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The stroke strategy mandates the establishment of stroke care networks as a cornerstone of its implementation. Through working co-operatively within a network, services can be better integrated and better planned, and ensure that patients experience seamless transitions across boundaries within and between health and social care.
I feel confident that social care will be raised with me today. The strategy acknowledges that networks are of huge benefit. All stroke services in England now fall within one of 28 networks.
The stroke improvement programme, or SIP as it is sometimes known, provides national support for improving stroke and transient ischaemic attack services, working with stroke networks, front-line services, charities and patient groups. Key areas of SIPs work include providing information and guidance through newsletters, websites and training events, and ensuring that those working to help services improve are in touch and up to date. SIP also runs national improvement projects with 40 front-line stroke and transient ischaemic attack teams, focusing on the main elements of the pathway: acute stroke, TIA, rehabilitation and transfer of care. The projects are putting best care into practice, helping their patients and showing others the way to improve. It is so important in our health service to share best practice.
SIP works with primary care trusts and public health departments to strengthen work on preventing strokes, aiming to prevent the estimated 4,000 strokes caused by the under-recognition and under-treatment of atrial fibrillation. SIP is also bringing together and writing up emerging good practice and providing national forums to bring together key leaders for implementing change. That, too, is an important element in any change in organisations, particularly in the health service. We have to have good leadership to encourage people to look at their practice and to take seriously the consultation involved, so that they understand why it is important and why it must be appropriately led.
The sum of £45 millionabout 40 per cent.of the £105 million of the central funding is going directly to the 152 local authorities with adult social services responsibilities as a ring-fenced grant. This is to encourage and develop good practice in delivering stroke services for adults in their communities, to improve outcomes for those who have had a stroke and to enhance their quality of living and degrees of independence, as well as those of their carers and families.
Local authorities are working hard to develop services according to local needs and prioritiesfor example, to reflect any special support needs of obviously disadvantaged groups, such as black and minority ethnic groups, those in much lower socio-economic groups, those who might find services difficult to access, and those at higher risk of a recurrent stroke.
Dr. Andrew Murrison (Westbury) (Con): The Minister is right to say that this is an important public health issue, and reducing health inequalities is extremely important. What account has she taken of the rural poor, who are particularly disadvantaged in relation to stroke, given that they are often unable to access stroke services expeditiously?
The hon. Gentleman raises an important point. I recall travelling to see patients when I worked as a community district nurse, and I know that many patients feel very isolated when they have no access to transport. If they have no close family to help them, the isolation can be awful. We need to go back to the leadership on this. The third sector does an amazing job in rural areas, but speed, access to services and quality of life can be difficult to achieve in those areas. I am
sure that the hon. Gentleman works positively to bring these matters to our attention, and I would be happy to look at whether there is a specific route that we could develop and share best practice on. Many members of the third sector will be able to offer the health service a lot in this regard.
Dr. Murrison: Rather than relying on the third sector, might it not be better to follow the suggestion of the Ministers own emergency group, which is looking into re-allocating resources in the ambulance service, that calls relating to strokes should be upgraded from category B to category A?
Ann Keen: That point has already been raised by the hon. Member for South Cambridgeshire (Mr. Lansley). We always need to see how we can improve these services, and I take that issue very seriously. Todays debate is about sharing our knowledge and raising problems in our constituencies, and we should use it positively to make improvements.
Sir Nicholas Winterton: Following up on the points that have just been raised about the difficulty that some people have in accessing the services that they need, may I say sincerely to the Minister that elderly people who suffer strokes often need intensive physiotherapy? They will get that physiotherapy in hospital, but when they return to residential care or, in some cases, to a residential nursing home, the availability of that treatment is minimal. Are we going to be able to provide the necessary level of physiotherapy and after-stroke care for those in residential care or in residential nursing homes? I believe that this is a crisis area.
Ann Keen: I share the hon. Gentlemans concern. The reality for some people receiving physiotherapy is that they wait for hospital transport to take them to their treatment, have their therapy for half an hour, then sit and wait all afternoon to be taken back home. I have often questioned the value of that approach. We are now working on transforming community services, following the High Quality Care for All review and Lord Ara Darzis Next Stage review, to see how long-term conditions can be treated in the home. The reality is that we need to deliver therapy to people where they are, rather than transporting them to it. If we look at this from any perspective, not least the value-for-money perspective, we can see that transporting patients in that way is not how we should be delivering services. Those services should be actively encouraged and delivered where the patient is. Training of staff in residential and nursing homes needs to be improved so that some of that physiotherapy can be given in a more gentle, passive way throughout the day.
Pursuant to the very pertinent question that my hon. Friend the Member for Macclesfield (Sir Nicholas Winterton) has just asked, is not the distinction in terms of access to the necessary care between those who, by virtue of being in hospital, arefor want of a better termabove the radar and therefore readily visible, and those in a more private environment who fall below the radar and are therefore less visible? Would the Minister care to comment on the need for central leadership, courtesy of the stroke strategy? I sometimes feel that all the parties are poisoned by the dogma of localism to
the extent that they do not always recognise that, to protect vulnerable minorities, some sort of central guarantee or leadership has to underpin local initiatives.
Ann Keen: Those points are being addressed through the strategy of caring for people with long-term conditions in the community. Perhaps I can give a plug to my own profession by saying that nurses are leading most of this change. The specialist stroke nurses have always been aware of how the care of the patient could be better delivered. We are aware that, when a stroke has gone badly wrong and disabled someone to a considerable extent, they have often received a Cinderella service. I think that we can all acknowledge that.
Now, however, we are addressing that matter and asking how we can improve the quality of patient care. We need to enable those patients to take small steps towards being able to dress and toilet themselves and to care for their own personal hygiene. It is important that each individual should have the extra care to enable them to do that. These are small steps; this is not high on the scientists agenda. The hon. Gentleman mentioned things being below the radar. The reality is that even a small improvement in the daily living arrangements that most of us take for granted will make a difference to the patients life, as will the ability to communicate following the horrendous experience of being unable to do so. At some stage, we are all going to be vulnerable to such an attack, and we must therefore go back to the basic question of how we would want to be treated and what care we would wish to receive. That must be our starting point, which is why the stroke strategy is so important.
I congratulate the all-party group on stroke, which is chaired by the hon. Member for North-East Cambridgeshire (Mr. Moss), on its sterling work. Survivors have come to the House and communicated with us about their difficulties. This debate is welcome, and I welcome the practice that has been acknowledged. I know that we will continue to work on this.
I would like to make some progress now. Local authorities are the pivotal access point to a range of services that can benefit people who have had a stroke and who want to live independently at home. They are working with their NHS partners locally, with stroke networks and the voluntary sector to help individuals and carers at an earlier point to reduce the likelihood of increased dependence at a later stage. To support that work, many local authorities have used some of this funding to appoint stroke care co-ordinators.
I want here to acknowledge the good work that the voluntary sector is doing to help implementation of the strategy and to recognise the support it has provided for stroke survivors over many years when stroke was barely ever debated in this House. Volunteers have dedicated their personal time to improving the quality of life for patients and their families. Third sector organisations such as Connect, the Stroke Association, Different Strokes and Speakability provide enhanced services to stroke survivors and their carers. They have much of the expertise and skill required to support further improvements across a broad range of issues.
All those issues are highly relevant to helping people who have had a stroke to achieve a good quality of life, maximum independence, well-being and, of course, choice.
Recently, the Stroke Association launched a report, Getting better: Improving stroke services across the United Kingdom. While recognising that there is more to be done, this report sets out some excellent examples of where significant improvements in stroke services have been made.
The strategy noted that staff working in stroke have variable levels of knowledge and skills and acknowledged that nationally recognised, quality-assured and transferable training and education programmes were needed. Once again, we know from our personal experience and our casework what constituents tell usthat the quality of care varies so much. That is why effective training and education programmes are an essential part of this strategy, and a stroke-specific education framework has been developed to help us achieve that. It is available for comment on the stroke page of the Department of Healths website until 12 June next week. Work to ensure that this framework is used to improve the stroke work force is continuing.
I also need to acknowledge the important work that individual professionals and multidisciplinary teams in the NHS and social care worlds are devoting to making the stroke strategy a reality. There are many examples to cite across all staff groups, but I will cite one example from the latest stroke sentinel audit, which says:
Marked improvements have been achieved in the last two years in speed of assessment by therapists after admission. While far from perfect it is clear that a major effort has been made to improve the quality of care being provided nationally.
Multidisciplinary teams are an essential component of world class stroke care and allied health professionals are already taking leadership roles in developing stroke services. I want to congratulate our AHPs. The front line of health services is always the recognisable face of the doctor and the nurse. However, our AHPs are providing a tremendous service to patients in all clinical categories. Given that we are discussing stroke today, I would particularly mention the importance of the work they do once the diagnosis has been made, the CT scan provided and the appropriate drugs administered. It is the after-care of the experts that then becomes so important, and teams of allied health professionals achieve so much in that respect. We have supported regional AHP leadership challenges, which will culminate in a national final in June to encourage more of them to do so.
Collectively, these markers set out on ambitious agenda to deliver world class stroke services, from prevention right through to life long support.
Work has begun to make this vision a reality and it will continue. I know that all hon. Members will continue to work to hold us to account on this strategy; we will work together to continue to improve stroke services for the people of our country.
Mr. Andrew Lansley (South Cambridgeshire) (Con):
First, may I welcome the debate and the opportunity it provides to consider the development of stroke services? It comes at an opportune moment, because, as the Minister said, it is approaching two years since we last had a debate whose purpose was to identify what needed
to be done. At that point, the Government had just published their document, A New Ambition for Stroke, but that was already more than a year and half after the National Audit Office had published its groundbreaking study of the delivery of stroke services. I remind the House of the work done by the NAO and by the Public Accounts Committee and I welcome the fact that the NAO is in the process of reviewing its report and the progress made on the strategy. That will be immensely helpful.
Our debate is also timely in the sense that, two years ago, we looked at the outcome of the 2006 national sentinel stroke audit, and now we are able to consider the results of the 2008 national sentinel stroke audit, which was published in April this year. This is a timely opportunity to look at the progress made. I am pleased to note from the 2008 audit that an improvement has been recorded in all the standards in respect of the hospital care of stroke patients in England. That illustrates the amount of work done by the Department of Health, health services and hospitals across the country after the findings of the original NAO report.
The Minister kindly expressed gratitude for the work done by the all-party group. As chair of that group, I would like to thank the Department for its unstinting support and I also thank hon. Members across the House for their participation. It is excellent that we have been able to work together to create an environment for the improvement of stroke care.
As I have said before, I wish it were not necessary for the Department of Health to publish a national stroke strategy in order for hospitals across the country to identify on the basis of clear research evidence the best available treatment for stroke patients. As we will discuss in the debate, we unfortunately remain in a health service where the central structure of guidance and incentivisation has had a big impact on the extent to which hospital and community services are reconfigured. I promise my hon. Friends that I will touch on how the reconfiguration has worked out in London, for example.
The Minister did not tell us in detail what the national sentinel audit said about the improvements, so I shall take a little time to put some of the key results on the record. First, as I have already said, the improvements recorded on all the set standards have taken the cumulative score in England up to 73 per cent.a considerable improvement on 2006. Only a small number of hospitals have failed to improve. I do not want to diminish in any way the progress that has been made, but it is important for us constantly to look at the gaps between where we are and where we ought to be. For example, 25 per cent. of patients do not get access to a multidisciplinary stroke unit, yet the incontrovertible evidence is that such access gives patients better outcomes. We want to get increasingly close to 100 per cent. on these figures.
My hon. Friend the Member for Westbury (Dr. Murrison) made an important point about the need to question why only 17 per cent. of patients reach a stroke unit within four hours. If patients have been admitted to an emergency department first, it is clearly not in their best interests to be sent to a medical admissions unit before being sent to an acute stroke unit. I recently visited Peterborough hospital, which has structured its services so that patients brought in in an ambulance are directly admitted to a stroke unit, bypassing the emergency department. I do not know whether that
is the right approach given that many emergency departments are perfectly capable of dealing with stroke patients in the first place and ensuring that they get an immediate CT scan. However, I cannot see the benefit of patients being transferred to a medical admissions unit, and then being transferred to a stroke unit. It is not in the best interests of patients to be moved from one place to another within a hospital. Given that probably about 60 per cent. of stroke patients are admitted to a hospital on the same day as suffering the stroke, a much higher proportion should be sent to a stroke unit directly.
The Minister spoke about the FAST test. The national sentinel stroke audit suggests that in 2008 only about a quarter of patients in total, in the sample, were subject to a FAST test by paramedics. That procedure needs to be embraced, not least because we have rightly told the public about the necessity of identifying the symptoms of stroke and treating such patients as a medical emergency. The last thing that should happen is that the public and patients do not see precisely those criteria being applied by ambulance services, by out-of-hours servicesin whose protocols there is often a gap in terms of categorisation of strokeand when patients are subsequently admitted to a hospital.
That brings me to the point about immediate scanning. The evidence is clear that it is in stroke patients best interests to receive a CT scan rapidly. In response to the audit, the Royal College of Physicians said that all patients admitted to hospital with a stroke or potential stroke should be scanned within 24 hours. As the Minister will know, in the absence of a CT scan, it is difficult to ascertain what kind of treatment a patient should receive. At a basic level, a stroke might be either ischaemic, resulting, for example, from a clot travelling to the brain, or haemorrhagic, from a bleed in the brain. As clinicians will make clear, unless one knows which type of stroke is involved as a result of a definitive scan, it is difficult to provide the appropriate treatment. As a proxy for providing good treatment, early CT scanning is integral.
The audit suggests that only 64 per cent. of such patients were being scanned within 24 hours. Almost by definition, a large number of the rest were not able to get appropriate treatment as rapidly as they should have. Only 21 per cent. were being scanned within three hourswe would not expect that to be possible for 100 per cent., not least because for many patients admitted it would be clear that their stroke occurred more than three hours before, so the option of thrombolysis probably would not be available. In 2008, barely 1 per cent. of stroke patientsand fewer than 10 per cent. of those for whom it would be appropriatewere being thrombolysed. That is a long way from where we need to be. Even four or five years ago, countries such as Australia were approaching 15 per cent. of total stroke patients being thrombolysed, which is nearly the optimum level. Therefore, although we are making progress, we have further to go.
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