Baroness Wheeler
To ask Her Majesty’s Government what plans they have to improve stroke services, care and support, and to update the national stroke strategy to commence implementation in 2017 when the existing 10-year plan ends.
Baroness Wheeler (Lab)
My Lords, I am delighted to be leading this debate today. Over the past eight years, as a result of the national stroke strategy, which was brought in by my Government and carried forward by the previous Government, there have been huge improvements in stroke outcomes. Stroke is now treated as a medical emergency, patients are getting specialist treatment from specialist staff, fewer people are dying as a result of stroke, fewer people end up with a disability after stroke because they are treated in time and the public are now much more aware of stroke, how to spot it and what to do, thanks to the excellent Act FAST national advertising campaigns. Stroke mortality has almost halved and today most areas have a hospital with a dedicated stroke unit. The number of strokes in the UK has decreased from 88,000 in 1990 to 40,000 in 2013, and incidence rates decreased by 19% over a 10-year period. The welcome reduction in the prevalence and severity of disability that stroke survivors are left with is largely because of Act FAST.
These outcomes have happened because the national stroke strategy drove the reorganisation of acute care in hospitals and ensured that ambulance and emergency care staff knew the key actions to take as soon as they reached the patient, and because more families, carers and members of the public were aware that some form of stroke had occurred when they rang 999 and that they had to act fast. The early periods of the strategy between 2006 and 2009 also saw the number of stroke consultant sessions double and the increase of stroke specialisms in multidisciplinary teams. These are all key elements that have saved lives and, in the process, millions of pounds for the NHS.
The national strategy, and the equivalent national strategies in Wales, Scotland and Northern Ireland, aimed at providing national leadership and drive from the centre to improve stroke outcomes. Today’s NHS in England is very different from the NHS in 2007 when the strategy was introduced. The changes have been enormous. As the current strategy draws to a close, the evidence shows not only the progress but just how much more needs to be done. There is wide and unacceptable variation in standards of care between and even within geographical areas. For example, in the north of England, 94% of stroke patients at North Tyneside General Hospital were assessed by an occupational therapist within 72 hours, but eight miles away at South Tyneside District Hospital, the figure was only 51%.
There are also still too many smaller hospital stroke units unable to offer 24/7 stroke care. The London and Manchester models of streamlining services in centres of excellence have helped save lives, reduce disability and save money. The NHS Five Year Forward View recognises stroke as a key area where concentration of care brings substantial improvements in the quality of care and outcomes. However, the 2015 stroke national audit programme—SSNAP—shows that, although stroke healthcare has improved overall, there are several hospitals not only underperforming but performing worse now than they were in the previous year. Nearly a quarter of patients admitted to hospital are placed in wards deemed unacceptable for dealing with stroke.
Since I put in for this debate, I understand that the Public Health Minister in another place has expressed reservations about the continuing need for a national strategy for stroke—this when stroke is still one of the top three causes of death in England, is the largest cause of adult disability in England and is costing the NHS more than £3 billion a year and society as a whole three times that, and also when CCGs’ record so far on commissioning stroke care, from prevention to long-term care, is so poor. Localised services that are accountable and sensitive to the needs of the communities they serve still need the leadership and direction of the national strategy, and I hope we will hear reassurances from the Minister today that the Government fully recognise this, because if they do not the progress made to date is in serious danger of being lost, and we will start to go backwards. The All-Party Parliamentary Group on Stoke, of which I am a vice-chair, has underlined the vital importance of the strategy continuing into the future.
The praise in NHS Five Year Forward View for the concentration of stroke care and the improvements to stroke outcomes will be just that without the framework of the national strategy. We know that most hospitals or CCGs will struggle to do this without direction and leadership from the centre, particularly in the face of huge financial pressures and cutbacks. Currently one in four commissioning bodies does not have an allocated lead for stroke services and only 56% have a commissioning group for stroke. Only 27% of CCGs, for example, commission vocational rehabilitation services which help stroke recoverers return to paid work, which is a major lost opportunity. How will the Government address these huge variations in quality and standards without an overarching national strategy to ensure that local service providers implement coherent stroke services from prevention to longer-term care?
The new strategy needs to set clear guidance on future reconfigurations of services to replicate the success of the London and Manchester stroke services and other models of care that have improved stroke outcomes. Reorganising and centralising stroke care has been proven to work, and this needs to be firmly set in the context of the forward view and the urgent need to reduce the number of people who are having strokes that could be avoided. For example, we heard in our recent debate on atrial fibrillation that better screening, diagnosis and treatment, including early detection of AF with an anticoagulant, would result in the prevention of more than 4,500 strokes a year and 3,000 deaths. Untreated AF is a contributing factor in 20% of strokes.
There are, of course, other key areas that the new stroke strategy needs to address, including the chronic underfunding of research into AF and stroke treatment and care compared with other killer diseases such as cancer and heart disease. The new strategy will also need to reflect the impact that new medicines, treatments and technologies, such as thrombectomy and anti-clot disrupting or retrieval treatment, could have on future care. More spending on research into the unmet needs of children who have strokes is particularly urgent. Childhood stroke affects around five out of every 100,000 children a year in the UK. People do not think that children have strokes, but they do, as the families of children who have had major strokes in the womb before birth, in early childhood or later in their teenage years know all too well. It is a key message for the awareness-raising campaign that is needed among health professionals, parents and the general public. What action do the Government intend to take to increase research funding into the unmet needs of childhood stroke, particularly into rapid diagnosis and treatment and whole-family support and advice, about which so little is currently known or understood?
Above all, the national strategy is needed to address the main area in which serious gaps in stroke care remain: post-acute care. There are around 1.2 million stroke survivors in the UK. Half of them have a long-term disability and require ongoing support. A seamless transition from hospital to home with domiciliary support, physio and occupational and speech therapy services in place is all too often the exception rather than the rule. As the carer of my partner, who had a major stroke eight years ago, I meet many stroke survivors and their carers, and their stories are frequently of a month or more waiting at home while services, adaptations and, particularly, therapies are arranged. This has to change if the five-year view of integrating care and shifting the focus into the community has any chance of being achieved.
Finally, I underline the everyday importance of being part of the stroke community to stroke survivors, their carers and their families. This is particularly important as today is carers’ rights day. In my area, we are very fortunate in having a very active stroke group just down the road run by the Stroke Association and an amazing local charity called TALK to support stroke survivors with speech, memory and communication difficulties. They are both run by volunteers. Other areas are not so lucky. Many people suffering severe strokes lose their speech altogether, but speech therapy, physical rehabilitation and occupational therapy sessions are hard to come by unless you pay or spend a long time waiting for precious NHS appointments to come free. Only 45% of NHS trusts commission outpatient therapy, which is hardly the strong support needed to get people out of hospital and able to have a good quality of life and independence in the community.
The SNAPP survey sums it up as follows:
“A portfolio of services is required to provide comprehensive post-acute stroke care ... including early supported discharge, longer term neurological rehabilitation, vocational rehabilitation, exercise programmes, vascular risk reduction advice and support, and longer term follow-up and intervention for patients whose functional ability deteriorates. There is widespread variation nationally in commissioning a portfolio of post-stroke services, with too many areas failing to commission comprehensive care”.
I hope I rest my case on why it is imperative that the national stroke strategy should be updated and continue into the future. It must push the reorganisation of acute care, tackle the unacceptable variation in after-stroke care and drive new advances in prevention, treatment and research. Without a national strategy, reflective of a radically different NHS, local commissioners will continue to neglect the needs of stroke survivors, improvements in stroke care will stall, and outcomes for stroke survivors will get worse.
Lord Colwyn (Con)
My Lords, I am grateful to the noble Baroness, Lady Wheeler, for raising this important issue. I have read the report of her debate just over a year ago when she drew our attention to the incidence of stroke in children, and I reread her contribution to the debate on atrial fibrillation on 4 November, which set the scene for our debate today. I congratulate the noble Baroness on the brilliant way in which she and my noble friend Lord Black have stimulated interest in the national stroke strategy. They have organised demonstrations of the walk-in clinics with Anti- Coagulation Europe and have had discussions with the all-party groups for stroke and atrial fibrillation—both of which I am a member of—about what might be the likely successor to the strategy in 2017.
I shall confine my few remarks to the need for a focus on prevention, particularly in relation to atrial fibrillation. I declare an interest in that I have atrial fibrillation myself, which is anticoagulated. Since the strategy was published in 2007, there have been significant advances in the prevention of AF-related stroke, including the introduction of new clinical guidelines and treatment options, but there is still more for the NHS to do and it is essential that preventing AF-related stroke is at the forefront of any new stroke strategy.
In 2014-15, there were 14,979 strokes in people with known AF and 8,831 strokes in people with known AF who were not on anticoagulation. Some 25 % of people with AF who were not anticoagulated before their stroke died, and a further 11% were severely disabled, bed-bound and in need of constant nursing care and attention. Ensuring that patients with AF are identified and anticoagulated in line with NICE guidelines could save lives, prevent disability and save the NHS money.
On average, the healthcare costs associated with an AF-related stroke are £11,900 in the first year of care alone, and the overall cost to the NHS of AF and AF-related illness has been estimated at £2.2 billion each year. I am sure we all agree that there is an urgent need for an improvement in the diagnosis of AF. Estimates suggest that about half of people with AF are undiagnosed, and therefore are not anticoagulated and are at risk of having a stroke.
The diagnosis of AF could be improved through the introduction of a national screening programme for AF in people over 65 and the introduction of pulse checks for older people at seasonal flu clinics and other settings, such as the dental surgery, where most patients are examined for problems that are likely to show up in future. Dental check-ups are unique in that patients who are well arrange appointments to see if anything is wrong and could be prevented. Screening for AF is not currently recommended by the UK National Screening Committee. Would the Minister urge the committee to reconsider the evidence for the introduction of a national screening programme for people aged over 65?
There are now four non-vitamin K antagonist oral anticoagulants, called NOACs, recommended by NICE for the prevention of AF-related stroke. The NOACs were specifically designed to overcome the limitations of warfarin. They provide predictable, stable and reliable levels of anticoagulation and do not require routine monitoring, ongoing dose changes or dietary restrictions. All patients with AF should have access to the full range of NICE-recommended treatment options, and should have the opportunity to choose the treatment that is right for them in consultation with their doctor. At present, though, about 31% of eligible patients with AF receive no anticoagulation at all, and only 11% of anticoagulants prescribed are NOACs.
Will the Minister provide further information on what action the Government are taking to ensure that patients have access to the full range of NICE-recommended treatments? Would she consider providing specific support for clinical commissioning groups with the lowest rate of NOAC use to ensure that patients in those areas have better access to treatment?
Lord Kakkar (CB)
My Lords, I, too, congratulate the noble Baroness, Lady Wheeler, on having secured this important debate, and I thank her for it. In so doing, I declare my own interests as chairman of University College London Partners and my own specific research interests in the area of cardiovascular disease, including those of stroke.
We have heard already in this important debate that stroke represents a substantial burden of disease. It is still the fourth commonest cause of death in our country, with an increase in prevalence of some 26% over recent years. This is because we have a growing and ageing population who are living as a result of successes in other areas in the practice of medicine, and are therefore susceptible to cardiovascular diseases. The lifestyle of much of our population, with increasing obesity, diabetes and other important cardiovascular risk factors, also heightens the risk of stroke. That means within the coming five years we would expect to see an increase in the number of deaths attributable to stroke in our country to some 22,000 extra deaths a year by 2020. This is an important increase in the burden of the disease.
Beyond the physical burden, of course, there is the economic burden. The management of stroke costs us some £9 billion a year. Half that sum is due to health and social care costs and the remainder to informal care costs, costs associated with the loss of productivity in the economy and of course the benefits that need to be paid to those who, regrettably, have sustained a stroke.
Of course there is good news. We have heard from the noble Baroness about the success of the national stroke strategy, an important development in the mid-2000s, which has resulted in increased awareness among the public about the importance of understanding the symptoms of stroke and responding to them early, thereby improving early attendance at hospital. Over the period of time of the stroke strategy, we have also seen that now, at some point in the course of the management of their illness, some 95% of patients who suffer a stroke are managed in a dedicated stroke unit.
However, while we have seen from the Sentinel Stroke National Audit Programme some interesting and exciting data on improvements in practice, we have also seen some very serious variations in practice. For instance, the audit shows us that when process and outcomes relating to practice in stroke units are graded, some two-thirds of them get the lowest possible grades, grade D or E, with only 2% of units achieving the highest grade, grade A. We see important variation in the most important feature of acute stroke management: timely intervention by way of radiological assessment of the nature of stroke, and intervention with regard to thrombolytic therapy to dissolve the blood clot responsible for the stroke or indeed more advanced interventions such as thrombectomy to remove the clot itself using interventional radiological techniques. The reality of that situation is that, although 60% of patients suffering a stroke are transferred from A&E to a stroke unit within four hours, the variation is from around 20% of patients in some hospitals to over 80% in others. That fourfold variation is clearly not appropriate, so we have to do more to improve acute stroke management.
I remind noble Lords of my declaration as chairman of University College London Partners. Our academic health science system has been at the forefront of moving forward the stroke treatment strategy in London, along with the other academic health science centres. This particular model has landed upon the development of eight hyper-acute stroke units in London that bring together expertise in radiology and acute intervention. Patients are taken directly by ambulance to the hyper-acute stroke unit, managed there for 72 hours and then transferred to one of 24 stroke units in London for their further management. That model has been shown to save 96 lives per year in London, providing a saving to the NHS in London of some £5 million a year in treatment costs. What plans are there to ensure that the experience in London, now extended to Manchester, can be assessed for its value and utility in other urban areas in our country? Clearly it may not be suitable for all rural areas.
Indeed, how will the national stroke strategy be built on in future to address questions of better prevention, better identification of high-risk populations and the further extension of successful models at scale and pace to improve clinical outcomes?
Lord Lansley (Con)
My Lords, I join other noble Lords in thanking the noble Baroness, Lady Wheeler, for securing this debate and for the chance for me, early in my opportunity to contribute to debates in this House, to talk about an issue that is close to my heart.
The noble Baroness and some Members of the House may recall that I was chair of the All-Party Parliamentary Group on Stroke for seven years, before the 2010 election. The noble Baroness is quite right—it was a very important time for the development of stroke services, and Members of both Houses, as well as the Stroke Association, can take some credit for keeping a consistent focus on the treatment of stroke as a medical emergency. It has dramatically shifted over that decade from being thought of as a condition which people suffered—they had a stroke and then nothing much happened—to something that was treated as an emergency. Now, increasingly, we are beginning to see the development of more effective pathways for treatment that follow the acute emergency care, which is very important. It all goes back to the National Audit Office report back in 2005—so much of it flowed from that. We should not forget the critical role that should be played by the constructive but critical scrutiny that can be placed upon the service.
We have done a great deal but, as they say, there is more to do. We now know from the evidence, which the noble Lord, Lord Kakkar, eloquently set out, that a significant proportion of patients who are admitted as a medical emergency can benefit from acute care for ischemic stroke. One day I hope that the research will enable us to do something for patients who suffer a haemorrhagic stroke. However, the point is that making that very early diagnosis is absolutely critical to get patients on the right path.
We know that if patients are admitted to a specialist stroke unit rapidly, receive intensive therapy in the early stages after their stroke, and are discharged relatively early with support, all of those actions will have a significant impact upon their outcomes and, as a consequence, from the health service’s point of view, will be a major benefit as regards the reduction of long-term disability. The NHS, I hope—that was my intention—should be focused on outcomes and focused for the benefit of patients on reducing the disability consequences of stroke. We will have more patients with stroke to deal with—the noble Lord is quite right about that—but that does not mean that we should not be relentlessly focused on trying to increase consistently the proportion of those patients who suffer a stroke but who avoid mortality in the 30 days after that stroke and whose long-term level of disability is reduced. I should declare an interest as a stroke survivor myself. I had my stroke 23 years ago or so, in a very different age. We can do much more for stroke patients today.
There is a need in the midst of that for the department to act as steward of the system. For the NHS, through NHS England and the commissioners, there is a responsibility to secure the best possible outcomes. There is a need to commission for the best care to meet those quality standards; I was privileged to launch the first quality standards that NICE produced, which were on stroke. However, through the stewardship of the system, the Department of Health and Ministers are able to tie together the public health activity, and we here can hold the system to account. In his reference to screening for AF my noble friend made it clear how there is a public health benefit and activity to be determined there. The social care support that follows discharge of patients in the long term is of critical importance, as, of course, is the research activity. There is now ample evidence that more research activity on stroke can pay enormous dividends as regards securing the best pathway for treatment.
In the midst of that, I will make a plea. The better care fund is a large NHS fund, whose purpose is to enable patients to leave hospital and be looked after in the community with their social care much better adapted in the future, relieving burdens on the social care system in the long run using NHS resources. There would be no better place to focus some of this better care fund than on the support of stroke patients to receive early supported discharge after they have had a stroke.
Baroness Masham of Ilton (CB)
My Lords, I thank the noble Baroness, Lady Wheeler, for securing this important debate.
It is said that when stroke strikes, it affects everyone who loves that person. How true this is. Every three and a half minutes someone in the UK has a stroke. Some time ago my late husband had a stroke while sitting in his armchair watching cricket on the TV. I was in the room on the telephone and I noticed immediately what was happening. When the ambulance came he did not want to be disturbed from the cricket. I followed in my car, and when I got to the hospital I was left in his room with a young student nurse from South Africa. The questions on the admission form were so inappropriate that she gave up trying to fill it in. The student nurse and I undressed him, and as soon as we got his pyjamas on, we had to change them. I had to show the nurse how to roll him, as he was a big man. When I left his room I found a charge nurse and a female chatting at the nurses’ station. Why the male nurse did not come to help remains a mystery to this day. My husband was admitted in the middle of the morning; by evening he had not been seen by a consultant and no treatment had been given, nor had he had a scan. In desperation I telephoned the chairman of the hospital, who I knew, and she got the consultant, who was in his house, to visit.
That experience is why it is so important to have a national stroke strategy and to update it in 2017, when the present 10-year plan ends. I am pleased that owing to the strategy, treatment has got better, but it is still patchy across the country. Some stroke treatment is excellent but some can still be improved. Stroke is one of the top three causes of death and the largest cause of adult disability in England, costing the NHS over £3 billion. My noble friend Lord Kakkar said that it is £9 billion, so perhaps it has risen. Some people do not know that young people and even babies also have strokes.
Prevention is so important. Atrial fibrillation can cause strokes. Automatic arrhythmia detection loop monitors will greatly improve the detection of AF. At a screening last week for AF, several of your Lordships were picked up as having AF, which shows how important screening is.
When someone has a stroke, you must act fast. At the debate on AF in your Lordships’ House recently I stressed that there is a need to have first aid taught in schools so that many lives can be saved by people who know and have confidence to help save lives in threatening circumstances. Little did I know that there is currently a Bill in another place on first aid in schools, presented by Teresa Pearce MP. I hope that it succeeds.
The streamlining of specialist services with specially trained staff, which has saved lives and money, needs to continue as we build upon the improvements in acute care. This can only be pushed through at a national level.
Post-acute care, where the most serious problems persist, is where many survivors and their families are not getting the help that they need. This has to be improved. Some people do not have family support and have to rely on carers and a variety of help. It is worrying that, with the cuts to local authorities, services such as Meals on Wheels are being reduced or cut. All those providing care services, including volunteers, should work in collaboration. We must improve the service.
Baroness Hodgson of Abinger (Con)
My Lords, I, too, thank the noble Baroness for bringing forward this debate on a subject that is all too often overlooked. Strokes are devastating—they not only kill but cruelly maim. I have seen it personally. My father, aunt and mother-in-law all had strokes, so I know only too well about the terrible suffering and anguish that they cause. For some, it will be the end of their normal functioning lives, and even those who return to independent living often feel very vulnerable and suffer from depression.
Sadly, strokes are all too common. In the UK around 150,000 people suffer a stroke every year and, as we have heard, it is one of the largest causes of death. Even when not fatal, strokes can be desperately debilitating. My aunt changed from being an energetic, lively and outgoing person to being paralysed down one side and unable to speak. Even the mildest strokes tend to leave a mark.
Despite all that, there is a concerning lack of awareness of the symptoms, of the fact that, as we have heard, people of any age, including children, are susceptible, of the risk being greater among those of Asian or African origin, and, perhaps more importantly, of the fact that so-called mini-strokes are often a precursor to a much larger, more threatening stroke. It is estimated that if mini-strokes were properly identified and treated, around 10,000 major strokes could be prevented each year.
The noble Baroness, Lady Masham, highlighted very well how prevention is crucial, and many strokes are preventable. Much can be done to reduce the risks: diets, alcohol consumption and levels of exercise can all play a key role. Underlying conditions such as high blood pressure need controlling where possible. As we heard from my noble friend Lord Colwyn, less well known is the fact that atrial fibrillation can also be a serious risk factor.
The national stroke strategy, which was introduced in 2007 and to which many have alluded, has sought to develop and implement a comprehensive way of treating strokes. A further milestone was the set of quality standards focusing on clinical aspects developed in 2010. The National Audit Office has found that these have not only improved outcomes but saved the National Health Service an estimated £456 million since 2007. Where research leads to the development of new, improved treatments, it is important that these are adopted because, although they may be initially more expensive, in the long term they will improve lives and thus will equate to further financial savings.
More needs to be done so that people recognise when someone is having a stroke, as outcomes for stroke patients are intrinsically linked to response speed. The acronym FAST—face, arms, speech, time—is now the standard for identifying stroke symptoms. For strokes caused by clots, there is a maximum three-hour window to administer clot-busting drugs that will minimise damage. After that, it is too late. However, according to the Stroke Association, 60% of stroke emergency attendees at A&E arrive out of time. Rapid response from ambulance services is crucial, particularly in rural areas, where hospitals with the necessary expertise may be a long way away. Therefore, I ask the Minister whether monitoring is in place to ensure that all those who call for an ambulance in response to a stroke receive timely treatment, wherever they live.
I understand that nearly half of all stroke patients are scanned within an hour of reaching hospital, and 90% within 12 hours, but what about the 50% who are not scanned within one hour? How many of them could have been helped had they been? And are patients who need speech therapy or physiotherapy now given enough to enable them to make as good a recovery as possible? My aunt, some years ago, was offered speech therapy once a week when she actually needed it several times a day in short bursts if she was ever going to speak again. Consequently, she never did. Can I have an assurance from the Minister that older patients are given the best possible treatment? Anecdotally, I have heard of cases where those over the age of 75 are less bothered with. Much more attention also needs to be given to rehabilitation, as in a survey of stroke survivors 43% said that they wanted more therapy support once discharged home.
I, too, hope that the national stroke strategy will be revisited at the end of its current implementation period in 2017. Consultation with a wide range of healthcare professionals, stroke sufferers, carers and voluntary organisations will ensure that a revised strategy builds on the gains and adopts the latest research and treatment.
To conclude, I hope that the Government will ensure that stroke medicine across the country is adequately provided for and funded, including prevention measures, timely access to specialist services and necessary aftercare support and therapy, including psychological support. This, in turn, will mean better outcomes, healthier lives and a lower overall cost to the taxpayer.
Lord Lisvane (CB)
My Lords, I should preface my remarks with a declaration: I am the patron of Herefordshire Headway, which provides services to adults who have a head injury or an acquired brain injury. It does marvellous work through its day centre, offering a range of activities and therapies led by specialists.
I warmly endorse the view of the noble Baroness, Lady Wheeler, that there needs to be a continuing national strategy, and I suggest that an important emphasis must be on increased resources for rehabilitation. I was delighted to hear what the noble Lord, Lord Lansley —I hope that, in view of our former happy and close working relationship, I may on this occasion call him my noble friend—said about funding at the point of discharge and thereafter.
In terms of rehabilitation, there needs to be greater availability of physiotherapy. Frequently, that is only 30 minutes or so a week, which clearly is simply not enough. Repetitive movement of affected limbs may well help the development of new brain pathways and connections. The improvement of robotic machines to help in this will play an important part, but once again resources are key. It is a real challenge for people to do the hard slog of rehabilitation on their own. Group support can make a real difference. Here again rehabilitation centres where that group support is available have an important part to play. There is a lot of scope for much greater joint working between the NHS and rehabilitation centres such as Headway, and for joint funding between health and social care. Rehabilitation after stroke helps people rebuild their lives, and the lives of their families. That in itself should be a strong argument for it to be a spending priority. But also it is the wider community that benefits, and faster and more effective rehabilitation leads to savings in other areas as well, as my noble friend Lord Kakkar pointed out a few minutes ago.
Point 7 in the original strategy’s 10-point plan for action is spot-on in seeking to ensure that,
“health, social care and voluntary services together provide the long-term support people need”.
It asks:
“Is commissioning and planning integrated across the whole care pathway in your area?”.
Spot-on indeed, but has it really happened?
If availability of longer-term support through the charities, with their low overheads and costs per hour, could be built into the national stroke pathway then CCGs would be encouraged to commission the most appropriate providers in their area. I am confident that we would thereby get more for less.
Baroness Walmsley (LD)
My Lords, I start by congratulating all those who lobbied for the 10-year national strategy and all those who have made it work so well. If it had not been for the vision behind its establishment, and the hard work and co-operation of all those who have made it work, many more people would have died of stroke and many more survivors would have struggled with inadequate services.
Clearly, the additional specialist services and the community stroke teams have been a great success. However, every plan of this nature, especially those starting from a low base, has to be seen as a work in progress. The national stroke strategy is one of those for several reasons.
Medical research has, of course, moved on over the eight years of the strategy so far, and new ways of preventing stroke and treating and supporting people who have a stroke have emerged. In addition, because of the lowered mortality rate, there are now more people living with the consequences of stroke, and they require support. Add to that the changes in the structure of the NHS and commissioning since the strategy began, and the further pressures on the NHS which we have debated many times in your Lordships’ House, and we find ourselves looking at a strategy that needs updating, even though it has not yet reached its nominal sell-by date. So I am most grateful to the noble Baroness, Lady Wheeler, for giving us this opportunity to take a long, hard look at it.
It is clear from the briefings we have received that the scope of the strategy needs to be wider to include vascular dementia, a set of conditions that are closely linked to what we normally think of as stroke because they affect the delivery of blood to the brain. It is also clear to me that we need to invest in the wonderful new methods of prevention that have been mentioned.
Many of today’s speakers will, like me, have attended the walk-in briefing and testing session about atrial fibrillation last week—I was delighted to get a big green tick. I was impressed by the modest cost and ease of use of the kit, which can identify atrial fibrillation, and its potential for preventing strokes before they happen. I look forward to the analysis of the pilot scheme, which is putting 200 units into GP practices. Prevention is always better than cure, especially when action can be taken to prevent a serious condition such as stroke. I hope that the Minister’s department will look carefully at the cost-effectiveness of this initiative. Combine this screening with access to the NOAC drugs mentioned by the noble Lord, Lord Colwyn, and we have a formula for saving lives and saving money.
We know that strokes kill about a quarter of sufferers outright, as I know from personal experience in my family. When I listened to the noble Lord, Lord Kakkar, I thought, “Well, if you’re going to have a stroke, the best place to have it is in London”. But 20 years ago, when my late husband had a massive stroke, it was in Brussels. He was picked up by an ambulance in minutes, and within half an hour of collapsing in our hotel room was in a scanner being screened. That is why I think that four hours is an awfully long time.
We know a great deal about the lifestyle changes that can help to prevent strokes, but successive Governments have struggled to persuade the population to take these known preventive measures. Perhaps we need another public information campaign. I think that the public still lack knowledge of how to recognise when someone is having a stroke, as the noble Baroness, Lady Hodgson, outlined. Having taken an interest in the matter, I think that I know what to look for, but many people do not. Go out on to the street and ask people—despite the public information campaigns that we have already had, I think at least half of people would not know what to look for. We have to keep on telling them.
Given that successful outcomes depend a great deal on rapid diagnosis and access to treatment, it is vital that we have regular public information campaigns as part of the new stroke strategy. I suggest that such campaigns combine information on how to avoid having a stroke yourself alongside the messages about how to recognise it in others. If those around you recognise that you are having a stroke and call for help quickly, you have a much better chance of survival—and survival without serious disability.
The other thing that has been criticised in the briefings and by some noble Lords tonight is the patchiness of services for stroke survivors. This can only get worse, unless local commissioners are on the ball. We have learned from the briefings about the economic and lifestyle benefits of speech and language assessment and therapies for stroke patients, but not all patients have access to adequate amounts of these. They are clearly services which need to move seamlessly from hospital into the community, but they vary a lot from place to place. As a lay person, I have long been aware of the need for physiotherapy for legs and arms that have been damaged by stroke and for help with speech problems, but I was not aware, before I read the briefing, of how widespread swallowing difficulties are. Apparently, 40% of stroke victims have difficulty swallowing and a third have communication problems. What can the department can do to ensure, first, that there is an adequate supply of speech and language therapists—I believe there is a shortage—and, secondly, that CCGs are aware of the benefits of providing the services that have been discussed this evening?
Finally, do we really have to wait another two years to amend the national stroke strategy? The evidence is there. Why can we not start now?
Baroness Chisholm of Owlpen (Con)
My Lords, I thank the noble Baroness, Lady Wheeler, for initiating this debate. As so often with these short debates, this was of a high standard, and I only wish we had longer to discuss the issues. Stroke is one of England’s biggest killers and is the largest single cause of serious adult disability in this country. Its effects can be devastating, both for those who have a stroke and for their families and loved ones. However, good progress on stroke has been made in recent years—the mortality rate has fallen by almost 12% since 2010—but we know more needs to be done.
Both the noble Baroness, Lady Wheeler, and my noble friend Lord Lansley spoke about the national stroke strategy and asked whether we are going to carry it on. There are no current plans to do so. The reason for this decision is that the NHS Five-Year Forward View recognises that quality of care, including stroke care, can be variable and that patients’ needs are changing and new treatment options are emerging. The Five-Year Forward View sets out high-level objectives to address these issues. Initiatives include ongoing work in virtually all parts of the country to organise acute stroke care to ensure that all stroke patients have access to high-quality specialist care, regardless of where they live or what time of day or day of the week they have their stroke.
The Cardiovascular Disease Outcome Strategy, published in 2013, includes many stroke-specific strategic ambitions. Alongside this, a CVD expert forum hosted by NHS England will co-ordinate delivery of the work initiated in the CVD Outcome Strategy. Also, NHS England’s National Clinical Director for Stroke works with the strategic clinical networks, voluntary agencies and individual providers to support best commissioning and provision of stroke care. Like the noble Baroness, Lady Wheeler, I want to pay tribute to the Stroke Association, the Carers Trust and the Princess Royal Trust for Carers, which do so much to help stroke victims.
Alongside initiatives being put into place when the national strategy comes to an end in 2017 is the Clinical Commissioning Group Outcomes Indicator Set, known as the CCGOIS. These are indicators for improving recovery from stroke. People who have had a stroke who are admitted to a stroke unit within four hours of arrival in hospital receive thrombolysis following an acute stroke, are discharged from hospital with a joint health and social care plan, receive a follow-up assessment between four to eight months after initial admission, and spend 90% or more of their stay on an acute stroke unit. These indicators are being monitored by the Sentinel Stroke Audit Programme.
I want to touch on prevention, which is so important if we are to see fewer stroke victims in our hospitals. First, we know that obesity and high salt intake greatly increase the risk of stroke. Tackling obesity, particularly in children, is one of our key priorities. We will put forward our plans for action in our childhood obesity strategy in the new year. Alongside this, the UK salt reduction programme is world leading, with the population’s average salt intake being reduced by 15%. Major retailers, manufacturers and caterers are working to meet these targets by December 2017.
Secondly, simple lifestyle changes can help reduce the risk of stroke, as we all know. Public Health England is working with a range of public sector and commercial partners to promote healthy behaviour across the course of life. These include encouraging greater physical activity, highlighting the harms of smoking and drinking and urging older people to make sure that they take action on the signs and symptoms of stroke.
Thirdly, the noble Baroness, Lady Wheeler, mentioned the treatment of atrial fibrillation, as did the noble Lord, Lord Colwyn, and the noble Baroness, Lady Walmsley. We covered most of the issues in our recent debate, but it is a high priority in NHS England’s Five Year Forward View. As we know, AF is a major cause of stroke. I want to mention NHS Improving Quality, which has developed GRASP-AF, an audit tool to identify patients with AF who are not receiving treatment. There are also the quality and outcomes framework indicators on the use of anticoagulation therapy for AF patients to incentivise good practice in prescribing anticoagulants in primary care. Screening for AF will be discussed at a meeting on 2 December—in which I think the noble Baroness, Lady Wheeler, will take part with my noble friend Lord Prior—where more will come out about what the plans are for such screening.
Improving awareness of signs and symptoms of stroke is key to improving outcomes. The hugely successful Act FAST campaign, as mentioned by the noble Baroness, Lady Walmsley, has helped 40,000 people to receive the immediate treatment they require, resulting in an estimated 4,600 fewer people becoming disabled as a result of a stroke since the campaign began in 2009. There are certainly no plans to stop this campaign. All ambulance trusts are now asked to use this treatment facility when they are triaging patients in an ambulance.
Diagnosis and treatment has improved over the years. Access to immediate brain scanning has improved, with 46% of patients being scanned within one hour of hospital arrival and 90% within 12 hours. Clot-busting drugs give a certain cohort of stroke patients a better chance of regaining their independence. Twelve per cent of all stroke patients admitted to hospital receive these drugs, which is a rate higher than most other developed countries.
We are aware that stroke patients do better when they are treated on stroke units. Some 83% of stroke patients now spend more than 90% of their time in hospital on a stroke unit.
As was mentioned by the noble Baroness, Lady Wheeler, the academic science networks and strategic clinical networks work at local level to help improve services. They work with local commissioners and providers on the configuration of stroke services. As we know, there have been problems in various areas.
We know that there have been issues in the past with stroke patients experiencing a poorer level of care at weekends and evenings than they might experience during weekdays. Ninety-nine per cent of hospitals are now providing a 24-hour, seven-day-a-week thrombolysis service, either themselves or through a formal arrangement with a neighbouring trust. Two-thirds of hospitals admitting acute stroke patients are operating seven-day-a-week consultant ward rounds.
The noble Lord, Lord Kakkar, mentioned the success of the London model, which is very true. Good practice is taking place in other places, too—indeed, the noble Lord mentioned how such practice had been set out in Manchester. Certainly, the Royal London, Tower Hamlets and Wandsworth are providing high-quality responses, seven-day in-patient rehab and early supported discharge. The Society of Chartered Physiotherapy highlights the good work of the North Devon Healthcare Trust stroke therapy team, which provides stroke rehabilitation services, including early supported discharge, across a rurally dispersed population. Not only does it give high-quality specialist integrated services but it delivers improved outcomes. It has reduced length of stay by six days, saving almost £900,000. We accept that there are areas where support can be improved, but some excellent work is definitely going on.
Following on from prevention, diagnosis and treatment, it is critical for stroke patients to receive good aftercare. That is why the NHS Outcomes Framework and our mandate to the NHS both set out improving recovery from stroke as a key area where progress is expected. There has been growth in availability of services such as early supported discharge and community neuro-rehabilitation teams over recent years. For example, recent data show that 74% of hospitals had access to stroke-specific early supported discharge and 72% to specialist community rehabilitation teams.
Transparency in information and data about the quality of the services provided will drive improvements. It worked in cardiac surgery and we are beginning to see the benefits of this approach in other services such as stroke.
Also incredibly important in all stroke care is joined-up care. My noble friend Lord Lansley mentioned the Better Care Fund. Some 84% of stroke patients on discharge have a joint health and social care plan, and 89% of patients are given a named contact on discharge in case there are issues they wish to discuss once at home. Whether it be speech, language therapists for aphasia, which is such a distressing side-effect for stroke suffers, or physiotherapy to improve mobility, joined-up care is absolutely vital as far as stroke rehabilitation is concerned.
Joined-up care must also include psychological support, as the noble Baroness, Lady Hodgson, mentioned. The CVD outcomes strategy and national stroke strategy both recognise that stroke services which incorporate psychological care deliver the best outcomes for people who have had a stroke. NHS England is exploring how to improve the existing resources to ensure that stroke patients receive the psychological and emotional support they need.
Noble Lords may be aware of an improving access to the psychological therapies programme, known as IAPT. This is an NHS programme rolling out services across England, offering interventions for people with depression and anxiety disorders. Many areas now have an IAPT service. Some IAPT services have developed psychological support skills through enhancing the training of nurses and therapists, and some have employed counsellors to support people with stroke in the community.
Clearly, ambulance times are paramount in rural communities, and where extra time is taken in travelling this will be made up as quickly as possible when they reach hospital. For example, in Northumbria, a new hospital is taking all acute stroke patients who previously went to three hospitals. This has shortened the time taken for patients to receive clot-busting drugs after arriving in hospital from over an hour to 30 minutes. A couple of trials are going on involving paramedics. In one, paramedics are recruited to help trial a rapid response treatment for stroke patients, whereby medicated skin patches that lower blood pressure quickly after a suspected stroke are administered in the ambulance. In the other, paramedics can request a brain scan and transfer the patient directly to the scan room on arrival, which can reduce the waiting time for thrombolysis.
I am running out of time, which always seems to happen on these occasions. I have not been able to mention much about childhood stroke, but spend on research for all types of stroke by NIHR increased from £20 million in 2011-12 to £26 million in 2014-15. However, I would like to get back to the noble Baroness, Lady Wheeler, on the specific research into childhood strokes, which is so important.
I hope that I have given some reassurance—although I feel that I have only touched on many issues—but if there are points I have not managed to deal with, I ask noble Lords to get in touch with me so that I can make sure they get the proper answers they want. As always with these debates, some fascinating issues have been brought up which we need to take further. Once again, I thank all speakers for their participation.