Examination of Witnesses (Questions 80-99)
SIR
NIGEL CRISP,
KCB, PROFESSOR ROGER
BOYLE, PROFESSOR
IAN PHILP
8 FEBRUARY 2006
Q80 Mr Curry: Does that high blood
pressure come in the genes? Is it a lifestyle issue?
Professor Boyle: We think it is
almost entirely genetically determined.
Mr Curry: Just like some people are lactose
intolerant. You can trace Western civilisation on the basis of
lactose tolerance or intolerance if you try hard enough. We are
talking about the messages.
Chairman: If you want to elaborate.
Q81 Mr Curry: I am happy to do so.
It is all to do with settling agriculture but we will not divert
on that now. For that group you will need to devise a specific
message which says you are more likely to have a problem, therefore
you must do this, which perhaps is not as relevant to the rest
of the population?
Professor Boyle: Indeed. We will
need to do a similar process, as we have been attempting to do
in the heart disease arena, for people of South Asian origin who
are more susceptible to vascular disease for other reasons. They
are more likely to develop insulin resistance and so-called metabolic
syndrome and early onset diabetes and that very much increases
the risk.
Q82 Mr Curry: If you want to get
that message through to the Afro-Caribbeans to focus on that then
what would be the medium you would choose to make sure you had
a high hit rate on that target group? What sort of messages would
it be?
Professor Boyle: It is a difficult
issue to handle because you have to get the community themselves
to understand that they are different for a particular reason.
We have managed to do that with the South Asian communities where
they are pushing hard for us to give them a step up in terms of
the risk assessment, in terms of establishing whether they are
at risk of vascular events and to treat them as a special case.
I think we need to do the same for people of Afro-Caribbean origin.
The initial work on this has not been greatly successful because
I think to get to the Afro-Caribbean community leaders is rather
more difficult. They, perhaps, are not a group that are not renowned
for being compliant with the medication when they are given it.
That is a challenge for primary care and it is a challenge for
our frameworks in terms of measuring the quality of what goes
on in primary care and raising awareness within the primary care
setting. This group do require special attention and maybe a different
strategy at local level.
Q83 Mr Curry: We are all bombarded
now, with messages particularly to do with food, with what is
good and what we should not eat. As far as I can see if I existed
entirely on a diet of cooked tomatoes, cranberry juice and Brazil
nuts then my susceptibility to prostate cancer would be massively
reduced but it would not make for much fun. If you had a 15 second
slot on television free, gratis and for nothing in prime time
and you had to get three non-killer messages out, what would they
be to get the maximum benefit in preventative terms?
Professor Boyle: Professor Philp
has been doing just that very thing on the BBC so maybe he could
tell you.
Professor Philp: We have been
supporting the BBC on a series called How to Live Longer
that is going out at the moment. The episode tomorrow will be
a man called Sugay who is a South Asian man and has a poor diet
and lack of exercise and he is at risk of heart disease and a
stroke. We make that clear and we are showing a case study of
the main messages, in his case his diet. On Friday we have got
a lady from an Afro-Caribbean background, Lisa, who is overweight
and has diabetes risk in the family and high blood pressure. We
were making the point through the medium of television that programmes
are going out to about 1.5 million people each morning to encourage
people to identify with people like themselves and adopt healthier
lifestyles. The big messages relate to blood pressure, cholesterol—which
we measure for all the participants in the programme—diet
and exercise.
Q84 Mr Curry: Every three years all
MPs have to go and see the House of Commons doctor and you are
always told to lose two stone, by and large. Do not tell me to
improve my lifestyle or my diet, give me three specific things
which I could do, good hard-hitting clear things that I would
understand?
Professor Philp: Your waist measurement
is probably now the best test, as a physical test, of your heart
disease and stroke risk from being overweight. Get your belt size
down two notches. Check your blood pressure, if you are in an
at risk population go and see your GP, make sure your blood pressure
has been checked and controlled. Change your diet because we live
in a land of plenty but we are programmed genetically to live
in a land of famine so we eat what is available to us readily.
We have to change our outlook so that we consciously start to
manage our dietary intake in the interests of our health and we
are modelling this, as I say, through this television programme
to show that people can change their lives, not through just following
a diet for a few weeks but by reprogramming their behaviours and,
in so doing, achieve happier as well as healthier lives and that
then creates sustainable change.
Mr Curry: May I ask one further question.
Chairman: As long as you do not get too
worked up, we do not want your blood pressure to go up!
Q85 Mr Curry: I have just had my
test. You might well get an elderly person who has had a stroke
and they live by themselves. As a result of the stroke they cannot
drive so they become wholly dependent on the Social Services and,
as this Report says, sometimes the most irksome things are what
we might call the banal problems like they cannot cut their toenails
or their fingernails, every single meal comes from Meals on Wheels,
which are not always the healthiest concoction as a matter of
fact. They cannot wash their cloths, or they cannot bathe themselves.
Yet Social Services are under colossal pressure. If you look at
the Chancellor's forward expenditure predictions then that comes
into the "everything else category" which is going to
have to fight over a limited amount of money once education and
health and perhaps overseas aid has been prioritised. What do
we do to prevent the dislocation between the health and the social
services and people, particularly vulnerable like that, who are
almost not going to let it be known when they do have a problem.
Sir Nigel Crisp: A general point
from me and then I will ask Professor Philp to carry on. We published
the White Paper last week which was very much focused on these
sorts of questions about deliberately health and care because
it is not enough to do the health intervention, there are all
the other interventions around it. We published it because we
know there is more to do with that area but I do not know whether
there is anything specific that you want to say on that area.
Professor Philp: I do think the
White Paper sets a better foundation for delivering care that
is more appropriate to people's long term needs through the better
alignment of the NHS and social care system. Specifically, I would
like to mention the push that we have on direct payment and the
pilot studies we are doing on individual budgets which would deliver
for the hypothetical person you described, much greater choice
in how they would spend the money that would be associated with
their level of needs and not rely, therefore, on the service to
define what the service response to them should be. The responsibility
of the service is to assess levels of needs and through the mechanism
of direct payments personalised budgets, including direct payments
for carers, people will have greater choice in accessing the services
which they think will best meet their needs.
Chairman: For the record, public awareness
is dealt with on page 35. It says "Public health campaigns
have had modest success in raising awareness specifically about
stroke and the least success with ethnic minority and deprived
groups". There is a comment from a carer saying, "She
had been warned about a stroke unless she got her weight and blood
pressure down but ignored it saying `A short life and a gay one'.
She is now unable to walk, incontinent, epileptic and has reduced
comprehension". I am sure one of our recommendations would
be that your public awareness campaigns do not yet seem to have
got through to the public.
Q86 Mr Khan: One of my problems is
when you are the seventh person to ask questions all the best
questions have been stolen. Can I underscore the point made by
Mr Clark, which is the reason why we are all a bit vexed and animated.
It is not simply our obsession with the value for money point,
it is that the Report tells us, and you have accepted the Report,
that 550 deaths per year could be prevented but also 1,700 people
could revert back to their normal standard of living and their
life but for the recommendations so far. You can understand, I
am sure, the reasons for our vexation. My first question is you
explained that international comparisons are difficult and you
also said, and the Report says, that the number of incidents and
deaths to do with strokes has gone down over the last decades.
Can you explain, and I think Kitty Ussher who is not here alluded
to this, why the chances of someone dying who has suffered a stroke
have remained consistent compared with the chances, for example,
of a heart attack, which have declined?
Professor Boyle: The numbers have
declined for stroke as well, they just have not declined so fast.
Q87 Mr Khan: Exactly. The percentage
of people who die post-stroke, the improvement that has been made
is less good than the improvement made in better contrast to heart
attack and deaths?
Professor Boyle: I think the message
we have been trying to get across to you is that we need to do
that effectively. We need to tackle the whole pathway right from
the individual calling for help, the speed of the ambulance service,
the access to the scan, the interpretation of the scan and then
the application for those with a thrombotic stroke, that is an
artery that occludes with a blood clot.
Q88 Mr Khan: My second question is
could you give us a note setting out—over the last 15 years
I would be happy with—the increase there has been or the
decrease, I assume there has been an increase, in the number of
CT scans over the last 15 years, the number of pre-staff like
radiographers, radiologists, neuro-radiologists, stroke consultants
and the rehabilitative staff for example psychologists, dieticians,
physiotherapists, occupational speech therapists and social workers,
those sorts of areas over the last 15 years. Is that a reasonable
request?
Professor Boyle: For a lot of
those staff groups the survey data is not complete.[10]
Q89 Mr Khan: As much as you can would
be useful. It provides us with a relative way of seeing in those
areas how steep the graph is about improvements made. My second
main issue is in the NAO paper on page five, there is a reference
to the total cost—it is in table two in the second column,
the second bullet point—"The total costs of stroke
care are predicted to rise in real terms by 30% between 1991 and
2010". Do you accept that?
Sir Nigel Crisp: Yes, I think
we do.
Professor Boyle: One of the problems
we have here is with an ageing population, age being a major risk
factor for stroke, you would expect the numbers to rise and therefore
the cost.
Q90 Mr Khan: Exactly. Is that because
more people will suffer strokes and the cost post-stroke will
rise or is that because you are buying more CT scans, training
more staff and having the staff working up to 36 hours rather
than 12, et cetera?
Professor Boyle: Basically, I
think the rate will not rise once it is adjusted for age but the
volume of work that we will have to deal with will rise because
we have an old population.
Professor Philp: On your point
comparing where will the costs be incurred, relatively more costs
will be incurred on the acute response and proportionately, therefore,
less cost on the long-term burden through better treatment and
reduction in long-term disability although the proportion of the
total cost of a stroke episode through care is largely accounted
for by the longer term costs.
Q91 Mr Khan: That is the answer I
was hoping for. Can I take you on to pages 16 and 17 in the Report,
figures six to eight. It is quite clear that there is a huge variation
in the service provision around the country. I know this because
at St George's Hospital in Tooting we have a specialist stroke
unit in a new wing built by PFI with a dedicated team of experts,
the top 10 in the country. We have access to TIA technology where
the one-stop clinic would have the availability of the thrombolytic
drugs that are referred to in the Report. We have now more access
to CT scans. Aside from your point, which I am sure you will say
is because they have got a good MP, what is the other reason why
places like Tooting have such a different experience to our colleagues
up in the North East in particular?
Professor Philp: It is local championing.
The best practice in the country—and the best practice in
our country does compare with the best practice in Australia,
Sweden—Newcastle, Cambridge, some centres in London and
others are delivering excellent care. Our challenge is to move
these from best practice because you have self-selected champions
with a strong interest in the area, many of whom are at the cutting-edge
of the research and building up the workforce so that we have
champions throughout the country. That is the main reason why
there has been differential growth, it has been the availability
of local champions, including no doubt local MPs.
Q92 Mr Khan: You are right, the average
time people spend in St George's is 22 days, it is still too long
but going the right way. Is that good enough? That is almost an
argument not for devolving power down to the trust because St
George's is blessed with a great MP and a good PCT and stuff.
What about the others?
Sir Nigel Crisp: A general point
about performance improvement is that it is on a normal distribution
of bell curve. You will have people at one end who are the leaders,
you have the bulk of people in the middle and then you have got
the people at the end who really are the laggards. Our task, as
a system, which I think Professor Philp was saying, is to make
sure that the best practice that is learned in places like Tooting
is spread elsewhere.
Q93 Mr Khan: How?
Sir Nigel Crisp: Amongst other
things by these sort of publications, having the strategy that
Professor Boyle is leading the development of and, to some extent,
by targets. Let me give you an example of something which has
not yet come up which is in the GP's contract, they get paid for
certain measures and for things that they do. We have now got
into it something like 30 payment points that are associated with
stroke which we did not have before. You are getting the incentives
into the GP, you are getting the spread of best practice, you
are getting clinical leadership, you are promoting what is happening
in Tooting and elsewhere and you are getting those people to go
and talk to other people in the country. Best practice does not
spread easily, it needs all those financial incentives as well
as the leadership.
Q94 Mr Khan: When should we expect
to be able to have you back here and ask you the questions about
the bell graph you talked about and refer to it as a significant
improvement? How soon?
Sir Nigel Crisp: I think it is
happening. Some of these figures, it is interesting, have changed
in the last couple of years, even within this Report. The people
who say that they have been in stroke units and so on have shifted
from 40% to 60% in three years, though if you were to invite us
back in three years' time or something I suspect you would see
a much better picture than that.
Professor Boyle: You mentioned
the North East, in fact, one of our exemplar hospitals is in Newcastle
and one our leading clinicians, who is helping us develop the
strategy, is based there. One of the reasons is that it is another
large hospital where you are likely to have a bigger cohort of
patients to manage, more resources and easier access to the scanning
and the other technology. Even there, in a big hospital, it is
not easy. This individual has also been appointed to run another
topic, which we have not mentioned yet, which is a UK Stroke Research
Network. We have funded them with £20 million over five years
to develop research networks across the country which will cover
about three quarters of the population.
Q95 Mr Khan: My final two questions
are that, first of all, the Chairman and Mr Curry already alluded
to public awareness campaigns, and you have been given a sneak
preview. One of the criticisms could well be your lack of success
in your public awareness campaign. One point that Mr Curry did
refer to, where there is a disproportion of sufferers, is women.
To pre-empt that criticism, or to make it less stark than it will
be, what are you doing to improve the public awareness campaigns?
Professor Boyle: The stroke does
get a mention in pretty well every one we have done in most of
the leaflets and certainly also in the work we are doing with
the Stroke Association to raise awareness that a stroke is important.
I think that is for the general public. I think we have got another
issue which is making sure that our professional groups are also
absolutely fully up to speed and that relates to your last point
in terms of how do we spread good practice. We are setting up
a series of attachments to the exemplar units to make sure that
that good practice is spread.
Q96 Stephen Williams: A lot of questions
I had prepared have been asked already so I probably will not
detain you for long. One of the issues that has come up repeatedly
in this session is blood pressure. Can I ask Sir Nigel, perhaps
more so than the clinicians, what is the Department doing so that
we encourage as many people as possible to have a blood pressure
test? The last time I went to see a GP, and I do not go very often,
he said to me, "it is not very often you get young men in
the surgery, I am going to take your blood pressure because we
have very poor data on young men's blood pressure". What
is the Department doing to have more statistical analysis of high
blood pressure in the country?
Professor Boyle: Blood pressure
is absolutely the key. What we have seen is a much improved performance
in terms of tracking down blood pressure which does not come with
symptoms so unless you get a measurement that is not easily recognised.
On the other hand, we have seen clear evidence that the increased
uptake of the drugs to treat blood pressure and spend on that
as a contribution to the £2.1 billion spend is having an
effect on the nation's blood pressure. The average blood pressure
is falling both for men and for women but faster in women for
some reason which we do not fully understand. One of the major
levers to bring this about has been the quality and outcomes framework
within the new GMS contract for primary care and where blood pressure
figures very high up the point scale in terms of encouraging primary
care to do this work. It is also becoming increasingly important
as part of an assessment of cardiovascular risk as a whole, which
means looking at all of your risk factors and then seeing whether
or not your threshold would warrant an intervention with treatment
for your blood pressure or for your cholesterol level as well
as the lifestyle advice that we have already covered. We are moving
into a position now, following a recent appraisal of statins by
NICE, that suggests that a 20% 10-year risk of an event would
be a reasonable threshold for a cost-effective intervention in
that arena. This is a big step forward because it would introduce
another three million or so individuals as being eligible for
treatment on top of the three million or so already receiving
treatment and regular follow-up. It is a big task for primary
care but one that they have shown they can achieve through this
quality and outcomes framework and we are looking to expand that
further in the coming years.
Q97 Stephen Williams: Young people
perhaps are far more likely to go to a gym or some sort of health
club than they are to see their doctor, in fact, where I have
my blood pressure tested on a fairly regular basis is at my local
sports centre. Nothing happens with the data thereafter even though
I know it is all stored on a database held by the council. Has
the Department considered, perhaps on a sample to see whether
it is worthwhile, working with other people and collecting this
data even though health is not their primary concern?
Professor Boyle: The issue is
Know your Numbers is a campaign which has been run by the Blood
Pressure Association, and I think it is a very good one, but knowing
your number and doing something about it are two different things.
We are working with the pharmacists to see whether the high street
is another option for those sorts of checks. The walk-in centres
clearly make it easier for people to access that kind of measurement
and again, within the White Paper, there is a clear drive to the
life check and to encourage people to take this sort of issue
seriously.
Sir Nigel Crisp: Can I make one
point on this which is what you were doing yourself which is the
primary prevention, stopping it getting there, rather than the
secondary prevention which is the pill, the drug, which is where
we do not want to be. We want to be encouraging people to be looking
after themselves in the first place rather than to be in the position
of needing us to provide medication to go with it. Your wider
point about whether or not we collect that information for useful
research purposes, maybe that is something we might come back
to.
Q98 Stephen Williams: You mentioned
the Health White Paper that came out last week or the week before
and the health MOT life check was one of the eye catching initiatives
within that White Paper and it seems to be a good idea. Presumably
regular blood pressure tests would be a key aspect of that, a
lot of that goes on at the moment. Do we need to have more of
an understanding of blood pressure statistics without this need
for health MOTs along with the work being done already?
Professor Philp: We know the statistics
in terms of population risk, the issue is raising awareness in
the population of the need to look after your health and get your
blood pressure checked, particularly the age group that we are
piloting the health checks first in, which is people in their
late 40s particularly at risk in that age group. Our Communications
Directorate in the Department of Health have been doing work looking
at how people receive health information and where the trusted
source is. The trusted sources are not always from health professionals,
they are from the neighbour down the road, what you see on a TV
programme, what you read in the magazines that people read and
so on. Our campaigns of raising public awareness about risks and
looking after your health are increasingly turning now to using
the media and the example I gave was the How to Live Longer
programme, for example. It is a multi-pronged approach, raising
public awareness through sources that the public will trust, having
access to means to get your health checked, targeting the specific
at risk groups including in the case of stroke people from Afro-Caribbean
backgrounds and South Asian communities, and then using the quality
and outcomes framework in the GP contract to incentivise primary
care to respond effectively as they have been doing to managing
the identified risk factors.
Q99 Stephen Williams: Mr Khan mentioned
earlier in his questions the fact that women often suffer from
strokes more disproportionately than people realise. I wear this
badge on my lapel which is to raise awareness of testicular cancer.
The pink ribbon for breast cancer is now well understood and the
breast cancer campaign has achieved a great deal but it says in
the Report that three times as many women will die of a stroke
than will die of breast cancer yet the resources that go into
breast cancer research and public information and awareness of
strokes is far lower. What work is the Department doing with various
campaigning groups to turn around this perception?
Professor Boyle: I think the big
issue here is to get into a position where individuals understand
the concept of risk because these events are always things that
happen to other people. Even if a risk level of 20% over 10 years
is explained to them, they will then have to decide whether that
is a big enough risk to warrant embarking on all the lifestyle
changes and possibly pharmaceutical interventions that would alter
that. The key thing here in the stroke arena is smoking just as
it is for heart disease and cancer, and that is why the vote on
14 February is becoming increasingly important.
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