Emergency-system drivers of intersectional inequities in prehospital stroke care in coastal eastern England

Background In acute stroke, prehospital decisions determine whether symptom recognition leads to timely prioritisation, specialist assessment, and transfer to definitive care. East Suffolk and North Essex include coastal and rural communities where deprivation, distance, workforce configuration, and hospital-interface pressures may combine to produce unequal access to time-sensitive stroke care. This study examined how emergency-system arrangements shape inequities in the recognition, prioritisation, assessment, conveyance, pre-alerting, and transfer of suspected stroke before definitive hospital care. Methods We undertook a qualitative study between May 2024 and July 2025 using semi-structured interviews with 11 purposively selected stakeholders in East Suffolk and North Essex, including paramedics, stroke nurses, general practitioners, managers, a neurologist, and an academic stroke researcher. The work was classified as a service evaluation. Data were analysed thematically in NVivo 14 and mapped to the World Health Organization Health System Performance Assessment (WHO-HSPA) framework and Tanahashi’s coverage model. Intersectionality was used to examine how organisational processes interacted with social and geographical circumstances to shape exposure to delay, misrecognition, and reduced access to stroke-capable care. Patients and carers were not interviewed; findings therefore reflect provider and system-stakeholder accounts. Results Participants identified inequity where recognition had to be converted rapidly into dispatch priority, on-scene capability, pre-alerting, and transfer. Rural and coastal distance became more consequential when combined with limited mobility, complex extrication, Category 2 ambulance queueing, or secondary transfer. Limited English, communication difficulty, and atypical symptoms became more consequential when crews lacked consistent access to translation, digital tools, or specialist support. Effective coverage was further constrained where Face, Arm, Speech, Time (FAST)-oriented recognition intersected with living alone, multimorbidity, or subtle presentations. Across these domains, participants described compounded disadvantage when social and geographical circumstances interacted with uneven organisational capability and pathway design. Conclusions Inequities in prehospital stroke care were described as arising from interactions between patients’ circumstances and emergency-system design. Organisational arrangements governing recognition, prioritisation, workforce capability, digital support, and transfer could make particular social, clinical, and geographical circumstances more consequential. The findings identify potential areas for local service review, including workforce development, digital and specialist support, transfer processes, and equity-sensitive feedback; their feasibility and effectiveness require further evaluation.