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Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data

BMJ 2019; 364 doi: (Published 24 January 2019) Cite this as: BMJ 2019;364:l1
  1. Stephen Morris, professor of health economics1,
  2. Angus I G Ramsay, senior research associate1,
  3. Ruth J Boaden, professor of service operations management2,
  4. Rachael M Hunter, principal research associate3,
  5. Christopher McKevitt, professor of social sciences and health4,
  6. Lizz Paley, stroke programme intelligence manager5,
  7. Catherine Perry, research fellow2,
  8. Anthony G Rudd, professor of stroke medicine6,
  9. Simon J Turner, senior lecturer7,
  10. Pippa J Tyrrell, honorary professor of stroke medicine8,
  11. Charles D A Wolfe, professor of public health medicine4 9,
  12. Naomi J Fulop, professor of health care organisation and management1
  1. 1Department of Applied Health Research, University College London, London WC1E 7HB, UK
  2. 2Alliance Manchester Business School, University of Manchester, Manchester M15 6PB, UK
  3. 3Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK
  4. 4Department of Population Health Sciences, School of Population Heath and Environmental Sciences, King’s College London, London SE1 1UL, UK
  5. 5Stroke Programme, Royal College of Physicians, London, UK
  6. 6Guy’s and St Thomas’ NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
  7. 7Health Policy, Politics and Organisation (HiPPO) Research Group, Centre for Primary Care, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
  8. 8Stroke and Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford M6 8HD, UK
  9. 9National Institute of Health Research Comprehensive Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, Guy’s Hospital, London SE1 9RT, UK
  1. Correspondence to: S Morris steve.morris{at}
  • Accepted 20 December 2018


Objectives To investigate whether further centralisation of acute stroke services in Greater Manchester in 2015 was associated with changes in outcomes and whether the effects of centralisation of acute stroke services in London in 2010 were sustained.

Design Retrospective analyses of patient level data from the Hospital Episode Statistics (HES) database linked to mortality data from the Office for National Statistics, and the Sentinel Stroke National Audit Programme (SSNAP).

Setting Acute stroke services in Greater Manchester and London, England.

Participants 509 182 stroke patients in HES living in urban areas admitted between January 2008 and March 2016; 218 120 stroke patients in SSNAP between April 2013 and March 2016.

Interventions Hub and spoke models for acute stroke care.

Main outcome measures Mortality at 90 days after hospital admission; length of acute hospital stay; treatment in a hyperacute stroke unit; 19 evidence based clinical interventions.

Results In Greater Manchester, borderline evidence suggested that risk adjusted mortality at 90 days declined overall; a significant decline in mortality was seen among patients treated at a hyperacute stroke unit (difference-in-differences −1.8% (95% confidence interval −3.4 to −0.2)), indicating 69 fewer deaths per year. A significant decline was seen in risk adjusted length of acute hospital stay overall (−1.5 (−2.5 to −0.4) days; P<0.01), indicating 6750 fewer bed days a year. The number of patients treated in a hyperacute stroke unit increased from 39% in 2010-12 to 86% in 2015/16. In London, the 90 day mortality rate was sustained (P>0.05), length of hospital stay declined (P<0.01), and more than 90% of patients were treated in a hyperacute stroke unit. Achievement of evidence based clinical interventions generally remained constant or improved in both areas.

Conclusions Centralised models of acute stroke care, in which all stroke patients receive hyperacute care, can reduce mortality and length of acute hospital stay and improve provision of evidence based clinical interventions. Effects can be sustained over time.


  • Contributors: SM, NJF, and AIGR designed the study. SM did the analysis of the Hospital Episodes Statistics data and drafted the manuscript. AIGR did the analysis of the SSNAP data. SM, AIGR, RB, RMH, CM, LP, CP, AGR, SJT, PJT, CDAW, and NJF made substantial contributions to the study design and interpretation of the findings. All authors contributed to the drafting of the article or critical revision for important intellectual content, gave final approval of the version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. SM and NJF are the guarantors.

  • Funding: This paper presents independent research commissioned by the National Institute for Health Research (NIHR) Health Services and Delivery Research Programme, funded by the Department of Health (study reference 10/1009/09). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. SM and NJF were supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Barts Health NHS Trust. CW and CM were supported by the NIHR Biomedical Research Centre at Guy’s and St Thomas’ National Health Service Foundation Trust and King’s College London, and the south London NIHR CLAHRC. RB was supported by the NIHR CLAHRC Greater Manchester. SSNAP is commissioned by the Healthcare Quality Improvement Partnership and funded by NHS England and the Welsh Government. The sponsor approved all aspects of the study protocol and any amendments thereto, but played no other role in design or conduct of the study.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work other than that described above; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; AGR is national clinical director for stroke in England and clinical director for stroke in London; PJT was clinical lead for stroke in Greater Manchester up to 2013 and led the Greater Manchester stroke service redesign from 2007 until 2012.

  • Ethical approval: The study received ethical approval in September 2011 from the London East NHS Research Ethics Committee (ref 11/LO/1396).

  • Data sharing: No additional data available.

  • Transparency: The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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