Health: Stroke Victims

My Lords, it is a pleasure to take part in another debate on stroke prevention and care initiated by my noble friend Lord Rodgers of Quarry Bank. He introduced it passionately and perceptively; I commend his dogged determination, dedication and persistence on the matter. I also thank him for giving me cause to read Professor Boyle’s report Mending Hearts and Brains. As Department of Healthreports go, it was clear, succinct, honest and mercifully free of the padding and self-congratulatory rhetoric characteristic of so many departmental documents. As someone who has to read a lot of them, I enjoyed it. But my noble friend is right: it distils many reports that have come before it. Many have been mentioned already but I would like to add Professor Ian Philp’s five-year review, the National Service Framework for Older People, which has a section on strokes. What is not clear is where this report sits in relation to all the other initiatives in the department and in the NHS. The report commendably took forward the model developed in Australia of treating stroke as an emergency, which has worked very successfully there. We needed to do something like that in this country because stroke is one of the most expensive diseases, costing us £7 billion a year. The area has been neglected for so long that a redesign of services offers great potential for savings and investment. The National Audit Office report showed that trials of stroke units demonstrate that, by treating people in those units rather than in general medical wards, the number of acute bed days could be reduced by six. If that is applied to the 100,000 people every year who suffer strokes, not only is it better for them to spend six fewer days in places that we know to be rife with MRSA and so on, but at an average cost of £125 a day times 600,000, there is a potential saving of £82 million. Much could be done, therefore, to make our services more rapid and better organised, releasing resources that could be used in better ways to support people. I listened to what my noble friend said about hubs, spokes and diagrams and I understand some of his comments. However, although it does not look anything like a working bicycle, the model is in theory right. Having acute specialist centres placed strategically and linked to spoke centres in which there can be more effective rehabilitation and treatment offers great potential for diseases such as stroke but could also be pursued in relation to cancer, for example, where regional centres of excellence support other bodies. My noble friend was right to ask how this will be achieved in practice. Given that the Government propose to devolve commissioning of treatment and care to GP practices or clusters of GP practices, who will be responsible for ensuring that a complete system of hubs and spokes exists? What happens if, in a particular area, GPs decide that they have a young population profile and that such provision is not a priority for them? Does that mean that the hubs and spokes are not built? Will the department issue guidance on the sort of populations to which these models should be applied? If so, will it take into account, as my noble friend said, that the timing of treatment varies enormously depending on geographical location? I noted Professor Boyle’s point about A&E departments not necessarily being the best place in which to diagnose people who have had a stroke. I sympathise with that, as I have spent hours in A&E sitting with someone in that situation. It is particularly true of people who have had a stroke before, when trying to work out whether they have had a second TIA—transient ischaemic attack. I can see the force of his argument. I welcome the proposal that ambulance staff should be better trainedand equipped to make a faster diagnosis. Will they have access to the necessary range of diagnostic equipment? What will happen when it is not immediately obvious that there has been a stroke? Will the default position be that people are taken to a treatment centre or to A&E? Although in A&E departments people have to wait a long time, they are usually attached to other services such as pathology labs. Will the system of accessing those ancillary services be changed at the same time? The key reason why the Australian system works is that it manages to have the right kit with the right people in the right place at the right time. That takes us straight to staffing. When the National Audit Office report was produced, we had only 86 whole-time equivalent stroke consultants, which was in its view20 per cent of the requirement. We also need specialist nurses who can deal with stroke patients who cannot swallow, for example, and physios who can begin to get the muscles working again. One thing absent from Professor Boyle’s report was a reference to deep vein thrombosis nurses. There has been a practice recently of having DVT nurses in A&E departments. They can often be a rapid source of information and support; they can get people’s warfarin levels sorted out and re-established; and they provide an awful lot of confidence and practical assistance to patients. When we debated this matter last year, the noble Baroness, Lady Royall, gave us an update on the national stroke strategy. Can the Minister provide a little detail on progress? The introduction of the picture archiving and communications system—the computer system by which images of organs are sent to specialists electronically—is key to enablingfast diagnosis. It is part of NHS Connecting for Health, which was due to be implemented in spring this year. The Minister has the joy of being in charge of Connecting for Health. What progress has there been? The noble Baroness, Lady Royall, said that the department was funding the programme developed by Professor Gary Ford at Newcastle on thrombolysis. I assume that his work has informed the model put forward by Professor Boyle. Can the Minister set out in detail whether the follow-up to acute care—whether in an A&E department or an independent treatment centre—will be by co-ordinated rehabilitation in a community setting? The report talks quite a lot about supported discharge, which enables people to recover much more of their capacity more quickly, but will that focus on rehabilitation be carried forward into residential and nursing homes, for example, where many who are disabled by stroke end up? I have one final point. We know that vascular disease is particularly prominent among black and minority-ethnic communities. That is not mentioned in Professor Boyle’s report, yet we know that those communities have a particular predisposition and risk. What is being done about that? Stroke victims need to recover their confidence. If they all recover it to the degree that my noble friend Lord Rodgers of Quarry Bank has recovered his, as shown by his opening speech, they will do well.