Health: Stroke Survivors

Baroness Wheeler Excerpts

Thursday 28th June 2018 Grand Committee

[Baroness Wheeler (Lab)]

My Lords, I too congratulate the noble Lord on securing this debate and on his informative speech. This is a key opportunity to focus on rehabilitation—that is, life after stroke. Like me, he is a strong admirer and supporter of the Stroke Association on stroke research, prevention, treatment, care and support. As usual, I am grateful for its briefing in support of this debate and for the key background documentation from the Lords Library.

I have spoken on a number of occasions about the importance of renewing and updating the 10-year national stroke strategy, which ran out last year. It has taken time but the strong and determined national campaign for this has resulted in the association and others from across the healthcare system now working closely with NHS England on a national plan for stroke.

There is no doubt that, despite the huge progress in the reorganisation of acute stroke care services as a result of the 2007 strategy, post-hospital support, rehabilitation and ongoing long-term community support for stroke survivors is an area that has seen least progress. It is vital that this be a declared ambition of the new plan and given urgent priority. Can the Minister update the House of progress on the national plan and a timeframe for its development and publication?

As we have heard, stroke is the fourth-largest single cause of death in the UK and is the largest cause of long-term disability. It results in over half of all stroke survivors having some form of disability. With major strokes disability is often profound and severe and, in this context, perhaps I may digress slightly and mention haemorrhagic stroke. Some 85% of strokes are ischemic strokes. Only 15% are brain haemorrhages and there is currently no acute treatment for them, despite their being associated with the most serious strokes and the worst patient outcomes. It is a significantly underfunded area of research into prevention, treatment and rehabilitation and I make a special plea for the Minister to look at this issue.

It is relevant to consideration of whole care pathways and long-term support for stroke survivors, especially those with the severe disabilities that result from a brain haemorrhage. It is also relevant to me as my partner is hemiplegic as a result of a major haemorrhage 10 years ago. He benefited from the early days of the FAST campaign and the successful reorganisation of London stroke services, which was referred to by the noble Baroness, Lady Barker. This meant that he received the emergency and stabilising care and treatment in hospital he needed within the four-hour period. Ten years on, I am pleased to say that he has a very good quality of life, lives well and is a part of the community. I single out four key basics that have led to that outcome for him.

The first is a good, reliable package of personal care, including washing and dressing, and a domiciliary agency that, overall, provides a good service with a regular team of care workers who we both know and trust. The second is a strong and active connectivity through the local community centre, with its excellent stroke support group, and other voluntary sector support. The importance of staying in touch in keeping well cannot be overemphasised as the key to rehabilitation. The third is weekly assisted disability exercise support through a local charity, which helps maintain his limited walking ability. It is not physio but movement exercises by trained assistants. Fourthly, he has the home adaptations and the disability aids he needs, such as a profile bed and splints, plus a power wheelchair, which means that he can get out and about locally on his own. I also add to the list his amazing assistance dog, who has made such a huge contribution to his mobility, independence and confidence, and pay tribute to the charity Canine Partners for its work in training such dogs and supporting disabled people in this way.

Of course, many other elements are involved in supported care at home, such as GP and primary care support, but the current support available is under huge pressure, as noble Lords have pointed out. We know that it is medical and reactive rather than proactive and focused on rehabilitation and staying well—on wellness rather than illness, as the Committee on the Long-term Sustainability of the NHS put it.

The noble Lord, Lord Lingfield, cited the Royal College of Physicians national guidance 2016 as the gold standard. It calls for stroke survivors to have,

“at least 45 minutes of each appropriate therapy … for as long as they are willing and capable of participating and showing measurable benefit”.

Hospital patients typically receive only one-third of that: the equivalent of 16 minutes a day of physio, 16 minutes a day of occupational therapy and 12 minutes a day of speech therapy. We know that, in the community, those therapies mostly have to be self-funded or obtained in the private sector.

The NHS RightCare Pathway included in the Library pack cites earlier RCP guidelines on what should be expected of NHS commissioners, which are clear and unequivocal. The guidelines stress:

“Commissioning organisations should ensure that their commissioning portfolio includes the whole stroke pathway from prevention (including neurovascular services) through acute care, early rehabilitation, secondary prevention, early supported discharge, community rehabilitation, systematic follow-up, palliative care and long-term support”.


It is vital that more CCGs and the STPs commission services that meet what is set out in the guidance. I should like the Minister to respond to that.

As all speakers have stressed, stroke is a recoverable condition. Many stroke survivors see improvements physically, communicatively and cognitively for months and years afterwards. The often-repeated adage that I heard when my partner first had a stroke—sadly, from both the public and some professionals—was that stroke improvements will not take place after two years. That is wrong. Improvements can and do happen with the right motivation, support and help along the care pathway.

I ask the Minister some questions on this issue. First, will he comment on the large regional variations in the availability and quality of community services for strokes shown in the latest national stroke audit? Secondly, will he comment on the unacceptably high waiting times for starting speech and language therapy post hospital—two months in some of the worst performing areas? Thirdly, will he comment on the 12-week waiting time for psychological support for stroke survivors across the country—up to five months in some areas, when the target is two weeks? Fourthly, will he comment on the action being taken to deal with CCGs which, despite the strong national guidance, are not commissioning ESD to provide intensive, multidisciplinary stroke-specialised rehabilitation and support for patients, carers and families? Forty per cent of patients should be eligible for this, but do not receive it. These are key questions, and I look forward to the Minister’s response.

It is small wonder that 45% of stroke survivors say that they feel abandoned when they get home from hospital, lacking in confidence, information and support. I can certainly relate to that. Fifty-one year-old Philippa Haslehurst, who had a stroke four years ago, received just two NHS sessions of physiotherapy and occupational therapy before having to pay for private treatment. She said:

“I felt like after a couple of rehabilitation sessions, the NHS had wiped its hands of me. I had made hardly any progress and I was still dealing with the debilitating after-effects of my stroke. If it wasn’t for private physio, I wouldn’t be walking now, let alone be back at work. I believe physio saved me”.


I also ask the Minister about the personalised care plans that stroke survivors are supposed to receive for their ongoing post-hospital treatment, care and support, and the findings of the recent Neurological Alliance survey that over 70% of patients are not offered one. Surely this should go hand in hand with the ESD plans for personal and domiciliary care support and generally to ensure that patients are discharged into a safe environment. Can the Minister also explain what action is being taken to ensure that all CCGs commission the six-month post-hospital review of stroke survivors’ progress and problems? Less than a third of stroke survivors receive this review and only half of all CCGs actually commission it. NHS RightCare guidance includes follow-up annual reviews, which are obviously needed if a patient’s progress is to be monitored effectively.

As the noble Baroness, Lady Barker, said, one of the key issues arising from this debate is the lack of post acute-stroke data in comparison with that for acute care. We need strong and consistent data on the provision of the different types of therapy, treatment and rehabilitation as well as on measurable patient outcomes; its lack is seriously hampering progress in this area. Can the Minister outline what work is being done and will the recommendations in the national stroke plan include ensuring that this key aspect is addressed?

This has been an excellent, thoughtful and wide-ranging debate, despite having few contributors, while we wait for the national stroke plan to be finalised and for the publication of the social care Green Paper, now promised for the autumn. I hope that the Government will recognise that prioritising effective rehabilitation for stroke survivors will achieve significant long-term savings across the health and social care system as well as being of huge benefit to stroke survivors themselves.