National Stroke Strategy

Baroness Wheeler Excerpts

Wednesday 18th November 2015 Lords Chamber

Asked by

[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.