World Stroke Day

Andrew Stephenson Excerpts

Thursday 23rd November 2023 Westminster Hall

[Rachael Maskell (York Central) (Lab/Co-op)]

Thank you for those kind words, Mr Hollobone. I will open by saying that I used to be a physiotherapist working in acute care, specialising in stroke care, so I bring other experience to the debate as well. I serve on the all-party parliamentary group on stroke, and I am indebted to the hon. Member for Bromley and Chislehurst (Sir Robert Neill) for securing today’s debate. We work assiduously on this issue here in Parliament, and it is so important for all our constituents. We believe there is real scope for change within the Government’s approach to help our constituents not only to prevent stroke, but to survive stroke, and to benefit from that.

As the hon. Member for Bromley and Chislehurst said, every single five minutes, somebody will experience a stroke. For some people, it will be brief—a transient ischaemic attack. For other people, it will clearly be very serious indeed, and for some people it will lead to mortality. To bring that home, during the course of the debate another 18 people will have experienced strokes. The urgency is now, and we cannot lose time. Over the course of a year, around 100,000 individuals experience stroke, but that means that 100,000 families also come into contact with the NHS. As a result, it is really important that the Government renew their focus. Although we welcome the major conditions strategy, it is simply not enough. Of course, the major conditions strategy is so major that the necessary focus needs to be brought to the fore. I suggest that we make 2024 a year of stroke, so that we really bring that focus down to deliver. If we had that focus across the system, we could make such a difference.

I will not go into all the statistics that my hon. Friend the Member for Bromley and Chislehurst did, but I just want to say that stroke is very avoidable. Of the people who experience it, 80% will have risk factors that can be controlled. We must talk about prevention. As a vice-chair of the Health and Social Care Committee, I must mention our inquiry into prevention in health and social care, which I am sure the Minister will pay much attention to. We must look at how we prevent individuals having stroke. Of course, we can undertake monitoring, for instance around blood pressure, with high blood pressure being an indicator and also atrial fibrillation. This is also about lifestyle choices; it is really important that we remember that smoking is still a major cause of stroke. We must ensure that individuals have early help, not least if there is a familial issue with stroke, to see how we can avoid that.

I also want to talk about health checks. It is really important to make those early interventions. We heard today about a 41-year-old who experienced a stroke, and one in four people who experience a stroke are under retirement age, so we must remember that it is often younger people who experience the need for this process. As a result, we should monitor people. The health checks that came in for those aged 40 are not often applied within integrated care board areas. We need a real sea change there, because monitoring things such as what is happening with blood pressure as early as we can, with really quick tests, can make a sizeable difference.

The Health and Social Care Committee has just returned from Singapore, where we heard about the early healthcare interventions being made there and, of course, saw the outcomes. If the Minister is determined to make a difference in his short time in the role before my hon. Friend the Member for Denton and Reddish (Andrew Gwynne) takes charge, introducing those interventions to monitor what is happening could be a life-changer.

I also want to highlight how we need to respond. Response is too slow, and I want to challenge the system. For ambulances, a stroke is currently a category 2 call. I would like it to be made a category 1 call and the response expedited, because every minute that passes in the golden hour can make a difference to somebody’s future and whether they will experience severe disability—or, indeed, die—or receive interventions that could prevent such disability. Changing the categorisation would save both money and lives. It is important to look at that again. It could make a difference, not least because the time lags for the ambulance service on category 1 and category 2 calls at the moment mean that categorisations are insufficient to get patients to the right place at the right time in order to get the right interventions. I hope that the Minister will take that away and carry out some work in that area to expedite the process towards diagnosis and treatment.

I turn to diagnosis. In a country like Germany, individuals are diagnosed at the kerbside, at home, or wherever they have their stroke, and the process will start immediately. At the point that the patient is experiencing deficits—perhaps they are still going through a cerebral event—or as soon as the ambulance is called, the clock starts on the diagnostic process and then treatment. Using the best diagnostic techniques to scan at the kerbside, using AI to help, we know—[Interruption.] It looks like the Minister is in some pain; perhaps he needs my physio skills.

[The Minister of State, Department of Health and Social Care (Andrew Stephenson)]

Sorry; it is my shoulder.

[Rachael Maskell]

Being able to undertake the diagnostic process really early means being able to get the information into the stroke unit of the hospital as early as possible, so that when the patient arrives at the door, they are whipped through the system and interventions can start. The problem is that we have such a time lag that intervention is often too late. Will the Minister look at what is happening on a global scale with interventions that could really make a difference?

Of course, there are two types of stroke: some people have a cerebral bleed and some have an infarct, or a blockage, where the brain is starved of oxygen. As a result, different treatments are undertaken. There is thrombolysis, which is a medical intervention to blast a clot through, and mechanical thrombectomy, which the hon. Member for Bromley and Chislehurst talked about, where a wire is fed through the femoral artery into the brain, captures the clot and withdraws it. As a result, the brain can receive the oxygen it needs so that it does not experience the damage that we have heard about.

We need to increase the specialist interventional neuroradiologist workforce. It is a highly trained specialism; we need enough of them, and a sufficient supply. We should have a workforce plan for the specialism to ensure we are training sufficiently and expanding the workforce. In other countries, there has been a real increase in the number of people able to access this treatment. As we have heard, the average across the UK is 3.3%, but in other countries it is 10%. Not all patients can benefit from this life-saving treatment, but of those who can, only about a third get access to it.

We need to think about where the centres are based. It is important that they are in major centres because doctors need to do a lot of these procedures to be expert in them. We need people to be expert in them, but we also need more centres. I ask the Minister to look at the mapping of that, and at specialist commissioning through NHS England to ensure provision right across the country. Will he also work with the ICBs in this area?

We need a specialist workforce. It is positive that we are training more people in stroke specialisms, but in physiotherapy, for example, significant further training is needed on Bobath—a technique used in stroke rehabilitation—and we need to ensure that it is easily accessible. Other professionals do not get the same access to training budgets as medics, so there is often a lag in getting people through the specialist training that is needed. I ask the Minister to look at that to ensure that the workforce is trained in the best techniques to treat stroke, and to carry that specialism.

This is all about investing to save money, because the better the intervention, the better the outcome for the patient. We need physios, occupational therapists, speech and language specialists—there is a significant shortage of them—and clinical psychologists to work as a team around the patient. They often work together. To give hon. Members an idea of how long it takes, a physio can spend an hour a day with a patient, because they have to break down and rebuild their tone and spasticity, which takes time. But as they are sitting the patient up, the speech therapist often comes along and does a swallow test, and an OT may do some function work. That team needs to come together. Unfortunately, the gaps in the workforce mean that it is hard to have the quality of treatment that will benefit the patient, from the most acute phases of the stroke right through to rehabilitation.

Of course, we want patients to go to stroke units—specialist rehabilitation places—where they can benefit from therapeutic intervention and get the best outcomes possible to optimise their baseline before they are discharged back home. Being in that environment is really important, but at the point of discharge, after all that cost—we have talked about diagnosis, intervention and therapy—what happens? Well, experiences are very varied, and 45% of survivors feel abandoned, so we know something is going wrong. Individuals can easily lose confidence and function.

If an individual is on a pathway to a care home, the care home should be properly trained in supporting people who have had a stroke. Everything matters: the person’s positioning, how they lie in bed, how they sit in a chair and how their hand rests can make a real difference to their function, and their hygiene and personal care. It is necessary to ensure that, if they are mobilising, it has an impact. How patients are transferred can make a difference to those outcomes, so it is important that a person is discharged not just to a care home, but to a care home that has undergone proper training. If someone is moving to the community, we need to ensure that the family around them are trained in how to support them, just as carers who provide domiciliary care must be.

I want to pick up on what the hon. Member for Bromley and Chislehurst said about people seeing improvements in their baseline functioning. It is possible that individuals do and will. Through the process of neuroplasticity, a person’s brain changes and can make alterations and repair, so we need to ensure that, when somebody gets home, there is ongoing therapeutic intervention. It is easy to slip into bad ways and take shortcuts, which can undo some of that good work, and those interventions to top people up can make a difference and keep people functional, mobile and independent. If people miss out on those interventions, they will rapidly require more acute care.

I draw the Minister’s attention to that and ask him to look at the whole pipeline. The lack of support is clear: only 37% of patients got their six-month check last year, which is completely insufficient. We need the figure to be 100%, so there is clearly some work for the Government to do. We are talking about 40,000 people who missed out altogether, which affects ongoing care and support. In the same way that a cancer care navigator works with patients, we need somebody who co-ordinates care and individual support on the stroke pathway, as a permanent process.

As I have already said, we have an opportunity next year to make a seismic difference to individuals by focusing on stroke. I hope that the Minister will take that opportunity, with a laser focus on a new stroke strategy across the country. If he does not, I will badger my hon. Friend the Member for Denton and Reddish to take that on, whenever he gets the first opportunity. It is important that we do that.

Finally, research in this area could be improved, and investment in research is needed. As we have seen in recent times, investment in thrombectomy has been a game changer. It gives people who experience a stroke real hope. Other interventions can and will be made: we need to understand more about our brain health, therapeutic interventions, and how to use new technologies to help people to be independent and live full and comprehensive lives. I trust that the Government will look at the research base and at investment in research as an opportunity. I trust that they will also work with the voluntary organisations that work so hard in this area—they are real experts—to ensure that we have the best stroke strategy and stroke outcomes that any country could ever have.

--- Later in debate ---

[The Minister of State, Department of Health and Social Care (Andrew Stephenson)]

It is a great pleasure to see you in the Chair, Mr Hollobone. I congratulate my hon. Friend the Member for Bromley and Chislehurst (Sir Robert Neill) on opening today’s debate, which is on such an important issue. He is a tireless campaigner for stroke survivors, and his experience is invaluable in bringing their voice into this place. I am sure that his wife is very proud of the work that he does.

I pay tribute to the hon. Member for York Central (Rachael Maskell) for her thoughtful contribution, drawing on her own professional experience, and for the helpful and constructive suggestions that she put forward during the debate. I also pay tribute to the hon. Member for Strangford (Jim Shannon) for his contribution and his kind words. As he knows, I have family in Northern Ireland, and I think it is vital that on issues as important as this, England, Scotland, Wales and Northern Ireland work together where we can to deliver the best outcomes for patients—something that I was also very grateful to hear the SNP spokesperson, the hon. Member for Motherwell and Wishaw (Marion Fellows), making clear in her response to the debate. I also thank the shadow Minister, the hon. Member for Denton and Reddish (Andrew Gwynne), for his contribution.

[Sir George Howarth in the Chair]

Finally, I thank my hard-working Parliamentary Private Secretary, my hon. Friend the Member for North Norfolk (Duncan Baker). He is not allowed to speak in the debate, but he was a founder member of the all-party parliamentary group on stroke. He lost his stepfather to a stroke in July 2019, just five months before he was elected to this place, and the stroke issue is a huge priority for him; he has done an awful lot of work on it since he was elected to the House.

I would like to start as my hon. Friend the Member for Bromley and Chislehurst and so many of the contributors today did, by paying tribute to the outstanding charities that support people up and down the country to thrive after stroke. I know that my hon. Friend works closely with the Stroke Association. I was pleased to meet its CEO, Juliet Bouverie, this morning while on a visit to the Royal Berkshire Hospital to see the innovative ways that the hospital is harnessing technology to improve stroke care. I look forward to continuing to engage with her, including on the major conditions strategy, which I will cover later in my speech. I also commend the many other charities involved in this field of work, such as The Brain Charity, Think Ahead Stroke and the other—many much smaller—charities referred to by many hon. Members today. They all do fantastic work to support patients and drive forward improvements in care.

Sir George, it is excellent to see you now in the Chair. In recent years we have made great progress in understanding the condition, but as has been said, more than 100,000 people have a stroke in the UK every year. As the hon. Member for York Central reminded us, that means that during this one debate alone, 18 people will have experienced a stroke. One third of them will be left with some form of long-term disability. I am grateful to hon. Members for giving me the opportunity, less than a month after World Stroke Day, to update the House on the work that the Government are doing in this space.

I will now address as many of the points that have been raised in the debate as I can. The Government’s priority is to prevent stroke in the first place. That is why I am pleased that we are rolling out an innovative, new digital NHS health check in the spring. The original programme saw the highest number of NHS checks between April and June since its creation in 2013. We are backing the programme with £17 million to deliver a million extra checks in the first four years. We have also appointed Professor John Deanfield to develop an ambitious vision for a modern, personalised cardio- vascular disease prevention service. We are investing up to £645 million over two years to expand services offered by community pharmacies, including expanding blood pressure services. That extra capacity in the first year could prevent over 1,350 cardiovascular events, including strokes.

One ambition of the NHS long-term plan is the inclusion of a national stroke programme, seeking to improve stroke services through increased access to specialist stroke units, with a flexible and skilled workforce and better rehabilitation services. We are making progress on expanding the range of scanning across the country. Between April and June, over 95% of stroke patients were scanned within 12 hours of arrival into hospital, and 87% of patients eligible for thrombolysis received clot-busting drugs to treat their stroke. While there is of course more to be done, stroke patients now have better access to scans than ever before, but as many have said, integration is key. That is why, since April 2021, we have established 20 integrated stroke delivery networks, which bring together key partners in our fight against stroke to deliver joined-up whole pathway transformation across integrated care systems. They are now responsible for delivering optimum stroke pathways and ensuring that patients receive high-quality specialist care from before they are admitted to hospital through to rehabilitation and life after stroke.

Over the past 10 years there have been clear improvements in access to community stroke care, and the percentage of patients discharged from hospital to community stroke services has risen to 61% from just 41% 10 years ago. Every patient with acute stroke should gain swift access to a stroke unit within four hours and receive early multidisciplinary assessment. The latest data shows that 60% of patients are currently admitted to a stroke unit within that time. We have to ensure that we do better across the whole United Kingdom. That has improved over the past five years, but I recognise, as many have said, that more needs to be done. I am pleased that NHS England is trialling a new virtual consultation project between paramedics and stroke teams. We are confident that these innovative pilots will ensure timely access for patients accessing stroke units. That is being promoted across the country, and I am pleased that phase 1 was successfully completed this month and phase 2 began last month.

The hon. Member for York Central made an interesting point about whether stroke cases could be classified as cat 1 by the ambulance service. That is something I am quite passionate about. For the past nine years, I have been a community first responder with North West Ambulance Service. She will probably be aware that at the moment only cardiac and respiratory arrests are classified as cat 1, so I am not sure that that is a change I instinctively would support. However, I completely and utterly agree that it is critical that ambulances arrive as soon as possible, and that we triage patients to the correct services as soon as possible. I am happy to look at that and some of the other suggestions she made because she suggested an awful lot of good things that if we are not already looking at, we should be.

There is strong evidence that, when used appropriately, thrombectomy significantly reduces the severity of disability caused by stroke. Thrombectomy is a suitable treatment for around 10% of stroke patients and is available now in 24 centres in England, with a further two non-neuroscience centres on the way. NHS England has assured me that it remains committed and on track to reach its 10% target for all eligible patients to receive a thrombectomy by the end of 2025-26. The latest data shows that the thrombectomy rate has more than doubled in the past three years. To reach the target, the General Medical Council has approved the thrombectomy credential to support neuroradiologists to perform the procedure and increase the number that can be conducted. We have made great progress in getting cutting-edge AI technology into now over 90% of acute stroke-care providers in England. AI brain-scanning is now installed in all these thrombectomy units, reducing the time between patients’ first experiencing stroke-like symptoms and receiving treatment by more than 60 minutes. I saw that for myself this morning at the Royal Berkshire Hospital and I was incredibly impressed.

We know that stroke survivors commonly experience serious psychological, emotional and cognitive effects. Those greatly impact a person’s rehabilitation, quality of life and ability to return to work. We understand that there is a high level of demand for space in hospitals for rehabilitation services, which play an important role in a patient’s recovery and discharge from hospital. NHS England has taken important steps to increase capacity as part of its winter planning by ensuring that functions such as physiotherapy have the space they need in hospitals to operate effectively.

Of course, stroke treatment is dependent on our amazing NHS staff providing the care. There has been good progress in addressing staff shortages in several rehabilitation areas, although again I appreciate that more needs to be done. Between 2019 and 2023, we grew the number of full-time equivalent physiotherapists working in the NHS by almost a fifth, to over 23,000. NHSE has been working to increase the number of available student placements, and we have developed the speech therapy apprenticeship. Clinical neuropsychologists are a flexible workforce specifically trained to intervene across multiple care pathways, including stroke, acquired brain injury and other conditions. By 2024, NHSE will have doubled the number of training places available compared with the start of 2022.

The major conditions strategy will tackle conditions that contribute most to morbidity and mortality across the population in England. The strategy will cover prevention and treatment for cardiovascular disease across a person’s whole lifetime. As I have already touched upon, some of the key planks of the strategy include prevention, unlocking the transformative power of AI, and tackling the comorbidities that cause ill health in the first place. We published the strategy in August, and I hope to keep my hon. Friend the Member for Bromley and Chislehurst and other Members across the House updated on progress.

My hon. Friend—and most Members who spoke—raised concerns about the variation of stroke services across England. The NHS England national thrombectomy implementation group is gathering data on regional variations in access to mechanical thrombectomy. It will report on the outcomes of that by the end of this year, and if I can, I look forward to sharing that information with the APPG and others. The major conditions strategy will set out that integrated care systems tackle clusters of disadvantages in their local areas. That will include addressing variations in outcomes and the care that people receive in the context of the recovery from the pandemic.

This Government have a profound ambition to improve the lives and health outcomes of people in this country who have survived a stroke. The contributions today have played a vital role in pushing this agenda forward. I am happy to reassure my hon. Friend, and the other Members who have spoken, that I will continue to do everything I can for this matter to remain a top priority for our health service, and that the thrombectomy target will stay on track. I am especially grateful to my hon. Friend for everything that he has done to encourage his constituents to sign up for the Our Future Health programme. Our work here will have huge benefits both to patients and to our NHS overall, so that all survivors may survive and thrive after stroke.