Does Size Matter? The Rationale for Centralising Acute Stroke Care into a Smaller Number of Larger Units

The experience from London where services were reconfigured in 2010 from 32 hospitals providing acute stroke care to just eight showed that processes of care were much improved with less door to needle time, higher thrombolysis rates, quicker access to stroke units, better swallow screening for dysphagia etc., mortality fell significantly compared to the rest of England. Although there were increased costs initially with the need to provide higher levels of medical, nursing and therapy, cover in the eight hospitals by 30 days after admission costs fell. This was due to lower use of intensive care beds and shorter lengths of stay. Projecting costs forward to 10 years fell very significantly largely down to patients having lower levels of disability and requiring less formal and informal care [2-4]. Manchester that initially reconfigured services to less stroke units but only focussing on getting potentially thrombolysable patients to the comprehensive stroke centre failed to show similar benefits. However, when they changed the model to one similar to London where all patients with acute stroke were taken to the comprehensive stroke centres, the outcomes improved to match those in London [5]. The plan in England now is to reduce the number of acute hospitals treating stroke from the current 120 to about 80, of which about half will be offering intra-arterial clot retrieval, and the remaining ones offering all other acute care and providing drip and ship facilities for patients appropriate for thrombectomy.