Health: Stroke Care

Debate between Baroness Wheeler and Lord De Mauley

Monday 30th January 2012 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what plans they have to address variations in health and social care support for people after stroke identified in the Care Quality Commission’s special review, Supporting Life After Stroke.

[Lord De Mauley]

My Lords, I respectfully draw noble Lords’ attention to the fact that, except for the noble Baroness, Lady Wheeler, and my noble friend the Minister, speeches are limited to three minutes.

[Baroness Wheeler]

My Lords, I am delighted to have secured this debate on the key issue of support in the community for people who have had a stroke and their carers. The Care Quality Commission report, Supporting Life After Stroke, was published a year ago this month, following a landmark special review by the commission, which charted what was happening in every primary care trust area in England.

I do not have a record of when I proposed the debate, but clearly patience has paid off. In fact, one year on and in the lead-up to the Government's promised spring White Paper on social care, consideration of the report's findings and proposed actions is timely indeed: both to address the widespread concerns about the impact that the major changes to the NHS will have on the huge progress that has been made in recent years; and to highlight the need for care pathways to address the need for long-term support for stroke survivors and not just help in the immediate period after hospital discharge.

Before moving to the report's findings, it is worth briefly providing a word of praise for the much beleaguered CQC itself. The special review is an incisive, excellent piece of work—precisely the type of national review report that the CQC should be undertaking—setting out a range of actions for service providers, commissioners and central government from its locally based assessments. However, there is doubt about the amount of meaningful follow-up work that has been done by the commission and indeed whether it will be able to undertake such review work in the future—but I will come back to that later.

For the record, I give the stark facts about stroke. Stroke is the third biggest killer, the largest single cause of severe adult disability in the UK, and the second major cause of dementia. There are about 110,000 strokes and 20,000 TIAs—that is, mini-strokes—per year in England and approximately 300,000 people are living with moderate to severe disability as a result of stroke. Stroke is also one of the most expensive conditions, with direct care costs to the NHS of £3 billion a year within a wider cost to the economy of £8 billion.

The central message of this debate, nearly five years since the start of the implementation of the 2005 national stroke strategy, is that there must be no turning back, no brake on the enormous progress that has been made and that we must keep up the momentum. As a carer of a severely disabled adult who most certainly would not have survived his major brain haemorrhage without the immediate care and treatment measures outlined in the strategy being in place, I can personally testify to the life-saving effectiveness of the strategy in the area where I live, and pay tribute to the marvellous skills of ambulance and hospital nursing, physiotherapists and medical staff in getting him through. We know that, as a result of the national strategy, that excellent early treatment experience is replicated in many stroke centres across the country. But we also know from the 2011 national stroke audit undertaken by the Royal College of Physicians that huge variations in standards of acute care still need to be addressed.

Similarly, the CQC report on community-based care for stroke survivors once they have left hospital found significant variations across England in the extent to which they are supported to cope with life after stroke. In many areas, the report found that people were unable to access the services they need when they need them. Early supported discharge, focusing on intensive rehabilitation in the home rather than in the hospital, was available in only 37 per cent of areas; 32 per cent of PCTs failed to commission physiotherapy in the community across the whole of their area; in 48 per cent of areas, people waited an average of two weeks until receiving speech and language therapy—vital lost days in a such a critical enabler to living and coping with stroke.

The CQC also found major problems with people and their carers accessing services and support after hospital discharge; information packs not easy to follow or not including information about local services; carers not given information about local carer support or befriending schemes; information not available in relevant community languages other than English; helpline staff not trained to deal with people with communications problems such as aphasia; and, most common, a named contact for support which did not look across health, social and community care.

However, the overall CQC message is that, despite the problems it identified, much has been achieved in improving post-hospital support and many of the building blocks necessary to achieve a transformation in care are now in place. In the words of the CQC, the report shows that the barriers to effective care after transfers home can be overcome and improvements made to which can help people both to recover from and cope with life after stroke. The report reinforces my message about keeping up the momentum and ensuring that it is not lost in the light of the threats to improvements in post-hospital stroke services from substantial cuts to local social care budgets and the impact of the reorganisation of the NHS.

The CQC recommendations cover a wide range of actions to address the variations in service provision that it found. These include PCT service improvement plans to address the problems and, most importantly, to ensure that services are adapted to individual needs, such as for people who have little or no support from carers or family members, people in care homes, people with aphasia, and people from black and ethnic minority communities. From my experience as a carer, often battling to ensure that the various support services actually happen and join up, I shudder to think what happens to the many stroke survivors living on their own.

The authors of the CQC report highlighted the importance of the NHS stroke improvement programme and the 27 stroke care networks that operate at regional level. They have a key role to play in helping to improve longer-term stroke support in the weakest performing areas, and I hope that the Minister will be able to give reassurances that funding of the networks will continue following the current review period.

It is clear from the problems highlighted in the report—and the CQC stresses this—that strong national leadership and support will continue to be needed for the foreseeable future to support the changes in the longer-term stages of the stroke care pathway envisaged. I hope that the Minister, in his response, will be able to reassure the House that the national Commissioning Board will commit to ensuring that the key elements of the national strategy are incorporated into future guidance to commissioners of stroke services and that it will also ensure that the strategy continues to move forward to meet the challenges ahead.

On the question of leadership at national level, the Department of Health’s continuing failure to appoint at least an interim national clinical lead for heart disease and stroke following the resignation of Sir Roger Boyle has caused much concern and has led to precisely the leadership vacuum that we must avoid at this critical transition phase. Moreover, the number of staff in the vascular team at the department has also significantly declined during this time. Meanwhile, there are still national clinical directors for other major areas such as cancer, diabetes and respiratory disease. Can the Minister explain how the Government justify not filling the heart disease and stroke post, even on an interim basis? How is this leadership role currently being undertaken, and how will he ensure that the Commissioning Board has the expertise to advise and deliver on stroke strategy without it?

In the time I have left, I have some key questions for the Minister arising from the report. First, I understand that the CQC’s remit has changed since publication of this report and that the review team working on stroke has been disbanded. In the absence of the proposed targeted CQC inspections, as well as training and support for the weakest areas, how will the Minister ensure that all PCTs, now in their clusters, have reviewed the CQC local assessments and are implementing action plans? Is this the last stroke review that the CQC will undertake?

Secondly, consistent and authoritative data on stroke care once people leave hospital is vital to gauge what progress is being made. How will information on the quality and standard of stroke services be monitored and reported in the future, and will more information be collected on post-hospital stroke care and support?

Thirdly, I am sure that the Minister will join me in recognising the valuable work undertaken by the voluntary sector in providing stroke support services. I refer in particular to the Stroke Association, although I should also like to give a quick plug for the amazing work of my local TALK charity in Surrey for stroke survivors with aphasia. However, the removal of the ring-fenced conditions from last year’s £15 million government grant to local authorities, combined with local authority budget cuts, uncertainties over NHS funding and future commissioning arrangements, will seriously threaten the viability and provision of services in the future. How will the Government ensure that local authorities provide adequate support for voluntary organisations and networks providing such vital community support for stroke recovery?

Fourthly, I draw your Lordships’ and the Government’s attention to the publication in May of the Stroke Association’s forthcoming Daily Life survey as part of Action on Stroke Month. It is the largest survey of the life experience of stroke survivors across the UK. I am sure that the Minister will want to commit to working with the Stroke Association on the outcomes to ensure that the long-term support that stroke survivors need are improved.

I end with a hobby-horse of mine concerning stroke. We were told rather authoritatively by a number of medical, nursing and social care staff, and well-meaning others, that there was a two-year “real” improvement window in stroke care—in other words, if improvements to impaired movement, paralysis or speech loss had not occurred by then, that was how it was going to be. That is a common myth and it is not true. With the right support and care, stroke can be, and often is, a long journey of small, continuing improvements—to memory, to motivation, to speech, to thought processes, to the ability to live with disability and to finding ways of enjoying a good quality of life. That is why making progress in strong and continuing support for stroke survivors in the community and addressing the current variations across the country is so important. I look forward to the contributions to the debate and to the Minister’s response.