Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 272 - 279)



  Q272  Chairman: Good afternoon, and welcome. My name is Sutherland and I am chairing the Sub-Committee of this Select Committee. My colleagues all have nameplates in front of them, so I shall not go round the table; we would rather use our time talking to you and hearing what you have to say. Just two points: first, thank you very much for the written evidence that has come in. I know that some of you have been directly, and all of you indirectly, involved in that. The written evidence is immensely important to us. That leads me to say that if, after this session, there are points that you would like to amplify that you feel we have not done full justice to, please feel free to communicate directly by e-mail or letter any further material that you think we should have. Lastly, I now must point out that we will be recorded and it may go out on air at some point—perhaps some lonely hour of the early morning—so anything you say will be heard by a larger group than now sitting round the table. Can I kick off with a fairly general question, then, and then we will go round the table asking our questions. As you respond, if you could just remind us who you are, partly for the oral record, and what organisation you represent that would be helpful. Clearly, cardiovascular is our central theme today. As your written evidence, and indeed as our other understanding, makes us well aware, it has a huge impact on the lives of many people but, particularly, older people. I wonder if you would like to talk just a little bit about the extent of this impact and how it affects more than the initial trauma situation but, perhaps, the social aspects of life: quality of life, economic aspects of life and what the impact of this form of illness is. If you would then say just very briefly (and we will come back to this in detail) what are the main areas of research that you think are or should be pursued as a result of this.

  Professor Fentem: My Lord Chairman, I am Peter Fentem, I am a trustee of the Stroke Association and I was the Stroke Association's first Professor of Stroke Medicine appointed in 1992, and I left my post in 1997. It is perhaps relevant that before that I was Professor of Physiology in Nottingham and my special interest was in the physiology of older people, particular cardiovascular function. On the particular question, clearly there are the figures available regarding mortality and so on, and there is no doubt that many people die of stroke—about, perhaps, 125,000 people in this country have a stroke and of those something like 70,000 people die each year. I think, perhaps, as a preliminary to this session, I could just quote what Professor Ian Philp said recently (perhaps he said it to you): "Having a stroke is one of the more alarming and devastating things that can happen to a person, and will happen to a quarter of us over the age of 45", always provided, as it were, we have a reasonable expectation of reaching the age of 85. Twenty years ago nothing could be done with stroke, there was a rather nihilistic attitude to management, but now things are very different. I think that is quite a good way of introducing things. I have mentioned mortality, but mortality underestimates the burden of stroke both for the individual who has the stroke and for the nation, and that I think is the important thing. The important characteristic of stroke is that it leads to disability. We talk about 125,000 having strokes but, of course, quite a number survive a stroke albeit with quite serious disability. So out there there are about a quarter-of-a-million people who have disability as a consequence of their stroke. That, of course, as I say, is a disaster for the quality of life of many of them but, also, of course, is exceedingly expensive for the country that looks after them.

  Q273  Chairman: Is there any estimate of how much?

  Professor Fentem: Two point three billion pounds, or 6 per cent of the national spend, approximately, when it was last estimated.

  Q274  Lord Mitchell: Six per cent of the national spend—on?

  Professor Fentem: On health and social care. The impact on quality of life, of course, is because of the range of disabilities; the outward, visible signs are that people suffer from problems with their mobility and with their ability to reach and so on, but there are others—sight, hearing, incontinence and, of course, difficulties in communication. There are some quite subtle cognitive impairments which interfere with social interaction. Skipping on, perhaps, to the question that you wanted me to deal with, I think it would suffice, at the moment, if I say that I think the possible areas for research are to do with acute care, with both primary and secondary prevention, with rehabilitation, with the delivery of long-term care (and I think this is where stroke has many things in common with the care that is required by many different groups of frail old people) and then there is the management of stroke in primary care, that we really have not touched on.

  Q275  Chairman: Where do you draw the line between primary and secondary prevention?

  Professor Fentem: Primary being preventing a stroke ever happening, and secondary prevention being to prevent people having a recurrence.

  Professor Weissberg: I am Peter Weissberg, I am currently the Medical Director of the British Heart Foundation, having just taken over that post two weeks ago, so I am not really familiar with the workings of the British Heart Foundation yet. Up until that time I was the British Heart Foundation's Professor of Cardiovascular Medicine at the University of Cambridge and a practising clinical cardiologist. My main research interest has been vascular disease, and that is what I feel I should speak about. Put in a nutshell, certainly the heart and, to a large extent, the brain are remarkably resilient organs and they are well capable of doing their job for eight decades or more, providing they have a decent vascular system and a decent blood supply. Virtually all of the mortality and morbidity that we see, either prematurely or of this age group, is as a direct or indirect consequence of a problem with vascular supply to that organ, and that is usually due to atherosclerosis which causes coronary arteries and causes heart attack. As you will all be aware, the incidence of heart attack, as we know it, is falling in the under-65s, but of course that means it is rising in the over-65s and it leaves behind the myocardial equivalent of a stroke, which is damaged tissue, and that is heart failure. Heart failure is a rapidly growing problem in the elderly, particularly as we get better at salvaging patients from what would have been a fatal heart attack, because we cannot prevent them having myocardial damage, very often, and, as a consequence of that, they accumulate more myocardial damage as time goes on and end up in the clinical syndrome of heart failure. It is estimated that there are about 900,000 people in the UK with heart failure, at the moment, and a not commonly recognised statistic is that the mortality from that for about 40 per cent is one year, and it is a very miserable year. The prognosis for heart patients is considerably worse. If we follow exactly the same track that Peter has been following, the estimated cost at the moment for people over the age of 65 to be treated for heart failure in the NHS is £625 million a year. So it is enormous morbidity and enormous cost. If it affects the cerebral arteries then stroke is a consequence and that has just been covered, although it affects the peripheral arteries as well—the arteries to the legs and to the kidneys—and that leads to renal failure, it leads to gangrene and it leads to the inability to walk, and maybe to blindness. So the major focus, I think, in terms of research has necessarily to be on the prevention of that vascular disease in middle age, because it is certainly my belief that if we could prevent the development of atherosclerosis in middle age then the consequences of vascular disease would be very much less in the elderly, and they would die of other things, in effect, because the organs involved are pretty robust. In terms of where I see research going, we have made pretty good headway, actually, in terms of understanding the biology of atherosclerosis and tackling it in middle age through lipid-lowering drugs, ace inhibitors—all drugs which have been shown in clinical trials to reduce the progression of vascular disease and the outcome of vascular disease. I think what we have to turn our attention to is accepting that we are not going to be able to prevent these problems and learn how to repair the organs that are affected. Whilst that once upon a time might have appeared rather science-fictional, I think with the advent of stem cell research it becomes not science reality yet but it certainly becomes plausible (and probably more plausible in the heart than in the brain) that one might be able to use cells, either embryonic stem cells, although they have their problems, or perhaps more realistically bone marrow derived or circulating stem cells (these are cells taken from that person and re-infused back into their heart). There is good scientific evidence, at least, that some of these cells can adopt the characteristics of a heart cell and, in effect, repair an organ which was traditionally thought of as being unrepairable. That is, in fact, the biggest problem. The reason why cardiac and cerebral disease is such a problem is that neither organ has the capacity to regenerate or repair, unlike the liver for instance, so that once damaged it remains damaged and probably goes downhill thereafter. So the scientific focus at the cellular and molecular biological level now is understanding the cellular processes that might allow one to induce repair in those organs. I have applications sitting on my desk at the moment for clinical trials in stem cells for heart attack patients, and I think that does offer some promise for salvage, if you like, of the heart and, therefore, downstream effects for the elderly.

  Q276  Baroness Walmsley: Professor Weissberg, you said that when the heart tissue is damaged, it tends to go downhill after. Is there potential for stem cell   therapy to actually prevent that further degeneration?

  Professor Weissberg: There are two reasons why it goes downhill thereafter. One is that there may be further vascular events. We are all familiar with the major heart attack that strikes somebody down in the street and is a very major event—and likewise with stroke—but what we are less familiar with is the fact that all the time most of us are having micro-infarcts ("infarct" is the term used for death of tissue); that is, little bits of the tissue in the heart and brain being picked off as a consequence of this vascular disease throughout life, and that accumulates. That is one reason why the heart may continue deteriorating. The other reason is that if you effectively wipe out a third or a quarter of the heart the other three-quarters can cope for a limited period of time before it starts to fail, and that is why it tends to be cumulative.

  Professor Lees: Kennedy Lees, I am Professor of Cerebrovascular Medicine at the University of Glasgow. My main work is as a clinician and clinical triallist in stroke, and I am interested very much in both the prevention and treatment of acute stroke. I do not disagree with anything my colleagues have said. I think the enormity of the expenditure on stroke, particularly, is absolutely massive. I do not think we can prevent all strokes. I think one of three things is going to get most of us: it is either going to be cancer, heart disease or stroke. We can delay this, I think, and that is a useful thing to do, but eventually one of those is going to get us. One of the things that really worries me and my colleagues is that stroke does carry a very similar prognosis if not a worse prognosis than most forms of cancer, in terms of mortality—the survival time—and also in terms of the disability. It is just as devastating to be left unable to communicate or unable to be independent as it is to realise that you are slipping downhill from cancer. However, we spend about 1 per cent on stroke research of what we spend on cancer research in this country. It is not just in this country, this does apply internationally, but we are particularly bad on that. It is a tiny proportion, and yet there are clearly things that we can do. The one area on which I absolutely agree with Professor Weissberg is that we must work on prevention and work on repair. The other area we can work on is dealing with the condition as it happens, because if you fail to prevent there is no point in sitting there for the first few hours after a stroke is happening and watching it develop to its full extent and then starting the rehabilitation process, because there are things you can do in that interim. So if it is an ischaemic stroke, a stroke that is caused by a lack of blood supply, where the brain tissue is dying from this lack of blood supply, we should be trying to restore the blood supply, and there is very   good evidence—proof—that treatment with thrombolytic drugs can restore the blood supply and can make a difference—not in everybody but if there is a Number Needing to Treat of eight—that is, for every eight patients treated, one extra complete recovery will occur—that is really a very powerful treatment, far more powerful in stroke than it is in myocardial infarcts.

  Q277  Chairman: Can I ask within what time period does it have an effect?

  Professor Lees: That is the point. There is a three-hour time window in which the drugs are licensed, at the moment, but there is pretty good evidence that they could work much later. One of the areas of research that we desperately need to look at is extending that time window. There is very good reason to think that we can extend it; in many other countries they have access to imaging—that is MRI scans or CT perfusion scans—which will allow us to detect salvageable tissue still there at later times and allow us to direct treatment to the patients in whom that treatment would be beneficial. We, unfortunately, in this country have virtually no centre that can provide that sort of imaging quickly; there are only half-a-dozen centres in the country that are really using the drugs regularly and really getting access to this imaging, which is not particularly high-tech; these are scanners that are available in most hospitals but we do not have access for our stroke patients. I think that is an area that we could definitely be working on.

  Q278  Baroness Hilton of Eggardon: You have already begun to address what you would like to do about the problems. I wonder whether you would like to develop that further and tell us what your priorities are and what you see as being the chief scientific challenges within each of your disciplines or organisations. Are you addressing different aspects of these problems or are you all addressing the same priorities?

  Professor Fentem: We are different organisations, of course, with a quite different remit. I think it is worth just saying a little bit more about acute care because acute care is high on the Stroke Associations' agenda. Although there are probably only a limited number of patients who after a stroke can benefit from thrombolycis—ie, clot-busters—nevertheless, I think the particular problem that we need to address and which, I am sure, Kennedy Lees would explain further, is that the mortality in this country in the first 30 days after a stroke is about 30 per cent, on average. There are problems because elsewhere in the world we are not always comparing like with like but the 30-day mortality in Canada is between 11 and 15 per cent. Those are a lot of deaths, and on the present evidence it would appear that it depends on the admission of patients to stroke units and the detailed care within those units. We do not know which components, at this stage, are producing this effect but one thing that we suspect is important is the imaging. The point I would like to make is that this, of course, would lead to changes in the way the ambulance service transports patients, because you would need to get rapid admission to hospital, and it is not only a matter of the scanners but where you put them; in Canada the scanners are in A&E, and the interpretation of the scan is undertaken by people either on site or on the end of a telephone link to a computer. So that is one area that we feel needs to be explored in detail. I suppose this will come up somewhere in the meeting, but this is where the opportunities will present when the National Stroke Clinical Research Network is formed, and this is an important opportunity, not only for stroke, of course, but for some of the conditions. In the case of prevention, certainly for patients in the younger age groups we think that prevention is feasible and the research area that we think is important is the question of what is the package and how do you deliver it? In South London, St Thomas's, Guy's and Kings have one of our programme grants and are looking at that particular question in the incidence of secondary prevention. It is no use identifying the fact that high blood pressure after stroke matters if you do not decide to do something about it, and clearly there are many, many patients who are not getting attention to their continuing problems after they have had their first stroke. Rehabilitation I mentioned as one of the other areas, and of course possibly your attention will have already been drawn to Professors Tallis and Frackowiaks' report on putting the neurosciences to work, and that covers many of the issues which are important in relation to  rehabilitation. We must understand the rehabilitation, we must understand what works and what does not work, and we must stop providing token rehabilitation. If you, by any chance, have had a chance to look at the National Audit Office report The Way to go Home, you will have seen that many hospitals were only providing 10 minutes of physiotherapy a day to many of their patients. It just so happens that stroke is used as a marker for that study but the approach to rehabilitation goes right across the needs,of older people whose independence is threatened. Then, of course, there is the question of continuing care, community care. Again, we feel we have to challenge adequately the current wisdom which is that you can have six weeks' physiotherapy after your stroke on the assumption that that is the end of the improvement that can be achieved. Yet those units which are being brave enough now to re-introduce physiotherapy to people who are obviously deteriorating have shown that it works. I hope that gives a flavour of some of the issues that the Stroke Association thinks are important.

  Q279  Lord May of Oxford: I had a specific question, going back to your comparison with Canada (and you did qualify it by saying you were not comparing like with like) but I am curious: it does seem to me there is a difference between keeping people alive and the quality of the life that you keep them alive for. I would ask, as it were, of the 30 people that die in Britain versus the 15 that die in Canada in the first 30 days, what is the quality of that surviving life of the 15 who survive in Canada? Is this a measure of the more heroic attempt to keep more people alive in some form of life in North America, or is it really something that is more operational?

  Professor Lees: May I respond to that? It definitely is not just keeping people alive who would otherwise be left disabled. If you look at the figures for the recovery as well, you will see that countries like Germany and Canada have a far higher proportion of patients making a good recovery. One of the extremely disturbing facts is that in this early period of acute care if you do not provide good care then somebody who could well make a good recovery can be left disabled unnecessarily or die unnecessarily. So I think it is extremely important to recognise that this is a measure of overall care, but we can move everybody up one or two stages and get many more people back home and functioning normally.

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