Health: Stroke Treatment

Baroness Neuberger Excerpts

Wednesday 30th June 2010 Lords Chamber

[Baroness Neuberger]

My Lords, I congratulate my noble friend Lord Rodgers on securing this debate and the National Audit Office on its excellent report showing that much needed progress has been made in improving stroke care. It is a good-news story. I congratulate also the Stroke Association on its fantastic work, which has to a large extent pushed us all into taking this issue more seriously.

Having read the report in detail, however, I have to say that it is not wholly a good-news story. One section, “Stroke patients in care homes”, set alarm bells ringing when I read it. The report argues:

“There is no single source of information on the proportion of care home residents who have had a stroke. The evidence we collected for our 2005 report suggested that at least a quarter of residents have had a stroke, although local data collected for an audit of care homes in Somerset gave a figure of 45 per cent ... About 11 per cent of stroke patients are newly admitted to care or residential homes after their stroke … The Royal College of Physicians’ guidelines recommend that nursing and care home staff should be familiar with the common clinical features of stroke and should know how to manage them; and the Strategy states that Commissioners should consider providing training on stroke to care home staff. However, there is no requirement for care home staff to be trained in the communication, mobility and other needs of stroke patients, and our interviews and case study visits revealed a lack of recognition among some care home staff that a suspected stroke or TIA should be treated as a medical emergency”.

One should add to that what is in section 3.17 of the report:

“The best way of improving the value for money of stroke care is by preventing strokes from occurring. Reducing stroke incidence requires managing the risk factors common to all vascular disease … including high blood pressure and cholesterol, smoking, unhealthy diet and lack of exercise. In March 2009 the Department announced a unified approach to the prevention of vascular disease through the introduction of the NHS Health Checks where everyone aged between 40 and 74 will be risk-assessed and, where appropriate, given information, access to services and treatment. Full rollout of the programme is expected by 2012-13, subject to the next spending review”.

But why stop at 74, particularly if, as we suspect, retirement ages are to go up still further in years to come and people will choose, for both financial and lifestyle reasons, to carry on working and having a full and independent life? Is not stopping at 74 discriminatory?

Indeed, stroke services provide one of the clearest examples of discrimination against older people. Access to specialised stroke services is considerably worse for older people than for younger. A piece of work published by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians back in 2007 showed clear evidence of an age effect on the delivery of stroke care in England, Wales and Northern Ireland, with older patients being less likely to receive care in line with current clinical guidelines. Analysing data collected for the Royal College of Physicians’ stroke audit, it found that older patients were less likely than younger patients to be treated in a stroke unit, which is very serious given that we know that admission to, and care in, a stroke unit is the single most beneficial intervention that can be provided after stroke. Only 39 per cent of patients over 85 were treated in a stroke unit, compared with 48 per cent of those under 65. Older patients were also less likely to have a brain scan within 24 hours of stroke, with only 51 per cent of those aged over 85 having an early scan, compared with 71 per cent of those under 65.

The report’s authors also say that the failure to include sufficient numbers of old patients in trials—that is a much bigger problem than in stroke care alone—has led to an evidence gap in effective interventions for those patients. This is sometimes used as a justification for limiting treatment. For example, trials of thrombolysis for stroke have included few patients over 80 years of age and the drug is therefore not appropriately licensed in Europe for patients over 80. That obviously means that the number of older people who may benefit from such treatment is limited, which is really quite serious.

Ageism was identified also by discharge from hospital: individualised care planning goals for older patients were less likely to include reference to areas of higher-level functioning, such as leisure pursuits—older people might want some leisure—driving and return to work. Older patients were also less likely to have received dietary advice to reduce fat intake and to have discussed other risk factors such as smoking and alcohol consumption. The report’s authors recommend better education of healthcare professionals, development of research programmes that test interventions in sufficiently large numbers of older people to provide clear evidence for treatment, and continuing audit that can identify where ageism persists.

There is more. Research conducted at Mayday Hospital in Croydon and published in the Postgraduate Medical Journal, and a large piece in the Daily Mail on the subject, showed serious discrimination yet again. The study assessed the treatment given to 379 patients at a rapid access clinic for suspected stroke or mini-stroke between 2004 and 2006. Although all patients experienced substantial delays, younger patients were scanned more quickly and were five times more likely than over-75s to be given a brain scan to check for bleeds. Only one in 20 over-75s was given an MRI scan, compared with one in four of those under that age. The younger patients were also more likely to be given dietary and weight loss advice, despite all the evidence showing that both groups were likely to benefit from such information. Dr Karen Lee, who led the research, said:

“A change in the attitude of healthcare professionals is needed to root out ageism”.

The Department of Health said that it was,

“determined to ensure high quality care for all, regardless of age”.

The question that this raises is important. The NAO report shows some promising progress in stroke care, which is much needed after we were lagging behind much of the world. However, if persistent negative attitudes to older people are not rooted out in healthcare, we will see discrimination against older people who have strokes—and, let us face it, they are more likely to have strokes than younger people—continue for years to come.

The former older people’s tsar, Professor Ian Philp, published his second report, A New Ambition for Old Age, back in 2006. In it, he proposed new targets and protocols for emergency responses to crises caused by falls, delirium, stroke and transient ischaemic attacks. One example is that everyone having a stroke should be seen at a specialist neurovascular clinic within one week, while the current position is that about half to three-quarters are seen by two weeks. Other scholars have been writing in the BMJ, such as Jackie Morris, who called for appropriate environments for care of older people and said:

“Although intermediate care in the NHS is expanding, it is not yet keeping pace with the rapid and continuing closure of rehabilitation beds and offers only patchy input from specialists”.

Despite general improvement, there is a real issue about stroke care for older people. The Government now have a golden opportunity, for there are to be serious evaluations of effectiveness of care and stringent examinations of the budget. If, as it seems on the face of it, not providing better stroke care to older people is in fact costly, given that they will then need greater care from social and health services in the longer term and will fail to get back to independent life, is there not a cast-iron argument for sorting this out now? Does not that fit neatly with the commitments to end age discrimination in principle, because it is wrong, and particularly in health services where evidence of a certain amount of institutional ageism appears to be commonplace?

Back in 1999, Alison Tonks, then deputy editor of the BMJ, talked about partnerships with older people to enhance core teaching and about giving older service users the power to shape the curriculum of professionals. That seems an extraordinarily good idea. In some medical schools in the United States, young students, before they begin their course, spend a month with a family where there is someone with a long-term condition, often someone who has had a severe stroke. We could learn from that and teach our students differently about what it is like to live with a disabling condition and what inputs might have improved things early on.

Will my noble friend the Minister tell this House what he thinks can be done in the short term to improve stroke care for older people in this country and how he believes ageism within health services can be dealt with in the longer term? I very much hope that he will reassure me and this House that changing attitudes in health services towards older people—stroke would be a prime example for a pilot—is high on the Government’s list of goals to be achieved.