The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I express gratitude to the noble Baroness, Lady Wheeler, for raising this very important issue, and to all noble Lords who spoke for their valuable and excellent contributions. It will be difficult if not impossible to do justice to the points and questions in the time available, but I undertake to write on those that I am unable to cover today.
Strokes in children are thankfully uncommon, but the effects of a stroke can be devastating both for those who have one and for their families and loved ones. This is particularly the case with children, where a stroke may have a lasting impact on their development and educational attainment, with grave implications for their future.
It is important therefore that there is awareness of childhood stroke. Public Health England is responsible for awareness campaigns and has run the Act FAST campaign to raise awareness of stroke for the last six years. It is its most successful campaign. The Act FAST campaign depicts older adults, and, while there is no specific focus on children, the message remains the same. However, as many noble Lords will know, the signs of a stroke in infants and young children may be less obvious, and Public Health England will want to consider whether a specific campaign aimed at raising awareness of strokes in children is needed.
The provision of stroke care by the NHS necessarily embraces a wide range of different services. There are different causes of stroke in children—including disorders of the heart, blood and vascular system, as well as infections—and the effect of strokes will also be different. As noble Lords will know, there is a heightened risk of childhood strokes from certain variants of sickle cell anaemia, for which all newborn babies in England are screened with a heel-prick test. I will write to my noble friend Lord Smith in answer to his questions on this subject.
The risks of stroke for children with these variants of sickle cell disease can be assessed using a test known as a transcranial Doppler scan, and those deemed at high risk can be treated with blood transfusions. An annual scan is recommended for children with these variants of sickle cell disease, and NICE guidelines and a national screening programme for sickle cell are already in place.
Not all strokes can be prevented, though, and where a child does suffer a stroke it is important that they get the right treatment. Where a stroke leaves a child with complex or specialist needs, their treatment will normally be delivered through specialised paediatric neurology services commissioned by NHS England. Noble Lords will be pleased to hear that NHS England is running a number of pathfinder projects looking at the care processes for paediatric neurosciences through its Paediatric Neuroscience Clinical Reference Group. This work seeks to define the best arrangements for paediatric neurology patients and encompasses children’s strokes. In addition, the Royal College of Physicians is currently updating its 2004 guidelines on childhood stroke and I would expect these standards to be considered by the Paediatric Neuroscience Clinical Reference Group in due course.
I understand the call to integrate childhood stroke into the cardiovascular diseases outcomes strategies. NHS England is currently leading a group to implement the 10 key actions to improve outcomes for cardiovascular disease. It would be for NHS England, working with key stakeholders, to consider whether childhood stroke should be included in this work, and I will ensure that it is made aware of noble Lords’ views on this issue. I am sure that NHS England will look to encourage an integrated and life-course approach to stroke care, ensuring that paediatric care is appropriately aligned with adult strategies.
Mainstream services, including ongoing care, for supporting children who have had a stroke—and their families—are commissioned by clinical commissioning groups. It is worth recognising that clinical commissioning provides an effective basis for ensuring that children who have suffered a stroke are effectively supported: CCGs are under a duty to obtain appropriate advice from persons who, taken together, have a broad range of professional expertise in the prevention, diagnosis or treatment of illness. This is essential for such a complex area of clinical practice which must be informed by emerging evidence.
The noble Baroness, Lady Wheeler, and the noble Lords, Lord Patel and Lord Imbert, referred to the need for research. As far as evidence is concerned, the National Institute for Health Research currently funds two studies on childhood stroke through its biomedical research centres at Imperial College and Great Ormond Street Hospital, including one looking at the outcomes of childhood stroke. The NIHR welcomes funding applications for research into any aspect of human health, including the needs of children and young people who have had a stroke.
A number of noble Lords, including the noble Baroness, Lady Wheeler, mentioned the need for good rehabilitation services for children. We are aware that there is a significant issue around capacity in paediatric neurological rehabilitation in England. I understand that NHS England is currently undertaking work to assess future capacity needed. Any expansion of capacity would, of course, have cost implications. In addition, in April 2014, NHS England established the specialised commissioning task force to make immediate improvements to the way in which NHS England commissioned specialised services, and put commissioning arrangements on a stronger footing for the longer term.
I mentioned the pathfinder projects looking at end-to-end care processes for paediatric neurosciences. In addition, I am advised that NHS England has indicated that it will ensure that due consideration is given to the Royal College of Physicians guidelines for treating children who have suffered strokes.
My noble friend Lord Rodgers made the telling point that GPs should be required to do training in child health. As part of the mandate to Health Education England, it committed to ensuring that GP training produces practitioners with the required competences to practise in the new NHS. To support this, Health Education England has been asked to work with the devolved Administrations and the Department of Health on responding to the recommendations of the Shape of Training report on postgraduate specialty training, and the provisional findings of NHS England’s review of primary care services. The case for a fourth year and enhancements to GP training will be explored further as part of this response, including specific training in that extra year in child health and paediatrics.
The noble Baroness, Lady Wall, and my noble friend Lord Rodgers raised concerns about the time until diagnosis. We are committed to working to improve the health outcomes delivered by the NHS for children. That is why we set up the Children and Young People’s Health Outcomes Forum in 2010. Its report set out a number of recommendations. One which we are working on is to develop a new indicator which would report the time from the first presentation to the NHS to definitive diagnosis and start of treatment.
As part of our response, we made a pledge alongside key partners, including NHS England, NICE, Health Education England and the Society of Local Authority Chief Executives, to work together to improve health outcomes for children. Our shared ambitions are for children, young people and their families to be at the heart of decision-making. Together, the organisations who signed the pledge are making progress towards meeting those ambitions. However, there is much work to be done and the Children and Young People’s Health Outcomes Forum will continue to actively monitor progress on the action taken as a result of the recommendations made in its initial report published in July 2012. This work will help to improve the outcomes and experience of children who suffer strokes and their families.
In reply to the noble Lord, Lord Patel, I say that the new integrated arrangements for children and young people with special educational needs, which the Children and Families Act introduces from September, are the ideal basis for ensuring that special educational services and social care can be planned in a joined-up way with the healthcare that a child needs arising from a complex condition. Children with SEN will have an education, health and care plan, which different sectors will come together to assess and plan for, focusing on the outcomes which make the biggest difference to the child. We are committed to ensuring that staff who work with children have the right skills and experience. That is reflected in our mandate to Health Education England.
There are therefore a number of opportunities on the horizon which could contribute significantly to improved outcomes for childhood stroke, and I again thank all noble Lords who have spoken in this excellent debate.