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The national sentinel audit looks at nine indicators, which are intended to represent a bundle of care that, if provided to patients, will be indicative of good quality. Thrombolysis is not included, because it is appropriate only for a minority of patients. However, many of the items mentioned by my hon. Friends are included: for instance, the swallow assessment, to which my hon.
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Friend the Member for Buckingham (John Bercow) referred. Interestingly, only 17 per cent. of patients surveyed in the national sentinel audit received all nine indicators of care. There is significant variation. For example, 69 hospitals achieved all nine indicators of care—the full care bundle—for fewer than 5 per cent. of their patients; in contrast, three hospitals achieved more than 70 per cent. As the audit points out, there is a big gap between those three hospitals and most of the others, which are bunching around 40 to 50 per cent. The three hospitals concerned are King’s College hospital, the Royal Free and Chelsea and Westminster.

That takes me on to London and the structure of its services. Undoubtedly, there is discussion to be had about where patients should be admitted for hyper-acute stroke care, immediate CT scanning, possible thrombolysis and so on. If we reform stroke services, we want that to be readily available. However, the approach differs across the country. As far as I can tell, NHS London’s approach was to ask an expert panel to assess the quality of care in a large number of hospitals across London, to establish whether they were capable of providing good-quality care: in effect, whether they should be commissioned for hyper-acute stroke care. Having spoken to someone on the expert panel, I know that it reached views on that, but then NHS London said that eight hospitals would be designated as hyper-acute centres. For the life of me, I cannot find out why the answer was eight.

Mr. Duncan Smith: That is exactly the point. In north-east London, we have puzzled over the matter. A reason for one to be made a hyper-acute centre is neurological services, but the Royal London hospital does not have that; it has cardiac services. It is almost as if NHS London sat down and decided which hospitals it wanted before the panel was brought into session and made its decisions. It is without any logic, as Whipps Cross—our hospital—actually has stroke services. It is absurd.

Mr. Lansley: I am grateful to my right hon. Friend for those interesting observations. I have had conversations with Sir Richard Sykes, chair of NHS London, and correspondence with Ruth Carnell, chief executive of NHS London. I urge NHS London to reconsider whether eight hyper-acute centres in London is the right answer. My view is that there is no evidence to suggest that substantial demand for throughput is necessary before it is possible to sustain a service. For example, the East of England strategic health authority has said that as long as a hospital is likely to be able to offer thrombolysis twice a month on average, there is no reason why it cannot sustain the service. From the commissioner’s point of view, London should have as many hospitals offering the service as are willing to offer it. On that basis, they should be commissioned to provide it, as long as they maintain the necessary quality of care.

Mr. Duncan Smith: My hon. Friend is being generous in giving way, and I appreciate it. As he will know, one of the big issues in London is traffic. In relation to the eight centres, the calculations are completely ludicrous. Today, it took me an hour to travel from my house in Chingford to the Royal London hospital. NHS London
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calculates that the journey takes less than half an hour. For local people, the decision to have eight centres is absurd.

Mr. Lansley: My hon. Friend makes a good point. There are several geographical curiosities. Clearly, NHS London’s intention was to have a geographical spread for the eight centres. For example, in north-east London, Queen’s hospital at Romford was identified for that purpose. If we look at the distribution of stroke patients in NHS London’s own document, however, we see that in north London, Enfield and Barnet have large numbers of elderly stroke patients, and there is nothing there at all. Barnet hospital is a potential location, but it is fanciful of NHS London to say that either Northwick Park or Barnet would be an option, because if one shifts to Barnet, a significant part of north-west London is left without a near facility.

Several hon. Members rose

Mr. Lansley: Let me finish my point about London, and then I will gladly give way.

In my view, a greater number of hospitals should be allowed to provide the service, if it is viable and the quality is maintained. Let me illustrate that point with reference to the two hospitals I mentioned. According to the national sentinel audit, Chelsea and Westminster is among the hospitals with the best quality of stroke care, but it is not one of those chosen by NHS London to offer hyper-acute care. The Royal Free, which is among the hospitals with the best standards of stroke care, is also not one of those recommended by NHS London to offer the service. Guy’s and Tommy’s is another example. As I am sure the Minister knows, the consultant stroke physician Tony Rudd has been an instrumental figure in the improvement of stroke care, and has worked as co-ordinator for the central audit. His hospital has been left out on, as far as I can see, purely geographical grounds. An arbitrary decision has been made about the number of hyper-acute stroke units that should be made available to a greater number of people.

Stephen Pound (Ealing, North) (Lab): Before the hon. Gentleman commits Northwick Park to take on the whole of Barnet, let me point out that in Ealing we have been told that the only hyper-acute unit that we can access will be either Charing Cross or that very same Northwick Park. We have also been told that the modelling is robust when it comes to analysing transport times. May I tell the hon. Gentleman something which I suspect he already knows, and which my hon. Friend the Minister certainly knows? Travelling from Ealing hospital to Northwick Park or Charing Cross is not an experience that one would wish on anyone except at 3 o’clock in the morning.

Mr. Lansley: This is what seems to me to have happened. In London there has been a successful first move to primary angioplasty in cardiac centres. The provision of that service requires a significant level of throughput to the cardiologist whose job is to undertake primary angioplasty. There are nine centres in London. There is therefore a trade-off between the necessary level of throughput and access. It is not possible for a large
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number of emergency departments or hospitals to offer primary angioplasty, because there would not be enough cardiologists, catheter laboratories and the like.

I do not think NHS London realises that it can take a completely different approach to thrombolysis for stroke. I believe that, given that most full-service accident and emergency departments have a protocol providing for immediate access to the next available CT scan and given that CT scanning is available at whatever time of day might be involved, they should be capable of offering a hyper-acute service.

Kate Hoey (Vauxhall) (Lab): I entirely agree with the hon. Gentleman about the arbitrary nature of the proposed number of acute units, and I hope that that will be reconsidered. Has not another issue been overlooked? The millions of people who come into central London during the day, including tourists, will also be affected by the proposed arrangement. It seems even more arbitrary that Guy’s and St Thomas’, which is in the heart of central London and has one of the best units in the country, may be left out.

Mr. Lansley: The hon. Lady will know from what I have said that I entirely agree with her.

Mr. Andy Slaughter (Ealing, Acton and Shepherd’s Bush) (Lab): The position is actually worse than the hon. Gentleman and my hon. Friend the Member for Ealing, North (Stephen Pound) have said. It is true that the Ealing stroke unit is closing and that Charing Cross will then be the nearest unit, but in two years’ time it will move to St Mary’s, which will make travelling even more inconvenient and will place the unit in a less appropriate location.

Mr. Lansley: Both the hon. Gentleman and the hon. Member for Ealing, North (Stephen Pound) have mentioned Charing Cross, which is also relevant to the way in which stroke services can be organised for thrombolysis. If CT scanning is available, there is no need for a radiologist on site to provide the necessary diagnosis. I have visited Charing Cross and seen a bank of radiologists providing a 24/7 service. Digital transfer of imaging means that there is no reason why images cannot be sent across London, or indeed across Britain, to a team of radiologists who can provide the diagnosis that is necessary for someone to decide whether thrombolysis is appropriate. I am told that the application of thrombolysis itself is not the most difficult part. The part that must be got right is the speedy interpretation of a CT scan so that the nature of the stroke can be determined.

Mr. Andrew Dismore (Hendon) (Lab): The hon. Gentleman referred to the question of the Royal Free. Because I was concerned about it as well, I asked the Royal Free about it, and was told that it had accepted the proposals. It said that it had

Mr. Lansley: The hon. Gentleman will recall that I visited the Royal Free about seven weeks ago and had a conversation there. I shall rest on my view that as it
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provides one of the highest-quality stroke services in the country, there is absolutely no reason why it should not continue to offer a hyper-acute stroke service through its emergency department. That is entirely a matter for the Royal Free. If it does not want to do it, that is fine. I merely say that the commissioners should encourage it to do it, because it will be better located for the purpose in relation to the population of north London if, for example, Barnet and Chase Farm choose not to offer the service.

Mark Hunter (Cheadle) (LD): May I take up the hon. Gentleman’s point about provision across the country? The last few Members who have intervened have referred exclusively to London issues, but I suspect that the hon. Gentleman will be the first to accept that the inconsistency of provision and the time that it takes to travel to hospitals to access this specific form of care are crucial in all parts of the country. In my area of Greater Manchester and my constituency of Cheadle we have local hospitals, but we face the same issues of access. We know from the Royal College of Physicians just how many more lives could be saved if travel times were shorter and access more readily available. Does the hon. Gentleman agree that we have a long way to go before we can be content with the consistency of access arrangements across the country?

Mr. Lansley: I do agree, and I think that significant variation is one of the issues on which we should focus. As the hon. Gentleman will know, Manchester has set about the task of reconfiguring its hyper-acute stroke services at a much earlier stage than other areas. I think that it, too, is beginning to realise that it may have unduly restricted the number of centres that should offer such services. There was an attempt to focus the whole of Manchester on Salford Royal hospital. I hope that it will be established that, as time goes on, other hospitals can and should provide those services.

There is, however, a risk. The Manchester proposals were based on the proposition that patients going to Salford Royal for hyper-acute care would be there for no more than a day or two, and would then be immediately transferred to their local stroke units for the remainder of their acute stroke care. That returns me to the issue of incentivisation. Such an arrangement is fine in circumstances in which, through the tariff, there is a clear distinction between the cost of the hyper-acute service and the cost of the other acute services. We fought a battle for a long time and secured, in the latest version of the tariff, the ability to “unbundle” it into the acute care and rehabilitation phases. If we are to support hyper-acute services, it is equally important for us to unbundle the tariff in order to separate hyper-acute services, including thrombolysis, from other forms of acute care, including care provided for patients for whom thrombolysis is not appropriate. That is not happening at present, and it needs to happen. I urge the Minister to bear in mind that it is important for the stroke team to get it right.

Before I leave the issue of variation, let me say that it remains a matter of considerable disappointment that stroke services in Wales appear to be consistently poorer than those in England or Northern Ireland. Scotland is not included in the central audit. As I said earlier, the
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figure for England has risen to 73 per cent., while the Welsh figure is 58 per cent., which is poorer than the figure in the 2006 audit. The rate of improvement in Wales over those two years has been lower than that in England.

One glimmer of hope in Wales is the pace at which physiotherapy services have improved. Members of the Welsh Assembly clearly wish to make progress. Speaking from over the border, as it were, I hope that Welsh Members—none of whom are immediately available—will receive the message, and, given that this is a devolved matter, will speak to their Welsh Assembly colleagues about it as a matter of urgency.

I do not want to go on too long because other Members want to speak. I will just make one or two more points. It is important that we continue to ensure that the National Institute for Health and Clinical Excellence guidelines on stroke care keep pace, as it were, with what the central audit is telling us and what the Royal College of Physicians guidelines tell us about the best available treatment. If we are going to mainstream the national stroke strategy throughout the NHS, we must ensure that NICE guidelines clearly set out what is the most cost-effective treatment and the most clinically effective treatment—often with stroke, those two things turn out to be the same—and that commissioners take responsibility.

It is also clear that most primary care trusts across the country have been commissioning stroke services on the basis of cost and volume and not taking sufficient account of quality. We need to think creatively about how to develop the tariff, not only unbundling it in the way I described, but applying it to the whole care bundle, so that the PCTs or other commissioners are able to ensure that they are clear that they are contracting for a standard of service, with quality indicators built into the services that they buy.

Sir Nicholas Winterton: My hon. Friend has mentioned primary health care. Where does he think general practitioners lie in this matter and in the stroke services strategy? Often, symptoms of a potential stroke display themselves over a period of time, before a stroke occurs. What is the role of GPs? Are they linking with other professionals to deal with it? Perhaps medication can be prescribed, which has not been mentioned so far in the debate, to prevent a stroke from taking place. That can often be in the hands of a GP.

Mr. Lansley: I am grateful to my hon. Friend for that intervention. He makes a good point. It is probably fair to say that, while quite a lot of GPs have taken a close interest in the development of stroke services over the past four or five years, others are still tending to cling to the view that, broadly speaking, people have strokes and the resultant level of disability is not likely to be much influenced by the speed of or access to treatment. However, we now know that speed and access to treatment can make a big difference. That is certainly true, especially for transient ischaemic attacks. The likelihood of someone who has had a TIA having a major stroke in the next four weeks is about 20 per cent. Often it is GPs who are aware that someone has had a TIA. Therefore, it is
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important for them to ensure that people then get access through the TIA clinic to proper treatment, including anti-coagulation.

Likewise, it is important that there is a seamless pathway of care. As my hon. Friend will know, we believe strongly that GPs should be much more instrumental in commissioning the care, given that they are aware of its quality. By virtue of that, they should be responsible for the subsequent delivery of rehabilitation and support in the community. Too many stroke patients who have been to see us at the all-party group feel that when they return to the community after hospital treatment it is as though they have fallen off a cliff edge. Services need to be joined up. There are various way we can do that, but the role played by GPs would be a big help.

Ann Keen: Would the hon. Gentleman therefore congratulate the Government on introducing the NHS health check programme, which started in April? As hon. Members have pointed out, it is about prevention. The programme has the potential to prevent, on average, over 1,500 heart attacks and strokes and to save at least 650 lives a year. I am sure that he would like to welcome that.

Mr. Lansley: Yes, I was about to discuss prevention. I am sure that the vascular risk assessment will provide a significant benefit in identifying people for whom there is scope for prevention. It would be helpful, when the Minister speaks about the number of lives that will be saved if the Department had responded to my requests for the supporting data to be published to justify those figures. I am sure that, now that she has mentioned them in the House, all the data to support those figures will be published.

There is still a job to be done in understanding, if people access vascular risk assessments, what the appropriate follow-up will be. We must be sure that we do not have a lot of people who become “worried well”. They may need an improved diet or physical activity—hopefully, they will not need medication to which they do not have access. We must ensure that the necessary resources to support primary prevention are put in place.

On prevention, an NOP poll from October last year showed that nearly one in five of the public still had no knowledge of the causes of stroke. It is important that we address that. There is good evidence to study. The World Health Organisation Monica—multinational monitoring of determinants and trends in cardiovascular disease—study published in The Lancet Neurology in 2005 made it clear that if we are going to improve stroke care

Therefore, the argument that we have often discussed here about the reduction of inequalities involves not just health inequalities in isolation—classic socio-economic determinants of health are important in determining the level of stroke mortality.

It is also important, and we can now see the benefit coming through, to note that one of the lessons of that study was that the


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What does that mean? I think that it means that by educating people in the NHS and beyond about the causes of stroke, its symptoms, the necessity to treat it as a medical emergency and the possibility of being able to impact positively on it through treatment, we are making people more aware of the risk, the disability, the mortality associated with stroke and the fact that they can do something about it. That will, I hope, make a big difference to stroke mortality.

We need to improve outcomes. It is not that we spend less on stroke; we spend a lot on it. However, for too long too much of what we have spent has been expenditure as a consequence of the disability that results from strokes. Too little has been spent to ensure that we prevent stroke and that where stroke occurs we access treatment rapidly.

There are still significant disparities between treatment in this country and in others. There is still more we can do. It is not just about thrombolysis. It is also about early supported discharge. Only about a third of patients get access to early supported discharge after a stroke. We need that figure to rise. There is a continuing agenda, which we will continue to support and press for to improve stroke services and make their quality more consistent across the country. I hope that through prevention and awareness of stroke, stroke outcomes will further improve in the years ahead.


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