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The 10-year national strategic framework is coming to an end but as yet we have no firm commitment from the Government to extend the strategy for a further 10 years. The British Heart Foundation, the Stroke Association,
the British Cardiovascular Society and the Royal College of General Practitioners and many other smaller organisations which belong to the coalition would like the Government to give a commitment to the strategy. The 10-year mental health strategy has been renewed. Why cannot the framework strategy for cardiac and vascular health be renewed in a similar way? I await the Ministers response to the letter that I recently sent her on that point.
Cardiovascular diseases, which include heart attack, stroke, diabetes and chronic kidney disease, affect the lives of more than 4 million people in England, cause 170,000 deaths each year, and are responsible for about one fifth of all hospital admissions. The challenge posed by those conditions is stark. Cardiac and vascular disease remains the No. 1 cause of death and disability in the United Kingdom, and strokes alone are the UKs third biggest killerthe second biggest if each type of cancer is counted separatelyand the single biggest cause of severe adult disability. To our continuing embarrassment, the death rate for coronary heart disease and stroke in men and women is still higher in the UK than in comparable western European countries, and some risk factors for cardiovascular diseases, particularly obesity and a lack of physical activity, are increasing. On current trends, 60 per cent. of males and 50 per cent. of females will be obese by 2050, and, if unchecked, it is predicted that that will lead to a massive increase in type 2 diabetes, with the current trend indicating that more than 4 million people in the UK will have the condition by 2025. That, of course, will result in a large increase in the number of patients who require medication to prevent cardiac and vascular events.
I welcome the national stroke strategy, which was launched at the end of 2007. Two central elements of the strategy are that patients should be admitted directly to a unit capable of undertaking immediate CT scanning and, where appropriate, undergo thrombolysis. It is absolutely crucial, as many contributors to this debate have said, that stroke victims are seen as quickly as possible. In that regard, I think that FAST, the new TV campaign, which has been mentioned on many occasions, has been successful. I commend the Government on their initiative in that regard.
There is no doubt that, on the whole, hospital-based stroke services are improving and more stroke survivors have access to long-term care and support in the community. Yet, despite those developments, stroke services throughout England remain patchy and in need of considerable improvement. Sustained financial and political investment is therefore essential to maintain the momentum behind improving services that the strategy created.
Rehabilitation and long-term support in the community remain the weakest element of the pathway for many stroke survivors. Previous investigation has found that only about half the individuals who experience a stroke receive rehabilitation that meets their needs in the first six months following discharge from hospital, with the figure falling to one fifth of individuals in the following six months. The Healthcare Commissions 2006 stroke patients survey showed that one year after discharge, more than halfabout 54 per cent.of patients said that they had not received any home help; that one third, or 32 per cent., had not received help with personal care; and that 45 per cent. had not received help with applying for benefits.
I should like to put two questions to the Minister. First, what progress is being made in ensuring health and social care services work together to provide stroke survivors with a seamless transfer of care from hospital to the community? Secondly, what progress has been made in providing high-quality specialist rehabilitation and support for as long as a stroke survivor requires it?
It is generally accepted that the Royal College of Physicians national sentinel audit of stroke has provided an extremely useful tool for monitoring the implementation of standards and improvements in services in the acute sector, but there has not been a similar focus on monitoring community services for stroke survivors. Is it therefore the Governments intention to consider funding an extension to community stroke care of the RCPs auditing process?
The operational plans for 2008-09 to 2010-11, entitled National Planning Guidance and vital signs, require PCTs to implement the stroke strategy. Monitoring will include, first, the number of patients who spend at least 90 per cent. of their time on a stroke unit and, secondly, the percentage of high-risk transient ischaemic attacks, or mini-strokes, that are treated within 24 hours. I am pleased to say that NHS Cambridgeshire, my local primary care trust, has responded positively through its newly published strategy. Indeed, as many contributors to this debate have emphasised, a key part of the strategy is prevention.
NHS Cambridgeshire recently began a specific initiative in the 20 per cent. most deprived practices to implement vascular risk checks and proactively identify more people with risk factors for CVD who will then be added to the CVD risk register. It intends to offer practices a range of options for providing vascular risk checks to those people aged 40 to 70 years old, ranging from practices managing the vascular checks in their entirety, to working with a health adviser and community pharmacy-based provision.
There is no doubt in my mind that in community pharmacies we have a fairly universal and readily accessible professional resource that could play a key role in an NHS health check programme. I strongly believe that community pharmacies could play a vital role in the battle against stroke by, for example, providing a regular blood pressure and cholesterol test. That new role seems to have been actively encouraged by parts of the NHS, but not universally. Some PCTs seem reluctantthrough ignorance, professional opposition, lack of focus or simple tardinessto embrace its great potential. I am delighted that NHS Cambridgeshire has alluded to the potential role of pharmacies, but it requires more than just a reference in a strategic document. A commitment to driving the concept through at ground level is vital, and I, for one, will monitor the PCTs progress.
The PCTs strategy also means that patients will be identified with risk factors using the Framingham method, including those with post myocardial infarction and those with transient ischaemic attacks. It means also that patients alert will be utilised for GPs, indicating when preventive measures are required, in line with National Institute for Health and Clinical Excellence guidance. The PCT will continue to make the links to smoking cessation services, with a guaranteed recording of data on lifestyle and outcomes, and it will work with
the public health directorate to support prevention messages, particularly in disadvantaged areas and groups. It is also vital to make appropriate links with the cross-government strategy for tackling obesity and with prevention work, in line with vascular checks. Finally, the PCT intends to roll out the scheme in the most deprived practices first. That will be of most benefit to my constituency of North-East Cambridgeshire, which has some of the highest deprivation indices in Cambridgeshire.
The Government say that they are committed to evaluating the implementation of the stroke strategy, but how do they plan to evaluate its implementation, when will the Department of Health commission an evaluation of progress of health, what form will it take and when can we expect the results to be made public?
In conclusion, stroke services are improving as a result of the stroke strategy, but there is still a long way to go to meet the standards contained in the 20 quality markers. Progress has not necessarily been made at the same rate throughout the country, and, in order to maintain and build on the achievements that have been made so far, continued investment will be required. In that regard, what plans do the Government have to ensure that improvements continue to be made after the current three-year funding round ends? How will the Government ensure that stroke remains a national priority?
Kate Hoey (Vauxhall) (Lab): I am very pleased to be able to make a short contribution to the debate. I also welcome the expertise that was so clearly demonstrated by my hon. Friend the Minister, by the shadow Secretary of State for Health, the hon. Member for South Cambridgeshire (Mr. Lansley), and by my hon. Friend the Member for Crawley (Laura Moffatt).
I speak not with any expertise in the matter, but as someone who has spent some time at their local hospital, Guys and St. Thomass, and received valuable advice from Dr. Tony Rudd. I am well aware that I am not an expert in the same sense as some of those who have already spoken, but, as a London MP, I want to look at the consultation in Londonthe Healthcare for London consultation entitled The Shape of Things to Come. I welcome much of it and believe that it is in line with the Governments excellent prioritisation of stroke services. To that extent, I welcome again the national stroke strategy and the work done by the all-party stroke group and the Stroke Association. I particularly welcome the dedication shown by the Under-Secretary of State for Health, my hon. Friend the Member for Brentford and Isleworth (Ann Keen), to the issue; it is great to have a Minister who has had hands-on experience of working in the national health service.
As we all know, we need to develop new, high-quality stroke services in London. There are inequalities that need to be addressed, and the document will have addressed many of them. The problem arises when I come to consider my own area and the rest of south-east London. At the moment, Kings college hospital and St. Thomass hospital have very good stroke units. Kings college London, the Maudsley, Kings college hospital, Guys hospital and St. Thomass hospital are working in an admirable way; they are doing hugely valuable work right across London.
Kings college hospital and St. Thomass hospital, together with their academic partners at Kings college London, have a long history of collaboration on stroke services; that will inevitably increase as a result of the successful accreditation of Kings Health Partners as an academic health science centre. The collaboration has included the primary care trusts of Lambeth and Southwark, encompassing the full pathway of stroke care, including out-of-hospital care. The two hospitals have consistently been among the highest scoring in the Royal College of Physicians national sentinel stroke audit, including the most recently published report of April 2009.
Under the proposals, there would be one large hyper-unit at Kings college hospital. Like other colleagues who have spoken, I genuinely cannot understand the rationale for going for the strict decision in favour of eight large units. As I said, I speak from a common-sense, not an expert, point of view, but to me there is no evidence that the model of very large acute stroke units with 20 to 30 beds and, say, 2,000 to 3,000 admissions a year, is a clinically effective, safe or feasible way of delivering stroke care. It has not been tested anywhere else in the world, and the vast majority of the professionals consulted during the development of the plans favoured a larger number of unitsperhaps 10 to 14 throughout Londonwith fewer beds.
There are concerns that big units will not make sense when so few people in London receive high-quality acute stroke care. The interim period, during which the eight high-quality units will be developed, will be a long timea minimum of three to five years, according to what I have been told; I am thinking particularly of the units that were not established beforehand. With the best will in the world, units designated for eventual closure are bound to suffer planning blight and will quickly deteriorate to unacceptable levels through the loss of good staff to other centres and the failure to recruit new staff.
The good units that we have at the moment will be needed to help, support and develop the increased new units. However, that will get more and more difficult if there is not the necessary flexibility, particularly if anything goes wrong or if there is a surge in demand.
Harry Cohen (Leyton and Wanstead) (Lab): My hon. Friend is making a good point. Does she agree that if a lot of investment has to go into the eight major centres, there is a danger that other, more local hospitals that have not been chosen to be hyper-units, but run good acute centres and transient ischaemic attack, or TIA, services, could be starved of the cash necessary to maintainor, indeed, improvetheir services as the money goes to the hyper-units? Is that a danger?
Kate Hoey: I welcome the increased investment that the Government are putting in, but the danger to which my hon. Friend refers is there. There is always a danger that large super-duper elements in any provision will tend to take away from what most people want, which is good local services.
I go back to the point about central London that I made in an intervention on the hon. Member for South Cambridgeshire. The consultation documents calculations for all the bed requirements do not take into account the non-resident population of Londonthe huge numbers
of commuters from outside the city, the tourists and so on. The majority of those people come to central London. That is not to say that we do not need to improve radically the services in outer London areas, but I do not see the rationale for getting rid of the really good unit in central Londonin the critical area of St. Thomass, with its access to railway stationsto create something bigger elsewhere. Kings college, Guys and St. Thomass hospitals are already working together, and they want to do so.
There is a need for a radical approach to modernised stroke services in London, and much in the proposals is excellent. For example, this is the first time that standards have been set with clear requirements on the providers to deliver appropriate staffing levels. The issue, however, is about the actual model that has been chosen for London; that needs to be considered again. The people who are already working well in those hospitals and really know what is happening have not been listened to enough. NHS London needs to listen to the professionals, not entrench itself in what seems to be a fundamentalist approach. The approach needs to change; the primary care group that makes the decision in July needs to go back and make sure that it has listened and understood what is happening in the units that already do extremely good work.
St. Thomass serves diverse communities, which are more likely to be in need of a stroke unit. It also deals with commuters and all the tourists who come to central London. It has the expertise. The idea is to let that go to create a bigger unit at Kings college hospital. Why do we not allow the two hospitals to plan and work out together what is in the best interests of the area? I hope that those making the decision at the end of the consultation will listen. If I had to choose between the expertise of Dr. Tony Rudd and that of members of the primary care trust, I know whom I would support.
Dr. Andrew Murrison (Westbury) (Con): I start by recognising the improvements that have been made to stroke services in recent years. There has, of course, been a gradual improvement since the war, but the focus on strokes has increased in the past few years. A great deal of the credit for that must go to our clinical networks, health care professionals and the research community. I say that particularly because 25 years ago I trained in a national health service that did not regard strokes as a particular priority. The hon. Member for Crawley (Laura Moffatt), who is no longer in her place, reflected on the standard of care and the expectations of stroke patients that prevailed at that time, and that put me in mind of the sorts of cases that I came across. It was all particularly to the disadvantage of older people; classically, elderly stroke victims have tended to be put to one side. I am pleased to note that that tends not to be the case these days, but there is perhaps some complacency, and a danger of forgetting that the elderly are still not given the priority that they deserve. Stroke, given that it is classically a condition that is more likely with advancing years, is a case in point.
Having marked the improvement in standards that has prevailed over the past few years, we must also recognise that it took rather a long time for the Government to come up with their national stroke strategysome 10 yearsand it required a bit of prompting by way of
the 2005 National Audit Office report, Reducing Brain Damage: Faster access to better stroke care. I may be a pedant, but I think that the hon. Member for Leeds, North-West (Greg Mulholland) was a little hasty in suggesting that the national stroke strategy had had demonstrable effects. It may well have had, and I suspect that it will be effective, but we must be careful about making premature assertions that are not firmly rooted in the evidence.
Greg Mulholland: I am not aware that I used the word demonstrable. In fact, I was referring to improvements mentioned in the audits, so they come from evidence, not opinion. That is an important point to make.
Dr. Murrison: I am grateful to the hon. Gentleman, but he needs to understand that there is a danger in extrapolating evidence from the sentinel studyI think that that is the one that he was citingwhich came out just a few months after the implementation of the national strategy. Given that it is a 10-year strategy, and given previous trends, it would be extremely rash to suppose that it had had any effect at the time of the sentinel audit. I very much hope that the strategy will prove to be successfulI suspect that it willbut we need to be a bit careful about the language that we use in anticipation of that.
It is important to compare this countrys outcomes and incidence of disease with those nations with which we can reasonably be compared. In this context, I think particularly of western Europe. Standardised death rates from stroke among men under the age of 64 are nine per 100,000 in the UK compared with seven per 100,000 in France. The equivalent figures for women are seven deaths per 100,000 in the UK compared with four per 100,000 in France and in Spain. The UK has some of the worst outcomes for patients in western Europe. In one study, the differences between the UK and eight other European countries in terms of the proportion of patients left dead or dependent were between 150 and 300 events per 1,000 patients. That statistical material is rather technical stuff, but it points towards patients in Britain not doing as well as they have a right to expect, and it certainly suggests that there is no room for complacency.
The Minister spoke about health checks and vascular risk assessments and invited the Opposition to support those initiatives. I have campaigned for many years for screening for abdominal aortic aneurysm, yet despite recommendations by the National Screening Committee we still do not have a credible roll-out of national screening for that particular condition. The Government need to be careful; interventions in the public health sphere, particularly in terms of prevention, need to be based on the evidence, which points towards instituting a screening programme expeditiously. I very much regret that that has not been done.
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