Presenting for diagnosis Not known Impairment/disability presentation (i.e. need acute care), all stroke With reduced consciousness 84 Severely dependent 140 Incontinent of urine 106 Disoriented/unable to communicate 132 Unable to get out of bed unaided 168 Impairment/disability at 3 weeks (i.e. need rehabilitation), all stroke Needs help dressing 86 Needs help walking 67 Needs help with toilet 66 Communication problems 49 Impairment/disability at 6 months (i.e. needing long-term support) Needs help bathing 71 Needs help walking 22 Needs help dressing 45 Difficulty communicating (aphasia) 22 Confused/demented (or severe aphasia) 39 Severely disabled (Barthel < 10/20) 13 Services at 6 months Needs long-term institutional care 23 Possibly needs speech therapy 24 This assumes (i) all stroke, first and recurrent (2 4 per 1000 per year), (n) 30% die by 3 weeks, (m) 40% die by 6 months, and (iv) minimal contnbution from SAH to care and rehabilitation needs From Wade3 In a population-based survey in south London, the vast majority of stroke survivors, 5 years after their stroke, lived in private accommodation, and the most disabled were only likely to be in private accommodation if they had an identified carer20 . One-third of survivors were severely or moderately disabled and two-fifths of survivors were more disabled than they had been at 3 months after their stroke. Respite care was only received by a few people. Nearly 75% had an adaptation to the environment and 75% were prescribed treatments aimed at preventing further vascular events. Some 23% were depressed and a further 14% had borderline depression scores. The assessment of quality of life, using the SF36 score and Nottingham Health Profile, suggested that the patients' scores on the various scales were related to their residual disability20 . 03250 by guest on 17 April 2022 The impact of stroke Quality of life after stroke is increasingly being measured but published assessments report widely different findings. These differences can be attributed to different methodologies, including the specific quality of life measure and time of investigation. Needs of families and carers In recent years, there has been an increasing, but unproven, emphasis on the need for stroke services managed in the community. The strategists and health service planners have not considered the considerable proportion of care undertaken by carers and families. As a result of the pressures, carers suffer from depression and anxiety and family tensions and financial problems are common. Four main areas of concern to carers can be identified through the literature. Carers want information, skills training, emotional support and regular respite. However, these have been highlighted as areas of major deficiency in informal carers' interactions with professionals. Carers frequently mentioned a failure of agencies to supply promised aids or services, a general lack of information and advice and the provision of irrelevant help. These points obviously have great implications for the type of help offered to carers. The nursing literature does suggest the importance of nurses in information giving and counselling: 'the support of informal carers must be seen as a legitimate and important focus for nursing interventions'. Yet the literature also highlights the fact that, on the whole, this has not been happening. The literature also cites the benefits of intervention such as support groups for patients and their carers. However, it has also been shown that these may only benefit certain people and there is a lack of proper evaluation of such groups21 . Current service provision for stroke It is estimated that stroke services accounted for at least 4-6% of the NHS budget in the UK, but these figures do not take into account social service and carer costs. Primary care The morbidity survey in general practice in the UK estimates that circulatory diseases account for 9% of consultations, 36% of which are 'serious' with the most common reason being essential hypertension22 . British Medical Bulletin 2000,56 (No 2) 283 Downloaded from https://academic.oup.com/bmb/article/56/2/275/303250 by guest on 17 April 2022 Stroke Overall, cerebrovascular disease prevalence was estimated at 5-8 per 1000 individuals. Nearly all patients who consulted for cerebrovascular disease did so for transient cerebral ischaemia or for acute but ill-defined cerebrovascular disease. Comparison of prevalence rates for 1971/2 and 1991/2 shows an overall 64% increase in consultation rates. The number of contacts for follow-up of a stroke would appear from the statistics to be low. These data will vary from country to country depending on the role of primary care in stroke management. Specific stroke surveys in the UK over the last 15 years indicate poor follow-up of patients once discharged. Under half of patients were followed-up by their GPs, less than a third by community nurses and less than 20% had access to other services. Secondary care Secondary care services for stroke management span many specialties. The patterns of care vary considerably between and within countries, depending on a variety of local influences such as historic patterns of care, priority of purchasers and providers to modify traditional service provision, and local enthusiasm and expertise in the management of stroke