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Of course, we must not allow the situation to arise whereby, when stroke symptoms develop, they are identified, an ambulance is called for and it takes the victim to an accident and emergency department, only for time simply to pass and brain function to be lost. We must take urgent action to ensure that that does not happen. I have been involved in the all-party group on stroke, of which I am now chairman, since its inception in early 2003, and we have argued for the taking of such action since early 2004. The protocols and
structures required have become increasingly clear; indeed, on visiting other places throughout the world—the NAO visited Australia—one can see precisely how they can be achieved.
The Sentinel audit tells us how far we have come. In Australia, after immediate CT scanning, all those patients for whom thrombolysis is appropriate get access to it. About 10 per cent. of stroke patients get such access. According to the audit, however, in the preceding year 218 patients in this country were thrombolysed, representing 0.2 per cent. of all such patients. That is an enormous disparity. Some 18 per cent. of hospitals in this country still have no specialist acute stroke unit, and only 10 per cent. of hospitalised stroke patients are admitted directly to an acute stroke unit.
Those two elements are central: patients should be admitted directly to a unit capable of undertaking immediate CT scanning; and, where appropriate, they should undergo thrombolysis. In any case, such patients should be admitted directly to specialist stroke units, and should in virtually all cases spend their time in hospital in such a unit. We have known about these issues for some time, but we have by no means made sufficient progress on them. The NAO report was clear on the benefits that could accrue from treating such cases as emergencies.
The point was brought home to me some three or four weeks ago, when I attended the memorial service for Sir Arthur Marshall. After the service, a gentleman named Ivan came up to me and said, “You’re interested in stroke and involved in Westminster’s all-party group on stroke—I’d like to help. I used to work at Marshall Aerospace, and I woke up one night a year or so back and I couldn’t speak, couldn’t feel anything and couldn’t move the left side of my body. I was taken to Addenbrooke’s hospital”—Addenbrooke’s is in my constituency—“and I had a CT scan straight away and I was thrombolysed.” Presumably, he is one of the 218 patients to whom I referred earlier. I looked at him and said, “Well, it’s clearly gone very well.” The extent of his subsequent loss of brain function is that occasionally he has pins and needles in his left hand. Previously, he would probably have had full left-side paralysis. So, dramatic differences have been made, and we need to be aware of the scale of what we can achieve if we take such steps.
Mr. Hugo Swire (East Devon) (Con): My hon. Friend is making a very good point. It is absolutely critical that we get patients scanned as quickly as possible, but in rural areas such as my own in Devon, that is not always possible. Will he join me in congratulating Devon air ambulance on its continuing work? It gets no money from the Government whatever, but it plays an absolutely critical role in getting people from remote areas to the hospitals that can treat them quickly.
Mr. Lansley:
I am very happy to share my hon. Friend’s support for the air ambulance service, which also plays a central role in parts of East Anglia. As I drive into Exeter, I always note the shop that the service has there. Perhaps I will stop next time I pass it, in order to support Devon air ambulance. The fundraising for the service provides a dramatic benefit.
The health service supports the paramedics and the other medical and clinical aspects of the service, but putting the helicopter in the sky and maintaining it is funded entirely from voluntary support.
The NAO report makes certain things very clear. For example, it estimates that admitting stroke patients to, and treating them in, a stroke unit could save up to 550 lives. It says that transient ischaemic attacks should be followed up rapidly in a clinic, given that there is a 20 per cent. risk of a stroke immediately following a TIA. Such action can forestall and prevent major strokes. For many patients who suffer from artery occlusion, sclerotic artery surgery produces benefits within 14 days. Interestingly, the PAC and the NAO identified that such changes, which would substantially improve outcomes for patients, would not cost the NHS more. If all those measures were implemented, there would be an overall saving to the NHS, not an additional cost. The aim is a change in the design of services, and to get the NHS to respond by prioritising service delivery, which would be better for patients and better for the NHS in value-for-money terms.
Where do we go from here? One purpose of the debate is to raise the profile of the issue of stroke. Another purpose was to try to make sure that the Government publish their consultation on a national stroke strategy before the House rises for the summer, but I am delighted to say that the Secretary of State did that on Monday, which means that we can debate it. Happily, plenty of Opposition Members are present, and a few Labour Members are too, but I hope that more colleagues are listening to the debate, or will read it.
I want to encourage colleagues in all parties to include in their constituency engagements a visit to their local hospitals to talk about the stroke services that are provided. In addition, I hope that hon. Members with a branch of the Stroke Association in their areas will talk to its members—for myself, I am patron of the Stroke and Dysphasia Association in Cambridgeshire. We should all make sure that we have conversations with everyone involved over the next three months, as the consultation on the national stroke strategy ends on 12 October, which means that the scope will be limited when we return after the recess.
I welcome the Government’s publication of the document “A new ambition for stroke”. Clearly, it was a very inclusive process, and many of the people I know to be leaders in the field were engaged in the working groups that led to the document. It is very important that the Government show that priority is now attached to stroke. Unfortunately, a top-down system such as the NHS needs to show top-down priority, so it is important that the Department of Health has published a document.
I do not want to be at all churlish but, although the document published on Monday sets out very well the sort of ambitions that we must have for a stroke service in the future, there were few surprises or novelties on top of what the National Audit Office produced 20 months previously. I am therefore slightly at a loss as to the purpose of having a consultation on a national stroke strategy now, given that the document makes it clear that the Government know what they think the stroke service should be like. As I understood it, the
Government’s document was intended to turn the NAO recommendations of 20 months ago into an action plan. It was supposed to show how we should get from here to there, but in many respects the document that has been produced does not achieve that.
As some of my hon. Friends made clear earlier, the availability of CT scanning is absolutely fundamental. Does the national stroke strategy make clear how, for example, diagnostic contracts and the like will be used to ensure that CT scanning is available 24/7? The strategy presents the model of a hub-and-spoke system, as we always knew it would, but its parameters are still too wide. For instance, we need to be clear about the scale of population to be covered by such a system, and the length of time that people will stay in each hyper-acute stroke unit. We also need to be sure that such questions are followed up in individual locations.
A month ago, Manchester started work on producing its local service plan. The document that has been produced there says that patients admitted to a hyper-acute stroke unit should be scanned and given immediate treatment—including thrombolysis, if necessary—and also be given access to the earliest possible rehabilitation. However, what is interesting is that the document suggests that people need spend only 24 hours in such a unit. I have visited many places across the country, and talked to a lot of senior managers. They tend to imagine that creating better acute care for stroke sufferers will involve concentrating stroke units into larger units at specialised hospitals. In contrast, the people in Manchester have not adopted that approach. Instead, they seem to be saying that the hyper-acute phase needs to be concentrated, but that patients should be referred back to their local hospitals 24 or 48 hours later; each such hospital should have a specialist, multi-disciplinary stroke unit, where hospital treatment can be concluded and people discharged early.
That is different from the approach adopted by many in the NHS around the country. Sir Ara Darzi’s report, “Healthcare for London: A Framework for Action”, does not appear fully to have taken on board the thinking in Manchester, as it continues to propose a limited number of specialist stroke units in a limited number of specialist hospitals. That does not have to be the structure at all.
Mr. James Gray (North Wiltshire) (Con): My hon. Friend is making an extremely interesting point. In my area, Chippenham hospital has one of the best stroke rehabilitation units in the country, and it recently won the Sentinel award for the best in England. However, it is not in the same PCT as Swindon’s Great Western hospital, which is where the acute unit is located. A number of patients have been stuck in the acute unit because Wiltshire PCT cannot afford to move them to the rehabilitation unit down the road. Is that example not especially worrying?
Mr. Lansley:
I am grateful to my hon. Friend, as he has illustrated very well the point that I hope I was making. His intervention leads me to the related point that a critic of the national stroke strategy would want to make sure that the incentives and levers available are being used to deliver the standard of stroke care that
we want to achieve. For some time we have argued that unbundling the tariff—that is, dividing the acute phase from the subsequent rehabilitation phase—is important. The Department of Health has done that, but the structure proposed in Manchester would require dividing the tariff into three phases: the hyper-acute first 48 hours, the subsequent initiation of rehabilitation and support, and then rehabilitation in the community.
The tariff is anything but clear about how it will support and incentivise the process of commissioning. Unfortunately, if it does not reflect the best possible standard of care, it can substantially inhibit the introduction of such care. For example, a manager at Kingston hospital told me that his hospital wanted to be able to provide acute stroke care in the form advised, but that the tariff did not support that. We therefore need to concentrate on the tariff: although I hesitate to talk about something that can be a preoccupation for NHS anoraks, it is very important that we get it right.
The document “A new ambition for stroke” contains many elements that read extremely well and are clearly the right things to do, but one or two criticisms remain. For example, GP protocols for the referral of patients after a transient ischaemic attack were set out first in the national service framework for older people in 2001. They were supposed to be implemented across the country by April 2004, but now they are being repeated in a document published in July 2007. It is not good enough for policy makers to publish documents which reiterate the standards of service that we want to achieve but find that progress is inadequate and that the available levers to ensure that those standards are achieved are not being used.
Obviously, the Secretary of State cannot add very much to a document that he published on Monday, but his foreword says that it is the “first step” to a national strategy. It is not the first step—it is about the 13th, and we need the strategy to be turned, rapidly, into action. I have talked to ambulance service staff across the country, and they know that in a few months they will be delivering emergency patients in acute need to hospitals. That is already happening in some places, but it will be no good if the NHS fails to treat patients as emergencies from that point onwards. The evidence is absolutely clear that such patients must be treated in specialist units, and that subsequent support by multi-disciplinary rehab teams in the community is vital.
Too often, stroke patients tell us that they feel that going out into the community is like falling off the edge of a cliff. They leave a supported service in a hospital context and move to a place where the social services and the NHS services do not join up and the necessary teams do not exist. From the Healthcare Commission’s report, we know that six months after leaving hospital 50 per cent. of patients feel that they are not getting the standard of care they should, and that 12 months afterwards the number has risen to 80 per cent. Half the stroke patients who want to be involved in a local support group are not; 28 per cent. feel that they are not getting help when they need it to deal with mobility problems; 49 per cent. do not receive help with emotional problems when they need it; and
26 per cent. feel they are not given help with speech problems when they need it. It is tragic that large numbers of physiotherapists and speech and language therapists cannot find jobs in those services when they leave college, even though we know there is a specific need for them to provide such therapy for stroke patients. Their participation is needed in community multi-disciplinary teams.
At the risk of borrowing a phrase, the purpose of the debate is to say that a lot has been done, but there is a lot more to do.
The Minister of State, Department of Health (Mr. Ben Bradshaw): Thanks for that.
Mr. Lansley: It was just to welcome the new ministerial team to their onerous but rewarding duties.
As I said earlier, the Secretary of State’s document is not the first step towards a national stroke strategy; the strategy should rapidly be put in place, because we already have the evidence base for it. International comparisons tell us just how far we need to go and how important it is that we make rapid progress. Even on adjusted mortality data, there are differences of between 10 and 30 per cent. between the UK and a range of European countries. We have higher than predicted levels of mortality from stroke, so we need to bring the rates down and match the best in Europe and, in this context, the best in countries such as Australia. We need to do it now.
I share Professor Roger Boyle’s view, expressed in his introduction to “A new ambition for stroke”. He said:
“As a nation we spend more money than most on stroke services—and a greater percentage of our health budget—yet, overall, we have worse outcomes.”
We spend £2.8 billion a year on direct care costs in the NHS—a large part of the overall budget—and, in terms of stroke services, we have a real possibility of using that money more effectively. We should adopt the recommendations of the NAO and the PAC and work with stroke patients, the Stroke Association and others to deliver better services. We must enable stroke physicians, stroke nurses and staff across the NHS to provide the quality of stroke care that they know is achievable, but that they feel unable to achieve at present.
I commend the motion to the House.
2.13 pm
The Secretary of State for Health (Alan Johnson): I beg to move, To leave out from “House” to the end of the Question, and to add instead thereof:
“commends the dedication and energy of the doctors, nurses, therapists and other professionals working tirelessly to help the 110,000 people affected by stroke each year; notes the significant recent progress made in stroke care with falling premature mortality rates and more people treated in stroke units than ever before; further commends the work of the National Audit Office, the Committee of Public Accounts and the All-Party Parliamentary Group on Stroke in scrutinising progress on stroke care and recommending further improvements; welcomes the opportunities offered by new treatments and the growing evidence on effective rehabilitation; celebrates the investment of £20 million in the UK Stroke Research Network to help ensure stroke medicine fit for the 21st century; further welcomes the additional training places made available in stroke medicine;
further welcomes the new guide and tools available to support improved commissioning of stroke services; thanks the Stroke Association, Different Strokes, Connect, the Royal College of Physicians and over 100 individuals for their work in developing proposals for a new stroke strategy; and commends the consultation document ‘A new ambition for stroke.’.”
I start by paying tribute to the hon. Member for South Cambridgeshire (Mr. Lansley) for his work over many years, both in a personal capacity and as chair of the all-party stroke group, in raising awareness of the terrible impact that strokes can have upon individuals and their families. He was kind enough to point out that we pay tribute to his work in our amendment, but he rather modestly neglected to mention the all-party group in his motion. I welcome the spirit in which the hon. Gentleman opened the debate. This is an issue where parliamentarians can get together to move things forward. There are many such subjects in health, but this is one of the most important on which we need to find consensus.
On behalf of Members on the Government Benches, I echo the hon. Gentleman’s welcome back to the hon. Member for Isle of Wight (Mr. Turner). We have missed him since December and are pleased to see him back looking so fit and well.
Every year, 110,000 people in England have a stroke, which is one every five minutes, so given the time available for this debate, between 15 and 20 people could have a stroke during its course. With 50,000 deaths, strokes represent the third biggest killer after cancer and heart disease—killing three times as many women every year as breast cancer. Strokes are the greatest cause of severe disability. More than 300,000 adults in England suffer lasting disabilities as a result of a stroke. The cost to our economy runs to billions—but that is, of course, immaterial when set against the terrible turmoil that befalls survivors and their families, whose lives can be devastated, literally overnight, by such attacks.
I disagreed little with the comments of the hon. Member for South Cambridgeshire; his analysis was right, in terms of both the debilitating nature of strokes and, more important, the need to give stroke prevention and care much greater attention and priority. It is true that the Department of Health has focused particularly on cancer and heart disease, which are the country’s two biggest killers, and we have made huge progress. Cancer deaths are down by 15.7 per cent. since 1997, saving more than 50,000 lives; while cardiovascular deaths are down by almost 36 per cent., saving almost 150,000 lives.
At the same time, attention has been paid to the third major killer. In 2001, as the hon. Gentleman mentioned, we published the national service framework for older people, pledging that every trust in England would have a specialist stroke service—a necessary target that has been achieved. We have also helped to improve standards. A recent study by the Royal College of Physicians showed that 95 per cent. of stroke units now have most of the necessary elements for a good-quality service, compared with just 72 per cent. in 2001. Our efforts to improve public health—on smoking, fitness and obesity—have played a vital role in our quest to reduce the number of strokes. Since 1993, deaths from strokes have fallen by 30 per cent. for over-65-year-olds and are down by 23 per cent. for those under the age of 65.
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