Health: Stroke Victims

My Lords, I am delighted that the noble Lord, Lord Rodgers, has given us this opportunity to debate stroke care—a subject on which he speaks with tremendous authority. This is one area of NHS activity which has witnessed huge improvements over the past few years, to the undoubted benefit of many thousands of patients. I look back in particular to 1991, when a close member of my own family, previously fit and well, had a stroke at the age of 66. She lived in the home counties. Though her mind was alert, she was paralysed down one side. She had difficulty swallowing. She was taken to the local acute hospital. There she languished for the next six months on a geriatric ward. There was no physiotherapy. There was not even any aspirin. It was weeks before a scan was done to see whether the stroke had resulted from a clot or a bleed. We were told that it had been a bleed—hence no aspirin being given. In fact it had been a blood clot. The aspirin should have been given but was not until months later. It was obvious then that the NHS was simply not geared up to treat stroke victims, and obvious too, with hindsight, that if it had been, my relative might have enjoyed a much better outcome. So I pay tribute to the Government for getting stroke care onto the map. The Stroke Association is also to be congratulated on its excellent and consistent lobbying on the subject. Stroke, as we have heard, is the third biggest cause of death in the UK, and the largest single cause of disability. Some 110,000 people each year suffer a stroke and 30 per cent will die within a few weeks. The rest are cared for at a cost to the NHS of £2.8 billion and a wider cost to the economy of more than £4 billion. It does not take a great mind to work out that even a modest improvement in those figures would result in enormous relief of suffering as well as significant cost savings. Six years ago, the National Service Framework for Older People kick-started the recent improvement in stroke services by including specific milestones and targets. I have always said that where we are dealing with a major public health issue like coronary heart disease or stoke, national targets have a definite role to play. They are quite distinct from targets to do with waiting times—about which the Minister knows that I have different views—because they are primarily about health outcomes. Nevertheless, if we look at the progress made in delivering those outcomes, there are mixed messages. So, although 91 per cent of English hospitals now have a dedicated stroke unit, which is a big and most welcome improvement, your chances of being admitted to a stroke unit in a quick and timely way when taken to hospital are woefully low. It has been shown beyond doubt that if your condition is managed on a stroke unit, you are statistically more likely to have a much better result than if it is not. However, only 15 per cent of stroke patients are admitted to a stroke unit on the same day that they arrive in hospital. If you have a minor stroke, you almost certainly will not be treated on a specialist unit at all. That has to change, because someone who has had a minor stroke is at high risk of having another one. As the sentinel audit pointed out, that person needs expert care and investigation just as much as the person who is more seriously ill. There are many who for some time have been urging the NHS to treat stroke victims as a medical emergency, for that is what they are. Ambulance crews around the country are to be commended for treating strokes as category A incidents and delivering patients swiftly to A&E. Yet all too often the patient arrives and has to wait before being diagnosed and treated. It is well established that if your stroke is due to a blood clot, as opposed to a haemorrhage, rapid access to clot-busting drugs can transform your chances of recovery. This process is routine treatment in other countries, but not here. To deliver it, stroke patients should be scanned more or less immediately they arrive in hospital so that the nature of the stroke can be ascertained. Again, this is not happening. The number of stroke patients going through a scanner within 24 hours—never mind three—is only 42 per cent, well under half, which the sentinel report called unacceptably low. Whatever you do, do not have a stroke on a Saturday or a Sunday, because you will not be assessed until the following Monday at the earliest. It appears that brain scans are done only between the hours of 8 am and 6 pm on week days. I say to the Minister that that is another situation that has to change. There are similar problems getting access to therapists and social workers. If you have difficulty swallowing, you need to be assessed rapidly by a speech and language therapist. Yet a third of patients in this category do not see one for over three days.If you have lost the use of a limb, you need physiotherapy at the earliest opportunity. Again, rapid access to physiotherapy is still the exception. One has to be critical of the fact that so many graduate physiotherapists who qualified in 2006 are still unemployed. Last December, the date of the most recent survey that I have, seven out of 10 of those graduates did not have a job. There is work for them to do, but trusts are too strapped for cash to employ them. That is a shameful state of affairs. As we have heard, some of those issues are brought out in the Mending Hearts and Brains report. Professor Boyle, the national director for heart disease and stroke, is one of those who has pressed for strokes to be treated as a medical emergency, but he has also said that A&E departments are not the best places to treat stroke victims. One cannot equip every A&E department with 24-hour consultant services or open access to a CT scanner, so the logic is that stroke services should be concentrated in centres of excellence to which paramedics should take the patient when they judge it appropriate. The noble Lord, Lord Rodgers, raised some very pertinent questions on that issue. Community services also need to raise their game. If the aims of Our Health, Our Care, Our Say are to be achieved, we need better ways of supporting stroke patients who have been discharged from hospital and more proactive monitoring. I question how this can happen as a generality when the tariff for treating stroke patients is so clearly inappropriate. It is inappropriate at the start of the process, because there is currently no financial incentive for hospitals to provide acute care for strokes and inappropriate for follow-up care because the tariff that we have has not been properly unbundled, although some formal unbundling has recently occurred. What is being done to address that aspect of the issue? Dr Tony Rudd, who is chairman of the Intercollegiate Stroke Network, has said that despite the improvements in stroke care too many patients still receive substandard service. I think that about sums it up. We have not made as much progress with preventing and treating stroke as we have with coronary heart disease. The disappointment in all this is the length of time that we have all been waiting for the national stroke strategy. It is almost as if clinicians and managers in the NHS have been hanging upon the publication of the strategy before deciding to go ahead and make key improvements to stroke services, which is equivalent to a sort of service blight. That kind of delay is deeply regrettable. The more closely the NAO recommendations are implemented and the sooner it is done, the better it will be for patients and the greater the long-term savings to the NHS. The same could be said about achieving better awareness among the public of the importance of monitoring blood pressure, which is the single biggest risk factor for stroke, and making quite simple lifestyle changes to prevent strokes happening. In that context, the needs of those for whom English is not a first language should be remembered. The noble Baroness, Lady Barker, made that point. The prevalence of stroke amongst African-Caribbean and south Asian men is particularly significant. Quite apart from setting out best practice for treating strokes, I hope that preventive measures of this kind will also be built into the strategy. It would be helpful if the Minister could tell us whether they will be. The noble Baroness, Lady Masham, is right. Stroke has tended to be the poor relation of coronary heart disease in terms of the emphasis placed on it and it deserves better. I very much hope that the Government will do all in their power to ensure that the NHS continues to raise its game in treating this most devastating of afflictions.