Health: Stroke Care

Lord De Mauley Excerpts

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.

Health and Social Care Bill

Lord De Mauley Excerpts

Tuesday 11th October 2011 Lords Chamber

[Lord De Mauley]

My Lords, I suggest that it may be convenient for the House to adjourn until Questions at half past two.

Debate adjourned.

Health: Mental Health Strategy

Lord De Mauley Excerpts

Monday 14th February 2011 Lords Chamber

[Baroness Murphy]

My Lords, 10 days ago, the first ever cross-government mental health strategy was launched, laying out plans for the future of mental health care in England. I congratulate the Government on recognising the crucial fact that mental health affects every area of a person’s life and impacts upon their ability to play an active role in society and I welcome the Cabinet-level commitment expressed so far. The strategy also makes plain that mental health has a parity of esteem with physical health—a lovely phrase—finally giving the issue the equal footing it deserves.

Sticking with the good things for the moment, I am delighted with the commitment to repeal the outdated law which forces MPs to stand down if they have been sectioned under the Mental Health Act for more than six months. This is an important anti-stigma signal by the Government.

However, I turn now to my—what shall I call them?—not exactly anxieties or worries but a sense of unease about the messages. I had niggles about the New Horizons strategy from the previous Government, so I am not blaming the coalition; rather I am blaming all of us in government, professional organisations and the voluntary sector for letting the ball slip through our fingers. I declare a personal interest¸ having spent most of my career working in specialist psychiatric services with people with serious, life-changing mental health disorders such as dementia, schizophrenia and other major psychoses and serious disabling developmental disorders of personality.

For me, the overarching theme of the strategy represents a misguided, somewhat soft-headed, utopianism focused on well-being and mental good health, as though there were a direct connection between a happy society and reduction in serious mental illness. But there is not. Events and circumstances, often unavoidable, play a significant part in the origins of serious disorders—but only a part, and often a very small part.

Let me make it clear that the broader public health issue of mental well-being and the aim to intervene to prevent the experience of distress are legitimate national strategic objectives. The toll of emotional human misery and minor psychiatric morbidity costs England an estimated £105 billion every year. This burden spreads beyond health services to education, employers, the social security benefits system, housing, the criminal justice system, families and communities. National well-being should influence our approach to economics and it is entirely legitimate to try to intervene to promote good mental well-being. However, I have doubts as to whether this should be the target of a mental health document which will largely be read by health and social care providers.

Many in the Chamber today have campaigned for the wider availability of psychological therapies, but again I have doubts about what Marjorie Wallace at SANE has recently referred to as the “therapy for the nation” strategy, which comes across as a panacea for the whole spectrum of mental health conditions and is being launched against a background of active planning for cost improvements of about £20 billion in the NHS, with local authorities shamelessly slashing and burning community services.

The experience of many local voluntary organisations which work with people with serious mental disorders is that people are being turned away from help, especially from in-patient care, when they feel desperate or they and their families have reached crisis point. Mental health services are still not getting it right for people with serious mental ill health and I want a strategy that does. Only today I received a deeply moving letter from the mother of a young man with a chronic enduring psychotic illness whose life circumstances were extraordinarily tragic and who was receiving inadequate support from the community services.

I am particularly critical of the public health outcomes framework in the strategy document, which seems to me to be mostly aspirational wishful thinking. It includes everything from reducing reoffending and self harm, all the way through to access to green spaces and “improving social connectedness”—a Facebook account for all? It is all lovely stuff but nothing to do with mental ill-health realities.

We know from studies in the US and our own research that social interventions that make a difference—for example, to the mental well-being of children and young people—have to be comprehensive, very focused, usually costly and require major changes in the way services are organised. Successful pilot schemes have been exceptionally difficult to replicate on a larger scale and to translate from experience in the United States. It is a waste of time, as we have known from so many social interventions, to intervene with individuals and families on a small scale, yet there is a real danger that that is what we will do.

Let us take maternal depression as an example. I am not denying that there is some evidence for the efficacy of preventive interventions, such as home visiting, parenting programmes, peer support, the refocused Sure Start children’s centres, parent support advisers working with school staff, and other family support workers, such as health visitors and early years outreach workers. Your Lordships may have noticed that I have already mentioned an army of helpers and workers of one sort or another. Then there is the family-nurse partnership programme, which works with the most disadvantaged young families with complex, interlinked problems and is aimed at interrupting the transgenerational cycle of poor health. The evidence is poor that this will work unless it is properly replicated on a very wide and expensive scale. The Government have pledged to increase the health visitor workforce by a further 4,200 posts, refocusing health visitors on maternal and infant mental health. However, the overall evidence for the efficacy of health visitors has been slight in the past. The NICE report currently on its website is based on an earlier Health Development Agency review of the evidence, which did not give much comfort in this area. Research has been small scale; much of it is interesting and encouraging, but its findings have so far been modest. Yet we are about to embark on vast investment.

To support these and other programmes, the Department for Education has introduced a new early intervention grant, which will bring together funding for a number of intervention and preventive services. These will replace the current targeted grant. I have no quarrel at all with the idea of a general grant that local authorities can use for the priorities in their area, but altogether the early intervention grant will be 11 per cent lower than the aggregated funding for this year, with a further major drop for next year. What of the £400 million extra for psychological therapies, which can and should, in my view, be targeted on those with the greatest need? It is in the baseline funding of the NHS, but do we really expect that it will be spent in the suggested fashion in the context of the £20 billion reduction? Some of it will be retained by a few areas, but I have grave doubts that it will find its way through to where it is really needed.

I suggest that a mental health strategy should focus primarily on those with the most severe disorders, whose lives are so often wrecked by the misery of mental illness. It has to be fit to be translated into measurable outcomes for the commissioning board and turned easily into commissioning intentions by GP consortia. We know that GPs lack confidence in commissioning mental health services. A survey last year by the charity Rethink found that, although three-quarters of GPs are happy to take on responsibility for commissioning diabetes and asthma services, fewer than a third feel the same for mental health services. They know that they do not like what they get at the moment for their patients with severe mental illness. Only half of GPs are confident about the quality of specialist care for depression and only a third are confident about the quality of care offered to people with psychosis. Many GPs doubt that patients with mental ill health will get the treatment that NICE recommends. In a way, that should encourage us, because GPs will want change for the better. I know that the Mental Health Network of the NHS Confederation is doing some very good work in collaboration with the pathfinder consortia.

The well-being of the nation is an important thing, but it is perhaps something other than a mental health strategy, so does the Minister not have doubts about whether we know enough to intervene cost-effectively or whether we have the public wealth to intervene on a wide enough scale to make a real difference? Will he accept that the well-being of a nation does not have a great deal to do with the sorts of services that will be delivered to people with serious and enduring mental health problems? I should like to see a strategy that really gets it right for the seriously ill.

Finally, I look forward very much to hearing other noble Lords on this topic. I firmly expect them all to disagree with me profoundly and I hope by the end of this debate to be converted back to my usual optimistic self.

[Lord De Mauley]

I have been informed that at least one noble Lord has withdrawn his name from the list of speakers for this debate, which means that all speeches, except for that of the Minister, will be limited to six minutes.