled people,
disadvantaged people into work.
I worked for an organization
that supported people with learning disabilities
and I think my longest stint has been
with the Stroke Association for the 11 years.
Fantastic, thank you.
And I'm glad that the UK drew you in and kept you
because it sounds like you're an amazing asset
at the Stroke Association based upon the engagement
that we've had.
Today we're talking about the AXREM paper
on the stroke pathway, which lays out one of the clearest
and most urgent pictures we've seen
of the challenges facing stroke care today.
With more than 100,000 strokes occurring each year
and demand projected to rise sharply,
the report highlights how performance across the pathway
has plateaued regional inequalities persist
and critical interventions like thrombosis
and thrombectomy remain underused,
but it's also a forward looking document.
AXREM sets out how advanced CT imaging,
AI driven decision support and tele radiology
can transform the speed, consistency and equity
of stroke care across the NHS.
It's a call for coordinated national action,
combining technology, workforce investment
and system redesign to ensure patients receive
timely specialist treatment wherever they live.
Today we're gonna dive into what the paper reveals,
why it matters and how these recommendations
could reshape the future of stroke services in the UK.
So I'm gonna hand over to Paige now
who will ask some of our questions.
Thanks Sally, hi Michelle.
It'd be good to hear your thoughts on what you think,
Michelle, what you think must be done
to meet NHS England's aspiration of 10% thrombectomy access
and how can this affect the outcome for a stroke patient?
All right, so in 2425, the thrombectomy rate in England
was 4.36%, so it has improved since then,
but you know, so the target of 10%, it is achievable.
I think around 15% of people could be eligible
for thrombectomy.
So mechanical thrombectomy, it's such a great treatment,
you know, in terms of acute care.
So people that are in receipt of mechanical thrombectomy
often have quicker recovery times,
they're often impacted less by degrees of disability,
you know, the amount of rehab would be lessened
if they get this treatment.
So it is extremely effective in improving,
you know, the quality of life for people
and their recovery following stroke.
Now, right now in England, not every centre
that does offer mechanical thrombectomy,
they don't offer it all on a 24 seven basis.
So in some areas you might be disadvantaged,
for example, if you have your stroke on a weekend
or in the middle of the night.
So part of, you know, what we've been working to support
the NHS to achieve is to offer 24 seven thrombectomy
everywhere that it's offered in England.
And right now I think there are 15 centres in England
that are providing this 24 seven,
and that, you know, further sites are closer
to kind of implementing this.
In some areas they might, like one centre might do it
24 seven on their own, and in other places
they might have an arrangement with another centre
where maybe one week on all the overnights, you know,
happen in one hospital and then, you know,
the following week it then changes.
So regardless, depending on where you live,
if you can access it 24 seven,
that will definitely improve and increase the number
of people that would be receiving it.
There's some other things that could also help
and will also help the increased take-up of thrombectomy.
And it's kind of the role of communities of practice
and clinical networks, because through these networks
and communities, there's, you know, peer support,
there's sharing of knowledge and, you know,
expertise and learning between the different centres.
So it's important that these things, you know,
continue and carry on.
Also, there is training and education and support.
So I think, you know, for a time,
the focus might've been on the number of,
oh gosh, let me get this right,
intranural radiologists who perform the thrombectomies,
kind of having a number of them available,
but it isn't just those who perform
and that you need the nurses,
you know what I mean, that support the procedure,
the anesthesiologist, you know, transport,
if then they're gonna go back to a stroke unit,
you need access to good rehabilitation following it,
because, you know, it isn't just enough
that you get some of the treatments
like thrombolysis or thrombectomy for the acute care.
It is really important that people have good access
to quality rehab.
So that kind of training, education and support
is key to increasing the number of thrombectomies.
And like, you know, I talked a little bit about workforce.
So the 10-year health plan, workforce plan in England,
you know, that's an opportunity for, you know,
the right levels of staffing to be in place
because that is kind of crucial to ensure
that there's effective safe treatment
across the whole stroke pathway.
So yeah, I talked, you know,
we're talking a lot about the acute,
but that I can't stress enough
how much the community rehabilitation is important,
you know, once people are discharged home
that they can carry on to recover.
And right now I think only 17% of community-based services
have the appropriate access to each core therapy.
So that would include like physiotherapy,
occupational, occupational therapy,
speech and language therapy.
So, you know, these are services that can be available
to stroke survivors after they've been discharged
from hospital to carry on, you know, rehabilitating at home.
And it isn't just kind of those communities of practice
within, you know, England, for example,
like there's a five nations thrombectomy committee,
which includes the four UK nations
plus the Republic of Ireland.
And they bring experts across the whole pathway,
thrombectomy pathway together,
and they explore learning and evidence and insights
across the nation and share best practice
to improve thrombectomy and address challenges.
I think there's some key things, yeah.
I was gonna say there is so much there to unpack.
I've just taken loads of notes
and now I just have so much I need to say about this.
So it's such a postcode lottery.
And I think we find that across the NHS
with lots of different things,
but, you know, when somebody suffers a stroke,
absolutely should not be a postcode lottery.
And when you said that there was 15 centers
that are currently offering that,
how many centers are there in total?
Um, I think 24, so.
Okay, okay, so there's still a long way to go
in order to get those, you know,
all of those centers being able to offer it.
And I think as well,
there's just so much to unpack around the workforce shortage.
You know, we have workforce shortage in our area of,
you know, radiographers and radiologists,
and absolutely the 10-year plan does set out some of that.
But I wonder what is the stroke association's view
on how we can increase the workforce?
Like, do you have a view on what needs to be done
and what the government needs to be doing
in order to do that?
Because it's easier said than done.
There's only so many people,
and there's, you know, there's only,
it takes many years to train up into one of these roles.
So there's not gonna be an instant fix.
So I just kind of wondered if you'd got any kind of views
from the stroke association on that.
Yeah, so my view would be like,
generally there needs to be investment,
but investment isn't always like investing
in the same thing that exists now and just many times over.
And we know that in, you know,
there isn't always a lot of money to be had.
So it's not that there's all this extra resource
sitting in the system.
So part of it, there's good pieces of work out there
where people are, you know, teams, you know,
within the NHS, they're trialing out different ways
of delivering therapy to achieve the same outcome.
So for example, in some areas they've made, you know,
they've tried using like rehab assistance.
So it could be their initial assessment,
might be with a therapist,
and then they'll plan out what the program is.
And in terms of supporting that stroke survivor
to engage in those exercises,
they make use of rehab assistance,
or family members, you know, carers, you know,
also helping, you know what I mean, people rehabilitate.
So it's kind of thinking creatively
on how stroke survivors can achieve the same outcome,
maybe not necessarily with that specific kind of therapist
in the room with them, using, you know,
like technology, doing things, you know,
remotely where maybe you can have group exercise
rather than one-to-one.
So I think it's, and this is happening,
which is why like those communities of practice
is really important, that teams that are finding different
and innovative ways of delivering, you know,
similar outcomes for people, that they share that,
and if it's replicable, so, you know,
that's why it is really integral that, you know,
the Stroke Association can play a role
in kind of convening and connecting.
Like for example, there are ISDNs across England
and they're kind of, you know, groups, networks,
that support with quality improvement.
And we host, you know, some ISDN residentials
where we bring together the ISDNs across England
and, you know, staff from NHS England
and the Stroke Association, other organisations
to come together and kind of discuss things
and do some, you know, learning and sharing.
So, you know, we can continue to try and support that
any which way we can.
Michelle, I'd like to circle back to something
you mentioned before about, you know, the challenges
with, I guess, accessing a 24-7 stroke service.
So, as you can tell, I'm from Australia
and I used to work as a CT radiographer over there.
So, obviously, it's such a vast country in Australia
and I worked in a rural area.
So, one of the biggest challenges we had
was establishing a 24-7 stroke pathway.
So, I was the lead CT radiographer
and it was my responsibility to get a CT service
implemented for this.
But there was only three radiographers.
So, if you can imagine setting up a 24-7 on-call service
with three people was very challenging.
And I was effectively on-call as a backup CT person
Monday to Friday for a full year
because, you know, such a small team.
And this experience kind of highlights
how important equity is for pathways.
Pathways obviously need to work for patients
but also for staff delivering them.
And in a country as big as Australia, logistics matter.
Technology and collaboration are what ultimately
make timely stroke care possible.
So, we relied heavily on things like IT and virtualization
and we actually leveraged our referral center,
which was seven, you know,
probably more than seven hours away.
We use video triage and I guess what we would call
networked radiology to transfer images rapidly.
And I guess facilitate that pathway.
But I just wanted to highlight that the challenges we see,
you know, staffing constraints, travel times,
variable access to specialist care,
these are barriers from all sides,
you know, all locations around the world,
whether you're rural or if you're in a city.
And I guess that was kind of a surprise for me
when I moved over here.
So, yeah, just wanted to share that.
Yeah, no, I think it's incredible how, you know,
people who live in much different like areas,
like, you know, that you've described,
like rural Australia, how you could provide a 24-7,
you know, service with, you know,
a referring hospital being seven hours away.
I think that's absolutely incredible.
I mean, in London, it's very different.
I think the aim is that everybody in London
is around 45 minutes-ish away
from the closest hyperacute stroke unit,
which is where you would get your acute stroke care.
However, like thrombectomy being, you know,
that wasn't delivered or available
at the time that these hyperacute stroke units were set up.
And in different parts of the country,
it might be called like comprehensive stroke center.
We use kind of different terminology.
Not every, I'm just gonna say HASU
because it's a lot of words.
Not every HASU in London performs a thrombectomy.
So it could be that, and it's so complicated,
like, you know, if the London Ambulance Service
or whatever brings you, so, you know,
one of the benefits of AI is kind of,
it supports with quicker decision-making.
And with that, you know, access to, you know,
that information, they can determine the best place to go.
So if you could be eligible for a mechanical thrombectomy
and you ended up going to a stroke unit
where they don't deliver mechanical thrombectomy,
you would need to be transferred.
And that's extra time that you don't want.
So that's why, you know, it's important, like, you know,
AI, all of these diagnostic tools help clinicians,
you know, make, you know, kind of faster decisions
that could result in someone getting quicker care.
That would be better outcomes, you know,
in terms of their recovery.
So it's complicated.
In London, you get a lot of patients
that might be from outside of London.
So I think, due to mean like a good proportion of it,
you know, they're not even London residents,
but, you know, so they're performing.
So, and even in how they commission,
so, you know, how they commission the stroke units,
the, you know, hypercute stroke units,
the community rehab, it's so different.
There's so many different commissioning bodies.
So it is, it's a complicated system.
So I appreciate we're all closer together.
It's not the same situation that you've described,
but there are other kinds of complexities.
Yeah, no, I understood.
And you've kind of touched on my next question there.
So in the AXREM paper,
the state of the stroke pathway in the NHS calls
for embedding digital technologies into pre-hospital triage,
community diagnostics and remote rehabilitation
to reduce front-end delays and improve long-term recovery.
How would these changes improve the long-term recovery
of a stroke patient, do you think?
Yeah, so definitely we always say kind of like time is brain.
So the sooner somebody can be in receipt
of one of these treatments,
such as thrombolysis or thrombectomy,
you know, like I'd mentioned before, the quick, you know,
it would all, you know, sorry, less degrees of disability.
So stroke is actually the leading cause
of adult disability in the UK.
So the sooner they can be treated,
and as I mentioned before,
you don't wanna be in a place,
do you mean where potentially you're not able
to get thrombectomy or the treatment that you need.
So these digital tools definitely help.
So in pre-hospital video triage, for example,
like in London, it's based on a video model,
I guess in some other areas it's telephone only,
but a clinician, you know, a stroke trained clinician
has the opportunity to see, you know, the patient
and, you know, interact, ask them questions, you know,
they might be like, can you lift your hands above your,
you know, they can actually make an assessment
as to the best place.
So if it's a suspected stroke, it could be, you know,
if they could be eligible for mechanical thrombectomy,
go to the hospital where they can perform
the mechanical thrombectomy.
Or if it's not a suspected stroke,
they could be treated out of the community.
So for example, if they might think it's a TIA
or not a stroke, there's no need for them
to be transported to a stroke unit.
So, you know, to free up that space and time
for the stroke specialist to treat stroke patients
because sometimes you do hear of that where stroke units are,
you know, the beds are full, they're at capacity.
And sometimes it's with stroke patients,
sometimes they're with other medical outliers.
So kind of system pressures play a part, you know,
on, you know, the beds and potentially staff
that are specialist stroke trained.
So, yeah, it definitely, and it helps also,
you mean the incoming hospital prepare
to receive that patient when they know more about them,
they can look up their records to, again,
speed up the process of potentially getting them
the quickest access to, you know, stroke treatment
like the thrombolysis or thrombectomy when they get there.
So it's quite important, helpful.
Yeah, and I think we need to also acknowledge
just the amount of charities that are involved
with helping stroke survivors.
Obviously the Stroke Association do such an amazing job
of raising awareness and research and everything.
I actually used to volunteer for a charity
and did it for about two years
where I worked with a chap who was a survivor of a stroke
who was left with quite a few difficulties with mobility.
And I used to go in once a week
and make sure that I got him moving.
So take him for walks, take him out in the car
and things like that.
And the difference that I saw in him in the two years
that I worked with him was being sat at home in a chair
and not having any extra curricular activities,
if you like, outside of the house
to actually his mobility improved so much.
He still couldn't walk unaided or alone,
but we used to go from just walking down the street
to actually one day we walked the whole length
of a canal that we went and visited.
So I think it just shows
that that rehabilitation piece is so important.
And I know that obviously there's a difficulty
in resources, but there are also,
and it shouldn't rely upon charities,
but there are lots of charities out there
that also can offer that additional help.
So I just really wanted to kind of note that.
For all our listeners,
could you tell us the signs and symptoms to look out for
for someone who's potentially suffering a stroke
and what should they do?
Okay, so there is the FAST test
and this is to help people identify signs of a stroke.
So the F stands for face,
like for example, is one side of their face dripping.
It could be their mouth or their eye.
The A is for arms,
can they raise both their arms and kind of keep them there?
The S is for speech.
So does someone have difficulty speaking
or do they have difficulty understanding
what other people are saying?
So the T is for time.
So if you recognize any of those symptoms,
we want you to call 999
because stroke is a medical emergency.
As we've discussed, time is brain.
So you wanna potentially get treated
if you are having a stroke as quickly as possible.
So definitely it's call 999.
And as we mentioned,
like not every hospital has a specialist stroke unit.
So the ambulance service will know,
do you mean like the best place to take you,
which is why we don't encourage people
to just go to their closest hospital
because we've heard stories,
we've spoken to people and they went,
I went to my nearest hospital,
but they don't treat stroke.
So then I had to,
so it's just kind of the delay.
But that's not, if you're having a stroke,
that doesn't necessarily mean you will experience
like face, arms or speech.
Those are the most common signs that we teach people
to kind of watch out for,
but people might have migraines
or they might have issues,
visual problems or issues with their balance, nausea.
So there are some other symptoms,
but definitely if people can familiarize themselves
with the FAST test,
then that's a good indicator.
And I guess maybe worth mentioning,
if someone has those symptoms,
it's okay to ask for help.
Even if you're in doubt,
because I know we had a family member recently
that had a heart attack,
they're absolutely fine now,
but we're like, oh, is it a heart attack?
Should we call for help?
So yeah, definitely ring an ambulance.
Yes, absolutely.
And also as well,
I think that when we think about some conditions
like a stroke or a heart attack,
we automatically assume that it's somebody more mature,
but actually I know people that have had strokes
that are actually, I would say, very young.
So I think we have to remember
that it actually can affect anyone.
So if any of those symptoms are affecting anybody,
whatever age they are, don't discount it
because it's a younger person.
Because I know that when I've been to stroke association
things in the past,
I think there was one I went to
and there was a young lady who was,
I think late teens, early twenties that had had a stroke.
So I think it's always just good to highlight that as well.
There's no discrimination against the age.
It can literally be anybody.
Absolutely.
And increasingly we're seeing people of working age
have stroke.
Even children have stroke.
They're only around several hundred a year in the UK,
but absolutely correct.
Look out for these symptoms in anyone of any age.
Yeah, thank you.
Okay, so I'm gonna mix things up a little bit now.
We're gonna get even more kind of,
we're gonna go very lighthearted now
with our quirky question.
So I'm gonna pose the quirky question first of all
to Michelle.
What fictional character would you be for a day and why?
Oh my, that seems like a very big question.
Which fictional character would I be for a day and why?
I don't know if like aging myself,
but I'm sure I'll have a better answer
if I had a few more minutes to think about it.
But off the top of my head,
because I'm watching something on Apple right now
with the same character, Jennifer Garner.
So I think it was nineties or two thousands.
She was on this show called Alias
and her name was Sydney Bristow.
And she was actually, I think like a double agent.
So she would often be in these like situations
where she's like traveling to countries abroad,
wearing get ups, being girl power, kicking some butt,
with the bad guys.
So I just thought she was like a little bit of a girl boss
or whatever.
So right now, my fictional character is Sydney Bristow
from Alias fame played by Jennifer Garner,
maybe on the top of my head
because I'm watching something with her in it right now.
Wow, very good.
I'm actually, I never normally answer the quirky question,
but before I go over to page, I've actually, as I said it,
I was like, who would I be?
I'd actually want to be Paddington Bear for the day.
A, because I'm a massive fan,
but also as well, I will never forget the scene
where Paddington sat with the queen
and she put marmalade sandwiches into her handbag.
So I would love to be Paddington to watch her do that.
So that's my fictional character.
So Paige, what fictional character would you be
for a day and why?
So I knew this question was coming,
but I didn't have to think about it too long.
Do just want to mention, I've never seen Paddington Bear,
so don't know what you're referring to
with the sandwich, I think it was,
but I would be Hermione Granger because we all love magic.
And I thought that moving to England
would be like being part of Harry Potter.
I've even got my wand here, so.
Oh my gosh, that's amazing.
That is a good one.
I remember once being asked
by one of my previous line managers,
what could be helpful to you in your role?
And I described that necklace that Hermione had
where you could turn back the time
and then just do different things at the same time
by going back.
So you've selected a good one.
Hermione's a good one.
Okay, I didn't think about that,
but yeah, that would be another reason.
And the handbag, come on, the best handbag in life.
Wouldn't that be an amazing thing
if you could turn back time,
like with the stroke, like with somebody having a stroke
and sometimes speed things up or do things differently.
So actually that's a really good one
from a person. Or prevent it.
Yeah, absolutely.
Oh, thank you so much for those answers.
I think we've all found out a lot more about Michelle
and the fabulous work and insights into the stroke association
and the stroke pathway paper that we've published.
A big thank you to Michelle for joining us
and to Paige for guest presenting with me.
And thank you to all of our listeners.