The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I am delighted that the noble Baroness, Lady Wheeler, has been successful in securing a debate on stroke care, and I thank her for introducing the subject so ably. As demonstrated today by the number and quality of contributions made by noble Lords, it is an area of great interest and one that it is vital to keep in the public eye. I shall do my best to cover as many issues that have been raised as I can, but I shall write to those noble Lords whose questions I have not been able to cover.
Stroke care has witnessed huge improvements over the past few years and many thousands of people have benefited. Stroke patients are getting treatment that is faster and better than ever before and data suggest that improvements are continuing. I pay tribute to the work of Sir Roger Boyle during his time as national clinical director. The latest data show that over 80 per cent of stroke patients are spending the majority of their hospital stay on a stroke unit, and the management of high risk transient ischaemic attack patients has also improved by 20 per cent since 2009. Access to immediate brain scanning has improved considerably and more patients are receiving thrombolysis giving them a better chance of regaining their independence following a stroke. There has been the very successful campaign to raise awareness of stroke—the Act FAST campaign.
We want the progress underway to continue but we also know, as was pointed out by the noble Baroness, Lady Pitkeathley, that we need to do more to improve support for people after stroke. As we acknowledged when the Care Quality Commission published its report last year, there is still more to do in ironing out the variations in stroke care, particularly in the support provided to patients when they leave hospital.
The noble Baroness, Lady Wheeler, asked about monitoring of outcomes with the benefit of robust information. At a national level, our focus on outcomes through the NHS, public health and adult social care outcomes frameworks sets out the areas we want to improve. Stroke specifically features in two parts of the NHS outcomes framework in terms of reducing premature mortality and in recovery from major illness.
Noble Lords will be interested to hear that the stroke indicator on recovery has been developed in collaboration with several organisations, including clinicians, academics and the NHS. The indicator, based on the modified Rankin scale, will assess the patient’s recovery from stroke after six months. It will provide an incentive for the NHS and social services to work together, getting the right services in place so that when patients leave hospital they have the support they need to make the best possible recovery. I hope that that reassures those noble Lords who are afraid that care will be fragmented. This outcomes framework will drive services in the opposite direction.
The social care outcomes framework is helping to gauge the progress made by local services and drive up standards across the country. One of the areas this framework covers is reducing the need for care and support and delaying dependency. This will help people to live healthy independent lives and properly manage any health needs. Local authorities will be able to compare their services with those of other authorities around the country and make improvements based on what has been proven to work elsewhere, integrating care and working together to provide care that suits individual patients. For stroke survivors, this means providing access to the kind of support that they need to enjoy the best possible quality of life after their stroke.
Building on the national stroke strategy, the NICE quality standard for stroke, which has been mentioned by a number of noble Lords, has been developed with patients, commissioners and leading doctors. This provides an authoritative definition of what high quality care for stroke actually means. They are the measures of quality that matter most to patients and the NICE quality standard for stroke recognises the key role that rehabilitation plays in making sure people can live their lives as fully as possible after their stroke.
My noble friend Lady Browning suggested that there is perhaps inadequate understanding of what patients need in care settings. The NHS, through the stroke improvement programme and the 28 stroke networks in England, is working to make sure that stroke care improves at all stages of the patient pathway. The stroke networks connect different organisations and teams that have roles to play when someone has a stroke so that patients can be sure of co-ordinated management from the moment they are first in touch with a doctor or nurse and throughout their lives as a stroke survivor. This whole approach takes the needs and wishes of stroke survivors and their carers into account when delivering these services. I should like to reassure the noble Baroness, Lady Wheeler, about funding of the networks. Funding is in place for 2012-13. The future of the networks is being actively considered as part of the development of the NHS Commissioning Board.
The stroke improvement programme and the stroke networks have made good progress in getting the stroke strategy up and running, and they have done the same with the NICE quality standard. Patients now see better acute care as a result of both. Attention is now being focused on improving care for patients who have left hospital. The accelerating stroke improvement programme was developed specifically to improve care in areas where progress needs to be made faster and is looking at improving post-hospital and long-term care. The stroke improvement programme, working with the stroke networks, is delivering this.
Accelerating stroke improvement is concentrating on four key areas of post hospital care: that is, providing early supported discharge; making sure patients and carers have a joint care plan on discharge from hospital, which was mentioned by my noble friend Lady Browning; making sure stroke survivors have a review six months after leaving hospital; and making sure psychological support is provided for those who have mood, behaviour or cognitive disturbance.
One example of where a stroke network has been working well with commissioners to improve access to stroke community services is south London. Through the ASI programme, the network has developed a service specification for early supported discharge and community services, and has helped commissioners to make the case for change. What is more, analysing data from the CQC review, the stroke network was able to identify areas that needed to do more in the provision of post-hospital services. This has resulted in one of the care trusts commissioning a stroke community rehabilitation service, which is an excellent example of how the CQC review has actually driven improvements in services.
A number of questions were put to me. The noble Baroness, Lady Wheeler, asked about clinical leadership in this area, a point also raised by the noble Baroness, Lady Thornton. The replacement of the National Clinical Director for Heart Disease and Stroke is being considered as part of the development of the NHS Commissioning Board, but I would just say generally that improving stroke services is a priority for the Government, and there should be no doubt about that. It is a priority against which we shall hold the NHS Commissioning Board to account. Tackling premature mortality from stroke is an area for improvement in both the NHS outcomes framework and the public health outcomes framework.
The noble Baroness, Lady Wheeler, mentioned the Stroke Association, and again I pay tribute to its work. My officials meet its representatives on a very regular basis. The local stroke networks are working with clinical commissioning groups and PCT clusters to ensure that improvements are made in stroke services, including those recommended by the CQC. I was asked how improvements in quality will be monitored. There are two audits running this year. The Sentinel Stroke Audit and SINAP will both publish their results, which will help commissioners and providers of stroke care to monitor and improve their services, helped by the local stroke networks. The noble Baronesses, Lady Wall and Lady Thornton, asked whether we agree with the hyper-acute model that has been adopted in London. We certainly acknowledge that the reconfiguration of stroke services in London has produced very good results. The Stroke Improvement Programme works through local stroke networks, which are responsible for disseminating good practice across the country. They have done so with the London example very much in mind and, indeed, other examples where reconfiguration has delivered better stroke care.
The noble Baronesses, Lady Masham, Lady Gould and Lady Rendell, my noble friend Lord Rodgers and the noble Lord, Lord Clinton-Davis, all spoke of aphasia services and speech and language therapy. Stroke survivors should receive care and support from staff with the skills and competence to meet their needs, ensuring that those with communication difficulties such as aphasia have opportunities to return to a full life back in their communities. A good example of working with those who have aphasia is the Access to Life project in Cornwall, run by Connect. Twenty people with aphasia have been trained to provide one-to-one support to others with aphasia at home or in hospital, which helps those with aphasia grow in confidence in the way they communicate, and so reduces their risk of social isolation, a point well made by my noble friend Lord Rodgers.
The noble Baroness, Lady Rendell, spoke about entitlement to reviews and reassessments. Patients should have reviews at six weeks and six months. The NHS outcomes framework will include an indicator in the recovery domain to ensure that patients are reviewed at six months, as I have mentioned. The noble Baroness, Lady Pitkeathley, referred to the needs of carers. Carers play a critical role in ensuring that stroke survivors enjoy the best possible quality of life. Local authorities, working with PCTs, should together make sure that appropriate services are available to support both stroke survivors and their carers. Health and well-being boards will in the future have responsibility for ensuring that these local needs are met. The noble Baroness, Lady Gould, asked about support for third sector organisations. It is for local commissioners to decide how to use the third sector in providing stroke services, but many local authorities and PCTs commission such services from organisations such as the Stroke Association.
We want our stroke services right across the pathway to match the very best in the world. As I have said, huge improvements have been made to that end, but significant improvements still need to be made. I have given a couple of examples of what is being done to address this, and there are many more examples from around the country of services continuing to improve. But we are not stopping here. Identifying how we can deliver better outcomes in cardiovascular disease, including stroke, is a key task. This is one of our biggest killers and causes of adult disability. That is why my right honourable friend the Secretary of State for Health recently announced the development of an outcomes strategy for cardiovascular disease, building on existing strategies and the national service framework. I hope that the noble Baroness, Lady Wheeler, will see this as good news.
The aim of the strategy is to create a joined-up approach across the NHS, public health and social care to improve outcomes for patients with CVD, which includes stroke survivors. This will mean even more stroke survivors living active and fulfilling lives.