The Long-term Sustainability of the NHS and Adult Social Care

Baroness Wheeler Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I, too, congratulate the noble Lord and his committee on this excellent report. The debates on the long-term future of the NHS and social care at this time, as we approach the 70th anniversary of the NHS, are invaluable, particularly as recognition of the need for long-term funding solutions is under the spotlight more than ever before. We also have the very welcome recent evidence from last year’s social attitudes survey that shows that the majority of voters now back a tax rise to fund the NHS. The Government’s response to the committee’s report, a year after its publication, has been described as anodyne, pedestrian and underwhelming—and those are the kind descriptions. In truth, it contained very little that could not have been said three months after the report was published. The Minister has been very apologetic on many occasions about the delay, so perhaps we might be rewarded today with an actual explanation as to why it took so long to say so little.

Noble Lords have spoken on the key funding, structural and workforce issues arising from the report. I want to speak about these in the context of the future of stroke services. I know that the noble Lord, Lord Patel, will welcome this, as it is an issue close to his heart, and I commend the key role that he has played in this House in support of improved stroke care.

Stroke is the fourth-largest single cause of death in the UK. It occurs approximately 152,000 times a year in the UK, there are over 1.2 million stroke survivors, and it is the largest cause of disability. Over half of all stroke survivors have some form of disability. Every year, 80,000 people in England are admitted to hospital after having had a stroke. Stroke costs the health and social care system over £8 billion a year, but research by the Stroke Association shows that when informal care and lost productivity are factored in, this spirals to £26 billion. Without action, this is expected to at least double or triple by 2035. Indeed, the quality of stroke prevention and care in England is a strong barometer of how our health and care system is working, as it is both a medical emergency and a long-term condition. As the committee’s report underlines, reorganising and centralising stroke services reduces disability and can save lives.

The 10-year National Stroke Strategy, brought in by the Labour Government in 2007, has led to major improvements in stroke prevention, treatment and outcomes. But progress has stalled as a result of funding cuts, CCGs not giving stroke reconfiguration the priority or support it needs, which results in huge variations in services across areas, and little attention being given to the whole stroke care pathway—and because of the Government’s mistaken refusal to update the strategy forward into 2018 and beyond. However, the news that NHS England, along with the Stroke Association and others from across the health and social care system, are now working in partnership to develop a new national plan for stroke in England, is welcome. It is essential that this plan is prioritised and effectively implemented to provide the leadership and direction needed to achieve better treatment, care and outcomes for those affected by stroke. Can the Minister update the House on progress on the national plan and on the timeframe for its development and publication?

While reconfiguration of services is planned or under way in many areas across the UK, progress is slow and patchy, with huge challenges in persuading local commissioners to prioritise these services, and persuading communities and patients that reorganisation works. In reality, much of the change is still small scale and limited in scope, such as shutting one unit and diverting ambulances to hospitals with better stroke facilities and staffing. Although 32 STPs have used the opportunity to review acute stroke services, most of these reviews have yet to be actioned and only four consider the whole stroke pathway. The committee’s report makes it clear that the jury is still out on the current effectiveness of STPs, and this is certainly true of their likely impact on stroke reconfiguration and services. As both ADASS and the Local Government Association have pointed out, STPs’ main focus is on NHS transformation, not on social care. The LGA sums it up, saying that,

“there has been little meaningful consideration of adult social care as a vital component of a resilient and sustainable health and care system”.

Can the Minister say how this is being addressed as STPs are taken forward?

Sadly, for stroke survivors the care pathway is the area that has seen least progress in recent times. For comprehensive post-acute stroke care, such a pathway means early supported discharge, long-term neurological rehabilitation, vocational rehabilitation, exercise programmes, vascular risk reduction advice and support, and long-term follow-up and intervention for patients whose functional ability deteriorates. Nearly half of all stroke survivors who responded to the Stroke Association’s recent survey say they felt “abandoned” after leaving hospital and lack confidence and information about how to navigate the post-acute pathway; two-thirds did not receive the vital six-month review of their care needs. Forty per cent of stroke patients are eligible for early supported discharge, which reduces the length of hospital stays and provides intensive multidisciplinary stroke-specific rehabilitation at home. But two out of 10 hospitals in England, Wales and Northern Ireland do not offer ESD, and it is not being commissioned by many CCGs despite national guidance. There are long waiting times in most areas for key post-stroke psychological and emotional support; on speech and communication, the average wait to start speech and language therapy is 22 days, varying from 8.5 days to two months between the best and worst-performing areas. These are precious lost days that can have a lifetime impact on the ability to communicate after a stroke.

On carer and family support, shockingly, one in three areas in England, Wales and Northern Ireland does not provide support for carers and families of stroke survivors. As a carer of my partner who is a stroke survivor of 10 years, I cannot stress enough how important being part of the local stroke community is to the well-being of stroke survivors, particularly those with severe disabilities.

In my area, we are lucky to have a stroke group just down the road, run and funded by the Stroke Association. We also have an amazing local charity called TALK, which provides support with speech, memory and communication difficulties. It is run by volunteers but against increasing odds. It was recently given one month’s notice by the CCG that its small grant is to be stopped this month. When we talk about NHS and social care sustainability, surely these are exactly the sorts of services where local authorities need increased national funding so that they are able to provide support.

Many of your Lordships know that I always have lots to say about stroke but in the time left I shall make just a couple of points. I really welcome the committee’s frank assessment and criticism of the current absence of coherent health and social care workforce planning. I hope that the Minister will today acknowledge this, look at the problems that are occurring and commit to a long-term workforce plan covering both health and social care. There are lots of examples of staff shortages in stroke services which I do not have time to go into. Again, I support what noble Lords have said about the need for increased social care funding.

Thirdly, straying a bit from the committee’s report, the excellent “Children get dementia too” adverts on the Tube have prompted me to remind the House that children get strokes too, because the debates in this House have led to some progress being made. Childhood strokes affect 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 or later in their teenage years know all too well. Awareness raising, more support for carers and families caring for children who have had a stroke, and much more research into childhood stroke, are needed.

Finally, I join other noble Lords in giving wholehearted support to the committee’s recommendations on prevention and public health, and the need to move from an “illness” to a “wellness” service. For stroke, this is very important, and there is a need for better screening and diagnosis of atrial fibrillation.

In summary, stroke embodies the challenges of planning for population health and delivering integrated, accountable care, and it requires the joined-up health, social and voluntary sector support called for throughout the committee’s report. I look forward to the Minister’s response.