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11 July 2007 : Column 1482

I fully accept, however, that there is more we must do to remedy the failings highlighted in the reports by the National Audit Office and the Public Accounts Committee. We are able to build on strong foundations. We now possess far greater knowledge about lifestyle factors and how they can cause strokes than we did 10 years ago. We have learned more about techniques in rehabilitative long-term care and how acute care can be managed in the community. Technology has advanced considerably, particularly for brain imaging and scanning, so we can now dramatically reduce the number of people killed or left severely disabled by a stroke. Through greater investment and reform, the NHS infrastructure is now equipped to provide the rapid response reactions that strokes require.

In response to the NAO and PAC reports, Professor Roger Boyle, the national director for heart disease and stroke, produced an excellent report, “Mending hearts and brains”. I point out to the hon. Member for South Cambridgeshire that it is a consultation document to enable us to arrive at a strategy, and I shall take his comments into account as part of the consultation. Yes, there are issues in respect of tariffs that we have to tackle, and the all-party group has raised many issues that are not fully covered in the text of Roger Boyle’s report, but the document turns an NAO-PAC issue into something that has had input from a vast variety of physicians, as well as from discussions with the Stroke Association and other voluntary groups, so that we could present it before arriving at a final strategy by the end of the year.

After detailed follow-up work by Professor Boyle and his six clinically led specialist project groups, my Department published a draft stroke strategy. I take this opportunity to thank the many leading clinicians and voluntary sector organisations who took part in the project groups, especially the Stroke Association, Connect and Different Strokes. I hope that Members on both sides of the House will give the document careful consideration and take the advice of the hon. Member for South Cambridgeshire to use the impending recess to contribute fully in their constituencies so that we can produce a final strategy by the end of this year.

I do not believe that improving our performance in this area is related purely to funding. As the hon. Gentleman said, England spends more on stroke services than many other nations, both in absolute terms and as a share of total health spending, and yet we do not get the best results. Many hospitals and primary care trusts, such as King’s College hospital, which I visited on Monday, are already achieving great things. We know that clot-busting thrombolytic drugs can make the difference between someone who has suffered a stroke leaving hospital on their feet or in a wheelchair. However, overall in England last year, a tiny percentage—less than 1 per cent.—of patients received thrombolysis. King’s has already achieved rates of 18 per cent. this year. The hon. Gentleman referred to Australia, which is achieving 10 per cent. As a result of a dramatic reconstruction along the lines suggested in the consultation document, Ontario is now achieving 37 per cent. thrombolysis, which is up from 3.2 per cent. just four years ago.

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Mr. Swire: I think that I am right in saying that there are 640 patients per stroke consultant, compared with 360 patients per cardiac consultant. Does the Secretary of State hope to reassess and address that figure in some way?

Alan Johnson: Yes, it is absolutely essential that we do that. I will come on to say something about that when talking about the report. That is obviously a mismatch. I believe that Professor Roger Boyle says in his report—he certainly said it to me—that the whole stroke area is where heart disease was 10 years ago. We need to bring it up to today’s levels, particularly in terms of the number of consultants and clinicians who specialise in the area. The key to success will be ensuring that more people do the right things at the right time at all stages of the patient pathway. Strokes, perhaps more than any other illness, are time-critical, so speed is of the essence.

There are three elements to the consultation report. First, there is prevention. Historically, strokes have been a poorly understood condition. They are inevitably linked to the over-65s and to old age. In the past, the fatalistic approach was to wait until a stroke occurred and then deal with the consequences afterwards—at great personal cost to the victim, and, incidentally, greater expense to the health service. About one in four long-term beds in the NHS are occupied by stroke patients.

Some strokes have genetic causes, but many people suffer needlessly because they do not recognise that they are risk or know what they can do to lessen that risk. Early action can help to prevent many strokes. We must ensure that better co-ordinated support is available for those at risk so that they are encouraged to monitor their blood pressure and cholesterol, take regular exercise, stop smoking and reduce their salt intake.

We must refute the myth that strokes affect only older people. One in four victims are under 65. We must also promote awareness among communities that are most at risk. People from African, Caribbean or south Asian backgrounds are twice as likely to suffer a stroke as the rest of the population. We have already funded some pilot publicity campaigns, together with the Stroke Association, and will look very carefully at the results.

Some people do not know how to recognise the symptoms of a stroke, either in themselves or in others. That can prove tragic when someone has suffered a minor stroke—known as a transient ischaemic attack or TIA. TIAs indicate a serious problem: part of the brain is not getting enough blood. Without treatment, around one in four people will go on to have a full stroke—most within the following few days. Provided that people are aware of that, it can be prevented—sometimes with something as simple as aspirin and sometimes with an operation to unblock the arteries in the neck. We need a radical transformation of attitudes and actions to prevent strokes from occurring. The consultation document sets out an ambitious new vision: people who are assessed as being at high risk of a stroke should be seen by specialists and scanned within 24 hours.

Secondly, we must ensure that there are quicker emergency treatments for those who have suffered from a stroke. Advances in technology mean that we can
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dramatically reduce the number of people who die or are left with severe disability after a major stroke—again, provided we get to them quickly enough. There is a window of only three hours in which patients must be seen, scanned and treated. With 2 million neurons lost for every minute of delay, we need a much faster pathway to treatment, as identified in Professor Boyle’s report. With all paramedics properly equipped to identify the patients in greatest need and proper specialist care readily available, we can resolve the problem.

On Monday, I saw the impressive speed with which people were moved from the accident and emergency department to a stroke unit at King’s, having been seen by a specialist and given a scan on the way. Professor Boyle says that if strokes were treated as emergencies, more than 1,000 stroke victims every year would regain independence, which makes a compelling case for reconfiguring acute services to ensure that highly specialised care is concentrated at centres that can offer round-the-clock expertise.

Mr. Lansley: That is an interesting point. I was talking to the chair of Peterborough and Stamford Hospitals NHS Trust, which does not directly serve my constituency, but serves people around Cambridgeshire. The service design that he and people in a number of other places are looking for is direct admission of emergencies to the acute specialist stroke unit. I know that in Addenbrooke’s hospital in my constituency, people are brought to the accident and emergency department and then transferred to the specialist unit, but direct admission is what we should be aiming for. It does not make sense for the specialist team to have to go down to the accident and emergency department to collect somebody.

Alan Johnson: That is interesting, as was the view expressed about Manchester. King’s has a triage nurse in the accident and emergency department. I guess that, in effect, the system means that someone is in the stroke unit as soon as they come in, although it happens to be located in a different place. The philosophy is to get people through the system as quickly as possible, making sure that scans are available and that TIA is taken into account if appropriate. Having specialists available 24 hours a day, seven days a week is the key issue at King’s and other such centres.

We should also look at improving ambulance response times. We are consulting about upgrading strokes from category B to category A events so that ambulances arrive within nine, rather than 18 minutes.

Thirdly, we must ensure that there is better aftercare for those who have suffered strokes. The best way to improve care for such people is by engaging with them and ensuring that they feed into the consultation, which is why we have produced an easy-to-read version of the document for stroke survivors who have communication difficulties. Often, stroke survivors say that they wish to be at home during the rehabilitative stages. Early supported discharge schemes get people home more quickly, provided that there is better rehab care available.

Recovering from a stroke can take many years. Our strategy needs to ensure that the NHS is able to remain on hand, helping patients to gain increased independence, with enhanced support available from local specialists,
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providing them with action plans and progress reports. There is still a huge gap between the number of cardiologists and the number of stroke specialists, as was mentioned in an intervention. We need to increase the work force capacity to resolve that, and we have already worked with the Stroke Association to fund an additional three specialist posts. We will invest in training 10 further specialists this year alone.

Having brought about huge reductions in cancer and heart disease, we must now promote the treatment of strokes to become our top priority. In the 1970s, England was the heart disease capital of Europe, but that has changed. We can, will and must ensure that a similar transformation takes place in this area. With record investment, new technologies and health professionals who are already gearing up to tackle this challenge we will succeed, thus truly transforming the lives and prospects of thousands of people and their families who are affected by this debilitating condition. I commend the amendment to the House.

2.29 pm

Sandra Gidley (Romsey) (LD): I, too, welcome the debate. However, the difficulty with going third, especially after the hon. Member for South Cambridgeshire (Mr. Lansley) has carried out his usual detailed and forensic analysis of the subject, is that quite a lot of one’s material has been snitched. However, it is worth repeating several points. This will be one of those occasions when hon. Members on both sides of the House will speak as one, and I hope that we can work together.

Dr. Ian Gibson (Norwich, North) (Lab): Just congratulate us.

Sandra Gidley: Well, I was going to start on a positive note.

According to a recent audit by the Royal College of Physicians, the death rate from stroke in a range of age brackets has fallen by approximately a third, which must be good news. Well over 90 per cent. of English hospitals now have a dedicated stroke unit. The vast majority of health boards and NHS trusts have achieved their targets, and stroke registers have been established in more than 60 per cent. of GP services.

Now comes the “but”. We have heard about the problems caused when stroke patients who are admitted to hospital receive insufficiently rapid access to a stroke unit. I shall outline problems all along the patient pathway later, but there are general problems that have a great impact on stroke services. For example, people have difficulty accessing therapists and social workers. Although we are training loads of physiotherapists, we are not deploying them where they could benefit patients. It has been pointed out that the tariff for supporting stroke patients is inappropriate and there is no financial incentive for hospitals to provide stroke services subsequent to initial treatment. Most importantly, there is little public awareness of the problem. A quarter of hospitals have no form of senior stroke nurse specialist, yet the national clinical guidelines on stroke say that specialist stroke services should be available in the community as part of an integrated system of care to facilitate early supported discharge.

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The new Health Minister who will sit in the other place recently had something to say about stroke services. In May, he pointed out that of the 30 hospitals in London providing stroke services, only four treated more than 90 per cent. of patients in a dedicated unit. He said that although patients should receive a CT scan within three hours, in only seven out of 30 hospitals did 90 per cent. of patients receive a scan within that time.

The number of patients receiving clot-busting drugs has been highlighted. My immediate assumption was that the situation was due to a lack of resources, but as hon. Members have pointed out, “A new ambition for stroke”, which the Department released on Monday, rebuts that because, importantly, Professor Roger Boyle states:

That raises serious questions. Given that the money and the national service framework for older people have been in place—a whole chapter of the NSF is dedicated to stroke services—what went wrong, and why was the money not targeted properly? We have hospitals such as King’s that provide a brilliant service, so why have stroke clinicians and workers in other parts of the country had difficulty getting together and achieving the same sort of outcome? Have they been blocked by hospital management, or was there no initiative on the ground? If we are to move forward positively, it will be worth considering such basic questions to determine what has happened and how we can learn from the mistakes that have been made.

The problem with the NSF for older people was that no funding was attached to it. Perhaps money was in the system, yet people did not know how to access it. I surveyed several PCTs to determine whether stroke targets were being met. It was clear that a number of proactive people had used the NSF as a lever to get local health commissioners and PCTs to go a little further. Such a thing can be done, but we need to learn why in many cases that has not happened.

The real tragedy is that, according to the Stroke Association, approximately 80 per cent. of strokes are preventable. I am pleased that several Health Ministers are in the Chamber. It would be nice to have official notice of which Minister is responsible for public health and their specific responsibilities —[ Interruption. ] I welcome the Minister of State, Department of Health, the right hon. Member for Bristol, South (Dawn Primarolo), to her job. It is difficult when people do not quite know which Minister to go to about what.

The public health aspect of stroke is important because there are many simple steps that can have an impact on outcomes relating not only to stroke, but to heart disease and cancer. According to the National Stroke Association, about 20,000 strokes a year could be prevented if health professionals and the public gave sufficient attention to awareness of people’s blood pressure, determining whether people have a normal heartbeat, and stopping smoking. Other steps that can be taken are the usual culprits in messages on public health and healthy living: cutting down on alcohol, keeping cholesterol under control and following a healthy diet. It has been proven that simple things such
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as eating more fruit and vegetables can reduce people’s risk of stroke. I hope that greater emphasis will be given to such messages.

Alan Johnson: I cannot resist mentioning this. Will the hon. Lady have a word with the Lib Dem authority in Hull, which has cancelled the free healthy school meals service that was specifically aimed at tackling obesity and raising educational attainment? It is a great shame that the service has been cancelled, but perhaps she can influence the leader of the council.

Sandra Gidley: I notice that the programme was aimed at children, among whom the rate of stroke is low. I understand the Secretary of State’s point about establishing healthy eating patterns, but I would like to know whether the meals were being eaten, because if healthy meals are not eaten, we have to look at the problem in a different way. If he sends me more details, I will follow that up.

Exercise is another factor. It is worrying that only 37 per cent. of men and 25 per cent. of women meet exercise guidelines. Even moderate activity can reduce the risk of stroke by up to 27 per cent. As has been suggested, people need to recognise the symptoms of stroke, so a public awareness campaign is needed. It is obvious when someone has had a full-blown stroke, but TIAs can result in minor symptoms. Patients who have had a TIA need to be examined by a doctor, because if they are treated properly we can reduce the overall impact of stroke.

We see the problem when we look at the timeline. A patient will first seek a GP appointment. The good news is that patients are supposed to be able to get an appointment within 48 hours. Although there can be problems if people do not ring their surgery at a certain time of day, access to GPs has generally improved. However, if a patient is not aware that their symptoms could be serious, they might write them off as something not worth worrying about.

There can be a lack of awareness among GPs. Even among GPs who are aware of the symptoms, a fifth do not refer TIA patients for further investigation, as was revealed in a recent survey. There have been attempts through the quality and outcomes framework to improve the situation, but things do not seem to be working at the moment. Only 55 per cent. of GPs say that they would refer TIA patients immediately.

If a patient is referred, there can be delay in accessing a clinic and getting the requisite tests. Only a third of people with TIA are seen in a clinic within 14 days, but the recommended time set out in most clinical guidelines is seven days. Attention is being given to improving patient pathways, but I hope that the obsession with the 18-week target, which in itself is a good thing, does not mean that attention is diverted away from the seven-day target, which also needs to be reached.

David Taylor (North-West Leicestershire) (Lab/Co-op): Will the hon. Lady acknowledge that there has been great improvement in some hospitals? Just a few weeks ago, a family member who had a suspected small stroke went from the general practitioner’s surgery to
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accident and emergency and on to a specialist stroke unit in another hospital in the city of Leicester within an hour or two. That shows the sort of service that can be provided, even by a large accident and emergency unit covering a million people in Leicester and the county of Leicestershire. That is a beacon for others, is it not?

Sandra Gidley: I understand that the hon. Gentleman has not been here for the whole debate. I do not know whether he was here for my opening comments, but his point was acknowledged: some places are beacons of excellence, and we should work towards ensuring that their standard applies in all places. If he has an excellent service locally, he is one of the lucky ones.

To return to the subject of the clinics to which patients who have had a TIA are referred, many of them are now run as one-stop shops. That can be a good thing, but sometimes, once tests have been performed, there is a delay in communicating the results to the GP. That is another part of the pathway that needs looking at. If attention is paid to the pathway, there is a strong chance that we will significantly reduce the number of people who have to call an ambulance because they have had a stroke. I, too, pay tribute to the Stroke Association for its campaign to have stroke treated as a medical emergency. In Hampshire, all the hospitals, the ambulance service and community nurses are working together to try to ensure that services are much more joined-up. They also work with groups that come into contact with patients soon after they have had a stroke, including St. John Ambulance and the Red Cross, to make sure that they are aware of the FAST—face, arm, speech test—campaign.

People have to recognise that they have had a stroke, and that can be a problem in itself. More public awareness would be helpful. Once the patient’s condition has been recognised, there is still the problem that only 10 per cent. of hospitals have a system, like that at King’s, which enables thrombolytic drugs to be administered quickly enough. As that system saves lives, we should really focus on it when considering how we can improve our services.

The clinically optimal model for stroke care is for care to be delivered in a specialised stroke unit, but we need clarity about what a stroke unit is. That might sound an odd question, but many stroke units have a high proportion of rehab patients, and a relatively small proportion of their resources are used to treat patients in their first couple of days in the unit. All the evidence seems to show that treating patients early delivers much better outcomes, so in many hospitals it may be a case of shifting attention or of providing slightly more resources for treatment at the earlier stage, because when the impact of the stroke is minimised, the long-term costs are reduced. According to Professor Boyle, that would make financial sense.

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