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Stroke Victims: Treatment

My Lords, I am truly grateful to the noble Lord, Lord Rodgers of Quarry Bank, for securing the debate and enabling us to discuss stroke services. The noble Lord speaks from great experience, sadly, but I particularly welcome his personal insight and all that I have learnt from his experience and courage, and that of my noble friend Lord Clinton-Davis. It is a significant time in the development of stroke services with the National Audit Office report bringing increased attention to the opportunities available, as well as the challenges to deliver high quality stroke services. Indeed, I think that the NAO report has acted as a healthy catalyst for change. Many noble Lords, including my noble friend Lady Rendell, asked why, given the scale of the problem, we have not done more to give stroke a higher priority. We should recognise that for too many years stroke was viewed as an inevitable part of getting old. We should recognise that it is only in recent years that experts have come to a consensus that much can be done to prevent and treat stroke. The growth of stroke medicine is a recent phenomenon and we welcome that. It is important to recognise the scale of the problem. Each year more than 110,000 people in England have a stroke. Every five minutes someone in the UK has a stroke. In England more than 900,000 people have had a stroke. It is expensive to treat and there are high costs to the wider economy through lack of productivity and informal care. I understand the concern expressed by noble Lords about the NAO report. It made 10 sets of recommendations for improving stroke prevention, treatment and care. I assure the noble Lord, Lord Rodgers, that the Department of Health is committed to taking all those recommendations forward. The comprehensive response will be through a new stroke strategy currently being developed with the help of six expert project groups chaired by leading figures in the stroke world.The department is also pursuing changes ahead of this strategy; for example, through a new toolkit developed for use by acute trusts which demonstrates the benefits of improved stroke care on an individual hospital basis. On prevention, the NAO recommended that there should be explicit references to stroke in the department’s public health campaigns and that primary care trusts should ensure access to transient ischaemic attack services. The department has already included more on stroke in its websites, in campaigns such as ““five-a-day””, for example, which encourage the consumption of more fruit and vegetables, so that perhaps husbands and wives will both grow thinner. It also has a project group dedicated to making specific recommendations on public awareness raising and prevention issues. Indeed, this Friday, the department is running a workshop with a range of campaigning experts to produce a menu of ideas for taking this forward. There are already points available in the quality and outcomes framework for GPs about access to specialist outpatients services. Of course, they now have to monitor blood pressure on a more regular basis. In the White Paper Our health, our care, our say, the department is committed to making a life check for everybody at key life stages. The department is working to set up pilots to explore how these will be most effective. My noble friend Lady Rendell asked about the wider use of statins. NICE has recently produced guidance recommending that people with a 20 per cent risk of cardiovascular disease should be treated with statins. We are also considering recommendations from the National Screening Committee about improving the detection of cardiovascular disease and diabetes at an earlier stage. On the subject of GPs, the noble Baroness, Lady Barker, asked whether the Connect protocols have been implemented. Locally, yes; but not yet set out nationally. Project groups on TIA and emergency response will make recommendations in this area. The Royal College of Physicians’ stroke guidance sets out what should happen, and the Department of Health accepts the need for a further push to ensure that it really does. The department’s TIA project group meets this week to set out detailed recommendations for improving rapid access in every health community. The department is also funding a campaign run by the Stroke Association to raise awareness of stroke symptoms. My noble friend Lord Clinton-Davis spoke movingly of the need for a high standard of acute treatment of stroke and ensuring a rapid response, as did the noble Baroness, Lady Gardner of Parkes. The National Audit Office has recommended that NICE should produce guidance on delivering thrombolysis, that scanning capacity should be improved—including by providing training for stroke consultants in reading scans—and that access to stroke units should be improved. These recommendations are being taken forward through implementing the toolkit, detailed work with the professional bodies for radiologists and radiographers, and the work of a project group looking at acute care. NICE will produce guidance on managing acute stroke and an accompanying technology appraisal of alteplase, a clot-busting drug. On post-acute support, the NAO recommended that the quality requirements of the national service framework for long-term conditions should apply for stroke patients, and that the voluntary sector should be involved in working more closely with the Government. The principles and guidelines set out in the long term conditions NSF focus on patient-centred care for people with neurological conditions and are highly pertinent to stroke. Professor Ian Philp, the national clinical director for older people, has been promoting their use in stroke care, and the department will build on this through the developing strategy. Indeed, Professor Philp also has a programme of action under way to root out ageism in the NHS and ensure dignity for life. The voluntary sectors involved in stroke, to which I pay tribute and thank for their untiring work, including the Stroke Association, Different Strokes and Connect, already play a vital part in delivering services to stroke survivors; for example, in running conversation groups for people who experience speech problems after their stroke. Indeed, my own grandmother, who had a couple of strokes, recovered her speech when my daughter was a baby learning to speak. My grandmother had confidence to speak to my daughter, because she knew that she could practise her speech on her. They both learned to speak together. I am delighted that it worked well for both of them. All these voluntary groups are helping the department to frame the new strategy, and the contribution of the voluntary sector will be pivotal to implementing it successfully. The department has already, as recommended by the NAO, brought stroke within a new unified framework for vascular disease management, with an integrated policy team across heart disease, diabetes and stroke, and Dr Roger Boyle is now the national clinical director for both heart disease and stroke. We are looking, with the Healthcare Commission and the Royal College of Physicians, at the next steps for improving stroke audit, building on the excellent basis of the sentinel audit. Already, we have agreed that the use of the FAST—face weakness, arm weakness, speech problems test—stroke symptoms protocol should form part of the Healthcare Commission’s assessment of ambulance trusts. We know what the challenges for stroke services are; the NAO report brought them clearly into focus. For example, not enough people really understand what a stroke is or would recognise the symptoms, as noble Lords have said. The noble Lord, Lord Rodgers of Quarry Bank, and my noble friend Lady Rendell were absolutely right about the need for better communication on the realities of stroke, a point that the noble Baroness, Lady Gardner, also made graphically. The Stroke Association has recently been allocated a Section 64 grant to assist with communication. Its campaign, entitled ““Stroke is a medical emergency””, urges people to know the warning signs. We fully support its excellent work but we need to make more efforts to explain that a stroke is a brain attack that needs urgent medical attention. We need to ensure that people who experience a mini-stroke seek help straight away rather than risk a really serious stroke later, and that the people with them understand what is happening and how best they can help them. Too many patients are not getting the scans they need as a matter of urgency, as many noble Lords have said. Although progress has been made, many patients still spend less than half their stay in hospital on a stroke unit, and the services are not always there to support patients and their carers when they leave hospital. Much has been said about rehabilitation, about which much more needs to be done. The noble Lord, Lord McColl of Dulwich, will be glad to know that the department is developing a picture archiving and communications system (PACS), which will be rolled out by spring 2007 and will provide opportunities to read scans remotely—rather like what he is doing on his Mercy Ships. Stroke scanning is complex; no one form of scanning provides perfect results. As many noble Lords have said, we must ensure that the appropriate individuals are available to interpret the scans. That is why the Department of Health will include training for a range of professionals as part of the stroke strategy framework that we are developing. Safe delivery of thrombolysis will be supported by NICE guidance on the management of acute stroke and its forthcoming technology appraisal of alteplase, a thrombolytic, or clot-busting, drug. It will give the NHS a clear steer in the interim, building on the existing guidance from the Royal College of Physicians. The White Paper that we published at the end of January addresses many of the issues faced by stroke patients. It aims to ensure that services are integrated and built around the needs of individuals, with more services delivered in the community or at home. It includes a new deal for carers, a commitment to integrated care plans and a range of measures to ensure that health and social services work more closely together. We must also ensure that those integrated services also address depression. On 1 March we held a national stroke conference, attended by more than 150 people, who will begin developing a new stroke strategy. We demonstrated the toolkit that I mentioned earlier, which brings together the key actions that hospitals can take. It calculates the benefits that taking certain actions can lead to for patients and the hospital itself. It also provides examples of teams that have been through radical change and how they went about it. For example, the Royal Free Hospital used to have one of the worst performing stroke services in the country, but in five years it turned that around and in the 2004 audit it was the best in the country. I understand, therefore, the specific concern that the noble Lord, Lord Rodgers, expressed about deficits at the Royal Free Hospital. I am pleased to say that one of its stroke doctors is working with the Department of Health on its hospital care project group. That doctor will be very happy to speak to the noble Lord, Lord Rodgers, to give him a more detailed briefing about the planned service developments at the Royal Free Hospital and more widely. I will seek to ensure that that happens soon. The noble Baroness, Lady Barker, asked about the UK Stroke Research Network. Apparently, we are giving £20 million over five years to the network, which is headed by Professor Gary Ford, a stroke physician in Newcastle who has trail-blazed thrombolysis, and who will oversee the local research networks. The network is at the very beginning of its exciting work, and I will be very happy to provide noble Lords with further details on it. The noble Baroness, Lady Barker, also asked whether restructuring of PCTs would delay developments. The department is absolutely determined that it will not. We will do our utmost to ensure that services are not disrupted in any shape or form, but if noble Lords find that they are disrupted, I am sure that we will be pleased to hear of those instances. I have described today just a few of the steps that we have taken in what will be a sustained and co-ordinated approach to improving stroke services. The challenge now is to spread this nationally so that all patients can benefit. We have a lot of hard work ahead of us, but I am confident that we can produce a comprehensive and effective strategy for delivering real improvements in stroke services. My noble friend Lord Clinton-Davis said that we needed to keep the Government on their feet. I am confident that debates such as this will indeed keep the Government on their feet and act as a catalyst to enable them to deliver even more changes.