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Another major element is how well they are cared for in terms of rehabilitation and whether their local authority looks after them well, giving them the aids and the confidence they need at home. According to Professor Boyle, people will spend less time in hospital and go home more quickly. When they go home, it is even more essential to see that the support is available to help them make a full recovery.

The services in the specialist units are great. At the time Kevin had his stroke, thrombolysis was not practised at all in the Chelsea and Westminster. I do not know whether it is yet. At the meetings of the Stroke All-Party Group, I have heard from a number of professors, including one in particular from Newcastle where thrombolysis is used successfully. It is used in Australia and the United States. Clearly there is a change taking place in the treatment of strokes due to a thrombotic effect, and this must be good. Again, it comes back to that essential factor, that above all we must know what we are treating and the patient must be aware of the need for treatment.

9.18 pm

Baroness Masham of Ilton: My Lords, I thank the noble Lord, Lord Rodgers of Quarry Bank, for instigating this debate on the Department of Health’s report, Mending Hearts and Brains. Some problems can complicate both conditions and there is often confusion in the minds of the public as to which is being referred to, so I am pleased the noble Lord has chosen to concentrate the debate on stroke victims. Strokes seem to be the poor relations, as great progress has taken place in heart disease.

Regrettably, I have to declare an interest as my husband suffered some strokes and I feel strongly that everything possible to prevent them should be done. The treatment and aftercare should be improved across the country so that everyone who suffers a stroke gets the correct treatment, and as quickly as possible, as stated in the report.

I have immense admiration for the several members of your Lordships’ House who have had strokes and have been able to continue work in your Lordships’ House. I know that has not been done without great concentration, determination and hard work in getting better.

The report stresses that strokes could be prevented if people kept their blood pressure under control, monitored cholesterol levels, ate healthily, stopped smoking and took regular exercise. That is the reason I have been badgering one of your Lordships who is taking part in this debate to get his blood pressure down. It can be a hidden danger. Not all stroke victims are old, by any means, and they may look the picture of health. They need the co-operation of their doctors.

When my husband’s stroke happened he was watching cricket on the TV. I was talking on the telephone and went over to ask him something, and to my horror found he was having a stroke. We called a doctor and an ambulance and I followed him to the local hospital. When I arrived I found him on a bed, and a young South African student nurse and I had to try and get him undressed. First, she started filling in the admission form, but after a few questions she threw it down and said that most of it was irrelevant. My husband was a big man, and I told her we would have to roll him like one would do with a tetraplegic. No sooner had we got his pyjama bottoms on than we had to change them, for obvious reasons.

All my husband wanted was to continue watching cricket on the TV. When I left his room I was surprised to find the charge nurse chatting to some young nurses, no doubt about their social life. I felt that the young student nurse and I should have been given some help. My husband was admitted at about midday, and by 8 pm he had not seen a consultant, so I rang the chairman of the hospital, who was a friend. She telephoned and found the consultant at his house. There seemed to be no sense of urgency, only apathy, and no communication, which was distressing for the family members.

I apologise for reliving the frustration of that experience, but it has made me adamant that what is written on page 8 of the report must be the aim for all stroke patients:

“You need to go from paramedic, to specialist, to scan, to clot-busting drug within three hours of the stroke hitting. So the speed with which you get a patient to a specialist is even more important. Some strokes are caused by bleeding rather than a clot and giving a clot-busting drug to these patients is extremely dangerous. Patients need a scan to show whether the stroke was caused by a clot or a bleed”.

I understand that all hospitals have not got enough personnel to provide 24-hour scanning provision. That is always a concern for the many people who have raised money for scanners, and they would like to see them working 24 hours a day, 7 days a week. The report suggests the sensible compromise of bypassing hospitals without 24-hour scanning facilities and taking stroke patients to special stroke units that can save lives and long-term disability by scanning, but it remains a very great problem in rural areas, as has been stressed by the noble Lord, Lord Rodgers.

Last Thursday I read an article in the Yorkshire Post headed “Postcode lottery affects care after stroke”. Maybe the noble Baroness will read that paper. The article says:

“Hundreds of stroke sufferers could be dying needlessly because of a postcode lottery for specialist care, new figures have revealed. More than a third of patients do not receive treatment in a stroke unit where their prospects are considerably better, a national audit found. Huge differences were found across the country and in Yorkshire. Only one in four patients treated in Dewsbury, Pontefract and Wakefield were treated on a dedicated stroke unit compared to nine in 10 in Bradford and two in three nationally ... Only 19 per cent of patients in Harrogate received a home visit before discharge compared to 94 per cent in neighbouring York. ... The audit of 224 units by the Royal College of Physicians criticised some hospitals for ‘failing to recognise that their stroke patients need 21st century management’”.

I would like to ask the Minister a few questions. Is there going to be a vaccine for strokes? Is eating mangos useful? I heard a young child carer of a stroke victim say last Saturday on the radio that paramedics would no longer come and pick up somebody who had fallen. If this is the case, what can be done? Many disabled people fall at home so something must be arranged. I saw recently on TV that a hand-held scanner was being developed in India. Might this be of use in the future?

I hope that this debate will help to motivate better treatment and care for those unfortunate people who suffer a stroke and I congratulate the Stroke Association on raising awareness and campaigning for the needs of stroke victims. I feel there is a need for trained volunteers to help patients who are recovering from strokes in hospital with such things as feeding, shaving and helping with communication rehabilitation. It takes time and patience. Perhaps the Stroke Association can help meet these needs, which often get neglected when hospital staff are too busy.

9.27 pm

Baroness Barker: My Lords, it is a pleasure to take part in another debate on stroke prevention and care initiated by my noble friend Lord Rodgers of Quarry Bank. He introduced it passionately and perceptively; I commend his dogged determination, dedication and persistence on the matter. I also thank him for giving me cause to read Professor Boyle’s report Mending Hearts and Brains. As Department of Health reports go, it was clear, succinct, honest and mercifully free of the padding and self-congratulatory rhetoric characteristic of so many departmental documents. As someone who has to read a lot of them, I enjoyed it. But my noble friend is right: it distils many reports that have come before it. Many have been mentioned already but I would like to add Professor Ian Philp’s five-year review, the National Service Framework for Older People, which has a section on strokes. What is not clear is where this report sits in relation to all the other initiatives in the department and in the NHS.

The report commendably took forward the model developed in Australia of treating stroke as an emergency, which has worked very successfully there. We needed to do something like that in this country because stroke is one of the most expensive diseases, costing us £7 billion a year. The area has been neglected for so long that a redesign of services offers great potential for savings and investment.

The National Audit Office report showed that trials of stroke units demonstrate that, by treating people in those units rather than in general medical wards, the number of acute bed days could be reduced by six. If that is applied to the 100,000 people every year who suffer strokes, not only is it better for them to spend six fewer days in places that we know to be rife with MRSA and so on, but at an average cost of £125 a day times 600,000, there is a potential saving of £82 million. Much could be done, therefore, to make our services more rapid and better organised, releasing resources that could be used in better ways to support people.

I listened to what my noble friend said about hubs, spokes and diagrams and I understand some of his comments. However, although it does not look anything like a working bicycle, the model is in theory right. Having acute specialist centres placed strategically and linked to spoke centres in which there can be more effective rehabilitation and treatment offers great potential for diseases such as stroke but could also be pursued in relation to cancer, for example, where regional centres of excellence support other bodies. My noble friend was right to ask how this will be achieved in practice. Given that the Government propose to devolve commissioning of treatment and care to GP practices or clusters of GP practices, who will be responsible for ensuring that a complete system of hubs and spokes exists? What happens if, in a particular area, GPs decide that they have a young population profile and that such provision is not a priority for them? Does that mean that the hubs and spokes are not built? Will the department issue guidance on the sort of populations to which these models should be applied? If so, will it take into account, as my noble friend said, that the timing of treatment varies enormously depending on geographical location?

I noted Professor Boyle’s point about A&E departments not necessarily being the best place in which to diagnose people who have had a stroke. I sympathise with that, as I have spent hours in A&E sitting with someone in that situation. It is particularly true of people who have had a stroke before, when trying to work out whether they have had a second TIA—transient ischaemic attack. I can see the force of his argument. I welcome the proposal that ambulance staff should be better trained and equipped to make a faster diagnosis. Will they have access to the necessary range of diagnostic equipment? What will happen when it is not immediately obvious that there has been a stroke? Will the default position be that people are taken to a treatment centre or to A&E?

Although in A&E departments people have to wait a long time, they are usually attached to other services such as pathology labs. Will the system of accessing those ancillary services be changed at the same time?

The key reason why the Australian system works is that it manages to have the right kit with the right people in the right place at the right time. That takes us straight to staffing. When the National Audit Office report was produced, we had only 86 whole-time equivalent stroke consultants, which was in its view 20 per cent of the requirement. We also need specialist nurses who can deal with stroke patients who cannot swallow, for example, and physios who can begin to get the muscles working again.

One thing absent from Professor Boyle’s report was a reference to deep vein thrombosis nurses. There has been a practice recently of having DVT nurses in A&E departments. They can often be a rapid source of information and support; they can get people’s warfarin levels sorted out and re-established; and they provide an awful lot of confidence and practical assistance to patients.

When we debated this matter last year, the noble Baroness, Lady Royall, gave us an update on the national stroke strategy. Can the Minister provide a little detail on progress? The introduction of the picture archiving and communications system—the computer system by which images of organs are sent to specialists electronically—is key to enabling fast diagnosis. It is part of NHS Connecting for Health, which was due to be implemented in spring this year. The Minister has the joy of being in charge of Connecting for Health. What progress has there been?

The noble Baroness, Lady Royall, said that the department was funding the programme developed by Professor Gary Ford at Newcastle on thrombolysis. I assume that his work has informed the model put forward by Professor Boyle. Can the Minister set out in detail whether the follow-up to acute care—whether in an A&E department or an independent treatment centre—will be by co-ordinated rehabilitation in a community setting? The report talks quite a lot about supported discharge, which enables people to recover much more of their capacity more quickly, but will that focus on rehabilitation be carried forward into residential and nursing homes, for example, where many who are disabled by stroke end up?

I have one final point. We know that vascular disease is particularly prominent among black and minority-ethnic communities. That is not mentioned in Professor Boyle’s report, yet we know that those communities have a particular predisposition and risk. What is being done about that?

Stroke victims need to recover their confidence. If they all recover it to the degree that my noble friend Lord Rodgers of Quarry Bank has recovered his, as shown by his opening speech, they will do well.

9.37 pm

Earl Howe: My Lords, I am delighted that the noble Lord, Lord Rodgers, has given us this opportunity to debate stroke care—a subject on which he speaks with tremendous authority. This is one area of NHS activity which has witnessed huge improvements over the past few years, to the undoubted benefit of many thousands of patients.

I look back in particular to 1991, when a close member of my own family, previously fit and well, had a stroke at the age of 66. She lived in the home counties. Though her mind was alert, she was paralysed down one side. She had difficulty swallowing. She was taken to the local acute hospital. There she languished for the next six months on a geriatric ward. There was no physiotherapy. There was not even any aspirin. It was weeks before a scan was done to see whether the stroke had resulted from a clot or a bleed. We were told that it had been a bleed—hence no aspirin being given. In fact it had been a blood clot. The aspirin should have been given but was not until months later. It was obvious then that the NHS was simply not geared up to treat stroke victims, and obvious too, with hindsight, that if it had been, my relative might have enjoyed a much better outcome.

So I pay tribute to the Government for getting stroke care onto the map. The Stroke Association is also to be congratulated on its excellent and consistent lobbying on the subject. Stroke, as we have heard, is the third biggest cause of death in the UK, and the largest single cause of disability. Some 110,000 people each year suffer a stroke and 30 per cent will die within a few weeks. The rest are cared for at a cost to the NHS of £2.8 billion and a wider cost to the economy of more than £4 billion. It does not take a great mind to work out that even a modest improvement in those figures would result in enormous relief of suffering as well as significant cost savings.

Six years ago, the National Service Framework for Older People kick-started the recent improvement in stroke services by including specific milestones and targets. I have always said that where we are dealing with a major public health issue like coronary heart disease or stoke, national targets have a definite role to play. They are quite distinct from targets to do with waiting times—about which the Minister knows that I have different views—because they are primarily about health outcomes. Nevertheless, if we look at the progress made in delivering those outcomes, there are mixed messages. So, although 91 per cent of English hospitals now have a dedicated stroke unit, which is a big and most welcome improvement, your chances of being admitted to a stroke unit in a quick and timely way when taken to hospital are woefully low. It has been shown beyond doubt that if your condition is managed on a stroke unit, you are statistically more likely to have a much better result than if it is not. However, only 15 per cent of stroke patients are admitted to a stroke unit on the same day that they arrive in hospital. If you have a minor stroke, you almost certainly will not be treated on a specialist unit at all. That has to change, because someone who has had a minor stroke is at high risk of having another one. As the sentinel audit pointed out, that person needs expert care and investigation just as much as the person who is more seriously ill.

There are many who for some time have been urging the NHS to treat stroke victims as a medical emergency, for that is what they are. Ambulance crews around the country are to be commended for treating strokes as category A incidents and delivering patients swiftly to A&E. Yet all too often the patient arrives and has to wait before being diagnosed and treated. It is well established that if your stroke is due to a blood clot, as opposed to a haemorrhage, rapid access to clot-busting drugs can transform your chances of recovery. This process is routine treatment in other countries, but not here. To deliver it, stroke patients should be scanned more or less immediately they arrive in hospital so that the nature of the stroke can be ascertained. Again, this is not happening. The number of stroke patients going through a scanner within 24 hours—never mind three—is only 42 per cent, well under half, which the sentinel report called unacceptably low. Whatever you do, do not have a stroke on a Saturday or a Sunday, because you will not be assessed until the following Monday at the earliest. It appears that brain scans are done only between the hours of 8 am and 6 pm on week days. I say to the Minister that that is another situation that has to change.

There are similar problems getting access to therapists and social workers. If you have difficulty swallowing, you need to be assessed rapidly by a speech and language therapist. Yet a third of patients in this category do not see one for over three days. If you have lost the use of a limb, you need physiotherapy at the earliest opportunity. Again, rapid access to physiotherapy is still the exception. One has to be critical of the fact that so many graduate physiotherapists who qualified in 2006 are still unemployed. Last December, the date of the most recent survey that I have, seven out of 10 of those graduates did not have a job. There is work for them to do, but trusts are too strapped for cash to employ them. That is a shameful state of affairs.

As we have heard, some of those issues are brought out in the Mending Hearts and Brains report. Professor Boyle, the national director for heart disease and stroke, is one of those who has pressed for strokes to be treated as a medical emergency, but he has also said that A&E departments are not the best places to treat stroke victims. One cannot equip every A&E department with 24-hour consultant services or open access to a CT scanner, so the logic is that stroke services should be concentrated in centres of excellence to which paramedics should take the patient when they judge it appropriate. The noble Lord, Lord Rodgers, raised some very pertinent questions on that issue.

Community services also need to raise their game. If the aims of Our Health, Our Care, Our Say are to be achieved, we need better ways of supporting stroke patients who have been discharged from hospital and more proactive monitoring. I question how this can happen as a generality when the tariff for treating stroke patients is so clearly inappropriate. It is inappropriate at the start of the process, because there is currently no financial incentive for hospitals to provide acute care for strokes and inappropriate for follow-up care because the tariff that we have has not been properly unbundled, although some formal unbundling has recently occurred. What is being done to address that aspect of the issue?

Dr Tony Rudd, who is chairman of the Intercollegiate Stroke Network, has said that despite the improvements in stroke care too many patients still receive substandard service. I think that about sums it up. We have not made as much progress with preventing and treating stroke as we have with coronary heart disease. The disappointment in all this is the length of time that we have all been waiting for the national stroke strategy. It is almost as if clinicians and managers in the NHS have been hanging upon the publication of the strategy before deciding to go ahead and make key improvements to stroke services, which is equivalent to a sort of service blight. That kind of delay is deeply regrettable. The more closely the NAO recommendations are implemented and the sooner it is done, the better it will be for patients and the greater the long-term savings to the NHS.

The same could be said about achieving better awareness among the public of the importance of monitoring blood pressure, which is the single biggest risk factor for stroke, and making quite simple lifestyle changes to prevent strokes happening. In that context, the needs of those for whom English is not a first language should be remembered. The noble Baroness, Lady Barker, made that point. The prevalence of stroke amongst African-Caribbean and south Asian men is particularly significant. Quite apart from setting out best practice for treating strokes, I hope that preventive measures of this kind will also be built into the strategy. It would be helpful if the Minister could tell us whether they will be.

The noble Baroness, Lady Masham, is right. Stroke has tended to be the poor relation of coronary heart disease in terms of the emphasis placed on it and it deserves better. I very much hope that the Government will do all in their power to ensure that the NHS continues to raise its game in treating this most devastating of afflictions.

9.47 pm

The Minister of State, Department of Health (Lord Hunt of Kings Heath): My Lords, I am sure that we are all grateful to the noble Lord, Lord Rodgers, for what I thought was a pretty forensic analysis of my department’s approach to strokes. I assure noble Lords that, after an extremely good debate, I will ensure that the very substantive comments that have been made will be reflected by officials in writing the strategy.

I do not need to repeat the statistics. It is very clear that stroke has to be a major priority for the National Health Service. As we heard from the noble Baronesses, Lady Masham, Lady Gardner and Lady Rendell, who spoke so eloquently of their personal experiences, there is no question but that we need to do much better in future. I also fully accept that the message of public education is vitally important. I echo their congratulations to the Stroke Association. It is clear that the public need much more information. The point made by the noble Earl, Lord Howe, about blood pressure tests was very important.

Equally noble Lords have shown really wonderful examples of the power of recovery, where the will is there. We need to ensure that we do everything to enable stroke patients to recover in the most effective rehabilitative approach as possible. I confirm that the strategy that we want to take forward will focus as much on rehabilitation as it does on the hub-and-spoke approach and all the other things that need to happen in dealing with stroke as an acute care incident.

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