Health: Stroke

Lord Rodgers of Quarry Bank Excerpts

Wednesday 23rd July 2014 Grand Committee

[Lord Rodgers of Quarry Bank (LD)]

My Lords, this week, in advance of today’s debate, I looked at my copy of the second edition of the manual, first published in 2000, that is simply called Stroke. It was written by a team headed by Anthony Rudd, now the distinguished Professor Rudd of St Thomas’ Hospital. I could find no reference to children and young people in the index. I also looked at the NHS Stroke Handbook put together by the NHS North Central London Cardiovascular and Stroke Network and published a couple of years ago. Again, I could find no reference to children and young people.

There have been rapid advances, as the noble Baroness, Lady Wheeler, mentioned, in dealing with stroke over the last dozen years, and books and documents may have been revised to take account of stroke problems for children and young people. I see, for example, that there has been a Royal College of Physicians paper dated 2004. Either way, I am delighted that the noble Baroness, Lady Wheeler, introduced this debate and pleased that the Stroke Association is making a stand.

Every six weeks or thereabouts I walk across Hampstead Heath to the Royal Free Hospital in north London for a blood test to regulate my warfarin. Most of the patients are elderly, although a few are middle-aged. Others are physically disabled. However, I have not seen any children and young people. The problem is not visible to those many adults who have suffered a stroke and learnt to live with its consequences.

The Stroke Association says that the causes of stroke and the recommended treatment for children are different. In that case, how often is stroke diagnosed in children and how quickly can the necessary action be taken? Over the years, in debates in the House, I have asked whether GPs are trained and equipped to recognise the symptoms of stroke. I remain concerned that many GPs know little about stroke in the absence of direct experience of handling their own patients. On the assumption that the Minister will share our concern, can he tell us how the message can be passed on to GPs and reach those who have day-to-day contact with the public through their surgeries?

The noble Baroness, Lady Wheeler, expressly addressed the outcome of children and young people but the Stroke Association says that there needs to be research into the causes of childhood stroke. There is growing awareness of the characteristics and consequences of sickle cell disease and teachers should try to identify the potential signs of stroke. One of my daughters, a head teacher, tells me that among her 500 primary schoolchildren there is a girl who had a stroke at the age of two, resulting from moyamoya syndrome. She can understand but she cannot speak. Her teacher is almost one-to-one: she needs to communicate to the child in a very different way.

Seven years ago, my noble friend Lord Darzi set out a report called Health for London: A Framework For Action. It led to a major consultation and an agreement that certain hospitals should offer a top-quality service to stroke problems, recognising that all general hospitals could not offer the same level. I am not aware of how far this trend has successfully spread over and out of London and through the country. Given the need for services for children and young people, where are the services located—in general hospitals, existing stroke units or a high-quality specialist hospital?

There are many and rising demands on the National Health Service and costs have to be limited. The Stroke Association—a charity—has put £140,000 into research on childhood stroke at Bristol University. Does the NHS contribute to that Bristol fund? Can the Minister give an overall nationwide figure of money coming from public funds covering research on childhood stroke and where that research falls?

Health: Stroke Care

Lord Rodgers of Quarry Bank Excerpts

Monday 30th January 2012 Lords Chamber

[Lord Rodgers of Quarry Bank]

My Lords, this debate is the latest in a series of short debates in which the House has explored the causes and consequences of stroke. Of today’s list, three—the noble Baroness, Lady Rendell, the noble Lord, Lord Clinton-Davis, and I—spoke at the first of them on 23 May 2006, arising from the pioneering National Audit Office report Reducing Brain Damage: Faster access to better stroke care.

The noble Lord, Lord Clinton-Davis, and I drew from our personal experience as victims—a term I do not like, but it is used. For my part, I was not physically disabled but my speaking, reading, writing and comprehension were severely affected. I needed two and a half years of speech therapy to recover my capacity, and longer for my confidence.

In her ministerial reply in 2006, the noble Baroness, Lady Royall of Blaisdon, gave a sympathetic response, saying that the hospital to which I had been taken following my stroke five years earlier used to have one of the worst performing stroke services in the country but that it had been turned round to one of the best.

I say that because stroke had been grossly neglected by the NHS until the late 1990s. Since then the perception of stroke has been transformed and I pay tribute to the Stroke Association as it has played an important campaigning role. I also pay tribute to Sir Roger Boyle for his leadership of the national stroke strategy. I am sorry that he has felt unable to continue his role during these turbulent NHS times. Among unfinished business is to ensure that GPs can recognise and take seriously the symptoms of stroke in a patient and to contribute towards the rehabilitation and care of stroke victims.

In reading the 2010 stroke sentinel audit reports, I have found no reference to GPs and only one in the Care Quality Commission report, in passing, on the role of GP consortia in the new commissioning procedures. I would be grateful for the Minister to bring up to date this aspect of the national stroke strategy—involving GPs in stroke—and explain where responsibility will lie on completion of the current Health and Social Care Bill.

I greatly welcome the initiative of the noble Baroness Lady Wheeler, in putting forward this debate, and I hope that we shall have further occasions in the House to maintain the momentum of change.

NHS: Reorganisation

Lord Rodgers of Quarry Bank Excerpts

Thursday 16th December 2010 Lords Chamber

[Lord Rodgers of Quarry Bank]

My Lords, I welcome the noble Lord’s success in the ballot and listened to his speech with great interest. However, I am disappointed that there has been so little discussion of the future of the NHS in your Lordships' House since the White Paper was published in July, five months ago. I had expected a substantive response on one of the Opposition days, as the National Health Service has been a central political issue for more than 60 years. This House is at its best in considered and fair-minded scrutiny, including Official Opposition scrutiny.

I am also disappointed that yesterday's government response to the lengthy process ended with a Written Statement. The House greatly respects my noble friend Lord Howe, but we would have liked to hear his own words. In a recent speech, the Minister said:

“The rhetoric about our reforms is overheated. This is evolution, not revolution”.

With respect, there seems to have been relatively little rhetoric around the White Paper. There are legitimate and strong differences, and a balance of opinion between welcoming radical change and genuine anxiety about upsetting the much improved 21st century NHS. Now, in a document three times longer than the White Paper, the Secretary of State broadly endorses his original thesis.

I was agnostic about the White Paper. I thought that there was too much hyperbole and too much fashionable jargon, and I am not yet wholly persuaded. But I do not share verdict of the hesitant critics, or cautious friends, such as the King's Fund: “Too far too fast”. Once the health Bill has appeared and pre-legislative scrutiny has been completed, I would much prefer Ministers to get a move on. In speaking to the NHS Alliance conference, my noble friend Lord Howe said that, while NHS managers are sometimes misrepresented as bogeymen,

“this is the opposite of the truth”.

He said that he wants a more innovative NHS but that,

“all of our reforms will be impossible without great management”.

I hope that my noble friend will repeat that today and on other major occasions. Hard-working, high-skilled and committed managers are too often diminished as nameless bureaucrats; in contrast to virtuous, efficient doctors and caring nurses.

On the National Health Service as it now stands, it is right to acknowledge that there have been outstanding improvements in the past 10 years. From my personal experience, the National Stroke Strategy is a success story compared to the Comptroller and Auditor General's report, Reducing Brain Damage, covering the earlier part of the decade. Similarly, a few years ago, there was a minimum waiting time for a hearing aid of between nine months and two-and-a-half years, and often there is now no delay at all. Waiting lists for treating major, critical conditions are dramatically down. I will be worried, and patients will be depressed and angry, if there is any reverse of that trend.

On the central issue of the White Paper, I am fascinated by the new NHS commissioning board. It threatens to become the quango of all quangos. In the White Paper, it is described as,

“a lean and expert organisation”,

despite its huge responsibilities—and the new document suggests that there may be more. Its original, tentative, regional dimension seems to have disappeared. I would be grateful if the Minister would explain the regional role of the NHS when the primary care trusts and the strategic health authorities have gone. There is a related problem. Will my noble friend explain the role of A&E departments within the new structure? On the eve of the general election, the then Secretary of State announced that he was personally intervening to prevent the closure of a dozen A&E departments.

Localism is the order of the day. Local people, say Ministers, with real powers, are to decide the services and facilities that they want. On the face of it, local people want high quality and very expensive treatment in every hospital. Who will choose the priorities? Who will decide? I say that because I was impressed by a recent consultation to choose a limited number of new sophisticated stroke hospital units in London. Thirty-one primary care trusts came together to reach an agreement. Who will now come together to make use of the highly contentious and political question of the future of other hospital departments nationwide when the PCTs have gone?

There are still many questions of how to turn the White Paper and yesterday's document into an even better NHS. I hope that I shall soon join the Ministers in the sunny uplands of success, but I have not travelled there yet.

Health: Stroke Treatment

Lord Rodgers of Quarry Bank Excerpts

Wednesday 30th June 2010 Lords Chamber

Tabled by

[Lord Rodgers of Quarry Bank]

To ask Her Majesty’s Government what steps they intend to take to ensure the efficiency and effectiveness of the treatment of stroke victims, in the light of the report of the Comptroller and Auditor-General, Progress in Improving Stroke Care.

[Lord Rodgers of Quarry Bank]

My Lords, yesterday, I was one of 66 speakers in a debate that extended over eight hours. Today, we have much fewer speakers, but this debate may do more to the health and happiness of our citizens than yesterday’s event. On 28 May 2006, I introduced a debate on stroke victims. My text was the Comptroller and Auditor General’s report, Reducing Brain Damage: Faster Access to Better Stroke Care, which had been published the previous November. On this occasion, I turn to the successor report, Progress in Improving Stroke Care, which was published this February.

Reducing Brain Damage was damning. In the debate, I noted some limited improvements in stroke services made by the Department of Health and paid tribute, as I do again, to the Stroke Association for its research, welfare and campaigning. But the report was deeply disturbing. The House of Commons Public Accounts Committee called it “scathing” and “shocking”, adding that the neglect of stroke had led to,

“shameful lost opportunities and lost lives”.

In her reply, the noble Baroness, Lady Royall, accepted the many shortcomings in the previous treatment of stroke and said that all the recommendations would be taken forward. She said that there had already been progress. The Royal Free Hospital, mentioned by the noble Lord, Lord Clinton-Davis, and me, which had been one of the worst-performing stroke services in the country, was now one of the best. There would be a comprehensive response to the report through a new stroke strategy.

I welcomed the noble Baroness’s promise, but I was sceptical about yet another “strategy” for this and for that, which is often a plan without a timescale and is illustrated by a sunshine booklet. I did not doubt her personal good intentions, but it was on record that health officials and Ministers had previously neglected interest, perception and energy in dealing with more than 100,000 strokes a year and in providing specialist stroke services.

When the department's document Mending Hearts and Brains was published at the end of that year I was far from convinced that this was a major step forward. It included “hub and spoke” care, which for example would take emergency patients from the Lake District to Middlesbrough rather than Carlisle for an urgent brain scan.

In a further debate on 7 December 2006, I said that in answering questions about stroke, the Government’s response had been “bland and lacked urgency”, while on another occasion, 14 May 2007, I scrutinised more fully Mending Hearts and Brains, which I found to be an odd document that was easy to ridicule. But the national stroke strategy, which was eventually published late in 2007, was right in principle. Much has since been done to implement important steps. I have seen well-attended “stroke weeks” in hospitals and I was impressed by a consultation document on major trauma and stroke services for London arising from the health initiative of the noble Lord, Lord Darzi, when he was Minister. I also welcome the Stroke Research Network, which is on track.

So, looking ahead, I do not diminish the substantial improvements made during the last six or seven years from what was once a very low level of ministerial and departmental interest and involvement. In parenthesis, however, I would be concerned, following the Queen’s Speech, if the voice of patients and the role of some doctors blunted the leadership of necessary changes. It would be damaging if a decision to keep open all the existing inadequate stroke hospital units rather than use fewer fully equipped specialist centres was the result of, say, a local referendum. I hope that that will not happen and I would be grateful if my noble friend Lord Howe would reassure me.

Some of what I have said so far is essential background to the new National Audit Office report. In describing its methodology, it refers to existing documents, patient experience and a survey of the stroke networks. The authors re-ran the Royal College of Physicians’ latest national sentinel stroke audit, which states that a quarter of stroke patients are not given the best treatment as few had been admitted to an acute stroke unit within four hours, and few had been given a brain scan within three hours. Clearly, emergency stroke care varies considerably around the country. The report reminds us that stroke is one of the top three causes of death and the biggest cause of physical disability in England. It costs the National Health Service £3 billion a year. The earlier report concluded that, historically, stroke had been a low priority in the NHS, but it goes on to say that that there has now been a major change in the Department of Health’s approach, and it approves the national stroke strategy and its progress.

I do not diminish any of that, but I want to draw to the Minister’s attention some current concerns, as I am alarmed at the removal of the ring-fenced conditions to the £15 million for the year 2010-11 for the revenue grant. Why has that been done? Beyond that, I assume that the intention remains to continue with and complete the 10-year plan, and unless the Minister says otherwise, that Professor Roger Boyle will continue as the national director for heart disease and stroke.

All relevant hospitals in England now have a stroke unit, but it appears that about 40 per cent of patients are not given a brain scan within 24 hours, and that weekend and evening access is significantly more limited. That means—this is my personal footnote, but a serious one—that if you want to have a stroke, choose it during the working week, otherwise you may not survive. If you do survive, only 24 per cent of patients suffering from atrial fibrillation who are discharged from hospital are offered treatment with the anti-coagulation drug Warfarin, which is highly cost-effective. Its full use would prevent around 4,500 strokes a year and 3,000 deaths.

The audit report states that improvements in acute care are not matched by progress in delivering more effective post-hospital support for stroke survivors because there are barriers to joint working between the health service, social care and other services. In figure 15 of the report, I notice that in longer-term care, fewer than half of the patients in the survey describe favourably ongoing speech therapy as “good” or “very good”. For psychological support, only a quarter describe it as “good” or “very good”.

However, overall the report shows that the current policy is saving lives and saving money. The national strategy for stroke is starting to improve levels of service and, in technically defined terms, there has been a significant increase in “quality-adjusted life years”. As Professor Boyle said, there are no simple quick fixes. However, I repeat, the 10-year plan is crucial. I hope that the Secretary of State, Andrew Lansley, who was a long-standing and effective chair of the All-Party Group on Stroke, and my noble friend will not dissent.

Meanwhile, I strongly recommend an early meeting between Ministers and the Stroke Association to discuss and explore current and rising anxieties. The NAO was able this year to call its report Progress in Improving Stroke Care. I hope that in four years time it will not call the next report Slipping Back.