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What has changed over the past few years with stroke? It has gone from being a condition with chronicity to one that is seen as existing within the acute sector. It has become a medical emergency; of course, it always was, but it was not recognised as such. Unfortunately, as the Stroke Association observes, it is still not necessarily seen as a condition that requires immediate treatment and managementneither by potential patients nor,
sometimes alarmingly, by health care professionals on the front line. That has been clearly shown by NOP and MORI polling over the past few years.
Since the figures came out in October 2008, we have had the Department of Health campaign. We have all seen the television adverts that are part of that, which have been extremely good. The images are disturbing, but it is sometimes necessary to be fairly hard-hitting in order to change attitudes and behaviour. We will have to see whether the effects of that campaign are enduring. I was concerned to hear the hon. Member for Crawley, who has some experience in these matters, suggest that in a few years time, when the funding runs out, we might simply move on to the next hot topic. Our approach needs to be a bit more long-term than that. As we have seen with road traffic campaigns, there is a danger that when we go on to the next topic we forget the public health messages that have been put across effectively, at least in the short term. That would be a great pity in the context of stroke. There have been a few measures of the campaigns effectivenessfor example, the Stroke Association has said that it has had more inquiries since the campaign kicked off in February. However, I should like the Minister to clarify what assessment the Government intend to make of its enduring effectiveness, which would, I hope, inform any future campaigns.
If we are serious about public health and dealing with health inequalities, we have to address stroke, which is far more prevalent in less advantaged groups in our society, as well as in certain ethnic groups. We need to try to work out why that is and put in place measures to reduce that inequality. In my intervention on the Minister, I mentioned the effects of stroke on the rural poor. It is bad being poor, but it is particularly bad in a rural location where access to services is extremely difficult. Following my intervention, and that of my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), I wonder whether the Minister has had any note from the Box about upgrading stroke from category B to category A, which is being considered by the Departments emergency call prioritisation group; if not, perhaps it would be possible to communicate separately on that subject. Such a step might be a way of improving access for people with stroke who live in rural areas.
There is evidence that someones chances of optimal management for stroke are best if they arrive at hospital by ambulance. However, according to the sentinel audit, only 17 per cent. of patients reach a stroke unit within four hours of arrival at hospital. I suspect that further work needs to be done in accident and emergency to improve triage and expedite the definitive management of stroke patients. That appears to be especially required at weekends, as, crucially, the chance of getting a scan, and therefore definitive treatment, is very much less out of hours.
Bob Spink (Castle Point) (Ind): The hon. Gentleman is making an excellent speech. A brain scan should take place within three hours, and it will determine the outcome for stroke victims, so it is absolutely essential. Will he at least give the Government credit for their policy of trying to ensure that stroke victims get taken by ambulance straight to a specialist centre rather than to a general hospital so that they can get that treatment early, which will improve outcomes for them?
Dr. Murrison: I am grateful to the hon. Gentleman for his intervention. I will deal with the question of specialist units versus district general hospitals in the remainder of my speech. However, his remarks spark me to reflect on the change in radiological protocols that has occurred in recent years. There has been a strong trend towards reducing the amount of elective work that is done out of hours. For example, it is now difficult to get a chest X-ray out of hours unless it is a real emergency, and very few are defined as emergencies requiring imaging. That is fineit is absolutely rightbut I sometimes wonder whether we have gone a little too far. I suspect that as part of the process, there is less willingness to do CT scans on stroke patients out of hours. We need to look again at our protocols to ensure that a medical emergency is investigated as such, 24/7.
Harry Cohen: The hon. Gentleman made a good point about the need to improve triage at the hospital to which a patient is taken, including at the weekend. Although there has been an improvement in ambulance services, does he believe that one missing element of the stroke service is a review of whether we can get further improvements, so that ambulances get to patients quickly and get them to the main centres quickly? Does he think that there is a case for that?
Dr. Murrison: Yes, and I understand that the Ministers Department is doing that work at the moment. It is reviewing whether we should upgrade from category B from category Afrom 18 minutes to nine minutesthe response time for stroke cases. It will be interesting to learn the outcome of that work. I suspect that part of the reason for the effectiveness of arriving by ambulance rather than under ones own steam, and the likelihood of getting prompter treatment when arriving by ambulance, is that triages are undertaken by ambulance crews. They are therefore able to warn specialist stroke units that a patient will be arriving. Across a range of clinical areas we find that such warning expedites admission to specialist units, as patients do not have to go through the sieve of accident and emergency and the inevitable delay that is caused. I have some first-hand experience of that.
Stroke services are somewhat patchy across the country. A postcode lottery applies, despite the fact that we have a national health service. The Stroke Association is concerned about that, as is the Royal College of Physicians, and the sentinel audit underscores that concern. In my own area, I find to my delight that according to the audit, the Royal United hospital and Salisbury hospital are reckoned to be good. However, my constituents go much further afield on occasion, and I find that Yeovil, Bristol, Weston and Gloucester are okay, but that Taunton and interestingly Swindon have much room for improvement.
I caution against the evidence that has accrued about the use of specialist centres being used to favour large centres at the expense of district general hospitals. Stroke is not an obscure disease, it is a condition that strikes somebody in England every five minutes and the third most common cause of death in this country. The hon. Member for Hendon (Mr. Dismore), who is no longer in his place, talked about critical mass, which is important in the case of tertiary services. Nobody doubts that a patient should go to a tertiary unit for obscure
conditions. Stroke is not unusual, it is bread and butter for district general hospitals. If it were removed from their responsibility, one would wonder about the foundations of the district hospital model. Quite honestly, a condition that causes the third most deaths in this country and sadly provides a patient every five minutes in England must be part of the underpinning of any acute service and part of its bread and butter.
The investigation and treatment of stroke is not particularly complicated. In saying that, I do not underplay in any way the expertise of those who specialise in it. It relies upon a CT scannerwe are working towards a position where pretty well every hospital will have oneand access to telemedicine. In other words, a particular hospital does not necessarily need a specialist, because the information can be relayed and, crucially, a diagnosis made in that way. The treatment itself should not be beyond any acute unit in this country.
Mr. Lansley: My hon. Friend will not have had an opportunity to look up the figures before responding to the hon. Member for Castle Point (Bob Spink), but the latest figures in the sentinel audit clearly demonstrate that Southend hospital had the best results anywhere in the east of England.
Dr. Murrison: I am sure that the hon. Gentleman will have noted that with some pleasure.
We need to be careful about using a Darzi extrapolation to the point where we lose immediacy and patient access. I speak as somebody who represents small towns and a rural area in Wiltshire. So far as I am able to gauge my constituents wisheswe have all had some opportunity to gauge interest on a range of subjects over the past few daysit seems to me that what they want is local services, locally provided, unless there is very good reason why not. Our national health service should be designed around their needs and wishes rather than necessarily the convenience of practitioners or how they want to operate.
Stroke is a good case in point, because there is no real reason why we cannot provide both diagnosis and treatment in a specialist context within district general hospitals. It would be a real pity if we were to rusticate stroke services to our great clinical cathedrals in our larger urban centres. London has been discussed at length today, and those services should not be restricted to a small number of hyper-acute units in the capital.
Mr. Andy Slaughter (Ealing, Acton and Shepherd's Bush) (Lab): I shall begin by talking about some improvements in stroke services. From that, my hon. Friend the Minister can see where my speech will go towards the end.
I make no apology for continuing to talk about London services, the increased investment in which is welcome. There has been £23 million of additional spending on stroke services, as my hon. Friend the Member for Hendon (Mr. Dismore) said. There is a predicted increase in survival rates of some 25 per cent. Notwithstanding the fact that, as he said, some deliberate misinformation has been put about by Opposition partiesI shall say something about that in a momentit
is interesting that all parties have taken on board the central point about the creation of hyper-acute stroke units.
I tend to agree with what the Opposition have said about the strict adherence to numbers. The idea that specialist stroke treatment will be a major factor in saving lives over the next few years was initially received with some scepticism, but in the light of overwhelming clinical evidence it has now been widely accepted, which is a good thing.
Like others, I pay tribute to my hon. Friend the Minister for her contribution, not only in her professional capacity and as a Minister but as my neighbouring MP. I was very pleased to celebrate the 60th anniversary of the NHS with her late last year at Charing Cross hospital, where she herself has worked and in which she continues to have a great interest and support me. The Minister of State, Department of Health, my hon. Friend the Member for Exeter (Mr. Bradshaw), who was briefly in his place, has been extremely helpful with regard to the difficulties that I have experienced in the current consultation.
Finally, I pay tribute to the Stroke Association, which others have mentioned. It has done an excellent job in its recent report and in encouraging the Government and giving them praise where it is due. I do not say that only because when its staff were testing blood pressure in Portcullis House last month, they said that I had the blood pressure of a young man. I think is the only thing that I can claim to have about me that is of a young man.
The current consultation ended on 8 May, and it has been mentioned several times this afternoon. The matter has been shockingly handled by Healthcare for London. I shall start by dealing with my simpler concern: the stroke unit at Ealing hospital. If the current proposals are implemented, that stroke unit will be closed. When I spoke to the neurologists and other professionals at Ealing, I found it was envisaged that the alternative provision would be at either Northwick Park or Charing Cross hospitals. Things have now moved on, and there is a worse plan. However, even at that stage, there was serious concern and some astonishment at such a proposal. I could speak for a long time about that one issue, and I am sure that other hon. Members could present arguments for hospitals in their constituencies or those nearby, which their constituents use extensively.
Ealing hospital stroke unit provides good care, has just been refurbished to a high standard and is in the top 25 per cent. of stroke units in the country. It is by no means clear from the current proposal how the many people from the borough of Ealing and around who use the unit will be accommodated in future. There is no evidence that the capacity problems arising from the stroke units removal will be picked up by the alternative proposals. However, at least the proposal for Ealing is clear. The unit is to close and there is to be alternative provision. I repeat that the case for the need to hone provision to eight units and the case for their location have not been well made, but at least the decision is clear, if incorrect.
The position of Charing Cross hospital, which is just outside my current constituency, but extensively used by my constituents, is far from clear. There is a proposal
no longer to have one of the new hyper-acute stroke units there in the longer term. To avoid doubt and to be brief, I can do no better than read out part of my submission to the consultation. I said:
I do not accept that this consultation has been properly or transparently conducted and I believe the outcome of itcertainly as far as it affects my constituentshas been pre-determined.
The right hon. Member for Chingford and Woodford Green (Mr. Duncan Smith) made that point earlier. My submission continued:
I remain hopeful that I am wrong in this surmise, but if I am not I hope there may be some challenge, legal or otherwise to the proposals Healthcare for London are currently recommending for Charing Cross Hospital.
Specifically, there is no clarity as to the process by which the preferred location of the fourth major trauma centre was switched at short notice from Charing Cross to St. Marys Hospital. This having been done however, there is a preferred option for St. Marys stated in the document with an attached footnote that the transfer of the hyper-acute stroke unit (HASU), currently proposed for Charing Cross, will in the space of two to three years follow the trauma centre to St. Marys. I have spoken to clinicians at Charing Cross who believe this is the wrong course of action both in clinical and geographical terms. But this aspect of the proposal does not appear to be open for discussion. Rather it is the settled view of Healthcare for London that co-location is the sine qua non in deciding the location of this HASU.
I do not see how Healthcare for London expect serious responses to such proposals which have all the appearance of being last minute, botched and above all so closely interconnected as to be incapable of being unravelled. I do not think the logistics of moving stroke and neurology services from Charing Cross to St. Marys have been properly studied: the site, the funding and the relative size and importance of the clinical units at both hospitals strongly suggest the better option is building on the excellent provision currently at Charing Cross.
I would like to be reassured that if as expected a HASU opens at Charing Cross later this year, if the proposal to move this to St. Marys in 2012 or shortly thereafter is pursued there will be a full and impartial consultation at that time.
The well respected and extensive stroke services at Charing Cross were to be combined with one of the major trauma centres for London, but the quality of the trauma bid was apparently not good enough, as was the case with the Royal Free, in which my hon. Friend the Member for Hendon has a constituency interest. Rather than those two bids being resubmitted, at short notice the trauma centre bid was switched to St. Marys and that is now the preferred bid. It has been admitted to me in several meetings with health care professionals, the hospital trusts, the primary care trust, Healthcare for London and, indeed, the Under-Secretary, that it is a done deal: St. Marys will be the trauma centre.
Suddenly, as an afterthought, and done by asterisk and footnote in the consultation document, and clearly because the co-location proposal is sacrosanct, the stroke unit at Charing Cross, which is currently being prepared and will open, function and doubtless be extremely good for two years, will somehow move to the St. Marys site, which is inappropriate. There is no provision for it and clinicians to whom I have spoken doubt whether there are funds for it. The proposal is a dogs breakfast, for want of a better phrase.
There may be a guarantee of further consultation in future. That is not good enough. I have made the point strongly to the chief executive of Healthcare for London that no proper consultation has been carried outthat
is clear from the documentand the matter needs to be revisited. Clearly, decisions have been made and put out for consultation thereafter.
One of the unfortunate side effects is the mischief that can be made, and mischief aplenty has been made with the future of Charing Cross hospital for more than four years. It is a perfect site for a hospital; it is perfectly accessible. The decision affects not only constituents in Hammersmith and Fulham and Ealing but those in the entire London boroughs of Hounslow and Ealing and the wider area of west London, to whom Charing Cross is far more accessible than St. Marys. The site is large, with plenty of room for redevelopment, which is already taking place. However, the botched decisions, the poor quality of decision making and the lack of information allow mischief to be made.
There have been persistent rumours of downgrading or closure since 2005. The hospital was a major issue in the general election campaign. It suits the Conservative party locally to continue to keep those rumours alive and I have therefore been in conversation and correspondence with successive Health Ministers since I was elected to get assurances about the future of Charing Cross hospital. Those assurances are freely and readily given, and I have a copy here of the latest letter from the chief executive of NHS London, which is dated 29 May.
The letter states that even if the hyper-acute stroke unit moves in due course from Charing Cross, the
stroke unit at Charing Cross hospital will be enhanced to deliver high quality stroke services for the people of Hammersmith and Fulham. We expect Charing Cross to retain a full range of services as a busy hospital for local residents maintaining its prominent position in the community.
The letter goes on to say that the hospital will provide
a broad range of elective specialist services, as well as emergency services with the associated medical specialties, and an active A&E. It will continue to provide neurology and stroke services, including post 72-hour stroke care, rehabilitation and outpatient services.
The chief executive could have added that one of the largest and most ambitious polyclinics is being built there, with a full GP practice on the side, in addition to many other new buildings, including the highly prestigious Maggies cancer centre, which was visited by Sarah Brown and Michelle Obama on the Presidents recent visit. There is therefore no question but that Charing Cross has a bright and expanding future, with or without the hyper-acute stoke unit and trauma centre. Again, let me make it clear for the record that the Government are to be praised for that investment. In addition, since the formation of the Imperial College Healthcare NHS Trust and the Academic Health Science Centre, the prospects for health care in west London have never been better.
However, the chief executive and the Minister can write as many letters to me as they wish, but what my constituents believebecause they are told so every fortnight in the only local newspaper in wide circulation, which is controlled by the Conservative councilis that Charing Cross is being downgraded or closed. That is deliberate disinformation, exactly as my hon. Friend the Member for Hendon said, put out with mischievous political intent by the Conservatives. However, they would not be able to do so were it not for the administrative confusion, complacency and lack of attention by health service managers in London.
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