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.