Examination of Witnesses (Questions 1-87)
DEPARTMENT OF
HEALTH AND
ROYAL BOURNEMOUTH
AND CHRISTCHURCH
HOSPITALS NHS FOUNDATION
TRUST
24 FEBRUARY 2010
Q1 Chairman: Good afternoon, welcome
to the Committee of Public Accounts. Today we are considering
the Comptroller and Auditor General's Report Progress in improving
stroke care. We welcome back to our Committee Sir David Nicholson,
who is the Department of Health's Accounting Officer and Chief
Executive of the National Health Service. Could you please introduce
your colleagues Sir David?
Sir David Nicholson: Professor
Roger Boyle, Professor Sir Bruce Keogh and Dr Damian Jenkinson.
Q2 Chairman: As you know, the Committee
has long since taken an interest, ever since the NAO's groundbreaking
Report in 2005. We are very proud of the pressure we have put
on you and obviously you have made progress, so congratulations
on the progress that you have made, although of course there are
still some regional variations and concerns about post-hospital
care, how soon you get a brain scan, all these issues which we
want to investigate with you during the course of this afternoon.
However, congratulations on the progress you have made. What are
the elements of the stroke strategy or the priority given to it
which have enabled you to make good progress?
Sir David Nicholson: The first
thing is that we spent quite a bit of time getting the strategy
right and it took us quite a bit of time to do that. One of the
benefits of that is that we bought in a lot of support from around
the service, from patient groups, from clinicians and from managers
around what was actually required and what was needed. So when
the strategy was finally published it had real buy-in across the
system as a whole and that is really important. The second issue
in terms of timing was that we were able to publish the strategy
just at the time we were doing the comprehensive spending review,
so we were able to use the development of the strategy as an opportunity
to get money through the Treasury in order to support it. Thirdly,
because of that, we were then able to make a national priority
for stroke services. As you know, it is a Tier One priority for
the operating framework and we identified both national money
and local money to support it. They are the things which helped
us make the progress we have.
Q3 Chairman: So it is important that
it is a Tier One priority obviously.
Sir David Nicholson: Absolutely
it is a Tier One priority.
Q4 Chairman: So if that is such an
important ingredient of improving stroke care, why have you not
made dementia a Tier One priority?
Sir David Nicholson: I hopefully
explained that last time and I will explain again. The issue about
the stroke one is that we were able to do it at the time of the
comprehensive spending review, when we identified the national
targets for the next three years. Dementia came after the spending
review and therefore was not part of that process. That is not
to say it will not be in the future, but certainly at this time
in a sense the timing of the stroke review was particularly significant.
Q5 Chairman: If we look at figure
nine in this Report, we can see that there are very wide variations
between regions and hospitals. What are you going to do to try
to bring the performance of the laggards up to the best practice?
Sir David Nicholson: You have
to understand—I am sure you do—that when we started
off people were in very different places. We have to understand
that as we go forward; they were in very different places and
it does take time to get everyone up to those kinds of standards.
What we have done of course is to identify it as a Tier One priority.
As we speak, every PCT is currently putting its plans into the
strategic health authorities by the end of March to set out how
they are going to get to the standards required in the strategy
by the end of 2010-11 and we are supporting it by 28 stroke networks
which Dr Damian Jenkinson is leading as well.
Professor Boyle: We were dealing
with a lot of very different starting points and the issues are
different in different parts of the country. For example, in some
of the urban areas, particularly Greater Manchester and London,
there has been a real process of re-designing how stroke is managed
altogether, which has required public consultation and that takes
time then for the new services to be established. They are now
established in London and Greater Manchester and beginning to
work and we will see therefore substantial improvement.
Q6 Chairman: May I interrupt? You
have this target of 80% of patients spending 90% of their time
on a stroke unit. What sanctions can you impose on units which
are not meeting this target?
Professor Boyle: We do this down
the performance management route, working with the performance
directors in the strategic health authorities. We have added to
that, as from the coming April, a new way of incentivising through
a best practice tariff which will incentivise trusts not only
to do much more urgent scanning but also directly admit patients
into the stroke unit and keep them there for the duration of their
stay in hospital.
Q7 Chairman: Obviously what is absolutely
vital is to have a scan quickly, is it not?
Professor Boyle: Yes; indeed.
Q8 Chairman: If we look a paragraph
2.11 of this Report, we see that 59% of patients are scanned within
a day of having their strokes. That means that a lot of people
are not being scanned within 24 hours, which is very worrying.
Professor Boyle: Yes, that is
where this best practice tariff will also begin to impact. For
those people who present within the time window to be considered
for thrombolysis, therefore requiring an immediate scan, 24 hours
even is not sufficient. We need to be much more ambitious than
that.
Q9 Chairman: We have an excellent
memorandum, as always, from The Stroke Association and we are
very grateful for the work they have done with us over the years
in bringing this to the public's attention. They tell us "In
particular it is unacceptable that only 17% of stroke patients
are admitted to a stroke unit within four hours of arrival in
hospital. There are also continuing problems with access to brain
scanning with only 1 in 5 eligible patients having a scan within
three hours of their stroke". Do you accept their point of
view that this is unacceptable, especially as they were key recommendations
in our Report in 2006?
Professor Boyle: Yes. We do find
that patients are still being migrated into medical admissions
units rather than direct to a stroke unit and this is a major
plank of our work plan for this coming financial year; we are
setting up an accelerated delivery programme to make really sure
we get every single trust across the country. That is absolutely
vital.
Q10 Chairman: Some of these figures
are very alarming. If you look at the two hospitals which serve
my constituents, Lincoln County Hospital and Diana Princess of
Wales Hospital at Grimsby, also serving Mr Mitchell's constituents,
even within these hospitals there is an enormous variation. It
is shocking that the weekday average scanning in the Diana Princess
of Wales Hospital in Grimsby is between 25 and 48 hours. This
means that if you have a stroke in Grimsby or in the rural areas—I
live 14 miles from Grimsby—you might have to wait 48 hours
to get a scan.
Professor Boyle: The importance
of the scan in that early first day is for most patients really
to decide whether they should commence Aspirin or not and there
is a timing issue as to whether it is crucial whether that is
within the first day or day or two. The one thing we really need
to get right is that we need to be scanning the people who present
within four and a half hours or three hours, that sort of time
window, from the onset of symptoms; much more quickly than within
24 hours.
Q11 Chairman: What worries me is
that someone who develops stroke symptoms in this part of London—look
at figure nine, there is even a wide variation within London—I
suspect would have a very good chance of having a brain scan,
even within three hours, but somebody living in Lincolnshire might
have to wait up to 48 hours. What would you say personally to
somebody you knew had had to wait over 24 hours for a brain scan
and as a result was disabled for the rest of their life?
Professor Boyle: It happened to
my sister. I have had personal experience with a family member
who had the same difficulty. It is not acceptable in the long
term, but it does require a big culture change and that is difficult
to bring about in the National Health Service. If you take the
East Midlands in particular, Lincoln is a focus to become a hyper-acute
centre as the East Midlands plan unrolls, but that has taken a
lot of consultation, which is still not quite complete across
the East Midlands, to make sure that this new model of care for
the East Midlands is put into place. Grimsby is an outlier which
we recognised and picked up in our research before coming to this
Committee. We know that there is still plenty of work to do to
get consistency. My experience in doing similar work in the heart
programme, dating back to 2000, was that it takes up to five years
before you can really get that consistency across the piece and
then have it embedded and sustainable over future years. We now
have that in the heart programme and I think we have to accept
that it takes time for some of these organisations to catch up
with the pace of the best.
Q12 Chairman: Let us look at all
the support services after you leave hospital. This is very varied
as well. If we look at pages 35, 36 and 37, this is very patchy,
is it not? Why have you allowed support services to remain such
a lottery around the country?
Professor Boyle: Because that
is the most difficult bit of the pathway to deal with. While there
is variation in the provision of services on the acute side, we
have seen ever more variation in the long-term support services
and the long-term rehabilitation. We have certainly had issues
of human capacity to deal with this whole pathway simultaneously
and where we have the best evidence of where clinical outcomes
will be substantially improved, most of the evidence about that
is around the acute section of the pathway, in other words getting
stroke units properly equipped, staffed and capable to do the
first part. We are now turning our attention in this next delivery
period over the next 12 months to look at that longer term part
of the pathway and to develop the metrics which will show us whether
or not we are gaining the same sort of improvements that we have
seen in most areas for the acute pathway.
Q13 Chairman: What happens when this
ring-fenced funding to local authorities for support services
stops? What are your plans?
Sir David Nicholson: It was always
given to local authorities on the basis that it was pump priming
for three years; £100,000 for each local authority every
year for three years. They have spent it in a variety of ways.
Our experience and our expectation is that the local authorities
will continue to fund it after the period ends; we made it very
clear that we do not propose to continue this pump-priming money.
Our experience is that the local authorities do respond in these
circumstances. The most obvious example was the older people's
programme that we have just pump primed for local government and
all but three local authorities have actually taken up the long-term
funding of that. So our expectation is that local authorities
will do it. I have no leverage directly over local authorities
to make them do it but our expectation and experience is that
they do.
Q14 Chairman: My last question is
about early discharge. If you look at paragraph 2.26, there is
some evidence that getting early discharge with proper support
services is the best thing but, again, it is very patchy, is it
not? Why are you not doing more to insist that hospitals have
a better coordinated plan for early discharge with proper support?
Dr Jenkinson: The stroke improvement
programme and the network of 28 across England have played and
will play a major role in changing the services. The figures you
referred to are completely valid as criticism. The major focus
of our further work will be ensuring that all patients go through
stroke units in a timely way and have a timely scan and as many
people as possible have access to early supported discharge. The
issue around early supported discharge—and, to take your
figures, it has increased by 15% of sites in the past couple of
years which is significant in itself—is that there have
been barriers perceived around the funding and costing of early
supported discharge which at face value appear to be in addition
to monies that primary care trusts are paying through the tariff.
We know however that if it is properly done with a properly specified
service it is not only better for patients but it works out in
a cost neutral, perhaps even cost-saving way for health communities.
It is part of the work of the stroke programme to address those
sometimes cultural barriers and resistance across the nation and
increase the percentage of eligible patients going through early
supported discharge.
Q15 Angela Browning: May I add my
congratulations to Sir David because we sometimes give you a hard
time in this Committee. I actually think that the progress you
have made has been very good and I particularly think that the
FAST advertising campaign that you have engaged in is one that
is easily understood by the lay public, is easy to remember and
I am sure will make a huge difference to people getting a relative
or somebody they think is a bit poorly or not very well to hospital
quickly. I do congratulate you on that and I think it is excellent.
However, I do of course have some concerns. I just wonder why
it is that when we look at the number of stroke patients who are
reaching hospital and then have a long wait before being scanned—I
assume most of these people will be admitted through A&E—that
what is happening at the triage stage when they first arrive in
A&E is that the triage nurse is not picking up that this is
somebody for whom there is a very clear pathway and that that
person should not be sitting around waiting. The triage system
is clearly not working properly.
Sir David Nicholson: Yes, this
is undoubtedly a major issue for us to tackle. It is a kind of
cultural issue in the way some of these services are organised
and it can happen that an ambulance paramedic can diagnose a stroke,
the patient then goes to A&E, they want to diagnose it, they
assess and diagnose it, then he goes to an MAU, they diagnose
it and then he goes to a stroke unit. That is clearly unacceptable
but it has been quite difficult to change the way some hospitals
work.
Professor Boyle: I visited University
College Hospital yesterday where they now have a system where
there is a pre-alert from the London Ambulance Service from the
paramedic who has done the FAST assessment. They use that as the
trigger to alert the scanner that they need to have an immediate
slot. They have reduced their call-to-needle time, that is the
call to the Ambulance Service, to the delivery of the thrombolysis
drug, from 90 minutes down to about 30 minutes just by looking
at the internal processes and mapping how many hand-offs you have
to get through before you actually get to the scanner and get
pictures and then have them interpreted. It is all about those
simple things which we have been learning through our experiences
with the networks and the stroke improvement programme. The challenge
now is to get that learning spread right across the NHS so that
everybody can have the best processes in place and the most rapid
ones.
Q16 Angela Browning: I hope you are
going to spread that out. It seems to me that the triage was a
very important implementation a few years ago but if triage nurses
are not locked into this then it does not make a lot of sense
really. May I just ask you about my own area as I am sure we are
all going to do? I live midway between the Taunton and Somerset
Foundation Trust and the Royal Devon and Exeter Hospital. I have
been a patient at the Royal Devon and Exeter, as I have been,
I have to say Dr Jenkinson, in your excellent hospital. I received
very good service there. However, there is a huge difference between
the Taunton and Somerset and Royal Devon and Exeter. Given that
in Devon that hospital serves a large catchment area along that
south Devon coast as a general hospital, Sidmouth, Budleigh Salterton,
a huge retired population. Why is it that a hospital which is
serving a particularly elderly population has such disproportionate
figures? I live half way between the two and I know which direction
I am going to ask the ambulance to go in, if I am able to speak.
Professor Boyle: You will have
to leave a note under your pillow.
Angela Browning: Do not worry; my husband
will make sure it is all done satisfactorily.
Mr Bacon: Get a tattoo.
Q17 Angela Browning: Yes, I will
get a tattoo saying "Take me to Bournemouth".
Dr Jenkinson: At the request of
Sir Ian Carruthers we did a review across the entire south-west
and all of the 17 acute provider trusts, so we have been to each
of those hospitals and actually been in them and I understand
the issues you are referring to. A lot of it is around clinical
leadership and one of the sites to which you refer has had difficulty
in appointing senior clinicians to help run and move that service
forward, whereas the other one has a national class figure. I
know, however, that those issues have been resolved more recently,
so I would expect that other site to improve and they are all
part of the Peninsula network in the south-west there and they
are all following similar protocols across the region. We would
expect to see the variances between those sites diminish.
Q18 Angela Browning: I am a little
bit more encouraged. Obviously now I have seen these figures I
shall be writing to the chief executive and no doubt she will
give me a more detailed blow-by-blow account of why I should not
be nervous about the hospital's performance because clearly it
has been very unsatisfactory. Is it the case that areas which
do serve a large catchment of elderly people—I know stroke
is not exclusive to elderly people—have got into a pattern
of dealing with elderly people, a matter which has been discussed
in this Committee before. I worry that when elderly people present,
they are shuffled off in a certain way which perhaps does not
address the importance of their symptoms on admittance.
Dr Jenkinson: I think you are
completely correct and part of the cultural problem is that many
people who have worked in stroke over the years, for instance
myself, have acquired a learned expectation that nothing much
was going to happen and when the stroke strategy and all the leverage
that came with it actually arrived, there was some resistance
amongst them to moving forward. I think you are right but I think
also that the FAST campaign and public awareness has completely
changed the profile of stroke for the public and also for healthcare
professionals. The trick we must play now is to make the very
most out of that.
Q19 Angela Browning: May I go to
the other end when somebody has been discharged from hospital?
After we did our initial Report on the NAO Report on strokes,
I did go to visit one of the small units in my own constituency
which actually takes patients from the Royal Devon and Exeter
Hospital and see how they were being rehabilitated ready for home
discharge. My worry there—and I have raised this before—was
that yes, there was some excellent work being done, but actually
the state people are in when they arrive through their own door
is not satisfactory compared with the progress that has been made
to date. There are certain key things. To recover from a stroke—as
with many other conditions but strokes particularly—ongoing
physiotherapy is very important and there are gaps of nine, 10
weeks before there is a home assessment and a programme put in
place; speech therapy also. Can you just give us some indication
as to where we are with physiotherapy and speech therapy for stroke
patients once they have got back home?
Dr Jenkinson: Talking about the
particular area you are speaking of, I know that within the business
case for the Exeter hospital they had a fully comprehensive and
fully specified early supported discharge programme which they
had not had previously and have clear plans on improving access
to the therapies you are describing. You are also correct in saying
that at the moment, as it exists, access to the professions for
all patients across England is not good. Part of the major emphasis
of the work we are going to take on from this point is focusing
on that part of the pathway, addressing that.
Q20 Angela Browning: My final point
is that it seems to me, from what I saw and heard, excellent work,
but once they are at home the progress is not as good as it might
be in order to get better, more mobile, able to cope independently.
Of course it then starts to be that transition of responsibility
from health to social services and again we are back to these
old questions which we have discussed before of silos of money
and responsibility. I just do not understand why for years we
have been talking about the need for health and social services
to work together which is a very good thing and essential, but
they do not. Can anybody do anything about these silos which prevent
that happening?
Sir David Nicholson: There are
lots of examples in the country where they do work really well
together. I am sure you can all think of places—and I can—where
they work really well together. We have thought long and hard
about whether this is a structural issue, whether changing structures
would change it but what we think is maximum flexibility from
the centre. So we should take many of the controls off people's
ability to move money from one part of the public sector to the
other and pooled budgets and all those sorts of things; a very
important part of that which we are doing, encourage people, support
it and all the rest of it and make sure that people do actually,
through joint commissioning, make these things work. There is
no simple way of doing it; it is a matter of people working together
to make it happen. There are some really good examples around
the country and there are more to make it a reality.
Q21 Geraldine Smith: I am quite interested
in the number of people who could potentially have a stroke but
who are not on Warfarin or blood-thinning drugs for it. What can
you do about that? Is it quite as simple as it looks when I read
a figure of only 24% on these drugs? Is it because maybe looking
at strokes you are looking in isolation and you are not looking
at the potential harmful effects of people taking these drugs?
Professor Boyle: We have this
as another major work plan which we have been working on over
the last year and we will be doing that over the next year or
two because it is going to take a couple of years to get to where
we need to be on this. When NICE produced their guideline on the
management of atrial fibrillation, which is one of the big risk
factors for developing stroke, they thought that probably only
about half of the eligible population who would be at high risk
from a blood clot coming from the heart to the brain were adequately
anti-coagulated with Warfarin. There is a considerable resistance
to putting a largely elderly population onto Warfarin. GPs are
reticent because it is a big logistical exercise to do the regular
blood tests and make sure the drug is being taken in a safe fashion.
More recent evidence has emerged from the trial done in Birmingham
which shows that even in the elderly population it is a much safer
thing to do than to leave untreated. People have suggested that
the risk of falls was so great and therefore the risk of serious
bruising would not justify the risk of taking Warfarin. The trials
showed conclusively that that was not the case and that overall
benefit was much greater than using Warfarin. We have to change
the mentality in terms of recognised cases. We have developed,
through our stroke improvement programme, some software which
is available free to every practice, which will interrogate the
practice system to find the people with high risk of atrial fibrillation
so they can then reconsider the treatment options. Then we have
a second big raft of work which is looking at better ways of identifying
people who have atrial fibrillation but have not been diagnosed.
Those are the two big rafts of work which we are trying to put
into place.
Q22 Geraldine Smith: Is there not
a new drug ahead of Warfarin which stops side effects?
Professor Boyle: There is a new
drug just about to emerge and we are not yet certain whether it
is going to be cost effective. It depends on the pricing and it
has not yet been widely tested in this group, particularly the
elderly population who are at most risk, to see whether it would
be an effective drug in that population, although the current
trial data does look quite encouraging. It is going to be a question
for NICE to consider and we have commissioned them. I chair the
group which selects the topics and they are working on that very
much.
Q23 Geraldine Smith: May I also congratulate
your team on the advertising and everything? It has led to a real
sea change and it was very simple, very clear and extremely effective.
Really well done on that. The next stage, if someone has a stroke,
is getting to hospital, getting the brain scan and getting the
blood clotting drugs. Can those blood clotting drugs be harmful
in certain strokes? Is that the reason why you would not give
them to everyone who presented with symptoms?
Sir David Nicholson: Yes, it is
absolutely the case that thrombolysis is a potentially quite dangerous
thing and planning, organisation and training is not something
you can switch on tomorrow in a hospital. Quite a lot of work
needs to be done before you are in a position to do it.
Professor Boyle: It is certainly
an effective treatment and reduces the extent of disability if
it is given in a prompt fashion but only to those people who have
the thrombotic strokes. If you gave it somebody who had had a
cerebral haemorrhage that would be almost a death sentence. At
the moment it is only licensed for people under the age of 80.
It is only thought to be effective if you can a treat a patient
within four and a half hours of the onset of symptoms. Only a
proportion of patients who are admitted will be eligible to have
the treatment.
Q24 Geraldine Smith: So any patient
over 80 would not be eligible for that treatment.
Professor Boyle: It is still used
off licence by clinicians, after discussion with the patient or
their family if they are not able to communicate, at discretion
and after explanation. It does not exclude the over-eighties from
access to the drug but at the moment the licence does not actually
sanction that approach.
Q25 Geraldine Smith: Obviously there
are more problems in rural type areas like my own constituency.
I notice in our area Blackburn does very, very well with strokes
but I want to see my area be as good. I know one of the things
the network is looking at is video link-ups, some sort of video
so they can link up with the consultant who can see the scans.
Can you tell me a little bit how that is progressing?
Professor Boyle: You have already
received the report from the Cumbria and Lancashire Health and
Stroke Network, from Sally Chisholm.
Q26 Geraldine Smith: Again may I
put on record my thanks for the time she took and the effective
manner in which she came and presented all the work they are doing.
Could you pass on my thanks to her?
Professor Boyle: She is a classic
demonstration of the capability of these networks to look across
organisational boundaries and across a bigger geography than just
a single primary care trust and really make some significant changes.
Yes, there is a serious geographic challenge in your area. My
mother lives in Cumbria and I am very interested in it myself.
The tele-medicine solution is being developed which allows a clinician
remote from the site where the patient is and where the scan has
been taken to guide the local clinician, who is not necessarily
a stroke expert, into making the right decisions and making sure
that they have at least equal access to the right treatments as
everywhere else. It still requires in those local hospitals for
the stroke unit to be properly staffed, equipped and skilled to
monitor those patients afterwards. That has been the time limiting
factor in terms of getting everybody up to that level of care.
Q27 Geraldine Smith: In the long
run that must be cost effective because the better you can treat
someone initially, the less aftercare they require.
Professor Boyle: Yes; absolutely
right.
Q28 Geraldine Smith: May I also say
from my own experience, someone I have seen who had had a bad
stroke, that the life-changing effect on a family is very, very
distressing to watch. Can you say a little more about the aftercare,
the post-hospital support because that is another area where people
feel more can be done?
Professor Boyle: What we are trying
to develop at this current stage of our progress is a system whereby
at discharge from hospital a joint care plan is developed which
deals with both health and social care issues. That is then shared
with the patient and their carer, if there is one, to make sure
that everyone is clear, including the general practice that is
responsible for them, about what the full plan is and what should
be in place. At least then, if the support services do not arrive
on time, you are quite clear what it is that is missing and who
should be contacted to make sure that gap is filled. Not only
that, but if the whole plan is then reviewed much more systematically
at six weeks and at six months and then annually thereafter, so
that people do not drop between the various holes which exist,
as we have discussed, between health and social care, so that
there is this drive at least from the individuals and the families
to make sure that there is better joined-up care for the longer
term. That is part of our development plan for the next 12 months.
Q29 Geraldine Smith: To have a stroke
is a terrible thing to happen. Where would you get the most effective
care in the country and where would you get the least?
Professor Boyle: We heard about
the Grimsby issue. At the moment in London the most effective
unit appears to be King's College Hospital and that is partly
because the Ambulance Service has latched onto the notion that
there they will be greeted by a nurse trained to do the early
assessment, that the X-ray department is immediately adjacent
to the A&E department and that the radiologists and radiographers
there will accept a referral from the nurse, so they have a very
rapid transfer through the system. They then have a very well
trained and skilled workforce in the stroke unit. The local authority
appointed dedicated social workers who visit the unit and assess
every patient so that they provide the link back out into the
community. For example, in Southwark PCT they have pooled budgets
between health and social care for dealing with these people with
long-term needs. That is a model we would want to take and share
around the country.
Geraldine Smith: I wish you luck. It
is not an easy task but it is important, particularly, as you
have already said, for rural areas and people living in North
Lancashire and Cumbria, my own area.
Q30 Mr Mitchell: I think the adverts
were very effective, but that is presumably the £11 million
referred to in the Report. It tells you what the symptoms are
and what is happening but it does not tell you what you should
do if you witness those symptoms. Should they tell us that?
Professor Boyle: Dial 999. It
says call 999.
Q31 Mr Mitchell: It says that but
is there anything else you can do?
Professor Boyle: No, there is
not much that a lay person can do other than standing by. Fortunately
our ambulance services across the country have shown themselves
very interested in this condition and have been very responsive.
Q32 Mr Mitchell: Yes, I think their
standards are improving considerably.
Professor Boyle: Absolutely.
Q33 Mr Mitchell: It is more dangerous
for a lay person to interfere and to do something.
Professor Boyle: There is a very
limited amount that you can do to help a stroke person in those
early stages.
Q34 Mr Mitchell: Returning to the
statistics to which the Chairman referred, I was horrified to
look at the statistics for Grimsby, in fact I am wondering whether
I should go back and fight the election there or stay in London
and be cosseted by the Health Service. Since they are so bad,
let me ask who is driving any improvement. What pressures are
being brought to bear on the trust to improve matters?
Professor Boyle: The strategic
health authority has now developed a comprehensive plan across
the whole of Yorkshire and Humberside to address these issues.
Q35 Mr Mitchell: That is a regional
effort.
Professor Boyle: Yes. They also
have a responsibility through these vital signs which we mentioned
in terms of performance managing the trust. It will meet regularly
with the trust to discuss their performance against those vital
signs and that is one lever. We hope also this best practice tariff
will impact on them. We know also from the Sentinel stroke audit
data, which has been so useful in telling us about the trends
of improvement over the last 10 years. We will also be able to
benchmark them in the current data collection which is going on
this year. That all gets pretty well out into the public domain
so that is something for their reputation. Ultimately the regulator
will have a view on the performance of the trust and will use
this information for their assessment purposes.
Q36 Mr Mitchell: Push them hard.
I could not quite understand what you were saying about the importance
of a scan. It is important to have a scan within the first three
hours so you can diagnose what to do or later. What is its importance
later?
Professor Boyle: The importance
early on is to see whether you are eligible for the clot-busting
drug and injection. After the first four and a half hours, then
the decision is a different one. The decision on the basis of
the scan is whether this is really a stroke or something pretending
to be a stroke, perhaps a brain tumour or something else.
Q37 Mr Mitchell: Will the scan detect
that?
Professor Boyle: The scan will
detect that. The clinical decision, in terms of treatment, is
whether or not to commence Aspirin to prevent further clots from
forming. That is the decision we want to make sometime in the
first day or two.
Q38 Mr Mitchell: The average waiting
for scans in Grimsby is 25 to 48 hours and then 48 hours for a
weekend. It looks as though they have knocked off for the weekend.
Why would that be the case?
Professor Boyle: There has been
a culture in some hospitals to lock the scanner out of hours.
Q39 Mr Mitchell: It just stops.
Professor Boyle: Yes.
Q40 Mr Mitchell: It should be open
all the time presumably.
Professor Boyle: There almost
certainly will be a radiographer in the hospital who is capable
of using the machine, who is doing the other emergency X-ray duties.
It may require some additional staffing hours and therefore there
is a cost attached to it which is then the deterrent to that hospital's
chief executive and finance director in the long term.
Q41 Mr Mitchell: What is thrombolysis?
I do not quite know what that is.
Professor Boyle: This is a process
just like when you have a heart attack and the artery to the heart
is blocked by a blood clot. It is having a treatment which will
remove that blood clot and dissolve it.
Q42 Mr Mitchell: Is it an injection?
Professor Boyle: Yes, it is an
injection, an infusion.
Q43 Mr Mitchell: Why do ambulances
not carry it then?
Professor Boyle: Because they
cannot do the scan to determine which type of stroke they are
dealing with.
Q44 Mr Mitchell: So it is not a universal
application.
Professor Boyle: No; no.
Sir David Nicholson: It can be
fatal, given to the wrong patient.
Q45 Mr Mitchell: You have granted
this money and it seems to be working well and there has been
a discernible improvement. How do you stop it leaking into other
services? If I were running a hospital trust and you gave me a
lump sum for this or that or the other, I would fiddle bits of
it into other categories of medicine. How do you keep it ring-fenced
for strokes?
Sir David Nicholson: We do not
keep it ring-fenced for strokes; there is no ring-fencing on the
money, but they have to report what they have spent it on. We
believe that transparency and publication is a more powerful lever
for change than is ring-fencing the resources.
Q46 Mr Mitchell: So it is accountancy
really.
Sir David Nicholson: It is accountancy.
The other thing is that Professor Boyle talked about the best
practice tariff. What that means is that if you treat a patient
with stroke and you treat them in the way, for example, you might
do for some of your constituents in Grimsby, they will get less
money than they would if they treated following best practice.
It gives an incentive for them to change their organisation to
make it work better and if they need extra resources for the extra
scanning, they can get that out of the extra money they get for
the best practice tariff. It is the first time we have used it
in the NHS and we are hopeful it is going to make a big difference.
Q47 Mr Mitchell: Are you happy that
it is working?
Sir David Nicholson: We are literally
just about to start it.
Professor Boyle: It starts in
April.
Q48 Mr Mitchell: I am happy to hear
that. What happens? You have been going around telling them they
have to prepare for this level of cuts and that level of cuts
and terrifying everybody in the Health Service. What happens when
this specific funding runs out?
Sir David Nicholson: I am not
trying to terrify people I am just trying to get them into the
place where they start to think about how they are going to work
through. There is no doubt that, when we reflected on the NAO
Report and recent work, we think a bit more urgency needs to be
put into the stroke strategy at the moment, hence Dr Jenkinson
talked about the accelerated development, because in 2010-11 we
still have 5.5% growth, so we do have the ability to invest resources.
It is critical that we get those stroke plans right for that period.
There are other opportunities in stroke that actually save resource.
The early supported discharge would of course mean you needed
fewer stroke beds so you would actually need to invest less in
hospital and more outside. So you can transfer that and make savings
when you do it. There are opportunities down the road in the stroke
service of saving resource as well as spending it.
Q49 Mr Mitchell: You are satisfied
that the improvement that has been gained so far will be sustained.
Sir David Nicholson: Yes; absolutely.
Dr Jenkinson and his colleagues are setting out a series of metrics,
of detailed measures, so that when organisations publish their
accounts we can track that they are continuously improving stroke
services.
Q50 Mr Mitchell: Another area where
we seem to be deficient, in my constituency certainly, figure
nine, page 25, proportion of patients spending 90% of their time
on a stroke unit, which is the lowest in Yorkshire and Humberside.
Why is that important? Why is it so low there?
Professor Boyle: The one intervention
which makes the most difference to outcome is admission to a stroke
unit. You then get the multidisciplinary care from people who
are skilled in caring for people with a stroke. If you go into
a general ward, a well-meaning ward orderly may come along and
say "Would you like a cup of tea, dear?". The answer
would be yes, they would sip the tea, if they could, and it would
go down the wrong way because they had not had a swallowing assessment
and they would immediately get a really bad outcome. Right from
the first hour of admission we really need to get these vulnerable
people into the place where the right skills are and that is our
big ambition for this coming year. We have made some progress,
but we have to go a lot faster and do better still.
Q51 Mr Mitchell: Figure 10, page
27, why are our actual staffing levels in England so much lower
than the minimum recommended level in Australia.
Professor Boyle: I visited Australia
in the early part of last year and these are recommendations,
they have not been achieved even in Australia.
Q52 Mr Mitchell: Those are the minimum.
Professor Boyle: Yes, but we have
seen substantial improvements in the numbers of staff in all the
staff groups in this country and that is a trend which hopefully
will continue if they are focused in the right way. We can still
do that in a cost-effective envelope and actually save money.
Coming back to your previous point, we do know from modelling
that the National Audit Office did in their original Report, that
actually better stroke care is cheaper care. We know that historically
we have spent more on stroke than equivalent countries to us and
yet have worse outcomes. It is just making sure that we focus
the attention of existing staff on doing things differently and
more efficiently and more effectively and getting better outcomes,
then everybody wins.
Q53 Mr Mitchell: Am I more likely
to have a stroke if I have had a stroke?
Professor Boyle: Yes.
Q54 Mr Mitchell: Why is there such
a gap in the coordination with social services for aftercare in
speech therapy and in six-week and six-month reviews of my improvement
after I have had a stroke? It is the biggest weakness in the system.
Professor Boyle: The long-term
risk issues are the biggest issues for the patients and their
carers, there is no doubt at all. In terms of protecting you from
a further stroke, the important thing to do is to make sure that
addressing the stickiness of your blood is one particular issue,
so Aspirin and another drug, Dipyridamole, to reduce the risk
of further clotting taking place and making sure that your blood
pressure is appropriately treated and, coming back to my other
hobby horse, statins, making sure that all the secondary prevention
opportunities are taken. Although there has been improvement on
that, we have seen that, in terms of the behaviour of primary
care in reducing risk to stroke victims historically, we still
have more to do in improving that aspect of preventive care in
the coming years.
Q55 Chairman: So statins are quite
useful, are they?
Professor Boyle: Yes.
Q56 Nigel Griffiths: Dr Jenkinson,
I want to congratulate you for being part of the Hospital Doctor's
Team of the Year, for winning the Team Innovation Award and in
particular for ensuring your local stroke services have achieved
recognition as an NHS Beacon Service. You are one of the reasons
why I believe in centralised NHS budgets and delivery and what
Sir David said earlier was music to my ears on the subject of
budgets. What do your team's achievements mean in terms of the
impact of treatment on the quality of stroke victims' lives?
Dr Jenkinson: Are you talking
about my work in my own trust?
Q57 Nigel Griffiths: Yes.
Dr Jenkinson: The most important
thing about the way that we have worked at the Royal Bournemouth
Hospital is that I believe we are genuinely patient centred, that
we understand the needs of our local population and we have incorporated
people with strokes and carers in the planning of our services.
Leadership in all the different disciplines and at all different
levels is critically important and I think that frontline staff
need to be given permission and the tools to be able to move services
forward. There is plenty of leverage in the system, there is money
in the system to improve stroke services but it needs leadership
at a local level and that needs commitment and resources within
organisations, so organisations have to be signed up to it as
well. It is a combination of factors about having a vision in
a trust, a leadership, a conducive atmosphere, understanding the
needs of your local population and responding to those in an evidence-based
way.
Q58 Nigel Griffiths: So it is your
experience that basically the funding is there but it is the leadership
and then the operation at a local level.
Dr Jenkinson: Yes; absolutely
right. Sir David talked today about the ring-fenced £105
million which was clearly the icing on the cake. There was an
increase in the allocations to primary care trusts to commission
better cerebrovascular or stroke services but that depended upon
people in localities taking the initiative and leadership to have
that vision and move their services forward and some move faster
than others.
Q59 Nigel Griffiths: Are you very
frustrated with the ones which are the laggards?
Dr Jenkinson: Yes; hugely. It
is an embarrassment.
Q60 Nigel Griffiths: Professor Boyle
said earlier that the changes in the heart programme took five
years, mainly for cultural reasons. Why is it that it may take
another five years to achieve what Dr Jenkinson and other top
clinicians have achieved when we are dealing with the finest minds
in the United Kingdom in charge of it?
Professor Boyle: I do not think
we have five years. Because the financial pressures are going
to hit us in another 18 months or so, we really have to make sure
that we get this consistency in place during the next 12 months.
We are not going to rest; we are going to make this absolutely
our number one priority, to get consistency across a range of
markers and challenge everybody to join in this process. We will
be collecting the data which will inform us about whether or not
we are making progress and we will be making that pretty explicit
to the public and others to make sure it happens.
Q61 Nigel Griffiths: That is rather
encouraging because my next question was why taxpayers in Grimsby
should put up with a second-rate service and you are saying that
in 12 months' time they will not.
Professor Boyle: We have made
special note of Grimsby.
Sir David Nicholson: We would
expect substantial improvements. The first thing is that the primary
care trust in Grimsby is currently putting its plans into the
strategic health authority to show how it can deliver top-drawer
stroke services by the end of next year. We will examine those
plans to satisfy ourselves that they are okay and we will expect
them to deliver on them the year after. That is exactly what we
need to do.
Q62 Mr Mitchell: I will go back in
three years' time.
Sir David Nicholson: I am sure
it is better now.
Q63 Nigel Griffiths: Professor Boyle
you gave us a very good illustration in Southwark where you said
they have a joint care plan for health and social services. Why
is this not mandatory throughout the country?
Sir David Nicholson: What? That
there is a joint plan?
Q64 Nigel Griffiths: An effective
one.
Sir David Nicholson: Essentially
it is and that is what the arrangements through the planning process
are doing at the moment. We expect those plans that come in to
be joint between local government and health. It is not the law
that they should be, but we would expect it. In fact they could
not give us a credible plan unless it was joint. That is what
we will be examining with them over the next few weeks as we accept
or reject the plans which have been put in.
Q65 Nigel Griffiths: Are you going
to remove all the money for stroke care from those who either
fail to submit a plan or submit an inadequate plan?
Sir David Nicholson: No, we will
not do that, but there is a whole series of interventions that
we can make: Dr Jenkinson and his team can be sent in to help
them do it; we have NHS Improvement who are doing a lot of work;
we have people and facilities we can put into those areas to make
sure they can deliver a plan which is acceptable.
Q66 Nigel Griffiths: When did this
work stream come about?
Sir David Nicholson: The accelerated
development programme is just about finished. We told PCTs in
November/December of this year what we expected by March, so they
have been working on that over the last three or four months.
Q67 Nigel Griffiths: Have you told
PCTs to unlock scanners at the weekend?
Sir David Nicholson: PCTs would
say they do not lock them up in the first place, that the hospitals
do that. A part of their plan is that they have to show how they
are going to provide access to CT scanners. That may not mean
that every organisation provides all of the services 24 hours
a day. It may be that in some places we concentrate on particular
hospitals in urban areas and others to make it happen but what
we want is to make sure that everybody, every person, every member
of the population has access to that service.
Q68 Nigel Griffiths: How long do
you think that is going to take effectively?
Sir David Nicholson: Our ambition
is to deliver it by the end of next year but we know that is an
incredibly tight and difficult thing to do. We do not want to
back off from that at the moment because we want to keep the pressure
on the system to get the improvements as quickly as we can. If
we are dealing with a culture problem which takes a long time
to change, what is your most effective way of persuading colleagues
to catch up really?
Dr Jenkinson: The most powerful
tool we have is the awareness of the public and we need to make
the very best use of that. You will know that awareness has gone
from 15% to 82% and there are all sorts of potential benefits
which can come out of there and not just acute illness behaviour
when someone is having a stroke, but also their involvement in
local services and demanding the highest calibre service in the
locality, being involved in implementation groups and describing
the services. I genuinely believe that is the strongest tool we
have at the moment.
Q69 Nigel Griffiths: Professor Boyle,
in another informative intervention you mentioned that the A&E
being next to the X-ray department was a particularly helpful
model. Is this now required for all new hospitals?
Professor Boyle: Yes, I think
it is built into the NHS Estates' advice about co-location and
it is also true that you need to have your emergency acute services,
things like coronary care and stroke care, very closely linked
to the A&E department. You do not want to linger in an A&E
department; it can be a bit like sticking paper. This is why you
need to clarify the immediate triage issues and the pre-alert
systems which are present in many more districts now than was
the case, so that the view of the Ambulance Service is taken seriously
and is not then double-checked unnecessarily.
Q70 Nigel Griffiths: If a health
authority is building a new hospital today, is there an option
for them not to use that model?
Professor Boyle: No.
Q71 Nigel Griffiths: Good. I notice
that training is an issue highlighted on page 26 or rather the
lack of training in terms of recognising the symptoms of stroke.
How has that been addressed?
Professor Boyle: The FAST campaign,
although it was directed at the public in general, has actually
been very informative to staff as well. Effectively a lot of them,
lay staff, people like GP receptionists, need to know these simple
messages as well and that has had a very great impact. It has
had a big influence on the way A&E departments behave because
they would pay more attention to somebody with chest pain or major
trauma than they would to somebody with a stroke. We know that
the impact of treatment for somebody with a stroke is just as
effective as managing a heart attack, if it is done properly.
Dr Jenkinson: On the training
issue, part of the work which flowed out of the creation of the
stroke strategy was the creation of an educational framework which
is stroke specific and that work is now done. It describes the
skills and competencies of any member of a workforce whatever
discipline they come from to meet the needs of people with strokes
along the entire pathway. That includes within it core competences
which would include any member of staff—and Professor Boyle
describes the domestic who gives a person with a stroke a glass
of water which could be catastrophic—to ensure that they
understand issues around dysphagia that a paramedic would know
that, somebody in radiology and in primary care as well. That
piece of work is now complete and that information and resource
is now nested within a new host, the United Kingdom Stroke Forum
and they are just coming on stream with that. In the future, in
the coming few months, you will see them accrediting courses and
accrediting individuals to enable people in stroke to get specialised
training, core competences and extended competences, to enable
the staff to have a career progression. It will be better for
patients and it will enable transfer between units of specialist
staff as well.
Q72 Nigel Griffiths: I had a constituent,
Jim Hill, whose quality of life was immeasurably improved after
a stroke by the TENS project, the electrical stimulation. Is that
rolled out nationally?
Dr Jenkinson: I am not aware of
clear evidence that TENS make a difference. I can look into that
and bring information to you. There is evidence for what is called
functional electrical stimulation, which is the stimulation of
nerves in a limb which is paralysed because the brain has failed
to function and drives the limb to work. Certainly for walking,
functional electrical stimulation can make a difference in terms
of speed of walking and quality of life. I am not sure of the
evidence base on TENS.
Q73 Nigel Griffiths: Do you recommend
that people who do not have stomach associated problems take Aspirin;
men over the age of 50?
Dr Jenkinson: No, there is not
good evidence, if you have not had a vascular event, for taking
Aspirin. If you have had a vascular event, heart attack or stroke,
it brings undoubted benefit but that is not clear for people as
primary prevention.
Chairman: Sorry to spring all this free
medical advice on you.
Q74 Mr Burstow: I just want to come
back to some of the issues around the must-do targets of 90% of
patients spending the majority of their time in the stroke unit.
Professor Boyle talked earlier on about the financial pressures
placing a great imperative on getting things completely right
in the next 12 months. How long do you think realistically it
will take to get beyond the 90% towards the 100%?
Professor Boyle: It is not going
to be very long. We know that on any one day the number of patients
in hospital with a stroke matches the number of stroke beds there
are. It is more a question of how those beds are used and a question
of bed management. Very often patients with other conditions end
up in a stroke unit for some other reason, pressure on the beds
in general, but that does not happen in coronary care units, so
why should it happen in stroke units. That is the message we are
really trying to major on at the moment.
Q75 Mr Burstow: Are the levers now
in place to make sure that over the next 12 months those changes
in management of beds actually deliver that?
Professor Boyle: Yes. We have
all the levers we can hope for in the present climate and quite
how we are going to do these measures and track each hospital
over time is something we are going to be planning tomorrow afternoon.
Probably we will get some monthly progress reports on whether
or not this initiative is being followed through sensibly.
Q76 Mr Burstow: So if the NAO did
another piece of work of this sort in 18 months or two year's
time, you would be confident.
Professor Boyle: That is certainly
our ambition. Some of the hospitals do not know that yet but they
will find out soon.
Q77 Mr Burstow: That is good. May
I pick up the cash as well as care benefits which arise out of
funding early supported discharge services which you were talking
about just now? Given that fact, why is it so difficult to identify
who will pick up the bill of actually setting them up?
Sir David Nicholson: The issue
is that what tends to happen in these circumstances is that the
theory is that if you put the supported discharge in place you
would need fewer beds but what comes first? Very often it is the
fewer beds which fund the supported discharge. What we have said
for 2010-11 is that every PCT should identify up to 2% of its
budget that it can use to invest to make these kinds of upstream
things happen. We said "Don't allocate that money in 2010-11
but use it for this kind of thing. So every PCT should have the
opportunity to have money in 2010-11 to make the investment to
early discharge before it closes the bed. We think that is a much
better way of doing it. It is having the confidence and understanding
to do that which has been the restriction.
Q78 Mr Burstow: Back to the question
earlier, within the next 12 months that is something where we
will see a significant change.
Sir David Nicholson: You should
see that over the next 12 months.
Q79 Mr Burstow: One of the things
the Report talks about on page 34 is around long-term care and
support. It makes the point that there is a host of recommendations
in many areas but there is a lack of clear guidance around what
works best when it comes to post-hospital care. What can you do
to try to provide some clarity there so services can be better
tailored and developed?
Sir David Nicholson: It is absolutely
true; it is the part of the strategy which has the least evidence
underpinning it. Because of that, it has been some of the most
difficult bits for us to do. I know there is quite a lot of work
going on in this area.
Dr Jenkinson: The evidence base
is relatively poor there compared with the rest of the stroke
pathway. We know what patients experience and what they want.
We know aspects of secondary prevention and what can be done in
that regard but clarity around psychological and social support
and evidence for that is not clear. Work is going on through a
national programme called CLAHRC, Collaboration for Leadership
in Applied Health Research and Care, which is clarifying those
issues and we are going to incorporate those findings into what
our programme will be doing over the coming months.
Q80 Mr Burstow: Part of the patient's
experience is the carer's experience.
Dr Jenkinson: Absolutely.
Q81 Mr Burstow: The Report highlights
emotional support, particularly counselling, access to respite
care and training on how to support the person at home, as being
areas where there has been a fairly substantial number of people
saying this is poor and in some cases very poor. What more are
you doing to make sure that that really begins to shift so that
if we saw another of these Reports in 18 months' time the numbers
of people indicating those were poor would not be poor?
Dr Jenkinson: Certainly the stroke
programme has run accelerated work in nearly 60 pilot sites with
five different programmes of work over the past year. Our learnings
from that are coming out now and our intention will be to disseminate
that across the country; that includes work in rehabilitation,
transfer of care and longer term care. It is important to note—I
am not for a moment saying it should be done for nothing—that
there are examples, for instance across the south-west, where
a major project was undertaken by an organisation called Connect,
which is a charitable organisation, along with a primary care
trust and the provider trust at Truro to help bring long-term
support for people with stroke who had communication problems.
That pilot ran for two years and it was clearly successful by
hard outcomes and also by how patients and carers judged that.
It is now being commissioned to continue. We would take learning
from major pieces of work like that and many of the services which
will help support people with stroke already exist; it is about
providing signposting and enabling those organisations to recognise
particular issues for people who have had a stroke.
Q82 Mr Burstow: On the issue of training,
there is reference in the paperwork to care homes and residential
homes and about 11% of stroke patients go there once they are
discharged. There appears to be quite a serious issue about lack
of awareness, part of which I suspect has been addressed by the
FAST campaign, but nevertheless a lack of awareness and recognition
of the symptoms and a lack of training around how to manage people
with stroke properly in that setting. You referred just now to
a new piece of workforce training development that is being done.
Does that include care home staff?
Dr Jenkinson: Yes, it does. It
includes the skills and competences that would be core and also
extended for that part of the pathway. You may know that the Care
Quality Commission is at the moment describing and analysing the
entire post-acute care pathway for everyone with stroke across
England and that would include people in nursing homes. It is
our intention to work with them and in the future to look perhaps
towards accrediting staff who care for people with stroke in care
homes and requiring them to have qualifications in stroke, as
they do for people with cognitive impairment.
Q83 Mr Burstow: It did occur to me,
apart from the fact that there would not be enough space at the
table, that in some ways the absence of the CQC at the table was
actually quite important here because they clearly hold some of
the levers to drive not just this issue about training in care
homes but also the other issue which has come up in a number of
questions which is this issue of the lack of alignment with social
care. I was wondering whether you could say a little bit more
about what the Department are doing in relation to that issue
of getting the local government part of this equation fully aligned
with the strategy and what discussions there have been with the
Department for Communities and Local Government.
Sir David Nicholson: There have
been extensive discussions, as you might expect, not least of
all because of all the debate going around the national care service
and the funding of long-term care by the Government in general.
We have been having lots of discussions with them about all of
that. The issue has been how to increase and improve integration
between services and it seems to me that is the central point.
We have come to the conclusion that structural change is not what
is required in these circumstances but getting the incentives
aligned and getting them right. You are absolutely right that
the CQC is a crucial part of that. It does go across that boundary
and the way in which they regulate the system, they collect information,
the things they do, will be critical to make that happen.
Q84 Mr Burstow: One of the tools
in that particular box is local area agreement. Is that one of
the things which is now actively being encouraged?
Sir David Nicholson: Absolutely.
As you know, the Tier One Vital Signs are all part of the local
area agreements that we talked about.
Q85 Mr Burstow: My final question
is returning to where I began around the must-do targets and a
session which you say took place about a month ago now around
dementia. Not so much to come back to that issue specifically
but what has been interesting has been some the points which have
been made in this session about lessons from this strategy. What
general lessons would you draw that could and should be applied
to the roll out of other strategies?
Sir David Nicholson: I think that
the stroke strategy is ahead of dementia in that sense. The lessons
we learned from stroke were first of all to get the strategy right
and get people bought into it. That is why in a sense we have
spent so long getting the dementia strategy in the right kind
of place because we know that the power of buy-in across health
and social care and patient groups is vital if you are making
this change happen. Get the strategy absolutely right. You need
relatively small amounts of seed corn, pump-priming money nationally
and you need to make sure that the service sees it as a major
priority. They are the kinds of things and the development of
networks around the system and some kind of improvement capacity.
Dr Jenkinson: I would say the
tricks are: raised awareness, if the public understands the issues
and biases about dementia and stroke are taken away and there
is a true understanding of what good care looks like, that helps
move it forward; strong leadership and that means resources and
time to give people headroom to do that both nationally and at
the local level; genuine leverage in the system has made a difference
for stroke care.
Q86 Angela Browning: Right at the
beginning of this session you mentioned the need to try to improve
on the diagnosis of atrial fibrillation because it is undiagnosed.
When the heart loses sinus rhythm the physical symptoms associated
with that can mean people then seek medical attention, but people
can have atrial fibrillation for a very long time without knowing
they have it. If you were to apply a Holter monitor to them, you
would pick up the sinus rhythm imperfections without them necessarily
knowing they have it. But you cannot apply the Holter monitor
until you have some indication that this is what it might be.
How are you going to improve the diagnosis of atrial fibrillation
in those people who do not present with dramatic symptoms?
Professor Boyle: We need to get
all the health professionals a little more adept at doing a very
simple diagnostic test which is feeling the pulse of the person
in the room. Know your Pulse is a campaign which the Arrhythmia
Alliance have campaigned on in this building. It is something
you can do yourself also. Sometimes there are other irregularities
which are quite difficult to differentiate from atrial fibrillation
so we are also quite keen to improve simple access to diagnostics
in primary care. You can do this now with very simple tele-medicine
devices, central reporting, which does not require great expertise
in the practice. We have also explored with some PCTs the notion
that you could, when giving the flu jab, because it is the same
high risk group that will be called in for seasonal flu protection,
also check the pulse and identify people that way. So we have
a lot of learning through our networks on that particular approach
which we are pursuing and spreading across the country.
Q87 Chairman: Professor Sir Bruce
Keogh, I never like to see a witness sit through an entire hearing
not saying a word. You are obviously a very distinguished Medical
Director of the NHS. What do you think are the wider lessons for
the NHS that we can learn from the implementation of the stroke
strategy?
Professor Sir Bruce Keogh: It
goes back to one of the previous questions about how strategies
interrelate. Roger Boyle was responsible for implementing the
national service framework for coronary heart disease and in many
senses there is great similarity there. There is similarity in
the pathology because it is vascular, it is simply that stroke
affects the brain, heart disease affects the heart. We learned
quite a lot from there about the disease processes, about how
they are treated, about the importance of coronary care units
which has led us to understand the importance of stroke units.
We have learned about the value of networks, we have learned about
the value of collaboratives, we have learned about the value of
national audits and the use of data when it is collected and used
effectively by those people who actually deliver the service and
we have learned, most importantly, about how to start building
the consensus for a strategy from the bottom up. There is a history
of people sitting in darkened rooms thinking they know how a service
should be delivered and that history has demonstrated that those
initiatives have faltered time and time again. One of the things
I think we learned fairly early on with some of the national service
frameworks was that there is a great synergy in a kind of tripartite
relationship between those people who receive and deliver the
service, coupled with those who actually administer the service,
such as the Department of Health and the administration of the
NHS, linked into the Treasury, in other words the people who have
to pay for it. The bit I think we are building on more and more
is a deep understanding that involvement of those who deliver
the service is important. Actually the intellectual capacity for
solving the sorts of problems which we have to address does not
reside necessarily in this building or in Richmond House: it resides
with those people who engage with patients on a day-by-day basis
and who feel the frustrations of those patients, and share some
of their emotions. Those are the people who, in my view, are best
equipped to advise on how services should be best delivered and
how they should be changed. One of the difficulties we have is
how we interpret that desire for change and ultimately effect
it into policy and strategies. The stroke strategy probably represents
among our strategies the pinnacle of that endeavour but we are
still learning from the stroke strategy so I think subsequent
ones will be even better.
Chairman: Thank you very much for that.
It is a very good answer and I do not even need to summarise the
hearing. Thank you.
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