National Stroke Strategy

Baroness Chisholm of Owlpen Excerpts

Wednesday 18th November 2015 Lords Chamber

[Baroness Chisholm of Owlpen (Con)]

My Lords, I thank the noble Baroness, Lady Wheeler, for initiating this debate. As so often with these short debates, this was of a high standard, and I only wish we had longer to discuss the issues. Stroke is one of England’s biggest killers and is the largest single cause of serious adult disability in this country. Its effects can be devastating, both for those who have a stroke and for their families and loved ones. However, good progress on stroke has been made in recent years—the mortality rate has fallen by almost 12% since 2010—but we know more needs to be done.

Both the noble Baroness, Lady Wheeler, and my noble friend Lord Lansley spoke about the national stroke strategy and asked whether we are going to carry it on. There are no current plans to do so. The reason for this decision is that the NHS Five-Year Forward View recognises that quality of care, including stroke care, can be variable and that patients’ needs are changing and new treatment options are emerging. The Five-Year Forward View sets out high-level objectives to address these issues. Initiatives include ongoing work in virtually all parts of the country to organise acute stroke care to ensure that all stroke patients have access to high-quality specialist care, regardless of where they live or what time of day or day of the week they have their stroke.

The Cardiovascular Disease Outcome Strategy, published in 2013, includes many stroke-specific strategic ambitions. Alongside this, a CVD expert forum hosted by NHS England will co-ordinate delivery of the work initiated in the CVD Outcome Strategy. Also, NHS England’s National Clinical Director for Stroke works with the strategic clinical networks, voluntary agencies and individual providers to support best commissioning and provision of stroke care. Like the noble Baroness, Lady Wheeler, I want to pay tribute to the Stroke Association, the Carers Trust and the Princess Royal Trust for Carers, which do so much to help stroke victims.

Alongside initiatives being put into place when the national strategy comes to an end in 2017 is the Clinical Commissioning Group Outcomes Indicator Set, known as the CCGOIS. These are indicators for improving recovery from stroke. People who have had a stroke who are admitted to a stroke unit within four hours of arrival in hospital receive thrombolysis following an acute stroke, are discharged from hospital with a joint health and social care plan, receive a follow-up assessment between four to eight months after initial admission, and spend 90% or more of their stay on an acute stroke unit. These indicators are being monitored by the Sentinel Stroke Audit Programme.

I want to touch on prevention, which is so important if we are to see fewer stroke victims in our hospitals. First, we know that obesity and high salt intake greatly increase the risk of stroke. Tackling obesity, particularly in children, is one of our key priorities. We will put forward our plans for action in our childhood obesity strategy in the new year. Alongside this, the UK salt reduction programme is world leading, with the population’s average salt intake being reduced by 15%. Major retailers, manufacturers and caterers are working to meet these targets by December 2017.

Secondly, simple lifestyle changes can help reduce the risk of stroke, as we all know. Public Health England is working with a range of public sector and commercial partners to promote healthy behaviour across the course of life. These include encouraging greater physical activity, highlighting the harms of smoking and drinking and urging older people to make sure that they take action on the signs and symptoms of stroke.

Thirdly, the noble Baroness, Lady Wheeler, mentioned the treatment of atrial fibrillation, as did the noble Lord, Lord Colwyn, and the noble Baroness, Lady Walmsley. We covered most of the issues in our recent debate, but it is a high priority in NHS England’s Five Year Forward View. As we know, AF is a major cause of stroke. I want to mention NHS Improving Quality, which has developed GRASP-AF, an audit tool to identify patients with AF who are not receiving treatment. There are also the quality and outcomes framework indicators on the use of anticoagulation therapy for AF patients to incentivise good practice in prescribing anticoagulants in primary care. Screening for AF will be discussed at a meeting on 2 December—in which I think the noble Baroness, Lady Wheeler, will take part with my noble friend Lord Prior—where more will come out about what the plans are for such screening.

Improving awareness of signs and symptoms of stroke is key to improving outcomes. The hugely successful Act FAST campaign, as mentioned by the noble Baroness, Lady Walmsley, has helped 40,000 people to receive the immediate treatment they require, resulting in an estimated 4,600 fewer people becoming disabled as a result of a stroke since the campaign began in 2009. There are certainly no plans to stop this campaign. All ambulance trusts are now asked to use this treatment facility when they are triaging patients in an ambulance.

Diagnosis and treatment has improved over the years. Access to immediate brain scanning has improved, with 46% of patients being scanned within one hour of hospital arrival and 90% within 12 hours. Clot-busting drugs give a certain cohort of stroke patients a better chance of regaining their independence. Twelve per cent of all stroke patients admitted to hospital receive these drugs, which is a rate higher than most other developed countries.

We are aware that stroke patients do better when they are treated on stroke units. Some 83% of stroke patients now spend more than 90% of their time in hospital on a stroke unit.

As was mentioned by the noble Baroness, Lady Wheeler, the academic science networks and strategic clinical networks work at local level to help improve services. They work with local commissioners and providers on the configuration of stroke services. As we know, there have been problems in various areas.

We know that there have been issues in the past with stroke patients experiencing a poorer level of care at weekends and evenings than they might experience during weekdays. Ninety-nine per cent of hospitals are now providing a 24-hour, seven-day-a-week thrombolysis service, either themselves or through a formal arrangement with a neighbouring trust. Two-thirds of hospitals admitting acute stroke patients are operating seven-day-a-week consultant ward rounds.

The noble Lord, Lord Kakkar, mentioned the success of the London model, which is very true. Good practice is taking place in other places, too—indeed, the noble Lord mentioned how such practice had been set out in Manchester. Certainly, the Royal London, Tower Hamlets and Wandsworth are providing high-quality responses, seven-day in-patient rehab and early supported discharge. The Society of Chartered Physiotherapy highlights the good work of the North Devon Healthcare Trust stroke therapy team, which provides stroke rehabilitation services, including early supported discharge, across a rurally dispersed population. Not only does it give high-quality specialist integrated services but it delivers improved outcomes. It has reduced length of stay by six days, saving almost £900,000. We accept that there are areas where support can be improved, but some excellent work is definitely going on.

Following on from prevention, diagnosis and treatment, it is critical for stroke patients to receive good aftercare. That is why the NHS Outcomes Framework and our mandate to the NHS both set out improving recovery from stroke as a key area where progress is expected. There has been growth in availability of services such as early supported discharge and community neuro-rehabilitation teams over recent years. For example, recent data show that 74% of hospitals had access to stroke-specific early supported discharge and 72% to specialist community rehabilitation teams.

Transparency in information and data about the quality of the services provided will drive improvements. It worked in cardiac surgery and we are beginning to see the benefits of this approach in other services such as stroke.

Also incredibly important in all stroke care is joined-up care. My noble friend Lord Lansley mentioned the Better Care Fund. Some 84% of stroke patients on discharge have a joint health and social care plan, and 89% of patients are given a named contact on discharge in case there are issues they wish to discuss once at home. Whether it be speech, language therapists for aphasia, which is such a distressing side-effect for stroke suffers, or physiotherapy to improve mobility, joined-up care is absolutely vital as far as stroke rehabilitation is concerned.

Joined-up care must also include psychological support, as the noble Baroness, Lady Hodgson, mentioned. The CVD outcomes strategy and national stroke strategy both recognise that stroke services which incorporate psychological care deliver the best outcomes for people who have had a stroke. NHS England is exploring how to improve the existing resources to ensure that stroke patients receive the psychological and emotional support they need.

Noble Lords may be aware of an improving access to the psychological therapies programme, known as IAPT. This is an NHS programme rolling out services across England, offering interventions for people with depression and anxiety disorders. Many areas now have an IAPT service. Some IAPT services have developed psychological support skills through enhancing the training of nurses and therapists, and some have employed counsellors to support people with stroke in the community.

Clearly, ambulance times are paramount in rural communities, and where extra time is taken in travelling this will be made up as quickly as possible when they reach hospital. For example, in Northumbria, a new hospital is taking all acute stroke patients who previously went to three hospitals. This has shortened the time taken for patients to receive clot-busting drugs after arriving in hospital from over an hour to 30 minutes. A couple of trials are going on involving paramedics. In one, paramedics are recruited to help trial a rapid response treatment for stroke patients, whereby medicated skin patches that lower blood pressure quickly after a suspected stroke are administered in the ambulance. In the other, paramedics can request a brain scan and transfer the patient directly to the scan room on arrival, which can reduce the waiting time for thrombolysis.

I am running out of time, which always seems to happen on these occasions. I have not been able to mention much about childhood stroke, but spend on research for all types of stroke by NIHR increased from £20 million in 2011-12 to £26 million in 2014-15. However, I would like to get back to the noble Baroness, Lady Wheeler, on the specific research into childhood strokes, which is so important.

I hope that I have given some reassurance—although I feel that I have only touched on many issues—but if there are points I have not managed to deal with, I ask noble Lords to get in touch with me so that I can make sure they get the proper answers they want. As always with these debates, some fascinating issues have been brought up which we need to take further. Once again, I thank all speakers for their participation.