The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)
My Lords, I congratulate my noble friend Lord Lingfield on securing this debate. As the noble Baroness, Lady Wheeler, has just pointed out, it has been short but sweet—rather, we have had a small cast list but a high quality of output. The experience of the noble Baroness and that of her partner has been invaluable, while the noble Baroness, Lady Barker, asked some searching questions, which I shall attempt to answer. The noble Baroness, Lady Coussins, will be amused to learn that in my briefing it states of her, “Does not normally ask health questions”. I am absolutely delighted that she is here, because hers is a perspective that we have not had before. I hope that it is not the last time that we see her taking part in a debate of this kind, and I shall come to the very interesting ideas that she mentioned. Along with other noble Lords, I recognise and applaud the work of charities like ARNI, while my noble friend also referred to the Stroke Association, Canine Partners and others. They make a valid and vital contribution to care in this area.
We have talked about the impact of stroke. In England some 80,000 people a year are being admitted to hospital. We also know about the impact that strokes can have not only on the lives of sufferers themselves, but also on their families, friends and carers. The statistic that stroke leaves half of those affected with a disability is a sobering one. We know also that the difficulties are not just physical. As we have discussed, they include communication difficulties, psychological cognitive fatigue and others. Indeed, stroke is the leading cause of complex disability, as well as the fourth largest cause of death, which is why it has quite rightly been the focus of successive Governments.
It is worth saying that major improvements have been made in stroke prevention, treatment and outcomes since the publication of the 2007 strategy, for which the then Labour Government deserve much credit. I shall highlight one or two of those outcomes, because they highlight some of the questions which have been asked. Over the past 20 years, the 30-day mortality rate has dropped from 30% to 13.5% in 2015-16. There is now better compliance with the occupational therapy standards, from 56% to 83%, while physiotherapy standards have risen, along with speech and language therapy. However, it is notable that even with speech and language therapy, where compliance has doubled, it remains at less than 50%, which goes to the heart of some of the points about variations in provision which noble Lords have pointed out. While improvements have been made, it is clear that a lot more needs to be done.
As several noble Lords mentioned, one way that we can improve rehabilitation is to get the care right in the first place. The noble Baronesses, Lady Barker and Lady Wheeler, mentioned mechanical thrombectomy, which is highly effective at preventing severe disability. The statistics are interesting: for every 100 patients treated, 38 will experience a less disabled outcome than with the best medical management—an extraordinary improvement—with 20 more achieving functional independence. Having national coverage is clearly important, and I will come on to how we try to achieve that.
The noble Baroness, Lady Wheeler, talked about how her partner had benefited from Public Health England’s Act Fast campaign. That is reducing the amount of time between someone having a stroke and arriving at hospital. The campaign has been going for about nine years now, during which 5,365 fewer people have become disabled as a result of a stroke, saving the equivalent of 12,200 quality-adjusted life years. This is quite an achievement for a public health campaign. The third area on the acute side where big improvements have been made, and which noble Lords have spoken about, is the centralisation of services, including hyper-acute stroke services. The noble Baroness mentioned the work which our colleague, the noble Lord, Lord Darzi, did in London. Because of that, a significantly higher proportion of patients are receiving care compliant with the guidelines and processes. That alone has delivered a 5% relative reduction in mortality at 90 days, another significant improvement.
Those things are at the acute end, but the topic for today is rehabilitation. As has been mentioned, there are over 1 million stroke survivors. Not only do half of those have a disability but half are also living with four or more co-morbidities. The question is: how do we get their lives back on track? We know that rehabilitation delivers better outcomes, improves quality of life and reduces health inequality. It also provides good value for money; it is the right thing to do on every level. It is also important to approach this with an optimistic mind set. As noble Lords have pointed out, stroke can be a recoverable condition, with survivors continuing to improve for months after their stroke.
We know from stroke survivors and the charities that represent them, and we have heard today, that they need early and ongoing rehabilitation and support. The testimony of the noble Baroness, Lady Wheeler, and her partner brought this to life. This includes holistic reviews of progress; a personalised care and support plan which is regularly updated; the provision of information; the availability of the right therapies; and so on. This obviously has to happen in the acute setting but, more importantly, it needs to happen in the post-acute setting as well.
My noble friend Lord Lingfield and the noble Baroness, Lady Wheeler, talked about the stroke working party guideline of 45 minutes, but they also said that that is being missed all too often. What are the Government doing about it? The governing document has been the strategy which began in 2007, which has now been replaced with the stroke programme board, established in March this year. It is chaired by the national medical director of NHS England and the CEO of the Stroke Association and is developing a costed stroke plan to address the challenges of prevention, service reconfiguration, optimising rehab services, workforce development and data. I do not have a date at this time, but I shall endeavour to write to the noble Baroness and other noble Lords with that.
The board is looking at some changes. It has been said, quite rightly, that there needs to be seven-day availability of the right workforce. We need to make sure that nurses, therapists and other medical staff are there round the clock. As we know, there is some silo thinking on clinical expertise in the NHS. As the noble Baroness, Lady Barker, pointed out, the availability of mechanical thrombectomy is hampered by a shortage not just of skilled neuroradiologists but of other trained consultants. Reconfiguration can deal with some of that, but we need to do more to deal with it at a national level.
Through the work of the programme board we intend, first, to include stroke-specific plans within workforce strategies and to support integration across care settings. Secondly, we will establish training pathways from other medical specialties to increase the interventional neuroradiology workforce. Thirdly, we will include experience in stroke medicine early on in the undergraduate curricula of foundation medical training programmes, to encourage early career choices to pursue stroke training.
The noble Baronesses, Lady Barker and Lady Wheeler, also talked about the need for better data. That is absolutely right, and is happening in a couple of ways. First, a new national clinical audit of cardiovascular disease prevention in primary care is being instigated. Secondly, in reference to one question that was put, we are making sure that the research strategy of the NHS will address key evidence gaps in stroke, particularly around post-acute care. I shall certainly take away the suggestion by the noble Baroness, Lady Wheeler, about a specific type of stroke and the under-resourced or under-researched nature of it.
Much of the funding for research comes through the National Institute for Health Research—a domestic source, although this issue is international in scale. As for Brexit, following our exit from the European Union, we are looking to achieve participation in the next iteration—the successor programme to Horizon 2020. Third countries are already participating, so it is within our grasp, as was set out in the Government’s Collaboration on Science and Innovation: A Future Partnership Paper.
On commissioning, which was also mentioned, NHS RightCare: Stroke Pathway was published in October 2017 and is the governing document. We need to ensure that the guidance that includes information about early supported discharge and community provision is adhered to. I do not know what the mechanisms are by which we will improve compliance, some of which is quite good and some, frankly, too low. That is a topic of work for the programme board. I shall write to noble Lords with its ideas on how it intends to make that bite, so that there is CCG compliance in commissioning frameworks.
Finally, we need a different approach to rehabilitation, one that is collaborative and integrated across health, social care and, critically, the third sector. In addition to rehabilitation, stroke survivors need a very broad set of services, including spasticity services, psychology, orthoptics, pain and continence services. As we have also heard, stroke survivors often need help with housing adaptations.
We have, therefore, three goals to achieve this rehabilitation revolution. First, we must make sure that there is proper commissioning of stroke specialist rehabilitation of the required intensity seven days a week for stroke victims through their in-patient stay, as recommended by the clinical guidelines. That will be driven by NHS England. Secondly, we must ensure that stroke survivors have access, within 24 hours of discharge from hospital, to a stroke specialist rehabilitation service that can provide support for the early discharged patient at the same rehabilitation intensity as stroke unit care, seven days a week. Thirdly, we need to develop a national service specification for the structure and process of stroke specialist rehabilitation services provided immediately after discharge, including early supported discharge, that describes appropriate staffing levels and, critically, addresses rurality. We must not only set those guidelines but make sure that they are complied with.
I shall briefly answer questions where I have not yet had a chance to do so. My noble friend Lord Lingfield asked about grants from public funds to rehab charities. Local authorities do that kind of work through their social care function. I am not aware of what CCGs and the NHS itself do, but I will endeavour to find out what support is available.
The noble Baroness, Lady Coussins, took us on a very interesting journey into the power of language, and second languages. I knew about its benefits for dementia sufferers, but not about its benefits for stroke sufferers. I shall certainly be happy to find out more about the scheme and whether we can help. It sounds like a fascinating idea; considering the annual cost of stroke, and what the cost of educating children in a second language at school would be, the cost-benefit analysis looks quite good. It is something to think about, and I am glad that my right honourable friend Nick Gibb is enthusiastic about it.
The noble Baroness, Lady Barker, asked about stem cell and gene therapies. It is a really good question. We have a fantastic network of biomedical research centres, funded by the National Institute for Health Research. I do not know if she has had the opportunity to visit any of them but I thoroughly recommend it. Sometimes we are a bit hard on ourselves in this country in asking ourselves whether we really have access to cutting-edge, world-leading therapies in cancer, stroke, cardiovascular, or whatever. This is where it happens—where the translation from lab to the clinical setting happens. People here are among the first in the world to get these therapies. I thoroughly recommend seeing that, and if the noble Baroness were to get in touch I would be delighted to recommend a suitable one. We have the opportunity to be involved in this field, and a good track record in it.
Finally, the noble Baroness, Lady Wheeler, asked several questions. I hope that I have responded to most of them. If I have not, I will of course follow up with a letter.
I close by once again thanking all noble Lords for their contributions. It has been a fascinating and useful debate. With the programme board in place, I think that we have the opportunity and the leadership to make sure that we improve stroke services. We are in the happy position of knowing what is necessary; now, we need to deliver it. I am sure that, working together, we can start to transform rehabilitation care so that it is of the intensity required and provides a lifeline to stroke sufferers.