Improvements in services enabling people of working age to reintegrate into the community after a stroke
Submitting InstitutionUniversity of Northampton
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
Research evaluating a pilot service for people who had had a stroke
showed that there was a lack of support to help them return to work,
insufficient attention to individual needs and that their ability to
reintegrate into the community was poor. Post-stroke conditions cost the
UK economy £7 billion annually. The research findings have made a distinct
and material contribution to refocusing services in Wales and England
towards helping patients fit back into society after a stroke. Three out
of ten services established in 2005/2006 in Wales and the original service
continue, and have informed the development of further services in
England. These services support patients to return to work and make other
lasting improvements to their lives.
Stroke is the main cause of severe long-term disability in the UK and
costs the economy £7 billion annually (National Audit Office 2005, http://www.nao.org.uk/report/department-of-health-reducing-brain-damage-faster-access-to-better-stroke-care/).
applied health research into practice by evaluating occupational therapy
and stroke rehabilitation services has a considerable impact on patients
recovering from strokes.
Evaluation of pilot service to support patients after a stroke: In
1998, the Stroke Association commissioned Professor Corr (University of
Wales 1998-2000, Professor of Occupational Science, University of
Northampton 2000-2013, Head of Research and Development at Leicestershire
Partnership National Health Service (NHS) Trust 2013-present) to evaluate
the benefits of the Cardiff Day Service, a pilot project set up in 1995 to
provide support specifically for working age individuals who had had a
stroke. The aim of this `post-stroke' service, the first of its kind, was
to offer people aged between 18 and 55 years a chance to identify and
pursue meaningful and realistic opportunities within the community.
The research, involving a questionnaire and interviews in a randomised
cross-over design, used novel Q-methodology to explore patients' attitudes
and evaluate their economic activity . All 26 patients in the study
were assessed when they were first referred after their stroke, then at
six months and one year. Assessment established their social,
psychological and occupational ability at each stage, considering social
interaction, leisure activities, quality of life, mood, roles they valued,
occupation and self-esteem.
Key findings on leisure: Following their involvement with the day
service, individuals showed a statistically significant (p=0.04)
improvement in their leisure activity. They perceived that the service
provided opportunities to try new activities . However, they reported
that involvement with the day service did not make it easier for them to
make use of community services by themselves.
Key findings on work: Prior to their stroke, 24 of the
participants had worked . Following attendance at the day service only
one individual out of the 26 resumed work even though 24 (92%) considered
work to be important. In 2003 Professor Corr and S Wilmer published a
paper highlighting this important research finding — that return to work
was a central but neglected area for working age individuals who had had a
stroke . This was one of the first papers on rehabilitation to raise
this issue. It has since been cited 27 times in international papers (www.ingentaconnect.com
at 31st July 2013).
Key social and psychological findings: Individuals gained social
and psychological benefits from the day service — feeling more
independent, happier and valued, and finding a sense of purpose. In
addition, their ability to interact socially improved. Despite these
improvements, there was a high incidence of both anxiety and depression,
suggesting that more specific psychological input was required. Although
the environment provided by the service was perceived to be `safe' and
individuals felt accepted, the environment was oriented more to
socialising than to providing an enabling environment .
The day service did not directly target carers but the findings suggested
that the service provided them with a break and that they began to feel
less strained. However, carers still felt the need for formal support
which was not being provided.
Key conclusions and recommendation: The research concluded that
although the day service for working age individuals who had had a stroke
provided support and social benefits, a broad range of needs were not
being addressed. The recommendation was that in future services should
focus on establishing individual needs and providing an enabling
environment to address those needs. The final report of the research was
submitted to the Stroke Association in July 2001 and was followed by
References to the research
1. Corr S, Phillips C, Walker M. 2004. Evaluation of a pilot
service designed to provide support following stroke: a randomised
cross-over design study. Clinical Rehabilitation. 18(1):69-75.
2. Corr S, Phillips C, Capdevila R. 2003. Perceived benefits of a
day service for younger adults following a stroke. Operant
Subjectivity: Journal of the International Society for the Scientific
Study of Subjectivity. 27(1):1-23.
3. Corr S, Wilmer S. 2003. Returning to work after stroke: an
important but neglected area. British Journal of Occupational Therapy.
4. Corr S. 2003. Life after stroke: the characteristics of those
aged 18 to 55 years and an evaluation of a support service. Ph.D. thesis.
University of Wales Swansea.
Details of the impact
Every year about 50,000 people of working age in the UK have a stroke
(Stroke Association Fact Sheet 09: Stroke in younger adults 2011).
Estimates of the proportion of people who do not return to work after a
stroke indicate that it is at least 27% (NICE Clinical guideline on
stroke rehabilitation: the rehabilitation and support of stroke patient,
2011; Stroke Association Fact Sheet 09: Stroke in younger adults
2011). Engaging charities, the NHS and government services with the
research has had very considerable impacts on understanding the needs of
working age individuals who have suffered strokes and the kinds of
services they require to help them begin again.
Research contribution to the work of the Stroke Association: The
research findings (see Section 3 [1,2,3,4]) have made a very considerable
impact on the work of the Stroke Association. The research conducted to
evaluate a pilot service for working age individuals recovering from a
stroke has had, and continues to have, an impact on the growth of services
developed and supported by the Stroke Association across the UK. In 2009,
the Stroke Association included enablement and social inclusion in `Back
to Life' services and return to work support in `Life After Stroke' .
Benefits to stroke victims, carers, families, employers, communities
and society: The key beneficiaries from this research are
individuals who have had a stroke, their carers, families and employers.
Communities and society have also gained as individuals have returned to
work, become less isolated and participated more in society. The 2010/2011
report from Bridgend Positive Action for Stroke contains impressive
testimonials from people who have had a stroke describing how the
services, based on the recommendations of a pilot service evaluation
conducted by Professor Corr, have had a very considerable impact on
changing their lives .
Continuation of service to stroke patients: The excellent research
made a distinct and material contribution to the continuation of the day
service in Cardiff [7,8], currently the only service in the UK funded by
the Stroke Association. The new manager, with experience of delivering
therapeutic services, appointed following the evaluation in 2000/2001
continues to manage the service.
Recommendations adopted: Changes to the post-stroke day service in
Cardiff take up the recommendations of the research. These include regular
input by an occupational therapist, discussions with individuals and
support relating to return to work — input from the Disability Employment
Office and the Shaw Trust. Individuals are encouraged to set SMART
(specific, measurable, attainable, relevant and time-bound) goals that
help them focus on their specific needs. Between October 2008 and October
2012, 53 individuals joined the Cardiff day service and 50 were
discharged. Of these, 26 improved their mood and reduced isolation, and 10
returned to full or part-time work. During the research period (1998-2000
see Section 2) only one of the 26 individuals discharged from the service
returned to work. The recommendations have enabled five individuals per
two-year period to return to work, an increase of 400%.
New services in Wales: Based on the research , in 2005 the New
Opportunities Fund (the forerunner of the Big Lottery) awarded a
three-year grant to establish ten Positive Action for Stroke services in
Wales. These were rebadged as community integration services in 2007 and
three (Bridgend, Ceredigion and North Carmarthenshire) continued with
funding from local authorities or other grants. Between October 2008 and
October 2012 these three services benefitted 84, 23 and 3 individuals
respectively. The remaining seven services did not secure ongoing funding.
Three evolved to become stroke clubs and four were disbanded.
Service replicated in England: The Community Integration Service
approach based on the research (see Section 3 ) has been replicated in
England . In 2009, a service funded by the North of England
Cardiovascular Network began and in 2012 reported lasting improvements to
more than 279 individuals (26% supported to return to work and 77%
supported to reintegrate into social and community activities). Those
helped to return to work required fewer benefits and hospital
readmissions, had improved their economic wellbeing and contributed as
tax-payers saving the government and NHS money . The NHS refers to the
Confederation of British Industry estimate (2008) that the cost to the
economy of a working day lost to sickness is about £77 suggesting that the
costs of people not returning to work after stroke are substantial .
Findings used in guidelines and tools: Dissemination of the
findings through peer-reviewed journal papers (see Section 3 [1,2,3]) and
conference presentations had led to significant use in guidelines and
tools. The research has informed the Stroke Association  and other
rehabilitation practitioners, researchers, guideline developers and
service deliverers on issues such as return to work and community
integration services for individuals who have suffered a stroke.
The 2011 NICE clinical guidelines  for stroke rehabilitation now
include `return to work' as a quality measure (see Section 3 ).
The Canadian Occupational Performance Measure (COPM) is used in more than
35 countries and has been translated into over 20 languages. The COPM
cites Corr and Wilmer 2003 (see Section 3 reference ) as an important
reference on its web page . The University of Illinois at Chicago
(UIC) Model of Human Occupation (MoHO) Clearing House  also refers to
the research (see Section 3 references [1,3].
Innovation award: In 2012 Professor Susan Corr won an innovation
award for identifying other patient groups that might benefit from
services similar to those developed based on her research evidence .
Sources to corroborate the impact
- Stroke Association `Life After Stroke' model in Stroke News, Winter
2009 Volume 27.4. p12
- Bridgend Positive Action for Stroke — Service Illustration
2010/2011 report. Stroke Association Confidential document. This
document outlines the activities at the service and includes
testimonials from service users regarding the benefits they experienced
through attending the service.
- Assistant Regional Manager or Deputy Director Wales, Stroke
Association in Wales
- Cardiff Day Service, Manager Cardiff Day Service Manager
- Haxon D, Moore P. Changing Lives — community integration services:
North of England.
- National Health Service (NHS). 2011 Stroke rehabilitation in the
community: commissioning for improvement. http://www.improvement.nhs.uk/documents/Stroke_Rehab.pdf
- National Institute for Health and Clinical Excellence (NICE). 2011
NICE clinical guideline on stroke rehabilitation: the rehabilitation and
support of stroke patients.
- Web page of the Canadian Occupational Performance Measure (COPM).
(Cites  as an important reference)
- The University of Illinois at Chicago (UIC) Model of Human Occupation
(MoHO) Clearing House. http://www.uic.edu/depts/moho/referencelists.html
- Professor Susan Corr 2012 Innovation Award `Scoping exercise:
Identifying new populations for interventions informed by Lifestyle
Redesign® and Lifestyle Matters'. The aim of the innovation award was to
support scoping new populations who might benefit from services informed
by the evidence-based occupation focused Lifestyle Redesign® and
Lifestyle Matters programmes delivered by occupational therapists and
build collaborative partnerships to undertake research. Professor Corr
established a steering group with clinicians and service users from St
Andrews Healthcare and researchers from University of Sheffield Hallam,
University College Cork and the University of Northampton.