---

Stroke Victims: Treatment

My Lords, I add my thanks to the noble Lord, Lord Rodgers, for initiating the debate. I pay tribute to him and to the noble Lord, Lord Clinton-Davis, for giving us the benefit of what it feels like to have had a stroke and for enabling us to hear first hand from people who have survived the experience. I declare an interest as a psychiatrist and gerontologist who has treated many stroke patients in the aftermath of their incident, and now as an outgoing chair of a strategic health authority monitoring the implementation of the National Service Framework for Older People. First, I acknowledge the recent, if very belated, progress that the Government have made in developing a strategy to improve stroke treatment. There is no doubt that there has been a lot more action recently. We still have no measurable targets, however, such as every stroke patient should have a scan within three hours of their incident to see whether they can benefit from thrombolysis treatment. We are way behind Canada and Australia, and that means lost lives and very significant economic and human disaster for those who would otherwise have been saved. We still monitor mainly service process measures in the national framework, which is regrettably incapable of measuring anything very useful except the ““creative writing talents”” of PCTs and trusts. About two years ago I visited every stroke unit in my own strategic health authority area in east London and found to my dismay that while some were exemplary—Tower Hamlets stroke service is an excellent example of the best—not all services were as advanced by any means, and none was getting every stroke patient in its patch into a specialist unit immediately as a medical emergency. It was pretty hit and miss whether people got specialist care. Many so-called ““special stroke units”” comprised merely a handful of allocated beds in a general ward, with no dedicated team or specialist staff, just identified persons known to have ““an interest”” in stroke. Those of us who can interpret NHS lingo will know that that usually means a person who has a major interest in doing something else. The pleasure I had felt at the apparent progress on the paper returns that we received at the SHA, and which I proudly sent on to the department, did not last when I saw the reality in some trusts and PCTs. Why has stroke until now not got the attention of other medical emergencies? It is due to ageism. Stroke is seen as an old person’s misfortune and an irremediable one at that. While overt age discrimination may be less acceptable than it used to be, there is still thoughtless neglect and passive lack of thought given to older people’s disorders. Cardiovascular disease has a separate national framework and a national network but stroke was shoved in with the older people’s framework. Stroke demonstrates a serious dilemma in the provision of services for older people. Unless they have access to the same acute diagnostics and treatment as younger people, and unless access is constantly audited to eradicate ageist clinical decision-making, very often they will receive an inferior standard of medical care, often in non-acute geriatric units. Often those units are provided with the best but, in my view, misguided paternalistic intentions. Gerontological practice can get rapidly isolated from the mainstream and stroke care is a good example of how slow we can be in using the existing technological kit properly and in implementing good clinical practice. One aspect of the National Audit Office report disappointed me, though. There was reference to emotional and social problems but practically none to the fact that the main long-term outcome of a stroke in terms of social and occupational rehabilitation is the extent of mental health problems, in cognition, perception, emotions, severe depression and other distressing mental symptoms. In this House there are many people with profound physical disabilities. Their presence reminds us that it is your brain that counts, not your muscles, when it comes to contributing to society and maintaining social relationships. With stroke the success of cognitive and emotional rehabilitation determines the eventual level of social reintegration, and whether a person can return home. I want especially to mention severe depression after stroke. Between 15 to 20 per cent of stroke patients—depending on which surveys you look at—experience a major depressive illness within two months of the stroke. This usually lasts just under a year. Those who suffer from severe depression are 50 per cent more likely to suffer another stroke than those who do not. You hear people say, ““Well, they would be depressed wouldn’t they?”” It is true that people will experience terrible feelings of sadness, loss and anxiety, and will struggle to cope, but most people do not develop a formal depressive illness. The sad thing is that depression is highly treatable, even when—as is so often the case with stroke—it is the direct result of organic brain damage. The problem is that once you have had a stroke, your chances of being referred to a specialist mental health service are somewhat less than if you were to experience the same problems without a stroke. Insufficient attention, too, is paid to the cognitive, perceptual and speech deficits we have heard so much about from the noble Lord, Lord Rodgers, and the noble Lord, Lord Clinton-Davis. There is such a lot that can be done in the early days and there are natural improvements that occur very quickly. But we must get appropriate and highly specialised rehabilitation into the field, especially mental health professionals such as treatment-orientated neuropsychologists and psychiatric nurses who understand cognitive problems in stroke and, as we have heard, some of the speech rehabilitation required. I fear that stroke services and psychiatric services are often so far removed from each other, geographically and philosophically, that this is unlikely to happen without central support and guidance. I would like to ask the Minister what the Government are doing to combat the ageism which is still endemic in hospital services, and which has led to this very poor situation. It is not only endemic in hospital services, but in medical research funding. The focus of research is very much determined by ageism. What numerical measures of outcomes will be introduced to ensure that the departmental strategy will work this time?