The range and availability of services for stroke survivors living in the community vary greatly across the UK. Research suggests that survivors experience unmet emotional, social and information needs. Many do not have their health and social care needs reviewed beyond the first six months. More effective long-term care could be achieved with regular review of post-stroke needs, and information available through a direct contact for stroke in General Practice. We have developed a new General Practice based model of care for stroke to address these issues.


This study aims to assess how well the new model works when introduced at a single Practice in Cambridgeshire. We will collect feedback from Practice staff and patients on how acceptable the new care components are to them, and how much they are used. This will help us fine-tune the model before testing it in a larger trial.


The following five new components of care will be added on to the usual care for stroke at a General Practice

  1. Structured review of post-stroke needs based on a checklist.
  2. Opportunity for patients to call a healthcare professional about stroke (direct point of contact; DPoC).
  3. Improved communication between General Practice and Specialists healthcare professionals.
  4. Information about local services for stroke (service mapping).
  5. Training for General Practice staff.

We will collect information on patients’ attendance at the review, calls made to the DPoC, additional workload, and any problems introducing the new care components. This will be done by reviewing patients’ records and through discussion with Practice staff at the end of the study. Before and 3 months after their review, patients will receive questionnaires about general well-being, ability to access health information, and satisfaction with the new service.


A refined model of care for stroke ready for testing in a larger clinical trial.


  1. Turner G.M., Mullis R, Lim L, Kreit E, Mant J.M. (2019) Using a checklist to facilitate management of long-term care needs after stroke: insights from focus groups and a feasibility study. BMC Family Practice. 20:2.
  2. Mullis R, Aquino M.R.J, Dawson S.N, Johnson VJowett SKreit EMant J.M. (2019) Improving Primary Care After Stroke (IPCAS) trial: protocol of a randomised controlled trial to evaluate a novel model of care for stroke survivors living in the community. BMJ Open. 18;9(8)