Stroke: Aftercare

Robert Neill Excerpts

Wednesday 21st April 2021 Westminster Hall

[Sir Robert Neill (Bromley and Chislehurst) (Con)]

I beg to move,

That this House has considered the National Stroke Programme and aftercare and rehabilitation services for stroke patients.

It is a pleasure to serve under your chairmanship, Sir Edward, and bring this debate to Westminster Hall. It is an important topic in which, as will become apparent, I have a personal interest. However, it is worth setting out the national significance of stroke and in particular stroke aftercare, because over recent years we have made huge advances in public awareness of the symptoms of stroke—the messages to look out for the signs of it, and to get urgent help, have cut through. The acute treatment of stroke has vastly improved, and many more people, thank heavens, are able to survive it. All those are good things. There have been real advances in medical science and technology in that regard.

The area where, I am sorry to say, we lag behind is what happens next. The NHS is brilliant at lifesaving and acute work, but it is in the follow-up for those who survive stroke and are left with the consequences where, it seems to me, we have more to do. In this debate, I want to concentrate on that and draw it to the attention of the House—and, I hope, to the attention of the wider public too.

I mentioned that I had a personal interest in this, Sir Edward. As some hon. Members may know, in July 2019 my wife, Ann-Louise, suffered a severe stroke—15 on the national stroke scale. We were fortunate that we had brilliant acute treatment at the Princess Royal University Hospital in Bromley and some good aftercare. She came through, but the truth is that she was left with a number of impairments thereafter because of the position of the stroke. Like so many stroke survivors I have met since, she continues to fight bravely and determinedly to come back from the stroke, and to get back to where she wants to be. It can be done, but it is a long and hard road. It requires courage and patience, but also consistent professional support, and it is that last thing that I think we need to do more to achieve.

In our case, Ann-Louise was unconscious for about three days. We were fortunate that the Princess Royal University Hospital at Farnborough Common is a regional centre of excellence, as part of the King’s College Hospital NHS Foundation Trust, and therefore she received superb treatment. However, she of course needed rehabilitation, which she received at the Ontario unit of Orpington Hospital, again provided by excellent and dedicated people.

However, the sad truth was that the unit was not resourced to deliver the level of consistent rehabilitation that it would wish to provide for Ann-Louise and other patients. For example, during the several weeks she spent there, it was not possible to deliver the therapies per week to the level set out in the National Institute for Health and Care Excellence clinical guidelines. I am sorry to say that is by no means an unusual state of affairs.

Frankly, there was a difficulty with the availability of therapists because of an inability to cover maternity leave, sick leave and so on, and there were shortages, particularly of speech and language therapists. It was never possible for Ann-Louise or the other patients to consistently receive the hours for five days a week that are set out in the NICE guidelines.

In the end, we were able to get private treatment and private rehabilitation for Ann-Louise at the Wellington Hospital in London. Again, dedicated people did great work there. However, the truth is that many families are not in a position to do that. I was very struck by one lady who was in the same bay as Ann-Louise in Orpington Hospital. She was only in her mid-40s, I think. She had a 16-year-old daughter and the consequences of the stroke that she suffered were much more severe than those of Ann-Louise’s stroke. She was there when we arrived and she was still there when we left, and frankly it was not possible to see any significant improvement in her condition. It is for people like her that one worries even more, because they are not in a position to seek some of the help that we were able to seek.

Ann-Louise eventually came home the day after the general election in 2019, so we are talking about a period of some weeks. As people may know, she was then entitled to a measure of aftercare in the community—it works out at about six weeks of occupational physiotherapy, and speech and language therapy—but thereafter it stops. I think that what we manage to do very often is to get people fit enough to be discharged back to their home, and to establish themselves initially at home. However, I do not think that we deliver on what is recognised by all the clinicians and well set out by the Stroke Association and others—consistent, long-term, programmed care over a longer period of time. That is what we want to see, and it is what is envisaged in the various programmes and plans that the Department of Health and Social Care has put in place for stroke. I think that is the area that we need to draw attention to.

After a period of time in our trust, which is a well-run trust, in effect one bids for further speech and language therapy. After another period and after a referral, hopefully one will get about three sessions, spread over a number of weeks. If targets are met, one may be in a position to seek a referral for perhaps three further sessions. However, if some of the targets are not met, and not everyone can meet them the first time around, then, because the resources are limited, very often that therapy will stop. That does not seem to me to be right or fair to people who are working terribly hard to come back from a life-changing experience.

Therefore, although there are dedicated professionals—nothing I say is to take away from the dedication of the professionals involved—we are not delivering on what we set out to do. That is a tragedy, because two-thirds of stroke survivors leave hospital with a disability. Stroke is the leading cause of adult disability in the UK. It affects about 1.2 million people in this country. Nearly 100,000 strokes happen in the course of a year. It is therefore a major issue, which needs to be addressed.

We have had in the past a national stroke strategy. There is a stroke plan, as part of the national plan. And now being developed—it is the subject of this debate—is a national stroke programme. All those plans and strategies are laudable but, as I have said, we are not actually able to deliver consistently on the targets that are set out in them, and if we cannot meet what is in the current plans, the concern is how we will meet the more ambitious targets for much more integrated stroke care that are set out in the strategy beyond that.

What we are looking at, according to all the clinicians whom I have talked to over the past 18 months or more, is really this: we have to provide effective support and rehabilitation. A lot of people think, and there is of course some evidence, that improvements are made in the first few weeks and months. Those weeks and months are critical, but there is also growing evidence that people can continue to improve, and improve significantly, beyond that, and actually we can find improvements going on over a number of years. But for people to achieve that, they must have the support.

Stroke is not a simple type of brain injury, which is essentially what it is. It varies according to the severity, where in the brain it has occurred and many other factors, and it will have varying consequences for each individual. Therefore, if we are truly to enable people to recover from stroke, they must have a personalised programme of care, rehabilitation and support, and that must be long term. Long-term personalised care is essential, but at the moment that is not happening. Sadly, the Stroke Association research suggests that some 45% of stroke survivors feel abandoned after their stroke. What is important in that context is not just the physical consequences of stroke; there are real psychological consequences as well, because it is life-changing.

My wife was a professional opera singer and a director of music at her local school. One can imagine what it has been like for her to have an impairment of speech; it weighs immensely heavily. We have met many other people who have had things that have, in effect, changed the nature of who they are. If they are to get back to who they are and can be, they need the really significant help that I have described, but they also need help with morale and the psychological impacts that there can be. That is one of the areas in which we have not been able to deliver to the level that our aspirations set out.

We are to move to the integrated national stroke service model. I am told that it is to be published imminently, but I hope that my hon. Friend the Minister will update us on that. Can we know when that is signed off? Can we know when it will come into force? If there are to be pilot schemes, where will they be? How long will that take to happen? What resourcing will be made available to support that integrated strategy? What is the plan to seek to recruit more specialist therapists, from all the disciplines, to stand behind it? All those are things that we need to have, and I hope that the Minister will be able to help us on that. Otherwise, the danger is that it becomes an aspiration, rather than a reality, for stroke survivors and their families.

Clearly, early supported discharge and integrated community stroke services are the aspiration, but at the moment, in an area such as mine, people will find that some services are provided through the hospitals. If people have more than one impairment, they may have to go to different hospitals—some for ocular work, some for vocal rehabilitation and some for physical rehabilitation. Some services will be provided through the GP, the networks and the clinical commissioning group—in Bromley, we have Bromley Healthcare, which does an excellent job—but others will be provided through a different hospital trust or health trust under contract; yet others will be provided through the local authority, social services and sometimes charities and voluntary groups. We have several stroke clubs and stroke groups in our area that do great work—the voluntary sector is amazing—but we cannot and should not depend on them to deliver part of the core service.

That is quite a minefield to negotiate. If it is difficult to negotiate for a professional family such as ours, think how difficult it is for people who may not have the resource and experience of the system, if I may put it that way, that we and others in our position have to fall back on. Pulling things together meaningfully, so that there is almost a one-stop shop that people can go to as a single point of reference and where they can call in expertise, seems to me and many experts in the field to be critical.

I referred to the importance of psychological rehabilitation. The psychologists I have met believe that much more needs to be done. I also referred to the importance of meeting our targets and the difficulties in some areas, such as speech and language therapy. For speech and language therapy nationally, the figures for meeting the NICE stroke guideline of

“45 minutes of each relevant…therapy for…5 days per week”

stand at 55.2%—just over half—and in some places they fall below that. There is a huge amount more to do on that issue, and a deal more also seems to be required in supporting early discharge. The proportion of patients treated by a stroke-skilled early discharge team nationally is 41%, and in some trusts the percentage drops into single figures. That is just not acceptable, as I know the Minister will recognise. What are we going to do to get those numbers up, so that we can move on to the next stage securely?

We need to think longer-term about this. We had the great good fortune to be introduced to the National Hospital for Neurology and Neurosurgery at Queen Square in London, which does amazing work. One programme there, an intensive aphasia course, is headed up by Professor Alex Leff. It is really full on, but that proves the point—this is one of the things that our current system does not deliver—that rehabilitation has the best outcomes when it is very intensive. Spreading it out to an hour one week, an hour the next and maybe another hour in two or three weeks does not come anywhere near to delivering the level of intensity necessary to enable stroke survivors to relearn skills for the neuroplasticity that is so important for recovery of the brain to kick in. Frequent use, repetition and intensity of the therapy is so critical.

That programme is funded as part of a research project, but as far as I know it is the only one of its kind in the country. That does not seem fair. If it is that good and well documented—it is; I have seen it—surely we should seek to roll out that type of intensive treatment across the piece. Somebody should not have to go privately to get the intensiveness necessary for their loved ones to get the level of recovery that they can achieve. I hope that we can look at that, too.

I hope that that is a start to the debate. We have an hour, and I know that several hon. Members wish to participate—I am grateful to them for coming—so I hope that I have set the scene. I look forward to the Minister’s response, but I hope that once we have considered the debate we will not leave it at that. We could have a greater awareness of the topic in Parliament—I was struck by how little debate there has been in the House and how few questions have been asked on it. When I looked at the list of all-party parliamentary groups, I noticed that there is no group on stroke, although there are groups on very many other serious, life-threatening and life-changing conditions. Perhaps that is a call for hon. Members who might be interested to think about the subject and keep it in mind as parliamentarians.

Having opened the debate, I will perhaps leave it there. I might say something at the end after the Minister has finished, but I have endeavoured to stress the importance of this, because it does change lives. People with the right support can come back. So much can be got back. There is always hope afterwards, and if people have the support to achieve that hope, they can restore their lives in huge measure. It is surely our responsibility as a society to enable them properly, with the aid of the skilled clinicians that we have, to do just that.

--- Later in debate ---

[Sir Robert Neill]

I am grateful to all hon. Members who have participated in the debate. I know that time is short. I am grateful to the Minister for the tone of her response. We will want to press her, in the most constructive way, on some of the detail of the funding, how we actually get the nuts and bolts done and how we deliver services on the ground. The aspiration is clearly there—we all share it—but we want to see that delivered. We are very happy to work with her on that; perhaps we can speak offline on how we might be able to achieve that.

I am grateful for all the expertise and the experience that hon. Members have laid out. I conclude by thanking everyone who takes an interest in stroke care, above all the carers. We ought to remember the informal carers—the families—who do so much, as well as the professionals. They need their recognition at the end of this debate too.