In the summer of 2023 I had two strokes in quick succession. The dedicated work of health professionals saved my life, urgently and expertly. Then, a few months later, the health service more or less said goodbye.
I didn’t have a word for what happened next until I started talking to other survivors. Almost all of them used the same one: abandoned. Not by any individual — the people who treated me were superb — but by a system that seemed to have decided my recovery had a deadline.
Today Maya Kuzalti and I are publishing The Discharge Gap, an independent policy report on what happens to stroke survivors in England once the NHS pathway ends. Maya had her stroke in 2021. We both came to this from careers in business — mine in financial services and running companies, hers in digital strategy and operations — where you learn to look for the exact place a complex system fails the people it is built for. Stroke aftercare fails in a very specific place, and we wanted to write it down precisely.
The Cliff
England’s acute stroke care is genuinely world-class. In 2024/25 the median time from arriving at hospital to clot-busting treatment was 56 minutes. But in hospital, physiotherapy is delivered on 70% of the days it should be. In community rehabilitation that falls to 15%. And after six months there is no national target at all.
Six months is where the national stroke audit, SSNAP, stops measuring. Only 35.1% of eligible survivors even received their six-month review in 2024/25 — down from 38.8% the year before. After that, nobody is counting. In the data, you have recovered.
I can tell you from the inside that six months is not when recovery ends. For me, the second stroke left significant cognitive problems and something harder to name: the loss of agency and purpose that a stroke can cause. A lot of the work of getting back happened well after anyone was officially looking.
It Isn’t A Mystery, It’s Three Decisions
The most important thing we found is that nobody designed this gap. It was built by three separate decisions, each sensible on its own:
- The national audit was built around acute care and stops at six months.
- The national guidance — NICE NG236 and the 2023 clinical guideline — already says survivors can benefit from rehabilitation at any point after a stroke. But it is advice, not a mandate.
- So many local commissioners don’t fund community rehabilitation to that standard, because nothing in their contracts or targets requires them to, and no data exists to hold them to it.
Professor Nick Ward, who runs the Queen Square upper limb programme and kindly wrote our foreword, puts the clinical side bluntly. People arrive at his clinic a year or more after their stroke, told they’ve hit a plateau. Given high-dose, intensive treatment, many of them improve substantially. “If rehabilitation was a tablet,” he writes, “we are underdosing our stroke survivors dramatically.”
The Money Is In The Wrong Place
Stroke costs the UK an estimated £25.7 billion a year, on the Stroke Association’s 2026 model, rising to nearly £36 billion by 2035. But only about a fifth of that falls on the NHS budget that would pay for better rehabilitation. More than half is social care. Another fifth is unpaid care and lost time — families, partners, children, absorbing the support the system no longer provides, until they can’t.
That is the real trap: whoever pays for rehabilitation isn’t who saves money when it works.
What Survivors Told Us
We surveyed 20 survivors. It’s a small, self-selected sample and we say so plainly in the report, but the pattern was hard to miss. Twelve had no discharge or care plan. Fourteen described their post-discharge support as little or nothing. Eighteen ended up turning to charities, private providers or friends. Nine out of nineteen paid out of their own pocket, or went without.
“My memory of it is that basically when you discharge, you just get pushed off a cliff and left to get on with things.” — Stephen Rimmer, stroke survivor
When we asked what would have helped, the answers were modest: longer rehabilitation, one named person to contact, and a scheduled review. That is not a wish list. It’s a design specification.
What We’re Asking For
Four things, each with one owner:
- Extend the national audit to twelve months. It’s the cheapest step — a change to a contract that already exists.
- NICE to publish standards that commissioners can actually be measured against.
- Local commissioners, with councils, to pilot a second pathway in two or three areas: a named coordinator, a way back into services for up to a year, and support for carers — paid for by redirecting existing money, and stopped if it doesn’t work.
- Survivors and carers as paid co-designers, in the room before the model is decided, not consulted afterwards.
None of it needs a new national budget. As we put it in the report: the case is not that this is affordable. The case is that the current arrangement is not.
Why I’m Putting It Here
This Substack is where I write about life after stroke, so this is where this belongs. If you’re a survivor, or you love one, or you work in stroke care, I’d be grateful if you read the report and shared it — and I’d like to hear what you recognise in it, and what we got wrong. You can reply here, or write to Maya and me at hello@thedischargegap.com. Maya is also building The Discharge Gap on Substack into a podcast and public platform; it’s well worth following.
The science has been available for some time. What remains, as Professor Ward says, is the will to act on it.
The Discharge Gap is an independent report by Maya Kuzalti and Paul Quinn, written without commission, sponsor or industry funding. Full methodology, disclosures and references are in the report.
Read the full report: the designed edition on Canva, the full report as a PDF, or the write-up on The Esk.
If you are a survivor or a carer, start here: the short version (accessible PDF, 10 pages, about 10 minutes to read). It is in large print and plain English, you can read one page at a time, and it works with screen readers.
