I beg to move,
That this House has considered the matter of stroke services.
When the House last debated stroke services in July 2007, we had not introduced the stroke strategy for England. However, it was clear from the content of that debate that Members on both sides of the House were united in their wish to see services across the stroke pathway improved for what is one of the major health conditions, and one that has historically been regarded as a poor relation.
The strategy was launched by my right hon. Friend the Secretary of State for Health at the stroke forum conference in Harrogate in December 2007. I know from what he has told me and many other Members that he found the occasion particularly moving, as the strategy was received with great pleasure. Indeed, it has been universally welcomed. The national stroke audit of 2008 by the Royal College of Physicians stated:
“For the first time since we started conducting a national sentinel audit for stroke…ten years ago, there is reason for optimism…If implemented,”
“should result in services that are the envy of the world.”
Strokes are devastating and the human cost is enormous. Every year, some 110,000 people in England have a stroke—one every five minutes. Some 900,000 people in England live with the consequences of strokes, which are the largest single cause of severe disability in adults. More than 300,000 adults in England have lasting disabilities as a result of a stroke.
Having a stroke has been described as an earthquake in the brain—it certainly is; it is a brain attack. Strokes can have shattering consequences for families and carers as well as the individuals who suffer them. There is also a major economic context to stroke, since the cost to the economy runs into billions of pounds every year.
The Under-Secretary has referred to the consequences of stroke, including disability. Will she confirm that something of the order of 100,000 stroke victims suffer the consequence of a communication disability? In that context, will she underline the critical role, which needs to be deployed early, of intervention by a speech and language therapist, not least to address eating, drinking and swallowing, and to attempt to ensure that permanent damage to the ability to communicate is not suffered? That is critical, and I welcome the fact that we are debating the subject today.
The hon. Gentleman has done so much work on the subject, and I know that the House will want to congratulate him on that. He is absolutely correct. I know from my many years of experience as a nurse the consequences for the patient and the family if the assessment is not made correctly. Not having a proper examination of a swallow reflex can lead to very serious consequences for the patient, making recovery so much longer. The issue that the hon. Gentleman has raised is crucial.
Does my hon. Friend accept that, as well as early intervention, those who suffer aphasia—an extreme form of stroke—need a lot of help over much time? There is always a problem about when that help is cut away. Does she agree that we must be sympathetic and ensure that it is done at the last possible moment, and not too early?
I certainly agree with my hon. Friend. The consequences after such a devastating attack on the brain for a person’s ability to lead any sort of normal life are catastrophic. I hope that, as the debate progresses, such issues will be raised and that I can address them.
We are aiming for a revolution in our stroke services. The strategy is a 10-year plan, and we are in only the first year—we have a long way to go. However, I want to outline some improvements that are already happening. My right hon. Friend the Secretary of State for Health said in the stroke debate in 2007 that he intended to make stroke a top priority for the NHS. We have done that, and that has been recognised in the NHS operating framework for 2009-10, in which stroke services are covered by a tier 1 vital sign—a “must do” for the NHS. Each strategic health authority’s vision for the next stage review is committed to improving stroke care.
In addition to the extra funding that has gone to all primary care trusts, we are providing £105 million of central funds over three years from 2008 to 2011 to support implementation of the stroke strategy. Some £77 million is being used to accelerate improvements in acute and community services. Another £16 million is being used for stroke-specific training for nurses, allied health professionals and other staff, as well as additional training for stroke physicians, and £12 million is being used to improve public and professional awareness of the symptoms of stroke and the need to act quickly.
The national awareness campaign—Act FAST—was launched in February. It cannot have failed to catch hon. Members’ attention, and many have commented on its success. I am therefore confident that I should not need to remind hon. Members that FAST stands for face, arms, speech and time to call 999, if the person shows any of those signs. The effectiveness of the campaign is now being assessed, but we already know that it has been seen in one medium or another by 92 per cent. of the population.
I am very impressed by what the Minister is saying, and I have a deep interest in the issue. She is talking about Act FAST, which is an essential policy if people are to suffer the minimum rather than maximum damage from strokes. However, is she satisfied that people are getting treatment fast, both when symptoms are showing and, sadly, after a stroke has taken place?
There is more work to be done in particular areas. The reconfiguration of some areas still has to be decided, but the understanding of how essential it is to act fast, go to the appropriate clinical facilities and be seen by physicians with expert training is paramount. The number of lives that have already been saved and, in particular, the number of severe disabilities that have been prevented show the progress that we are making.
I welcome everything that my hon. Friend has been saying. On the issue of speed, she will know of the consultation that Healthcare for London has just concluded on the future location of stroke centres in outer London. Does she agree that it is critical that the locations chosen for those centres should have ease of access, so that people can get to them as quickly as possible, and, in the light of that, that Northwick Park hospital, which already serves a growing elderly population and a highly multi-ethnic population, is an ideal candidate for such a centre?
My hon. Friend raises some interesting points about the recent consultation, which was completed only on 8 May. Announcements will be made in relation to the London strategic health authority on about 20 July, and I know that Northwick Park hospital is held in high esteem for the service that it gives.
I am most grateful to the Minister for giving way. She is being very generous indeed with her time. We are all agreed that treatment in a specialist unit is the preferred option. However, some 81 per cent. of all stroke patients are initially admitted to a generic admission unit. We all want that figure to be much lower. Can the Minister therefore give us some indication of the Department’s timeline—say, over five to 10 years—for ensuring that more than simply 19 per cent. of people are admitted to a specialist unit, which will of course be far better for them?
Our strategy is timed to run over a 10-year period. We are well past the first year, and great improvements have been made. As we are speaking, primary care trusts are working, particularly in London, which I am more familiar with, to see how some of those services can be brought forward, particularly through the training and education of staff, because we need expertise in this area. We have made very good progress on cardiac conditions by channelling patients in a particular specialist way, so we know that once we have the evidence to say, “We will save lives and correct disabilities if we do it in a particular way,” it will be our duty to speed that up to the best pace that we can.
I rise because there are concerns in my area in north-east London, which are shared, by the way, across the Floor of the House by the hon. Members for Leyton and Wanstead (Harry Cohen) and for Walthamstow (Mr. Gerrard), who are both with me on this. We believe that the process by which decisions are made on hyper-acute services is not at all transparent or clear. We have tried to press those responsible on whether the process is set in stone. They say that it is, but then they change it. For example, the Royal London hospital received a decision on hyper-acute services on the basis that it had a cardiac centre aligned, yet its scores were no better than those of Whipps Cross hospital. Queen Elizabeth hospital got a decision because of its neurological service, but it has no cardiac service aligned, while others are ruled out on the basis that, somehow, they have neither of those things. It seems that decisions are made on the basis of picking winners, rather than on having a set, transparent form that says, “If you have these things, you are likely to get it and we will adjudicate you accordingly.” Will the Minister look at that carefully and ask Richard Sumray and his group how they reach such conclusions? Does she think that they are fair?
I acknowledge what the right hon. Gentleman has said, particularly in relation to the specific case that he raises. I would be very happy if he would write to me about that, so that I can take it forward, because it is our duty to get things right clinically and in the right area. Everybody is agreed on that. The Royal College of Physicians has congratulated us on how we are managing most of our consultation. However, if there are flaws in it that the right hon. Gentleman wants to raise with me further, I will be happy to look at them.
My point is not about London. To return to what the Minister said about the rapid response associated with the FAST test, the way in which the ambulance service responds is very important. We know from the original work in Newcastle that ambulance staff are entirely capable of making as good a judgment as GPs can about whether somebody may have had a stroke. However, a recent report in the Emergency Medicine Journal showed that the software used by ambulance staff to triage calls was missing up to half of potential strokes, that only one in four stroke patients were given a category A ambulance response and that in a minority of cases—3 per cent.—potential strokes were given category C responses. Is it the Government’s view that we should seek to improve those figures and, in particular, to give possible strokes a category A response?
The hon. Gentleman raises an issue that I need to look at. I need to see the figures that he has presented and take the matter up, along with my ministerial colleagues who have responsibility for the ambulance service. I am very happy to do that, because—I cannot say this enough—we have to get it right. All our knowledge to date is saying that we are progressing in that direction. However, if there are problems in some areas that we need to address, which the hon. Gentleman has highlighted, it is my responsibility and the responsibility of my ministerial colleagues to take them seriously and to take them up. Again, I would be very happy if he would like to bring the matter to my attention in a way that I can take up.
Although we can never measure the real achievements of a campaign such as the FAST campaign, it is more than likely that outcomes have already been improved for many people and it is possible that lives have been saved too. The campaign is ongoing, and it is likely to return to television later this year. Many people have phoned and written in to refer to the life that they have saved, having seen the campaign and been made aware, when they were out at social or sporting events. There have even been people who saw the advertisement in our country and, when travelling abroad, were able to notice the symptoms and make people aware, and they have also saved lives.
The stroke strategy mandates the establishment of stroke care networks as a cornerstone of its implementation. Through working co-operatively within a network, services can be better integrated and better planned, and ensure that patients experience seamless transitions across boundaries within and between health and social care. I feel confident that social care will be raised with me today. The strategy acknowledges that networks are of huge benefit. All stroke services in England now fall within one of 28 networks.
The stroke improvement programme, or SIP as it is sometimes known, provides national support for improving stroke and transient ischaemic attack services, working with stroke networks, front-line services, charities and patient groups. Key areas of SIP’s work include providing information and guidance through newsletters, websites and training events, and ensuring that those working to help services improve are in touch and up to date. SIP also runs national improvement projects with 40 front-line stroke and transient ischaemic attack teams, focusing on the main elements of the pathway: acute stroke, TIA, rehabilitation and transfer of care. The projects are putting best care into practice, helping their patients and showing others the way to improve. It is so important in our health service to share best practice.
SIP works with primary care trusts and public health departments to strengthen work on preventing strokes, aiming to prevent the estimated 4,000 strokes caused by the under-recognition and under-treatment of atrial fibrillation. SIP is also bringing together and writing up emerging good practice and providing national forums to bring together key leaders for implementing change. That, too, is an important element in any change in organisations, particularly in the health service. We have to have good leadership to encourage people to look at their practice and to take seriously the consultation involved, so that they understand why it is important and why it must be appropriately led.
The sum of £45 million—about 40 per cent.—of the £105 million of the central funding is going directly to the 152 local authorities with adult social services responsibilities as a ring-fenced grant. This is to encourage and develop good practice in delivering stroke services for adults in their communities, to improve outcomes for those who have had a stroke and to enhance their quality of living and degrees of independence, as well as those of their carers and families.
Local authorities are working hard to develop services according to local needs and priorities—for example, to reflect any special support needs of obviously disadvantaged groups, such as black and minority ethnic groups, those in much lower socio-economic groups, those who might find services difficult to access, and those at higher risk of a recurrent stroke.
The Minister is right to say that this is an important public health issue, and reducing health inequalities is extremely important. What account has she taken of the rural poor, who are particularly disadvantaged in relation to stroke, given that they are often unable to access stroke services expeditiously?
The hon. Gentleman raises an important point. I recall travelling to see patients when I worked as a community district nurse, and I know that many patients feel very isolated when they have no access to transport. If they have no close family to help them, the isolation can be awful. We need to go back to the leadership on this. The third sector does an amazing job in rural areas, but speed, access to services and quality of life can be difficult to achieve in those areas. I am sure that the hon. Gentleman works positively to bring these matters to our attention, and I would be happy to look at whether there is a specific route that we could develop and share best practice on. Many members of the third sector will be able to offer the health service a lot in this regard.
Rather than relying on the third sector, might it not be better to follow the suggestion of the Minister’s own emergency group, which is looking into re-allocating resources in the ambulance service, that calls relating to strokes should be upgraded from category B to category A?
That point has already been raised by the hon. Member for South Cambridgeshire (Mr. Lansley). We always need to see how we can improve these services, and I take that issue very seriously. Today’s debate is about sharing our knowledge and raising problems in our constituencies, and we should use it positively to make improvements.
Following up on the points that have just been raised about the difficulty that some people have in accessing the services that they need, may I say sincerely to the Minister that elderly people who suffer strokes often need intensive physiotherapy? They will get that physiotherapy in hospital, but when they return to residential care or, in some cases, to a residential nursing home, the availability of that treatment is minimal. Are we going to be able to provide the necessary level of physiotherapy and after-stroke care for those in residential care or in residential nursing homes? I believe that this is a crisis area.
I share the hon. Gentleman’s concern. The reality for some people receiving physiotherapy is that they wait for hospital transport to take them to their treatment, have their therapy for half an hour, then sit and wait all afternoon to be taken back home. I have often questioned the value of that approach. We are now working on transforming community services, following the High Quality Care for All review and Lord Ara Darzi’s Next Stage review, to see how long-term conditions can be treated in the home. The reality is that we need to deliver therapy to people where they are, rather than transporting them to it. If we look at this from any perspective, not least the value-for-money perspective, we can see that transporting patients in that way is not how we should be delivering services. Those services should be actively encouraged and delivered where the patient is. Training of staff in residential and nursing homes needs to be improved so that some of that physiotherapy can be given in a more gentle, passive way throughout the day.
Pursuant to the very pertinent question that my hon. Friend the Member for Macclesfield (Sir Nicholas Winterton) has just asked, is not the distinction in terms of access to the necessary care between those who, by virtue of being in hospital, are—for want of a better term—above the radar and therefore readily visible, and those in a more private environment who fall below the radar and are therefore less visible? Would the Minister care to comment on the need for central leadership, courtesy of the stroke strategy? I sometimes feel that all the parties are poisoned by the dogma of localism to the extent that they do not always recognise that, to protect vulnerable minorities, some sort of central guarantee or leadership has to underpin local initiatives.
Those points are being addressed through the strategy of caring for people with long-term conditions in the community. Perhaps I can give a plug to my own profession by saying that nurses are leading most of this change. The specialist stroke nurses have always been aware of how the care of the patient could be better delivered. We are aware that, when a stroke has gone badly wrong and disabled someone to a considerable extent, they have often received a Cinderella service. I think that we can all acknowledge that.
Now, however, we are addressing that matter and asking how we can improve the quality of patient care. We need to enable those patients to take small steps towards being able to dress and toilet themselves and to care for their own personal hygiene. It is important that each individual should have the extra care to enable them to do that. These are small steps; this is not high on the scientists’ agenda. The hon. Gentleman mentioned things being below the radar. The reality is that even a small improvement in the daily living arrangements that most of us take for granted will make a difference to the patient’s life, as will the ability to communicate following the horrendous experience of being unable to do so. At some stage, we are all going to be vulnerable to such an attack, and we must therefore go back to the basic question of how we would want to be treated and what care we would wish to receive. That must be our starting point, which is why the stroke strategy is so important.
I congratulate the all-party group on stroke, which is chaired by the hon. Member for North-East Cambridgeshire (Mr. Moss), on its sterling work. Survivors have come to the House and communicated with us about their difficulties. This debate is welcome, and I welcome the practice that has been acknowledged. I know that we will continue to work on this.
I would like to make some progress now. Local authorities are the pivotal access point to a range of services that can benefit people who have had a stroke and who want to live independently at home. They are working with their NHS partners locally, with stroke networks and the voluntary sector to help individuals and carers at an earlier point to reduce the likelihood of increased dependence at a later stage. To support that work, many local authorities have used some of this funding to appoint stroke care co-ordinators.
I want here to acknowledge the good work that the voluntary sector is doing to help implementation of the strategy and to recognise the support it has provided for stroke survivors over many years when stroke was barely ever debated in this House. Volunteers have dedicated their personal time to improving the quality of life for patients and their families. Third sector organisations such as Connect, the Stroke Association, Different Strokes and Speakability provide enhanced services to stroke survivors and their carers. They have much of the expertise and skill required to support further improvements across a broad range of issues.
All those issues are highly relevant to helping people who have had a stroke to achieve a good quality of life, maximum independence, well-being and, of course, choice. Recently, the Stroke Association launched a report, “Getting better: Improving stroke services across the United Kingdom”. While recognising that there is more to be done, this report sets out some excellent examples of where significant improvements in stroke services have been made.
The strategy noted that staff working in stroke have variable levels of knowledge and skills and acknowledged that nationally recognised, quality-assured and transferable training and education programmes were needed. Once again, we know from our personal experience and our casework what constituents tell us—that the quality of care varies so much. That is why effective training and education programmes are an essential part of this strategy, and a stroke-specific education framework has been developed to help us achieve that. It is available for comment on the stroke page of the Department of Health’s website until 12 June next week. Work to ensure that this framework is used to improve the stroke work force is continuing.
I also need to acknowledge the important work that individual professionals and multidisciplinary teams in the NHS and social care worlds are devoting to making the stroke strategy a reality. There are many examples to cite across all staff groups, but I will cite one example from the latest stroke sentinel audit, which says:
“Marked improvements have been achieved in the last two years in speed of assessment by therapists after admission. While far from perfect it is clear that a major effort has been made to improve the quality of care being provided nationally.”
Multidisciplinary teams are an essential component of world class stroke care and allied health professionals are already taking leadership roles in developing stroke services. I want to congratulate our AHPs. The front line of health services is always the recognisable face of the doctor and the nurse. However, our AHPs are providing a tremendous service to patients in all clinical categories. Given that we are discussing stroke today, I would particularly mention the importance of the work they do once the diagnosis has been made, the CT scan provided and the appropriate drugs administered. It is the after-care of the experts that then becomes so important, and teams of allied health professionals achieve so much in that respect. We have supported regional AHP leadership challenges, which will culminate in a national final in June to encourage more of them to do so.
As my right hon. Friend the Secretary of State for Health said in his foreword to the strategy:
“Collectively, these markers set out on ambitious agenda to deliver world class stroke services, from prevention right through to life long support.”
Work has begun to make this vision a reality and it will continue. I know that all hon. Members will continue to work to hold us to account on this strategy; we will work together to continue to improve stroke services for the people of our country.
First, may I welcome the debate and the opportunity it provides to consider the development of stroke services? It comes at an opportune moment, because, as the Minister said, it is approaching two years since we last had a debate whose purpose was to identify what needed to be done. At that point, the Government had just published their document, “A New Ambition for Stroke”, but that was already more than a year and half after the National Audit Office had published its groundbreaking study of the delivery of stroke services. I remind the House of the work done by the NAO and by the Public Accounts Committee and I welcome the fact that the NAO is in the process of reviewing its report and the progress made on the strategy. That will be immensely helpful.
Our debate is also timely in the sense that, two years ago, we looked at the outcome of the 2006 national sentinel stroke audit, and now we are able to consider the results of the 2008 national sentinel stroke audit, which was published in April this year. This is a timely opportunity to look at the progress made. I am pleased to note from the 2008 audit that an improvement has been recorded in all the standards in respect of the hospital care of stroke patients in England. That illustrates the amount of work done by the Department of Health, health services and hospitals across the country after the findings of the original NAO report.
The Minister kindly expressed gratitude for the work done by the all-party group. As chair of that group, I would like to thank the Department for its unstinting support and I also thank hon. Members across the House for their participation. It is excellent that we have been able to work together to create an environment for the improvement of stroke care.
As I have said before, I wish it were not necessary for the Department of Health to publish a national stroke strategy in order for hospitals across the country to identify on the basis of clear research evidence the best available treatment for stroke patients. As we will discuss in the debate, we unfortunately remain in a health service where the central structure of guidance and incentivisation has had a big impact on the extent to which hospital and community services are reconfigured. I promise my hon. Friends that I will touch on how the reconfiguration has worked out in London, for example.
The Minister did not tell us in detail what the national sentinel audit said about the improvements, so I shall take a little time to put some of the key results on the record. First, as I have already said, the improvements recorded on all the set standards have taken the cumulative score in England up to 73 per cent.—a considerable improvement on 2006. Only a small number of hospitals have failed to improve. I do not want to diminish in any way the progress that has been made, but it is important for us constantly to look at the gaps between where we are and where we ought to be. For example, 25 per cent. of patients do not get access to a multidisciplinary stroke unit, yet the incontrovertible evidence is that such access gives patients better outcomes. We want to get increasingly close to 100 per cent. on these figures.
My hon. Friend the Member for Westbury (Dr. Murrison) made an important point about the need to question why only 17 per cent. of patients reach a stroke unit within four hours. If patients have been admitted to an emergency department first, it is clearly not in their best interests to be sent to a medical admissions unit before being sent to an acute stroke unit. I recently visited Peterborough hospital, which has structured its services so that patients brought in in an ambulance are directly admitted to a stroke unit, bypassing the emergency department. I do not know whether that is the right approach given that many emergency departments are perfectly capable of dealing with stroke patients in the first place and ensuring that they get an immediate CT scan. However, I cannot see the benefit of patients being transferred to a medical admissions unit, and then being transferred to a stroke unit. It is not in the best interests of patients to be moved from one place to another within a hospital. Given that probably about 60 per cent. of stroke patients are admitted to a hospital on the same day as suffering the stroke, a much higher proportion should be sent to a stroke unit directly.
The Minister spoke about the FAST test. The national sentinel stroke audit suggests that in 2008 only about a quarter of patients in total, in the sample, were subject to a FAST test by paramedics. That procedure needs to be embraced, not least because we have rightly told the public about the necessity of identifying the symptoms of stroke and treating such patients as a medical emergency. The last thing that should happen is that the public and patients do not see precisely those criteria being applied by ambulance services, by out-of-hours services—in whose protocols there is often a gap in terms of categorisation of stroke—and when patients are subsequently admitted to a hospital.
That brings me to the point about immediate scanning. The evidence is clear that it is in stroke patients’ best interests to receive a CT scan rapidly. In response to the audit, the Royal College of Physicians said that all patients admitted to hospital with a stroke or potential stroke should be scanned within 24 hours. As the Minister will know, in the absence of a CT scan, it is difficult to ascertain what kind of treatment a patient should receive. At a basic level, a stroke might be either ischaemic, resulting, for example, from a clot travelling to the brain, or haemorrhagic, from a bleed in the brain. As clinicians will make clear, unless one knows which type of stroke is involved as a result of a definitive scan, it is difficult to provide the appropriate treatment. As a proxy for providing good treatment, early CT scanning is integral.
The audit suggests that only 64 per cent. of such patients were being scanned within 24 hours. Almost by definition, a large number of the rest were not able to get appropriate treatment as rapidly as they should have. Only 21 per cent. were being scanned within three hours—we would not expect that to be possible for 100 per cent., not least because for many patients admitted it would be clear that their stroke occurred more than three hours before, so the option of thrombolysis probably would not be available. In 2008, barely 1 per cent. of stroke patients—and fewer than 10 per cent. of those for whom it would be appropriate—were being thrombolysed. That is a long way from where we need to be. Even four or five years ago, countries such as Australia were approaching 15 per cent. of total stroke patients being thrombolysed, which is nearly the optimum level. Therefore, although we are making progress, we have further to go.
The national sentinel audit looks at nine indicators, which are intended to represent a bundle of care that, if provided to patients, will be indicative of good quality. Thrombolysis is not included, because it is appropriate only for a minority of patients. However, many of the items mentioned by my hon. Friends are included: for instance, the swallow assessment, to which my hon. Friend the Member for Buckingham (John Bercow) referred. Interestingly, only 17 per cent. of patients surveyed in the national sentinel audit received all nine indicators of care. There is significant variation. For example, 69 hospitals achieved all nine indicators of care—the full care bundle—for fewer than 5 per cent. of their patients; in contrast, three hospitals achieved more than 70 per cent. As the audit points out, there is a big gap between those three hospitals and most of the others, which are bunching around 40 to 50 per cent. The three hospitals concerned are King’s College hospital, the Royal Free and Chelsea and Westminster.
That takes me on to London and the structure of its services. Undoubtedly, there is discussion to be had about where patients should be admitted for hyper-acute stroke care, immediate CT scanning, possible thrombolysis and so on. If we reform stroke services, we want that to be readily available. However, the approach differs across the country. As far as I can tell, NHS London’s approach was to ask an expert panel to assess the quality of care in a large number of hospitals across London, to establish whether they were capable of providing good-quality care: in effect, whether they should be commissioned for hyper-acute stroke care. Having spoken to someone on the expert panel, I know that it reached views on that, but then NHS London said that eight hospitals would be designated as hyper-acute centres. For the life of me, I cannot find out why the answer was eight.
That is exactly the point. In north-east London, we have puzzled over the matter. A reason for one to be made a hyper-acute centre is neurological services, but the Royal London hospital does not have that; it has cardiac services. It is almost as if NHS London sat down and decided which hospitals it wanted before the panel was brought into session and made its decisions. It is without any logic, as Whipps Cross—our hospital—actually has stroke services. It is absurd.
I am grateful to my right hon. Friend for those interesting observations. I have had conversations with Sir Richard Sykes, chair of NHS London, and correspondence with Ruth Carnell, chief executive of NHS London. I urge NHS London to reconsider whether eight hyper-acute centres in London is the right answer. My view is that there is no evidence to suggest that substantial demand for throughput is necessary before it is possible to sustain a service. For example, the East of England strategic health authority has said that as long as a hospital is likely to be able to offer thrombolysis twice a month on average, there is no reason why it cannot sustain the service. From the commissioner’s point of view, London should have as many hospitals offering the service as are willing to offer it. On that basis, they should be commissioned to provide it, as long as they maintain the necessary quality of care.
My hon. Friend is being generous in giving way, and I appreciate it. As he will know, one of the big issues in London is traffic. In relation to the eight centres, the calculations are completely ludicrous. Today, it took me an hour to travel from my house in Chingford to the Royal London hospital. NHS London calculates that the journey takes less than half an hour. For local people, the decision to have eight centres is absurd.
My hon. Friend makes a good point. There are several geographical curiosities. Clearly, NHS London’s intention was to have a geographical spread for the eight centres. For example, in north-east London, Queen’s hospital at Romford was identified for that purpose. If we look at the distribution of stroke patients in NHS London’s own document, however, we see that in north London, Enfield and Barnet have large numbers of elderly stroke patients, and there is nothing there at all. Barnet hospital is a potential location, but it is fanciful of NHS London to say that either Northwick Park or Barnet would be an option, because if one shifts to Barnet, a significant part of north-west London is left without a near facility.
Let me finish my point about London, and then I will gladly give way.
In my view, a greater number of hospitals should be allowed to provide the service, if it is viable and the quality is maintained. Let me illustrate that point with reference to the two hospitals I mentioned. According to the national sentinel audit, Chelsea and Westminster is among the hospitals with the best quality of stroke care, but it is not one of those chosen by NHS London to offer hyper-acute care. The Royal Free, which is among the hospitals with the best standards of stroke care, is also not one of those recommended by NHS London to offer the service. Guy’s and Tommy’s is another example. As I am sure the Minister knows, the consultant stroke physician Tony Rudd has been an instrumental figure in the improvement of stroke care, and has worked as co-ordinator for the central audit. His hospital has been left out on, as far as I can see, purely geographical grounds. An arbitrary decision has been made about the number of hyper-acute stroke units that should be made available to a greater number of people.
Before the hon. Gentleman commits Northwick Park to take on the whole of Barnet, let me point out that in Ealing we have been told that the only hyper-acute unit that we can access will be either Charing Cross or that very same Northwick Park. We have also been told that the modelling is robust when it comes to analysing transport times. May I tell the hon. Gentleman something which I suspect he already knows, and which my hon. Friend the Minister certainly knows? Travelling from Ealing hospital to Northwick Park or Charing Cross is not an experience that one would wish on anyone except at 3 o’clock in the morning.
This is what seems to me to have happened. In London there has been a successful first move to primary angioplasty in cardiac centres. The provision of that service requires a significant level of throughput to the cardiologist whose job is to undertake primary angioplasty. There are nine centres in London. There is therefore a trade-off between the necessary level of throughput and access. It is not possible for a large number of emergency departments or hospitals to offer primary angioplasty, because there would not be enough cardiologists, catheter laboratories and the like.
I do not think NHS London realises that it can take a completely different approach to thrombolysis for stroke. I believe that, given that most full-service accident and emergency departments have a protocol providing for immediate access to the next available CT scan and given that CT scanning is available at whatever time of day might be involved, they should be capable of offering a hyper-acute service.
I entirely agree with the hon. Gentleman about the arbitrary nature of the proposed number of acute units, and I hope that that will be reconsidered. Has not another issue been overlooked? The millions of people who come into central London during the day, including tourists, will also be affected by the proposed arrangement. It seems even more arbitrary that Guy’s and St Thomas’, which is in the heart of central London and has one of the best units in the country, may be left out.
The position is actually worse than the hon. Gentleman and my hon. Friend the Member for Ealing, North (Stephen Pound) have said. It is true that the Ealing stroke unit is closing and that Charing Cross will then be the nearest unit, but in two years’ time it will move to St Mary’s, which will make travelling even more inconvenient and will place the unit in a less appropriate location.
Both the hon. Gentleman and the hon. Member for Ealing, North (Stephen Pound) have mentioned Charing Cross, which is also relevant to the way in which stroke services can be organised for thrombolysis. If CT scanning is available, there is no need for a radiologist on site to provide the necessary diagnosis. I have visited Charing Cross and seen a bank of radiologists providing a 24/7 service. Digital transfer of imaging means that there is no reason why images cannot be sent across London, or indeed across Britain, to a team of radiologists who can provide the diagnosis that is necessary for someone to decide whether thrombolysis is appropriate. I am told that the application of thrombolysis itself is not the most difficult part. The part that must be got right is the speedy interpretation of a CT scan so that the nature of the stroke can be determined.
The hon. Gentleman referred to the question of the Royal Free. Because I was concerned about it as well, I asked the Royal Free about it, and was told that it had accepted the proposals. It said that it had
“considered…the preferred solution…in the consultation document… that the trust should work collaboratively with UCLH to provide a combined offer which has the potential to deliver a truly world class service. Having taken the advice of its clinical community it now endorses the UCLP proposals which would see a combined comprehensive service with one hyper-acute stroke unit… based at UCLH.”
The hon. Gentleman will recall that I visited the Royal Free about seven weeks ago and had a conversation there. I shall rest on my view that as it provides one of the highest-quality stroke services in the country, there is absolutely no reason why it should not continue to offer a hyper-acute stroke service through its emergency department. That is entirely a matter for the Royal Free. If it does not want to do it, that is fine. I merely say that the commissioners should encourage it to do it, because it will be better located for the purpose in relation to the population of north London if, for example, Barnet and Chase Farm choose not to offer the service.
May I take up the hon. Gentleman’s point about provision across the country? The last few Members who have intervened have referred exclusively to London issues, but I suspect that the hon. Gentleman will be the first to accept that the inconsistency of provision and the time that it takes to travel to hospitals to access this specific form of care are crucial in all parts of the country. In my area of Greater Manchester and my constituency of Cheadle we have local hospitals, but we face the same issues of access. We know from the Royal College of Physicians just how many more lives could be saved if travel times were shorter and access more readily available. Does the hon. Gentleman agree that we have a long way to go before we can be content with the consistency of access arrangements across the country?
I do agree, and I think that significant variation is one of the issues on which we should focus. As the hon. Gentleman will know, Manchester has set about the task of reconfiguring its hyper-acute stroke services at a much earlier stage than other areas. I think that it, too, is beginning to realise that it may have unduly restricted the number of centres that should offer such services. There was an attempt to focus the whole of Manchester on Salford Royal hospital. I hope that it will be established that, as time goes on, other hospitals can and should provide those services.
There is, however, a risk. The Manchester proposals were based on the proposition that patients going to Salford Royal for hyper-acute care would be there for no more than a day or two, and would then be immediately transferred to their local stroke units for the remainder of their acute stroke care. That returns me to the issue of incentivisation. Such an arrangement is fine in circumstances in which, through the tariff, there is a clear distinction between the cost of the hyper-acute service and the cost of the other acute services. We fought a battle for a long time and secured, in the latest version of the tariff, the ability to “unbundle” it into the acute care and rehabilitation phases. If we are to support hyper-acute services, it is equally important for us to unbundle the tariff in order to separate hyper-acute services, including thrombolysis, from other forms of acute care, including care provided for patients for whom thrombolysis is not appropriate. That is not happening at present, and it needs to happen. I urge the Minister to bear in mind that it is important for the stroke team to get it right.
Before I leave the issue of variation, let me say that it remains a matter of considerable disappointment that stroke services in Wales appear to be consistently poorer than those in England or Northern Ireland. Scotland is not included in the central audit. As I said earlier, the figure for England has risen to 73 per cent., while the Welsh figure is 58 per cent., which is poorer than the figure in the 2006 audit. The rate of improvement in Wales over those two years has been lower than that in England.
One glimmer of hope in Wales is the pace at which physiotherapy services have improved. Members of the Welsh Assembly clearly wish to make progress. Speaking from over the border, as it were, I hope that Welsh Members—none of whom are immediately available—will receive the message, and, given that this is a devolved matter, will speak to their Welsh Assembly colleagues about it as a matter of urgency.
I do not want to go on too long because other Members want to speak. I will just make one or two more points. It is important that we continue to ensure that the National Institute for Health and Clinical Excellence guidelines on stroke care keep pace, as it were, with what the central audit is telling us and what the Royal College of Physicians guidelines tell us about the best available treatment. If we are going to mainstream the national stroke strategy throughout the NHS, we must ensure that NICE guidelines clearly set out what is the most cost-effective treatment and the most clinically effective treatment—often with stroke, those two things turn out to be the same—and that commissioners take responsibility.
It is also clear that most primary care trusts across the country have been commissioning stroke services on the basis of cost and volume and not taking sufficient account of quality. We need to think creatively about how to develop the tariff, not only unbundling it in the way I described, but applying it to the whole care bundle, so that the PCTs or other commissioners are able to ensure that they are clear that they are contracting for a standard of service, with quality indicators built into the services that they buy.
My hon. Friend has mentioned primary health care. Where does he think general practitioners lie in this matter and in the stroke services strategy? Often, symptoms of a potential stroke display themselves over a period of time, before a stroke occurs. What is the role of GPs? Are they linking with other professionals to deal with it? Perhaps medication can be prescribed, which has not been mentioned so far in the debate, to prevent a stroke from taking place. That can often be in the hands of a GP.
I am grateful to my hon. Friend for that intervention. He makes a good point. It is probably fair to say that, while quite a lot of GPs have taken a close interest in the development of stroke services over the past four or five years, others are still tending to cling to the view that, broadly speaking, people have strokes and the resultant level of disability is not likely to be much influenced by the speed of or access to treatment. However, we now know that speed and access to treatment can make a big difference. That is certainly true, especially for transient ischaemic attacks. The likelihood of someone who has had a TIA having a major stroke in the next four weeks is about 20 per cent. Often it is GPs who are aware that someone has had a TIA. Therefore, it is important for them to ensure that people then get access through the TIA clinic to proper treatment, including anti-coagulation.
Likewise, it is important that there is a seamless pathway of care. As my hon. Friend will know, we believe strongly that GPs should be much more instrumental in commissioning the care, given that they are aware of its quality. By virtue of that, they should be responsible for the subsequent delivery of rehabilitation and support in the community. Too many stroke patients who have been to see us at the all-party group feel that when they return to the community after hospital treatment it is as though they have fallen off a cliff edge. Services need to be joined up. There are various way we can do that, but the role played by GPs would be a big help.
Would the hon. Gentleman therefore congratulate the Government on introducing the NHS health check programme, which started in April? As hon. Members have pointed out, it is about prevention. The programme has the potential to prevent, on average, over 1,500 heart attacks and strokes and to save at least 650 lives a year. I am sure that he would like to welcome that.
Yes, I was about to discuss prevention. I am sure that the vascular risk assessment will provide a significant benefit in identifying people for whom there is scope for prevention. It would be helpful, when the Minister speaks about the number of lives that will be saved if the Department had responded to my requests for the supporting data to be published to justify those figures. I am sure that, now that she has mentioned them in the House, all the data to support those figures will be published.
There is still a job to be done in understanding, if people access vascular risk assessments, what the appropriate follow-up will be. We must be sure that we do not have a lot of people who become “worried well”. They may need an improved diet or physical activity—hopefully, they will not need medication to which they do not have access. We must ensure that the necessary resources to support primary prevention are put in place.
On prevention, an NOP poll from October last year showed that nearly one in five of the public still had no knowledge of the causes of stroke. It is important that we address that. There is good evidence to study. The World Health Organisation Monica—multinational monitoring of determinants and trends in cardiovascular disease—study published in The Lancet Neurology in 2005 made it clear that if we are going to improve stroke care
“socioeconomic factors seem more important than classic risk factors for the establishment of stroke trends in the population”
Therefore, the argument that we have often discussed here about the reduction of inequalities involves not just health inequalities in isolation—classic socio-economic determinants of health are important in determining the level of stroke mortality.
It is also important, and we can now see the benefit coming through, to note that one of the lessons of that study was that the
“quality of stroke care makes a profound difference, not only to the patient and his or her family but also to the burden of stroke in the population at large.”
What does that mean? I think that it means that by educating people in the NHS and beyond about the causes of stroke, its symptoms, the necessity to treat it as a medical emergency and the possibility of being able to impact positively on it through treatment, we are making people more aware of the risk, the disability, the mortality associated with stroke and the fact that they can do something about it. That will, I hope, make a big difference to stroke mortality.
We need to improve outcomes. It is not that we spend less on stroke; we spend a lot on it. However, for too long too much of what we have spent has been expenditure as a consequence of the disability that results from strokes. Too little has been spent to ensure that we prevent stroke and that where stroke occurs we access treatment rapidly.
There are still significant disparities between treatment in this country and in others. There is still more we can do. It is not just about thrombolysis. It is also about early supported discharge. Only about a third of patients get access to early supported discharge after a stroke. We need that figure to rise. There is a continuing agenda, which we will continue to support and press for to improve stroke services and make their quality more consistent across the country. I hope that through prevention and awareness of stroke, stroke outcomes will further improve in the years ahead.
I am delighted to be able to take part in the debate. I was pleased to hear the hon. Member for South Cambridgeshire (Mr. Lansley) talk about how we can prevent stroke and the devastation that it brings. I do not think there can be a family in the UK who has not been affected by stroke in one way or another and does not understand how difficult it is to live with the consequences.
My hon. Friend the Minister will understand if I start by talking about how we used to treat people with stroke and how we treat them nowadays. Stroke is one of the key indicators of how the NHS has transformed the way it deals with such devastating conditions. I am sure she remembers what we did when someone was admitted to the ward and we knew that they were suffering from stroke or some cerebral vascular accident. We made them comfortable in the ward and they stayed with us for several weeks. We put their affected arm on a cushion, walked them up and down the ward sometimes and hoped that all went well when they went home. How different it is today, thank goodness.
It was interesting to listen to the debate about the London reconfiguration of services. There was a time when we would not have even discussed where a stroke patient was admitted. In fact, for a while I was very concerned that we were considering the effects of a cardiac incident in much more detail and much more forcefully than we were ever thinking about the effects of stroke. We should therefore be congratulated on having this debate and on how we now address stroke.
My hon. Friend the Minister clearly set out the effects of stroke, and how frequently people are affected by it. In the UK, it kills someone every five minutes. When we cite the figures, it can sometimes be difficult to understand how devastating stroke can be. Eighty per cent. of strokes are caused by the clot—the one that could respond to thrombylisis. That is why it is so vital that people with stroke are treated immediately. I hope that in my brief contribution I shall be able to offer some examples of how we can address stroke and reduce the incidence of it, and make sure that the unfortunate people who suffer a stroke can have better treatment.
Crawley has a very diverse population, and 14 per cent. of people there come from black and minority ethnic groups. We do not know why—there is not the research for us to understand it—but such groups, and particularly Afro-Caribbean people, are disproportionately affected by stroke. I was therefore delighted when the South East Coast Ambulance Service NHS Trust decided to focus on three areas in Surrey, Sussex and Kent with a particularly high proportion of people having to dial 999 because of a stroke, and Crawley was one of those areas. The trust decided to think about the strategy for dealing with that, and to look at not only responding quickly and getting people into an appropriate unit swiftly, but what role the ambulance service could play in reducing stroke. That is why I am delighted to be able to talk about the work that that service has done.
We have debates about the reconfiguration of such services, and some of us—most of us, I think—have been through some very difficult and uncomfortable times, but stroke services illustrate why we have to make sure that these devastating events are dealt with in the best possible unit. Paul Sutton, chief executive of SECAmb, has always said that the problem is not to do with getting people who have experienced an event such as a stroke into the nearest front door, but with getting them into the right front door—that of an emergency centre that will be able to treat them properly. When our ambulance services arrive at a site, they often do not pick people up immediately and rush them to the closest institution. I know that people sometimes feel that they should do that, but time is taken to examine the patient and to understand what is going on. Often, the ambulance will stay at the home for some time, while staff take advice about how best to treat that patient and where best to take them. Stroke is one of those conditions that serve to illustrate why we have to make sure that patients go to the right place.
SECAmb has chosen Crawley as one of the areas on which to focus, and it will soon have on its streets ambulances with wraparound advertising for the FAST campaign. I do not think there is a single Member who will not accept that that has been the most amazing campaign. I pay tribute to the actors who took part in it—I genuinely hope they are actors—as I think they did an extraordinary job in taking viewers through the process of understanding what a stroke can look like. Their work has had a tremendous effect. Our ambulances will have all that advertising on their sides.
One of our stroke leads in SECAmb is David Davis. He is an amazing gentleman from Crawley. [Interruption.] No, he is not the Member who has just been referred to from a sedentary position; this David Davis is much better. He is taking a fantastic lead in getting out into the communities that most need to understand the causes of stroke. He will therefore be found in the gurdwara, in temples and in mosques, helping people understand about stroke. If I can make one plea to the Minister it is that I want David to do more of this work. I want him to be out there preventing stroke, but he has to do his other job as well, of course, and it is difficult for a busy ambulance service to be able to free up him up along with the colleagues who help with this work. I want to make sure not only that our ambulance service staff are visible out in our communities doing that fantastic work, but that we have enough paramedics and paramedic technicians to back them up and support them. I want that work to continue because I believe it is having a considerable effect in helping to reduce the number of strokes in our communities. We need to make sure that much more of that preventive work takes place.
The FAST campaign has featured in the contributions of several hon. Members, and it has, of course, been a great success, but I understand that the funding that supports it is in place for only three years. Does the hon. Lady agree that there is a danger that some of this excellent work could be undone if there is not a longer-term commitment to funding it beyond the current three-year period?
I thank the hon. Gentleman for that intervention, but I believe that the health services move so quickly that in three years’ time we will have moved on to new campaigns. I certainly hope the FAST campaign becomes part and parcel of our understanding as citizens of what can happen to people. I see it very much in the same terms as the seat belt campaign in that there is an initial start-up process, but the point then becomes embedded in our psyche and in our understanding of how we address things. I am fairly certain that there will come a time when we do not need a stroke campaign, but that we will then have to focus on other causes.
We have talked about the need for a quick and adequate response for those with stroke, and it will be a disappointment to all Members if that falls short of the excellent stroke strategy requirements for treatment. I do not think any of us would shy away from being a critical friend of the NHS if that were necessary, and from trying to make the situation right if it had gone wrong. All of us would happily highlight these campaigns in order to make sure that all our constituents got the service they deserved if they were affected by stroke.
I believe the stroke strategy has given focus to the whole stroke campaign and an understanding of where we are going with it. Interestingly, in a recent review of health services in the north of West Sussex, stroke was one of the principal issues that was addressed to try to strengthen our services. Crawley hospital has an amazing stroke unit; people come to it quickly after their initial treatment and there is a great sense of camaraderie. The staff are tremendously well motivated and qualified to deal with stroke.
The Minister will completely understand my second plea to her, as she is a former nurse, and once a nurse, always a nurse. Stroke mainly affects people who are over 55, and more commonly over 65, and the treatment of it should be a well-respected specialism that takes its rightful place alongside all other emergency care. Those who deal with stroke should be well regarded by those within the wider profession and be regarded from outside the profession as engaged in a field that contributes enormously to well-being. It is not a second-class field. Those in the nursing profession used to say, “Oh well, I’m going to go and look after older people.” That should be seen as up there with the most interesting of services. By making sure there is such high regard, we will be able to ensure that the service continues to improve and attracts the very best quality nurses.
To make sure that that happens, we must ensure that the professionals in our communities come together. In February, my right hon. Friend the Secretary of State launched a well-being programme in Crawley, dedicated to ensuring that people are exercising, that they are dealing with issues such as hypertension, which of course is associated with one of the highest predispositions to stroke, that such conditions are being properly monitored and that diet is being addressed. We also know that those who are obese have a predisposition to stroke. This is about tackling all those issues at a very basic level within our primary care services and about our emergency services coming together to ensure that people are less affected by this horrible condition.
When somebody has a stroke and receives the initial treatment—we hope that goes well and that the damage to the brain is reduced—we must ensure not only that they get the care in hospital that they desperately need but that it continues. Local authorities have a huge role to play in ensuring that timely adaptions are done at home, but co-ordination can sometimes be a difficult issue for local authorities to face. They need to ensure that when people are at home—be it in their own private home or in local authority or social housing—and needing to stay mobile, because that is crucial following a stroke, the adaptions are done in a timely fashion so that life is at least decent for them.
We want to ensure that throughout the service, from the first moment that horrible event happens to when people start to make progress through speech therapy and physiotherapy, things are as good as they possibly can be. The way we can properly tackle this is by ensuring that more research is done. The Stroke Association is a great advocate of ensuring not only that the research is done but that people are treated properly, and it does excellent research in all sorts of areas. The Minister may be interested to learn that because of the work being done in Crawley, the Stroke Association gave SECAmb a beacon of good practice award. That is something of which we can be justly proud in our area.
That is not to say that we are going to rest on our laurels, because we must continue to fight for better services for people who have a stroke. We must make sure that the emergency care is as it should be; we must continue to do much more preventive work; we must ensure that everybody within the professions is up to speed, and that includes GPs, nurses and practitioners throughout the national health service and beyond; we must improve the co-ordination of services when people return home, to ensure that adaptions are done in a timely fashion; and we must support the excellent voluntary groups, which make life better for those who have had a stroke, allowing them to come together with others to share experiences and to laugh and cry together over what can be a devastating event for a family. That is so important, and those groups are such a crucial element to all the work, as the Minister has said. In that way, we can genuinely ensure that people who suffer a stroke in the United Kingdom—and in England and Wales in particular—will have the best possible outcome following what can be the most appalling thing that can happen.
I am grateful to my hon. Friend, not only for the knowledge and expertise that she brings to this subject but for her personal commitment to it. Does she agree that if we are seeing a move from the widely established stroke units to hyper-acute stroke units for our thrombolytic treatment, there is a problem when it comes to repatriating the patients from the hyper-acute unit to their home without the intervening phase of the ordinary stroke unit? Does she agree that an essential component of precisely the process to which she referred is that the patient move from the hyper-acute unit to a stroke unit and then home?
I thank my hon. Friend for that intervention, because he precisely illustrates the difficulty. Stroke is such an interesting condition because it involves the immediate and pressing nature of trying to reduce the effect and then the very long and ongoing rehabilitation that needs to take place. My opinion is that intermediate stroke units have an enormous role to play; I have seen them working well in my constituency and I have no reason to believe they would not be right for the rest of the UK, particularly London, which I know he is very concerned about.
I hope that we feel passionate about stroke, because we should do. It affects so many families and we have made enormous strides in tackling it over the years. I am very proud to be able to visit the units and see how people are treated—I can certainly say that about Crawley. I very much hope that the Minister will be able to say a few words about the work of SECAmb, because I believe it to be a gold-star service.
I, too, warmly welcome this important and timely debate, and pay tribute to Members on both sides of the House for their contributions and to the all-party group, which has done so much to push this important area of health care and health policy up the agenda. As stroke is the third biggest killer in this country, after heart disease and cancer, and the leading cause of adult disability, it must remain an absolute priority for the NHS.
The Minister has mentioned the cost of stroke care to the NHS. The relevant figure is £2.8 billion, and the individuals involved—those unfortunate people who have suffered a stroke—take up more than a fifth of all hospital beds in the country. This issue has an economic cost, as well as a real and tragic human one. Some 45 per cent. of those who suffer a stroke die from it, not to mention the fact that stroke causes the many levels of disability that other hon. Members have mentioned.
We all acknowledge that in the past stroke care did not get the attention or the funding that it deserved, given those stark statistics. Until a few years ago this country had one of the worst stroke care regimes in western Europe, but things have turned a corner and improved since the publication of the national stroke strategy in December 2007, which was warmly welcomed in all parts of the House. It is encouraging to see the impact that the strategy has already had and the improvements made since that very important milestone.
It is also important that stroke was established as a “national priority” in the NHS operating framework of 2008-09, which obliges primary care trusts to set out their plans to improve stroke services. I emphasise to the Minister that although that welcome strategy is in place, we need to monitor things at the PCT level to ensure that improvements are happening on the ground. It is also important to stress that although the strategy is extremely welcome, the Minister must acknowledge that there are issues to address in respect of not having set time scales for some of the improvements within the 10-year period. Perhaps we need more milestones to aim for in order to see how the strategy is being implemented. It is excellent that we are talking about this nearly two years after the strategy was introduced, but it would be encouraging to say exactly where we are aiming to make tangible improvements in stroke care over the course of the 10-year period. I also welcome the Government’s announcement of their intention to commission an independent evaluation of the strategy and its implementation—that is enormously important, because we all need to follow its progress. Will the Minister let the House know when those results will be made public and when that process will be complete?
Several matters relate to the strategy and to stroke care in general. The first, as has been mentioned, is the great need for awareness of the symptoms of stroke and the need for proper referral from that point. Data from October 2008 show that 18 per cent. of public respondents had no knowledge at all of the symptoms of stroke. Rather more alarmingly, a 2005 National Audit Office report showed that only just over half of GPs would immediately refer someone with suspected stroke for the emergency care that is so crucial to the outcome for stroke patients from that initial point.
I want to echo comments made by other hon. Members about the Act FAST campaign, which we all agree has been enormously powerful in demonstrating the situation visibly and in an easy to understand way.
As my hon. Friend has said, the Act FAST campaign has been acknowledged by Members on both sides of the House. One of the direct consequences of the success of the campaign is that the number of calls to the Stroke Association’s helpline has increased by some 36 per cent. The association says—this is perhaps an indication that it is struggling to meet demand—that it estimates a 200 per cent. increase in the number of calls that have been abandoned while people were waiting to get through. It might be said that that is a consequence of the success of the campaign, but there is a real issue about support for the Stroke Association. I invite my hon. Friend to agree with me, and I hope that when the Minister responds later she will discuss what further support the Government can give the Stroke Association.
I thank my hon. Friend for that valuable and important contribution, which addresses a point that I was about to make. I echo his comments in asking the Minister, in light of the extra volume of calls, what additional help hospitals and voluntary organisations are being and will be given, so that they can cope with the very welcome additional strain that has resulted from the success of the campaign. That is an important area for the Minister to concentrate on.
Do the Government intend to do any quantitative analysis of the success of the campaign? I think that it would be very insightful. As has been mentioned by the hon. Member for Crawley (Laura Moffatt), have they considered the impact on particularly high-risk groups, such as those in certain black and minority ethnic communities—in particular those from south Asian or Afro-Caribbean communities? If the Minister can give us some indication of how the Government plan to target those particularly at-risk groups, that would be very useful.
Let me turn to prevention. Hon. Members have already said that that is absolutely crucial. When we consider that 20,000 strokes a year could be avoided through preventive work on high blood pressure, irregular heart beats, smoking cessation and the wider use of statins, we see that prevention is an absolute priority in dealing with strokes. Again, if we consider the economic impact, preventing just 2 per cent. of strokes in England would save £37 million of care costs. That is a matter that needs even higher priority in the strategy.
I welcome the NHS health check programme. It can highlight those most at danger from stroke, as well as those at danger from other conditions. How many people have been invited to these health checks, and are the most at-risk groups—the most susceptible groups—being invited? That is crucial, if the checks are to have the kind of impact that we all hope that they will in reducing the number of strokes that happen in the country.
On treatment, as has already been mentioned the most crucial thing for stroke patients is to arrive swiftly at a stroke unit. The concerns that suspected stroke patients are not being prioritised sufficiently within the ambulance service are very real. In terms of the provision of CT scans and thrombolysis, the importance of specialist stroke units cannot be overstated. The Stroke Association has described stroke units as
“the single most beneficial intervention that can be provided after stroke”.
As other hon. Members have said, however, there are disparities in care between those who are admitted immediately to stroke units and those who spend time on general wards or in accident and emergency departments. The simple fact, borne out by the figures, is that patients who are admitted to stroke units quickly are more likely to survive and to make a better recovery. Again, we should consider the costs, the impact on patients and the length of time involved; such patients will spend less time in hospital than their general ward counterparts, who have a 14 to 25 per cent. higher mortality rate.
The 2008 Royal College of Physicians audit shows that there has been a huge increase in the number of hospitals that have protocols for ambulance service emergency transfer of patients to stroke units from 4 per cent. in 2004 to 49 per cent. in 2008. That is extremely welcome, but, as we have already heard, it is not happening up and down the country. I make reference to the particular concerns in London and echo the concerns about the somewhat arbitrary natures of the decisions that appear to be being taken.
The provision of thrombolysis, as has been mentioned, is much too limited. I hope that the Minister will agree that that is an area where the strategy so far is not achieving what we all hope that it will achieve. Last year, only 8 per cent. of patients received thrombolysis, even though 15 per cent. of patients were eligible for that kind of treatment. Both CT scans and thrombolysis fall below National Institute for Health and Clinical Excellence standards.
Before the hon. Gentleman carries on, I think that he will find that just over 8 per cent. of the appropriate population receives thrombolysis. The appropriate population is about 15 per cent., and about 8 per cent. of those receive it. In fact, the proportion of stroke patients who receive thrombolysis is just under 1 per cent.
I apologise and thank the hon. Gentleman for that correction. I meant to say 0.8 per cent. and appreciate the intervention. May I echo what he has said about the inadequacies in CT scans and thrombolysis? NICE guidelines clearly state that all patients should be scanned, diagnosed and treated with thrombolysis, if required, within an hour. We have to acknowledge that we have a long way to go before we achieve that.
Treatment of mini-strokes—TIAs—has already been mentioned. Effective treatment of TIAs is very important, as the risk of having a stroke within the first four weeks of a TIA is 20 per cent. According to the 2008 RCP stroke audit, only 45 per cent. of hospitals meet the stroke strategy’s recommendation of investigating and treating high-risk TIA patients within 24 hours, which means that 55 per cent. of them are not doing so. Again, there is a lot of work to do on that, and I ask the Minister to give us her thoughts on how the figure will be improved.
After-stroke care is the final area of focus in this debate. There are real concerns about stroke patients—and indeed their families, who clearly have an important role to play in the rehabilitation and care of stroke patients—not yet having their needs fulfilled in that regard. After-stroke care is essential to regaining and relearning skills, sometimes even basic skills of everyday living. Rehabilitation is therefore absolutely essential. There have been improvements in that area, but even so, only half of stroke survivors receive rehabilitation in the first six months after discharge, and only a fifth do so in the next six months. I am afraid that it is an area in which, so far, the strategy is simply not delivering.
Post-hospital rehabilitation needs to be organised while the patient is still in hospital, and not when they are discharged, and that has to be addressed. For example, home adaptations clearly have to be done before a patient returns home, so that they can carry on living their life, which is what we very much wish them to be able to do. The provision of information is an easy, cheap way to assist in the important process of rehabilitation, but there need to be improvements to that, too. The stoke audit of 2008 that I mentioned found that there had been little progress since 2006 in improving the amount of information given to patients and carers in hospital about reducing the risks of a further stroke. Of course, the whole purpose of rehabilitation is not just recovery, but prevention of further strokes. Some 58 per cent. of those patients for whom diet advice was applicable are recorded as having received it, and much of the information that is provided is not particularly helpful. A survey carried out by the Healthcare Commission, admittedly back in 2005, found that only 55 per cent. of patients understood the information that they received in hospital.
I now come to the issue of care for those who are not able to return home. The voluntary sector does a wonderful job in many cases, assisting people in coming to terms with life after a stroke, yet the resources are simply not there, as is the case, I am afraid, for a great deal of social care for people recovering from conditions. I ask the Minister whether it is not time for the Government to consider making more resources available to voluntary groups to enable people to carry on living their lives in the community, or in specialist homes, if that is what medical professionals deem that they need. The whole issue of social care needs more work, and I ask the Minister to address the issue in her comments.
I welcome the opportunity for this debate. I hope that we can have such debates at regular periods throughout the 10-year strategy, no matter which party is in government. It is important that all of us with an interest in this area of health care continue to monitor the implementation of the strategy, because all of us in all parts of the House are absolutely committed to ensuring that stroke care is a priority for the health service, and is very much at the top of the health policy list. All of us will continue to have that commitment, and we want the strategy to succeed.
I particularly want to address the issue of the expansion of stroke services in London, on which Healthcare for London has recently been “consulting” as part of its stroke and major trauma consultation exercise. I put “consulting” in inverted commas, as it has been such a botched consultation that the public see that expansion of services as a cut. In my area, we have seen the unsightly picture of one NHS body advertising and lobbying against another, adding to the atmosphere of confusion and disinformation all round, and turning what should be a positive story into a negative one. Members of Parliament have been kept somewhat out of the loop, too.
Barnet and Chase Farm Hospitals NHS Trust wrote to me on 7 April to plead its case, as opposed to that of Northwick Park hospital, for being one of the proposed eight hyperacute stroke units, on the basis of its location. Its letter refers to its existing transient ischaemic attack centre and the need for a local stroke unit. It implied that current services would go as a result of the changes, but of course they will not; they will be continued, as will the services provided by TIA centres and local stroke units everywhere else, and certainly in my area.
Barnet and Chase Farm Hospitals NHS Trust then took out a full-page advertisement in the local newspaper—an advertisement that I can describe only as a scare story. It somewhat irresponsibly implied that cuts, which are not proposed, would be made, and that people’s chances of survival would be reduced if the trust did not get its own way. It exhorted people to write into the consultation supporting its views, without giving a true picture of what is proposed, and it whipped up a climate of fear in the area. The Tory council then joined in the act, spending £42,500 on a letter to every household, signed by the leader of the council, who is the Finchley Tory parliamentary candidate. Again, it did not put the argument fairly, but I am pleased, or not pleased, to say that it gave the wrong details regarding how people should send their response by e-mail, so not many responses came in. That was rather a waste of £42,500 of council tax payers’ money.
That set off the local papers, which ran stories about NHS cuts, although no cuts, only an expansion of services, were proposed in our area. A headline in the Barnet press stated, “Council kicks out at NHS bid to ditch stroke unit”, although there is no bid to ditch any stroke unit. Slightly more responsibly, the Hendon & Finchley Times said:
“Every minute you lose is crucial.”
There has been no attempt by NHS London or Healthcare for London to show a true picture of what is planned. There was not one effort to write a letter to the local papers explaining what is going on, so a good news story ended up as a cuts story by default. This is my question for my hon. Friend the Minister: when will the NHS get its act together in explaining what is actually going on? When will clinically led plans—that is what the plans are—be properly explained by clinicians to the public? Is it not time that the NHS had a decent communications strategy, with proper, objective, wide consultation on such major plans? If we can do that locally, why can it not be done London-wide, and why has the NHS simply ignored all that is going on? It is simply unacceptable, because the proposals are a good news story.
Clinical evidence shows that patients are 25 per cent. more likely to survive or recover from a stroke if they get treated in a specialist centre. In London, there are big differences in the quality of stroke care. Rates of death in different hospitals vary considerably, and people in outer London have the most limited access to high-quality stroke services, which is why the proposals are particularly important. For some strokes, clot-busting drugs can stop and reverse the damage, but only after a high-quality scan has shown whether the patient is suitable for the drugs, so stroke patients need fast access to scanning facilities to have the best chance of recovery. Currently fewer than 10 per cent. of suitable patients are offered thrombolysis.
So what is proposed? As I have said, the proposals are not a cut. The NHS plans to invest more than £23 million a year extra in new stroke services for London, with more and better trained doctors, nurses and therapists to deliver those new services. There is a proposal for eight hyperacute stroke units, which will provide the immediate response in the first 72 hours after a stroke, or until the patient is stabilised. They will be open 24 hours a day, seven days a week. Anyone having a stroke in London will be taken to one of them to have a brain scan. If appropriate, they will receive the clot-busting drugs within 30 minutes of arriving at the hospital.
More than 20 stroke units will provide ongoing care once the patient is stabilised, and the transient ischaemic attack services will provide rapid assessment and access to a specialist within 24 hours for high-risk patients, or seven days for low-risk patients. Everyone in London will be within a 30-minute ambulance drive of one of those services. Obviously, the issue of how long that journey will take is a matter of contention. It is easy for us who drive around in cars to try to compare how long it would take us to do a journey with how long it would take a blue-light ambulance, but there is no comparison.
The Tory leader of Barnet council—the Finchley Conservative candidate—has suggested that the figures are based on journey times at half-past 2 o’clock in the afternoon. As part of its analysis, Healthcare for London sourced the details of every single ambulance journey in London for three years—about 4 million records. It compared 100,000 blue-light journeys with 2 million other urgent ambulance journeys. It assessed the impact of the day of the week and the rush hour on the journey times, and it conducted a lot more detailed analysis besides. The figure is also backed up by the day-to-day experience of the London ambulance service in taking patients to eight specialist cardiac centres across the capital, so it is not surprising that the LAS supports the proposals. To give my own snapshot, I spent a shift driving around with the ambulance emergency services, and my experience supports the idea that the times are probably achievable.
Locally, research by my PCT in Barnet shows that people living in deprived areas are more likely to die of vascular diseases, to smoke and to be obese, and they are thus at greater risk of having raised blood cholesterol levels, pre-diabetes, diabetes or high blood pressure. They are also less likely to visit their GP and have vascular disease risk factors identified and managed. There is thus a higher risk and incidence of stroke in the most deprived part of the borough—the west—which is my constituency. That has been confirmed by the opinion of the PCT medical director, Dr. Andrew Burnett, with whom I spoke last night. Northwick Park is easier to access from the west, my constituency, than Barnet hospital—a matter to which I shall return.
For our part of London, consideration was given to Northwick Park, Barnet, University College hospital and the Royal Free. NHS London preferred Northwick Park to Barnet, because it provides better travel times and reflects existing patient flows. These arguments are supported by the London ambulance service. From my area the road to Northwick Park is mainly a straight, wide major road, whereas the road to Barnet is little more than a country lane.
“The shape of things to come”, the compact document which is easier to handle when making a speech, states:
“We believe that hyperacute stroke care should be delivered in no more than eight sites across London”—
this is on page 20. It continues:
“This would optimise the number of patients being treated at each site, ensure expert teams are available 24 hours a day—improving survival and reducing disability”.
The hon. Gentleman will be aware that if the aim is to provide very specialised high-quality services, it becomes an argument—[Interruption.] If he will stop intervening from a sedentary position and let me make the point, I shall be happy to give way to him again. The argument in this case is very much the argument advanced back in the early 1990s by the Government, whom he supported, for the closure of Edgware general hospital and the merging of the accident and emergency department there with that at Barnet hospital, on the basis that by creating a critical mass of patients, a higher quality service could be delivered.
That is exactly what is being proposed in relation to the stroke units. If somebody were to convince me and Healthcare for London that an equally high-quality service could be delivered at Barnet hospital, I would have no objection. My concern is for my constituents—not for the whole of Barnet, not for Enfield, but for my constituents, who would find access to Northwick Park rather easier from the particularly deprived parts of my constituency than they would to Barnet.
I had not realised that the consultation in London was somehow the fault of the previous Conservative Government, but then everything that the hon. Gentleman complains about is probably the fault of the previous Conservative Government. My point is not that some of his constituents should be advantaged by using Northwick Park rather than Barnet. I contend that there is nothing in the consultation document that demonstrates why it is not possible, as has been said, by NHS East of England, for example, for a large number of emergency departments to continue to offer acute care of stroke, including thrombolysis, as long as they are able to have, for example, immediate access to CT. The emergency departments of most hospitals increasingly have access to CT. The images can be sent somewhere else for interpretation—the specialist part—if necessary.
I certainly do not hold the hon. Gentleman responsible for the consultation. His Government were not interested in spending an extra £23 million on services. They were interested in cutting services. The point that I am making is that a very similar argument was advanced by his Government for closing Edgware general hospital—that better A and E services could be delivered through the critical mass resulting from a bigger patient base at Barnet hospital than at the two hospitals, Edgware and Barnet.
I listened to what the hon. Gentleman said, and no doubt my hon. Friend the Minister will respond to it later. We need a critical mass of patients to be able to deliver high-quality services. We have a difference of view. Obviously, if it is possible to have stroke care at both hospitals, I have no objection, but if that is not possible, I prefer, on behalf of my constituents who live in the deprived part of the borough, the existing proposals for Northwick Park to the case for Barnet.
We debated across the Floor the subject of UCH and the Royal Free. Preference was given to UCH, although I agree with the hon. Gentleman that the services at the Royal Free are of a very high quality. As I explained to him, I raised the matter with the Royal Free. It has accepted the proposal that it should work in partnership with UCH on the basis that UCH is able to provide better standards than the Royal Free at the National Hospital for Neurology and Neurosurgery, which is part of UCH. It is also important to point out that the Royal Free and UCH scored higher than Barnet on future clinical standards.
Given the criteria in the consultation, I understand why Northwick Park was preferred to Barnet. It is important to recognise that the hyperacute units are only part of the story. I object to the scare stories run by the Conservative party that we will see the closure of stroke units and TIA units across London, which is not the case. As far as I can see, not only in my constituency but in my sector of London, those units will continue. That is the general picture, from what I know of other parts of the capital. It is wrong to suggest that those units will close and to scare people in that way.
The TIA services for people who have had a mini-stroke will be provided at hospitals with hyperacute units or ordinary stroke units, as they are now. These assessment services will reduce the chance of someone going on to have a full stroke by up to 80 per cent. TIA and stroke services are provided at Barnet and at the Royal Free, as well as at Northwick Park and UCH, and they will continue to be there. The intention is to provide a comprehensive service, including the existing units at Barnet and the Royal Free.
An additional point that I put forward in my response to the consultation was that I would like to see continuing care and rehabilitation services provided at Edgware community hospital as well. The rehabilitation services there have extra capacity, which could be expanded to deliver additional help in a constructive way and closer to home for patients suffering from the long-term after-effects of stroke.
I begin by apologising to the Chair, the Minister, colleagues and Members in that I may not be in the Chamber for the full duration of the debate. I have other commitments at the Foreign Affairs Committee later this afternoon.
Strokes are one of the most widespread and expensive conditions in the UK, costing the nation around £7 billion every single year, and on current trends the prevalence is set to increase at a worrying rate. Years of neglect in this area of public health policy have left the UK with the unenviable reputation of having some of the worst outcomes for stroke patients in the whole of western Europe.
I was lucky enough in April to secure a Westminster Hall debate on cardiac and vascular health. May I take this opportunity to thank the Minister for honouring her commitment to answer the questions that remained outstanding at the end of the debate, and for the detailed responses that she sent me? It was during that debate that I highlighted the work of the Cardio & Vascular Coalition, which has published key recommendations for a new integrated approach to cardiac and vascular conditions for policy makers to consider.
The 10-year national strategic framework is coming to an end but as yet we have no firm commitment from the Government to extend the strategy for a further 10 years. The British Heart Foundation, the Stroke Association, the British Cardiovascular Society and the Royal College of General Practitioners and many other smaller organisations which belong to the coalition would like the Government to give a commitment to the strategy. The 10-year mental health strategy has been renewed. Why cannot the framework strategy for cardiac and vascular health be renewed in a similar way? I await the Minister’s response to the letter that I recently sent her on that point.
Cardiovascular diseases, which include heart attack, stroke, diabetes and chronic kidney disease, affect the lives of more than 4 million people in England, cause 170,000 deaths each year, and are responsible for about one fifth of all hospital admissions. The challenge posed by those conditions is stark. Cardiac and vascular disease remains the No. 1 cause of death and disability in the United Kingdom, and strokes alone are the UK’s third biggest killer—the second biggest if each type of cancer is counted separately—and the single biggest cause of severe adult disability. To our continuing embarrassment, the death rate for coronary heart disease and stroke in men and women is still higher in the UK than in comparable western European countries, and some risk factors for cardiovascular diseases, particularly obesity and a lack of physical activity, are increasing. On current trends, 60 per cent. of males and 50 per cent. of females will be obese by 2050, and, if unchecked, it is predicted that that will lead to a massive increase in type 2 diabetes, with the current trend indicating that more than 4 million people in the UK will have the condition by 2025. That, of course, will result in a large increase in the number of patients who require medication to prevent cardiac and vascular events.
I welcome the national stroke strategy, which was launched at the end of 2007. Two central elements of the strategy are that patients should be admitted directly to a unit capable of undertaking immediate CT scanning and, where appropriate, undergo thrombolysis. It is absolutely crucial, as many contributors to this debate have said, that stroke victims are seen as quickly as possible. In that regard, I think that FAST, the new TV campaign, which has been mentioned on many occasions, has been successful. I commend the Government on their initiative in that regard.
There is no doubt that, on the whole, hospital-based stroke services are improving and more stroke survivors have access to long-term care and support in the community. Yet, despite those developments, stroke services throughout England remain patchy and in need of considerable improvement. Sustained financial and political investment is therefore essential to maintain the momentum behind improving services that the strategy created.
Rehabilitation and long-term support in the community remain the weakest element of the pathway for many stroke survivors. Previous investigation has found that only about half the individuals who experience a stroke receive rehabilitation that meets their needs in the first six months following discharge from hospital, with the figure falling to one fifth of individuals in the following six months. The Healthcare Commission’s 2006 stroke patients survey showed that one year after discharge, more than half—about 54 per cent.—of patients said that they had not received any home help; that one third, or 32 per cent., had not received help with personal care; and that 45 per cent. had not received help with applying for benefits.
I should like to put two questions to the Minister. First, what progress is being made in ensuring health and social care services work together to provide stroke survivors with a seamless transfer of care from hospital to the community? Secondly, what progress has been made in providing high-quality specialist rehabilitation and support for as long as a stroke survivor requires it?
It is generally accepted that the Royal College of Physicians’ national sentinel audit of stroke has provided an extremely useful tool for monitoring the implementation of standards and improvements in services in the acute sector, but there has not been a similar focus on monitoring community services for stroke survivors. Is it therefore the Government’s intention to consider funding an extension to community stroke care of the RCP’s auditing process?
The operational plans for 2008-09 to 2010-11, entitled “National Planning Guidance and ‘vital signs’”, require PCTs to implement the stroke strategy. Monitoring will include, first, the number of patients who spend at least 90 per cent. of their time on a stroke unit and, secondly, the percentage of high-risk transient ischaemic attacks, or mini-strokes, that are treated within 24 hours. I am pleased to say that NHS Cambridgeshire, my local primary care trust, has responded positively through its newly published strategy. Indeed, as many contributors to this debate have emphasised, a key part of the strategy is prevention.
NHS Cambridgeshire recently began a specific initiative in the 20 per cent. most deprived practices to implement vascular risk checks and proactively identify more people with risk factors for CVD who will then be added to the CVD risk register. It intends to offer practices a range of options for providing vascular risk checks to those people aged 40 to 70 years old, ranging from practices managing the vascular checks in their entirety, to working with a health adviser and community pharmacy-based provision.
There is no doubt in my mind that in community pharmacies we have a fairly universal and readily accessible professional resource that could play a key role in an NHS health check programme. I strongly believe that community pharmacies could play a vital role in the battle against stroke by, for example, providing a regular blood pressure and cholesterol test. That new role seems to have been actively encouraged by parts of the NHS, but not universally. Some PCTs seem reluctant—through ignorance, professional opposition, lack of focus or simple tardiness—to embrace its great potential. I am delighted that NHS Cambridgeshire has alluded to the potential role of pharmacies, but it requires more than just a reference in a strategic document. A commitment to driving the concept through at ground level is vital, and I, for one, will monitor the PCT’s progress.
The PCT’s strategy also means that patients will be identified with risk factors using the Framingham method, including those with post myocardial infarction and those with transient ischaemic attacks. It means also that patients alert will be utilised for GPs, indicating when preventive measures are required, in line with National Institute for Health and Clinical Excellence guidance. The PCT will continue to make the links to smoking cessation services, with a guaranteed recording of data on lifestyle and outcomes, and it will work with the public health directorate to support prevention messages, particularly in disadvantaged areas and groups. It is also vital to make appropriate links with the cross-government strategy for tackling obesity and with prevention work, in line with vascular checks. Finally, the PCT intends to roll out the scheme in the most deprived practices first. That will be of most benefit to my constituency of North-East Cambridgeshire, which has some of the highest deprivation indices in Cambridgeshire.
The Government say that they are committed to evaluating the implementation of the stroke strategy, but how do they plan to evaluate its implementation, when will the Department of Health commission an evaluation of progress of health, what form will it take and when can we expect the results to be made public?
In conclusion, stroke services are improving as a result of the stroke strategy, but there is still a long way to go to meet the standards contained in the 20 quality markers. Progress has not necessarily been made at the same rate throughout the country, and, in order to maintain and build on the achievements that have been made so far, continued investment will be required. In that regard, what plans do the Government have to ensure that improvements continue to be made after the current three-year funding round ends? How will the Government ensure that stroke remains a national priority?
I am very pleased to be able to make a short contribution to the debate. I also welcome the expertise that was so clearly demonstrated by my hon. Friend the Minister, by the shadow Secretary of State for Health, the hon. Member for South Cambridgeshire (Mr. Lansley), and by my hon. Friend the Member for Crawley (Laura Moffatt).
I speak not with any expertise in the matter, but as someone who has spent some time at their local hospital, Guy’s and St. Thomas’s, and received valuable advice from Dr. Tony Rudd. I am well aware that I am not an expert in the same sense as some of those who have already spoken, but, as a London MP, I want to look at the consultation in London—the Healthcare for London consultation entitled “The Shape of Things to Come”. I welcome much of it and believe that it is in line with the Government’s excellent prioritisation of stroke services. To that extent, I welcome again the national stroke strategy and the work done by the all-party stroke group and the Stroke Association. I particularly welcome the dedication shown by the Under-Secretary of State for Health, my hon. Friend the Member for Brentford and Isleworth (Ann Keen), to the issue; it is great to have a Minister who has had hands-on experience of working in the national health service.
As we all know, we need to develop new, high-quality stroke services in London. There are inequalities that need to be addressed, and the document will have addressed many of them. The problem arises when I come to consider my own area and the rest of south-east London. At the moment, King’s college hospital and St. Thomas’s hospital have very good stroke units. King’s college London, the Maudsley, King’s college hospital, Guy’s hospital and St. Thomas’s hospital are working in an admirable way; they are doing hugely valuable work right across London.
King’s college hospital and St. Thomas’s hospital, together with their academic partners at King’s college London, have a long history of collaboration on stroke services; that will inevitably increase as a result of the successful accreditation of King’s Health Partners as an academic health science centre. The collaboration has included the primary care trusts of Lambeth and Southwark, encompassing the full pathway of stroke care, including out-of-hospital care. The two hospitals have consistently been among the highest scoring in the Royal College of Physicians national sentinel stroke audit, including the most recently published report of April 2009.
Under the proposals, there would be one large hyper-unit at King’s college hospital. Like other colleagues who have spoken, I genuinely cannot understand the rationale for going for the strict decision in favour of eight large units. As I said, I speak from a common-sense, not an expert, point of view, but to me there is no evidence that the model of very large acute stroke units with 20 to 30 beds and, say, 2,000 to 3,000 admissions a year, is a clinically effective, safe or feasible way of delivering stroke care. It has not been tested anywhere else in the world, and the vast majority of the professionals consulted during the development of the plans favoured a larger number of units—perhaps 10 to 14 throughout London—with fewer beds.
There are concerns that big units will not make sense when so few people in London receive high-quality acute stroke care. The interim period, during which the eight high-quality units will be developed, will be a long time—a minimum of three to five years, according to what I have been told; I am thinking particularly of the units that were not established beforehand. With the best will in the world, units designated for eventual closure are bound to suffer planning blight and will quickly deteriorate to unacceptable levels through the loss of good staff to other centres and the failure to recruit new staff.
The good units that we have at the moment will be needed to help, support and develop the increased new units. However, that will get more and more difficult if there is not the necessary flexibility, particularly if anything goes wrong or if there is a surge in demand.
My hon. Friend is making a good point. Does she agree that if a lot of investment has to go into the eight major centres, there is a danger that other, more local hospitals that have not been chosen to be hyper-units, but run good acute centres and transient ischaemic attack, or TIA, services, could be starved of the cash necessary to maintain—or, indeed, improve—their services as the money goes to the hyper-units? Is that a danger?
I welcome the increased investment that the Government are putting in, but the danger to which my hon. Friend refers is there. There is always a danger that large super-duper elements in any provision will tend to take away from what most people want, which is good local services.
I go back to the point about central London that I made in an intervention on the hon. Member for South Cambridgeshire. The consultation document’s calculations for all the bed requirements do not take into account the non-resident population of London—the huge numbers of commuters from outside the city, the tourists and so on. The majority of those people come to central London. That is not to say that we do not need to improve radically the services in outer London areas, but I do not see the rationale for getting rid of the really good unit in central London—in the critical area of St. Thomas’s, with its access to railway stations—to create something bigger elsewhere. King’s college, Guy’s and St. Thomas’s hospitals are already working together, and they want to do so.
There is a need for a radical approach to modernised stroke services in London, and much in the proposals is excellent. For example, this is the first time that standards have been set with clear requirements on the providers to deliver appropriate staffing levels. The issue, however, is about the actual model that has been chosen for London; that needs to be considered again. The people who are already working well in those hospitals and really know what is happening have not been listened to enough. NHS London needs to listen to the professionals, not entrench itself in what seems to be a fundamentalist approach. The approach needs to change; the primary care group that makes the decision in July needs to go back and make sure that it has listened and understood what is happening in the units that already do extremely good work.
St. Thomas’s serves diverse communities, which are more likely to be in need of a stroke unit. It also deals with commuters and all the tourists who come to central London. It has the expertise. The idea is to let that go to create a bigger unit at King’s college hospital. Why do we not allow the two hospitals to plan and work out together what is in the best interests of the area? I hope that those making the decision at the end of the consultation will listen. If I had to choose between the expertise of Dr. Tony Rudd and that of members of the primary care trust, I know whom I would support.
I start by recognising the improvements that have been made to stroke services in recent years. There has, of course, been a gradual improvement since the war, but the focus on strokes has increased in the past few years. A great deal of the credit for that must go to our clinical networks, health care professionals and the research community. I say that particularly because 25 years ago I trained in a national health service that did not regard strokes as a particular priority. The hon. Member for Crawley (Laura Moffatt), who is no longer in her place, reflected on the standard of care and the expectations of stroke patients that prevailed at that time, and that put me in mind of the sorts of cases that I came across. It was all particularly to the disadvantage of older people; classically, elderly stroke victims have tended to be put to one side. I am pleased to note that that tends not to be the case these days, but there is perhaps some complacency, and a danger of forgetting that the elderly are still not given the priority that they deserve. Stroke, given that it is classically a condition that is more likely with advancing years, is a case in point.
Having marked the improvement in standards that has prevailed over the past few years, we must also recognise that it took rather a long time for the Government to come up with their national stroke strategy—some 10 years—and it required a bit of prompting by way of the 2005 National Audit Office report, “Reducing Brain Damage: Faster access to better stroke care”. I may be a pedant, but I think that the hon. Member for Leeds, North-West (Greg Mulholland) was a little hasty in suggesting that the national stroke strategy had had demonstrable effects. It may well have had, and I suspect that it will be effective, but we must be careful about making premature assertions that are not firmly rooted in the evidence.
I am grateful to the hon. Gentleman, but he needs to understand that there is a danger in extrapolating evidence from the sentinel study—I think that that is the one that he was citing—which came out just a few months after the implementation of the national strategy. Given that it is a 10-year strategy, and given previous trends, it would be extremely rash to suppose that it had had any effect at the time of the sentinel audit. I very much hope that the strategy will prove to be successful—I suspect that it will—but we need to be a bit careful about the language that we use in anticipation of that.
It is important to compare this country’s outcomes and incidence of disease with those nations with which we can reasonably be compared. In this context, I think particularly of western Europe. Standardised death rates from stroke among men under the age of 64 are nine per 100,000 in the UK compared with seven per 100,000 in France. The equivalent figures for women are seven deaths per 100,000 in the UK compared with four per 100,000 in France and in Spain. The UK has some of the worst outcomes for patients in western Europe. In one study, the differences between the UK and eight other European countries in terms of the proportion of patients left dead or dependent were between 150 and 300 events per 1,000 patients. That statistical material is rather technical stuff, but it points towards patients in Britain not doing as well as they have a right to expect, and it certainly suggests that there is no room for complacency.
The Minister spoke about health checks and vascular risk assessments and invited the Opposition to support those initiatives. I have campaigned for many years for screening for abdominal aortic aneurysm, yet despite recommendations by the National Screening Committee we still do not have a credible roll-out of national screening for that particular condition. The Government need to be careful; interventions in the public health sphere, particularly in terms of prevention, need to be based on the evidence, which points towards instituting a screening programme expeditiously. I very much regret that that has not been done.
What has changed over the past few years with stroke? It has gone from being a condition with chronicity to one that is seen as existing within the acute sector. It has become a medical emergency; of course, it always was, but it was not recognised as such. Unfortunately, as the Stroke Association observes, it is still not necessarily seen as a condition that requires immediate treatment and management—neither by potential patients nor, sometimes alarmingly, by health care professionals on the front line. That has been clearly shown by NOP and MORI polling over the past few years.
Since the figures came out in October 2008, we have had the Department of Health campaign. We have all seen the television adverts that are part of that, which have been extremely good. The images are disturbing, but it is sometimes necessary to be fairly hard-hitting in order to change attitudes and behaviour. We will have to see whether the effects of that campaign are enduring. I was concerned to hear the hon. Member for Crawley, who has some experience in these matters, suggest that in a few years’ time, when the funding runs out, we might simply move on to the next hot topic. Our approach needs to be a bit more long-term than that. As we have seen with road traffic campaigns, there is a danger that when we go on to the next topic we forget the public health messages that have been put across effectively, at least in the short term. That would be a great pity in the context of stroke. There have been a few measures of the campaign’s effectiveness—for example, the Stroke Association has said that it has had more inquiries since the campaign kicked off in February. However, I should like the Minister to clarify what assessment the Government intend to make of its enduring effectiveness, which would, I hope, inform any future campaigns.
If we are serious about public health and dealing with health inequalities, we have to address stroke, which is far more prevalent in less advantaged groups in our society, as well as in certain ethnic groups. We need to try to work out why that is and put in place measures to reduce that inequality. In my intervention on the Minister, I mentioned the effects of stroke on the rural poor. It is bad being poor, but it is particularly bad in a rural location where access to services is extremely difficult. Following my intervention, and that of my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), I wonder whether the Minister has had any note from the Box about upgrading stroke from category B to category A, which is being considered by the Department’s emergency call prioritisation group; if not, perhaps it would be possible to communicate separately on that subject. Such a step might be a way of improving access for people with stroke who live in rural areas.
There is evidence that someone’s chances of optimal management for stroke are best if they arrive at hospital by ambulance. However, according to the sentinel audit, only 17 per cent. of patients reach a stroke unit within four hours of arrival at hospital. I suspect that further work needs to be done in accident and emergency to improve triage and expedite the definitive management of stroke patients. That appears to be especially required at weekends, as, crucially, the chance of getting a scan, and therefore definitive treatment, is very much less out of hours.
The hon. Gentleman is making an excellent speech. A brain scan should take place within three hours, and it will determine the outcome for stroke victims, so it is absolutely essential. Will he at least give the Government credit for their policy of trying to ensure that stroke victims get taken by ambulance straight to a specialist centre rather than to a general hospital so that they can get that treatment early, which will improve outcomes for them?
I am grateful to the hon. Gentleman for his intervention. I will deal with the question of specialist units versus district general hospitals in the remainder of my speech. However, his remarks spark me to reflect on the change in radiological protocols that has occurred in recent years. There has been a strong trend towards reducing the amount of elective work that is done out of hours. For example, it is now difficult to get a chest X-ray out of hours unless it is a real emergency, and very few are defined as emergencies requiring imaging. That is fine—it is absolutely right—but I sometimes wonder whether we have gone a little too far. I suspect that as part of the process, there is less willingness to do CT scans on stroke patients out of hours. We need to look again at our protocols to ensure that a medical emergency is investigated as such, 24/7.
The hon. Gentleman made a good point about the need to improve triage at the hospital to which a patient is taken, including at the weekend. Although there has been an improvement in ambulance services, does he believe that one missing element of the stroke service is a review of whether we can get further improvements, so that ambulances get to patients quickly and get them to the main centres quickly? Does he think that there is a case for that?
Yes, and I understand that the Minister’s Department is doing that work at the moment. It is reviewing whether we should upgrade from category B from category A—from 18 minutes to nine minutes—the response time for stroke cases. It will be interesting to learn the outcome of that work. I suspect that part of the reason for the effectiveness of arriving by ambulance rather than under one’s own steam, and the likelihood of getting prompter treatment when arriving by ambulance, is that triages are undertaken by ambulance crews. They are therefore able to warn specialist stroke units that a patient will be arriving. Across a range of clinical areas we find that such warning expedites admission to specialist units, as patients do not have to go through the sieve of accident and emergency and the inevitable delay that is caused. I have some first-hand experience of that.
Stroke services are somewhat patchy across the country. A postcode lottery applies, despite the fact that we have a national health service. The Stroke Association is concerned about that, as is the Royal College of Physicians, and the sentinel audit underscores that concern. In my own area, I find to my delight that according to the audit, the Royal United hospital and Salisbury hospital are reckoned to be good. However, my constituents go much further afield on occasion, and I find that Yeovil, Bristol, Weston and Gloucester are okay, but that Taunton and interestingly Swindon have much room for improvement.
I caution against the evidence that has accrued about the use of specialist centres being used to favour large centres at the expense of district general hospitals. Stroke is not an obscure disease, it is a condition that strikes somebody in England every five minutes and the third most common cause of death in this country. The hon. Member for Hendon (Mr. Dismore), who is no longer in his place, talked about critical mass, which is important in the case of tertiary services. Nobody doubts that a patient should go to a tertiary unit for obscure conditions. Stroke is not unusual, it is bread and butter for district general hospitals. If it were removed from their responsibility, one would wonder about the foundations of the district hospital model. Quite honestly, a condition that causes the third most deaths in this country and sadly provides a patient every five minutes in England must be part of the underpinning of any acute service and part of its bread and butter.
The investigation and treatment of stroke is not particularly complicated. In saying that, I do not underplay in any way the expertise of those who specialise in it. It relies upon a CT scanner—we are working towards a position where pretty well every hospital will have one—and access to telemedicine. In other words, a particular hospital does not necessarily need a specialist, because the information can be relayed and, crucially, a diagnosis made in that way. The treatment itself should not be beyond any acute unit in this country.
My hon. Friend will not have had an opportunity to look up the figures before responding to the hon. Member for Castle Point (Bob Spink), but the latest figures in the sentinel audit clearly demonstrate that Southend hospital had the best results anywhere in the east of England.
I am sure that the hon. Gentleman will have noted that with some pleasure.
We need to be careful about using a Darzi extrapolation to the point where we lose immediacy and patient access. I speak as somebody who represents small towns and a rural area in Wiltshire. So far as I am able to gauge my constituents’ wishes—we have all had some opportunity to gauge interest on a range of subjects over the past few days—it seems to me that what they want is local services, locally provided, unless there is very good reason why not. Our national health service should be designed around their needs and wishes rather than necessarily the convenience of practitioners or how they want to operate.
Stroke is a good case in point, because there is no real reason why we cannot provide both diagnosis and treatment in a specialist context within district general hospitals. It would be a real pity if we were to rusticate stroke services to our great clinical cathedrals in our larger urban centres. London has been discussed at length today, and those services should not be restricted to a small number of hyper-acute units in the capital.
I shall begin by talking about some improvements in stroke services. From that, my hon. Friend the Minister can see where my speech will go towards the end.
I make no apology for continuing to talk about London services, the increased investment in which is welcome. There has been £23 million of additional spending on stroke services, as my hon. Friend the Member for Hendon (Mr. Dismore) said. There is a predicted increase in survival rates of some 25 per cent. Notwithstanding the fact that, as he said, some deliberate misinformation has been put about by Opposition parties—I shall say something about that in a moment—it is interesting that all parties have taken on board the central point about the creation of hyper-acute stroke units.
I tend to agree with what the Opposition have said about the strict adherence to numbers. The idea that specialist stroke treatment will be a major factor in saving lives over the next few years was initially received with some scepticism, but in the light of overwhelming clinical evidence it has now been widely accepted, which is a good thing.
Like others, I pay tribute to my hon. Friend the Minister for her contribution, not only in her professional capacity and as a Minister but as my neighbouring MP. I was very pleased to celebrate the 60th anniversary of the NHS with her late last year at Charing Cross hospital, where she herself has worked and in which she continues to have a great interest and support me. The Minister of State, Department of Health, my hon. Friend the Member for Exeter (Mr. Bradshaw), who was briefly in his place, has been extremely helpful with regard to the difficulties that I have experienced in the current consultation.
Finally, I pay tribute to the Stroke Association, which others have mentioned. It has done an excellent job in its recent report and in encouraging the Government and giving them praise where it is due. I do not say that only because when its staff were testing blood pressure in Portcullis House last month, they said that I had the blood pressure of a young man. I think is the only thing that I can claim to have about me that is of a young man.
The current consultation ended on 8 May, and it has been mentioned several times this afternoon. The matter has been shockingly handled by Healthcare for London. I shall start by dealing with my simpler concern: the stroke unit at Ealing hospital. If the current proposals are implemented, that stroke unit will be closed. When I spoke to the neurologists and other professionals at Ealing, I found it was envisaged that the alternative provision would be at either Northwick Park or Charing Cross hospitals. Things have now moved on, and there is a worse plan. However, even at that stage, there was serious concern and some astonishment at such a proposal. I could speak for a long time about that one issue, and I am sure that other hon. Members could present arguments for hospitals in their constituencies or those nearby, which their constituents use extensively.
Ealing hospital stroke unit provides good care, has just been refurbished to a high standard and is in the top 25 per cent. of stroke units in the country. It is by no means clear from the current proposal how the many people from the borough of Ealing and around who use the unit will be accommodated in future. There is no evidence that the capacity problems arising from the stroke unit’s removal will be picked up by the alternative proposals. However, at least the proposal for Ealing is clear. The unit is to close and there is to be alternative provision. I repeat that the case for the need to hone provision to eight units and the case for their location have not been well made, but at least the decision is clear, if incorrect.
The position of Charing Cross hospital, which is just outside my current constituency, but extensively used by my constituents, is far from clear. There is a proposal no longer to have one of the new hyper-acute stroke units there in the longer term. To avoid doubt and to be brief, I can do no better than read out part of my submission to the consultation. I said:
“I do not accept that this consultation has been properly or transparently conducted and I believe the outcome of it—certainly as far as it affects my constituents—has been pre-determined.”
The right hon. Member for Chingford and Woodford Green (Mr. Duncan Smith) made that point earlier. My submission continued:
“I remain hopeful that I am wrong in this surmise, but if I am not I hope there may be some challenge, legal or otherwise to the proposals Healthcare for London are currently recommending for Charing Cross Hospital.
Specifically, there is no clarity as to the process by which the preferred location of the fourth major trauma centre was switched at short notice from Charing Cross to St. Mary’s Hospital. This having been done however, there is a preferred option for St. Mary’s stated in the document with an attached footnote that the transfer of the hyper-acute stroke unit (HASU), currently proposed for Charing Cross, will in the space of two to three years follow the trauma centre to St. Mary’s. I have spoken to clinicians at Charing Cross who believe this is the wrong course of action both in clinical and geographical terms. But this aspect of the proposal does not appear to be open for discussion. Rather it is the settled view of Healthcare for London that co-location is the sine qua non in deciding the location of this HASU.
I do not see how Healthcare for London expect serious responses to such proposals which have all the appearance of being last minute, botched and above all so closely interconnected as to be incapable of being unravelled. I do not think the logistics of moving stroke and neurology services from Charing Cross to St. Mary’s have been properly studied: the site, the funding and the relative size and importance of the clinical units at both hospitals strongly suggest the better option is building on the excellent provision currently at Charing Cross.
I would like to be reassured that if as expected a HASU opens at Charing Cross later this year, if the proposal to move this to St. Mary’s in 2012 or shortly thereafter is pursued there will be a full and impartial consultation at that time.”
The well respected and extensive stroke services at Charing Cross were to be combined with one of the major trauma centres for London, but the quality of the trauma bid was apparently not good enough, as was the case with the Royal Free, in which my hon. Friend the Member for Hendon has a constituency interest. Rather than those two bids being resubmitted, at short notice the trauma centre bid was switched to St. Mary’s and that is now the preferred bid. It has been admitted to me in several meetings with health care professionals, the hospital trusts, the primary care trust, Healthcare for London and, indeed, the Under-Secretary, that it is a done deal: St. Mary’s will be the trauma centre.
Suddenly, as an afterthought, and done by asterisk and footnote in the consultation document, and clearly because the co-location proposal is sacrosanct, the stroke unit at Charing Cross, which is currently being prepared and will open, function and doubtless be extremely good for two years, will somehow move to the St. Mary’s site, which is inappropriate. There is no provision for it and clinicians to whom I have spoken doubt whether there are funds for it. The proposal is a dog’s breakfast, for want of a better phrase.
There may be a guarantee of further consultation in future. That is not good enough. I have made the point strongly to the chief executive of Healthcare for London that no proper consultation has been carried out—that is clear from the document—and the matter needs to be revisited. Clearly, decisions have been made and put out for consultation thereafter.
One of the unfortunate side effects is the mischief that can be made, and mischief aplenty has been made with the future of Charing Cross hospital for more than four years. It is a perfect site for a hospital; it is perfectly accessible. The decision affects not only constituents in Hammersmith and Fulham and Ealing but those in the entire London boroughs of Hounslow and Ealing and the wider area of west London, to whom Charing Cross is far more accessible than St. Mary’s. The site is large, with plenty of room for redevelopment, which is already taking place. However, the botched decisions, the poor quality of decision making and the lack of information allow mischief to be made.
There have been persistent rumours of downgrading or closure since 2005. The hospital was a major issue in the general election campaign. It suits the Conservative party locally to continue to keep those rumours alive and I have therefore been in conversation and correspondence with successive Health Ministers since I was elected to get assurances about the future of Charing Cross hospital. Those assurances are freely and readily given, and I have a copy here of the latest letter from the chief executive of NHS London, which is dated 29 May.
The letter states that even if the hyper-acute stroke unit moves in due course from Charing Cross, the
“stroke unit at Charing Cross hospital will be enhanced to deliver high quality stroke services for the people of Hammersmith and Fulham. We expect Charing Cross to retain a full range of services as a busy hospital for local residents maintaining its prominent position in the community.”
The letter goes on to say that the hospital will provide
“a broad range of elective specialist services, as well as emergency services with the associated medical specialties, and an active A&E. It will continue to provide neurology and stroke services, including post 72-hour stroke care, rehabilitation and outpatient services.”
The chief executive could have added that one of the largest and most ambitious polyclinics is being built there, with a full GP practice on the side, in addition to many other new buildings, including the highly prestigious Maggie’s cancer centre, which was visited by Sarah Brown and Michelle Obama on the President’s recent visit. There is therefore no question but that Charing Cross has a bright and expanding future, with or without the hyper-acute stoke unit and trauma centre. Again, let me make it clear for the record that the Government are to be praised for that investment. In addition, since the formation of the Imperial College Healthcare NHS Trust and the Academic Health Science Centre, the prospects for health care in west London have never been better.
However, the chief executive and the Minister can write as many letters to me as they wish, but what my constituents believe—because they are told so every fortnight in the only local newspaper in wide circulation, which is controlled by the Conservative council—is that Charing Cross is being downgraded or closed. That is deliberate disinformation, exactly as my hon. Friend the Member for Hendon said, put out with mischievous political intent by the Conservatives. However, they would not be able to do so were it not for the administrative confusion, complacency and lack of attention by health service managers in London.
There is now a ridiculous conflict of interest, whereby the managements of the Conservative local authority and the local health service have fused. Therefore, the person who is charged locally, as the chief executive of what was called the PCT, with rebutting the accusation that the health service is not receiving investment, is being downgraded and is in decline, is exactly the same person putting out the propaganda saying that it is. The situation is quite surreal. I have raised the matter with Healthcare for London, but it prefers to make no comment. Just as in Hendon, where one part of the NHS is briefing against another, we now have a chief executive of the local authority who damns the health service in the morning and then, as the chief executive of the health service, tries to defend or praise it in the afternoon.
That cannot be allowed to continue, because at bottom it affects my constituent’s confidence in the local health service, which is excellent and improving. In my opinion, the only solution is to abandon at least those parts of the consultation that are discredited and were never consulted on in the first place, and which can only lead to a conclusion that is at best inadequate and at worst detrimental to patient care. I would ask my hon. Friend in responding to this debate to say that she will ask Healthcare for London to look at the situation again, because it is not satisfactory for us to go forward with, on the whole, an excellent proposal for stroke and trauma care—one that will improve services and save lives—without the certainty that things are being done with honesty and integrity, and in a way that will not confuse or undermine the health service in west London or people’s opinion of it.
Let me start by declaring an interest, in that I am very much in the age group of those who can expect to suffer a stroke at some time in the not-too-distant future. I support the hon. Member for Vauxhall (Kate Hoey) and have visited the stroke unit at St. Thomas’s, which is absolutely excellent, and I would be delighted to go there, if I had to.
I will be as brief as I can and cover just three aspects, the first of which is emergency calls. It is crucial that emergency calls are taken seriously by all facilities—that is, by the ambulance people as well as by the doctors. I have long argued in favour of having another telephone number in addition to 999 for those who do not think that they are an acute emergency, but would like advice. That is particularly important for someone who gets a transient ischaemic attack, but then gets better and does not know what to do. It would be useful if they had another number that they could contact easily, which would tell them that such an attack is a serious warning that they have to act on.
Let me turn to stroke care networks. I would like the Minister to tell me in her winding-up speech what her idea of the stroke care network is. An article in the 21 May edition of the Health Service Journal entitled “Sink or Swim” deals with the importance of district general hospitals to local communities. We should be considering two different kinds of stroke unit, namely larger units in major centres and local units, which are crucial for sorting out people with transient ischaemic attacks and with strokes that do not necessarily need thrombolysis. NHS East of England has already been referred to in the debate, and it is mentioned in the article:
“Many district general hospitals are keen to retain core emergency services. NHS East of England has committed to retaining A&E and consultant led obstetrics at all its trusts and thrombolysis for stroke patients, at least part of the time.”
It seems possible to have pretty widespread local stroke units that will deal with all forms of stroke, with a number of them being able to give thrombolysis as well. At this point, I must refer to the National Institute for Health and Clinical Excellence’s technology appraisal, which is mandatory. It states:
“The Committee was aware that in the UK, physicians with experience in stroke care are not always the same as those specialised in neurological care. The Committee concluded that alteplase”—
“should be used by a physician trained and experienced in the management of acute stroke and only in centres with facilities that enable it to be used in full accordance with its marketing authorisation.”
That sets quite a high target for the stroke units that will be providing that therapy, but it is something that we should aim for. We have already heard that the time limit for administering that treatment is exactly three hours. For a patient to get to a unit, have the scan and receive the treatment within three hours is enormously demanding. That is why I hope that, as well as there being networks, some of the local units will also be able to provide thrombolysis, at least part of the time.
Speaking from an out-of-London perspective, I believe that transport is also crucial. If the major stroke centres are to be located only in a few places, we are going to need to use the air ambulance service much more than we do at the moment. That raises the question of when the Government are going to consider making some sort of contribution to running air ambulances.
I hope that the local stroke units will become widespread, but I must point out the necessity of their each having a complete team. They will need not only doctors and nurses but, as has been pointed out many times, speech therapists. Unless things have changed in the past few months, speech therapists are almost as rare as hens’ teeth. The units will also need physiotherapists and occupational therapists, but they, too, are shortage specialties. Rehabilitation is essential for the long-term care of people with strokes when one has not been able to prevent the completion of the stroke.
Finally, the Next Stage review recognises the risk that reconfiguration can make services fall down. The Under-Secretary of State in the House of Lords has made it clear that we must never reconfigure until alternatives are in place, otherwise there will be an untenable gap.
I am delighted to follow the hon. Member for Wyre Forest (Dr. Taylor). I want to begin my speech on a personal note. My father-in-law, Sir John Keegan, had a stroke four weeks ago. He survived due to the swift response of his local ambulance service and the immediate care that he received at Salisbury district hospital in the critical first three hours following his stroke. I want to thank the doctors and nurses in the Farley unit at Salisbury district hospital for all their after-care in the past four weeks. In particular, my mother-in-law, Susanne, my wife, Lucy, my brothers-in-law, Tom and Matthew, and my sister-in-law, Rose, share my gratitude.
As we have heard from my hon. Friend the Member for Westbury (Dr. Murrison)—in whose constituency my in-laws live—stroke is the country’s third largest killer. It is also the single largest cause of adult disability, a point made by my hon. Friend the Member for Buckingham (John Bercow) at the beginning of the debate. We all have constituents who have been affected and I suspect that most of us may have experienced a stroke within our own families, as I did recently. Yet for too long, strokes have been the poor relation in the NHS, so I welcome the long overdue national stroke strategy of 2007, which finally prioritised stroke care for health and social care providers. Our response needs to be commensurate with the sheer size of the problem.
The strategy has undoubtedly brought progress, but we must not stand still on the issue. Not enough patients are receiving the treatment and care that they need quickly enough and too many are subject to a dangerous postcode lottery. Inequalities in access to stroke units and long-term care all too often mean that where people live can dramatically affect the length of recovery from a stroke—or even whether they recover at all.
If we want to improve stroke services, we must focus essentially on three elements: first, saving lives in hospital; secondly, reducing disabilities and long-term damage; and, thirdly, preventing strokes altogether. Speed is of the essence with a stroke. A scan and early treatment within the first three hours can, as we have heard, make the difference between complete recovery, a lifelong disability or even life at all. For example, a brain scan will crucially confirm the diagnosis of someone admitted to hospital. For people with ischaemic strokes, swift thrombolysis or treatment with clot-busting drugs within three hours will significantly reduce the chances of dying, yet last year, only 0.8 per cent. of patients received thrombolysis.
I know that having a specialist stroke unit can do much to improve survival rates and recovery times for stroke patients. Commendably, early access to a stroke unit has improved significantly since 2006. However, in 2008, one quarter of patients were still not being offered this service—a service that I know, through personal experience, really can make a difference. As our population ages, the demand for these specialist units can only grow, so we must ensure that we can cope.
Having swift and high-quality stroke services from day one makes sense for our country’s financial health, too. Caring for stroke patients currently costs the UK about £7 billion each year because of the long-term implications of a stroke and the detrimental effects of delays in treatment. Given that about a third of stroke survivors will be left with a moderate to severe disability, long-term social care is often a necessity, not a luxury. However, the Stroke Association says that rehabilitation and long-term care in the community is one of the weakest elements of a stroke survivor’s pathway. Only around half of those who have experienced a stroke receive the necessary rehabilitation in the first six months following discharge from hospital, which falls to a fifth in the following six months.
The transition from hospital back to the community can also be extremely difficult. Not only do about a third of stroke survivors have communication difficulties— including, as highlighted in the Stroke Association’s recent “Lost without Words” campaign, aphasia and speech impacts—but many experience a loss of confidence and independence as they struggle to regain their basic capabilities and rebuild their lives.
I am pleased that as part of the national stroke strategy, every local authority now receives a ring-fenced grant of around £100,000 a year for stroke services. However, I believe that the scheme is currently intended for only three years, so just as services are really starting to make a difference, I fear they may be shut down for lack of long-term financial support.
Finally, it is not enough to just to treat the symptom of the problem, as its cause is also important. We can reduce the likelihood of a stroke through preventive work on high blood pressure, irregular heartbeats and smoking, for example. That alone could prevent thousands of strokes each year, saving not only many families from having to watch a loved one suffer, but millions of pounds each year in care costs. For progress on stroke services, we must look carefully at three elements: the urgency of immediate health care; the long-term nature of recovery; and the opportunity to prevent strokes in future. Only if we can weave those into a more seamless approach, applied evenly regardless of where the patient lives, can we say that we are doing the best for the thousands of stroke sufferers each and every year.
I appreciate being given a few minutes to contribute to the debate, especially as I missed the opening speeches, for which I apologise to those on the Front Benches.
I praise the Government for the improvement that they have tried to make in stroke care. The service in the NHS has been patchy and unsatisfactory for too long, and that is not what is needed in a modern health service. The national stroke strategy and the efforts in relation to hyper-acute centres are moving it in the right direction. A consultation process has taken place in London, including my area of north-east London. As part of that consultation, I have written to express my dissatisfaction about the way in which Whipps Cross hospital, in my constituency, was treated. It had a good case for being a hyper-acute centre—better than that for Queen’s hospital and the Royal London, which were the ones chosen. The decision has been made on the basis of having two locations, and Whipps Cross has missed out unfairly in that regard.
A lot of money will be needed to bring Queen’s and the Royal London up to a decent standard, and it is important that local hospitals such as Whipps Cross are not starved of moneys to run a good acute and TIA service. As money is pumped into the chosen centres, that is a risk. The Minister and NHS London must take on board the point that good local provision of acute and TIA services is still needed.
In my intervention on the hon. Member for Westbury (Dr. Murrison), I made a point about ambulance services. Further improvements are needed to enable ambulance services to act promptly, and perhaps we need to look at traffic arrangements to ensure that ambulances get to centres on time for patients. The hon. Gentleman made a crucial point about the need for triage efficiency at A and E centres to deal with people as soon as they come in.
The hon. Gentleman also made a good point about acute services taking advantage of investment in telecommunication links—for instance, to enable people who have reported there to get treatment without having to go off to the hyper-acute centre. That needs improvement, and the expertise needs to be in local hospitals.
In north-east London, another plan being considered includes the option of a reduction in beds. That would be wrong for stroke care, because the beds are needed for rehabilitation of patients. In a proper stroke care model, there is no case for a reduction in beds.
Improved rehab and community stroke care provision, which remain weak, are needed. We have talked about NHS provision for stroke patients being patchy, but that in local authorities is even patchier: some are good; others are not, or they set high criteria to be met before giving help. A good look at what local authorities do is necessary, and they should be helped to provide such support in conjunction with the local NHS.
Only half of people get rehab in the first six months after having a stroke, which is too low a figure. As has been mentioned, the figure falls to a fifth in the next six months, which is not satisfactory. Only a third of patients in England benefit from early discharge support, which enables them to be rehabilitated in their own homes. That position needs to be improved substantially. I think I am right in saying that according to figures provided by the Stroke Association, only 12 per cent. of people who experience communication difficulties following a stroke are given speech therapy, and I believe that only 6 per cent. of people in London receive such support. Much more needs to be done in that regard.
My last point about rehab and community stroke care concerns people who suffer transient ischaemic attacks. Because of the fear that they will go on to suffer a major stroke, those people need to be seen within 24 hours, but I understand that at present only 45 per cent. of them are seen within that time. It has been estimated that if the figure were 100 per cent., which is the Government’s target under the national stroke strategy, the number of people subsequently suffering full strokes would fall by as much as 80 per cent.
There are many issues surrounding hyper-acute centres, acute centres and TIA services in the more local hospitals. While the Government are pushing ahead with the centres and trying to improve the service, they must not lose sight of local provision, which I believe can play a very important role. By that I mean provision either by local hospitals or by local authorities in conjunction with the NHS. A great deal of credit is due to the Government, but there is much more to be done, and they should not forget that local role.
I thank all Members who have contributed to this important debate. I am particularly grateful for the way in which they congratulated the Government. Of course we all recognise that there is more to be done, but by bringing us together the debate has demonstrated that consensus across the House is a vital ingredient if we are to make progress on an issue as important as stroke. I acknowledge again the important work of the all-party parliamentary group on stroke and the contribution that it has made.
We are tackling all the work that needs to be done through the stroke improvement programme and the stroke care networks that it set up. The strategy is a 10-year plan, and there are no simplistic quick fixes to bring about the improvements that we want to see. We are the first to acknowledge that there is a long way to go.
In the short time available to me I shall respond to as many as possible of the points that have been raised, but if, as is likely, I fail to respond to all of them, I shall of course write to Members and ensure that all their points have been properly addressed.
My hon. Friend the Member for Crawley (Laura Moffatt) shared her experience with us, telling us how stroke patients had been treated in the past. Let us ensure that it definitely is the past. I, too, acknowledge the work done by David Davis with the South East Coast ambulance service: it is well known and recognised in the Department.
London Members in particular, including my hon. Friends the Members for Hendon (Mr. Dismore) and for Ealing, Acton and Shepherd’s Bush (Mr. Slaughter), have raised the scare stories that have been put about concerning closures that will not, in fact, take place, for instance at Barnet, Finchley and Charing Cross. I am more than familiar with that debate. No wonder the local community is engaged in the debate over Charing Cross. As long ago as 1992, when the then Conservative Government introduced the internal market, it was said that the market would decide whether Charing Cross or Hammersmith would stay open. There is no closure of Charing Cross; there will be no closure of Charing Cross. Imperial college is making sure that all the services that are coming from the Imperial College Healthcare NHS Trust are of the highest possible standard, but I note what has been said about the consultation, which ended on 8 May. Announcements are due on 20 July, I believe. If the process still needs to be looked and monitored in any way, I know that Members will make their views known to me. I will do my best to ensure that NHS London is aware of the debate and how that has progressed.
The hon. Member for Westbury (Dr. Murrison) asked about the category for stroke. I have some information to share, but our discussions will continue. The software used to telephone-triage patients has recently been updated and is being rolled out across ambulance trusts. The new version includes questions based on the face, arm, speech test for stroke. Any patients with positive FAST symptoms will get a category A response, with a target to reach them within eight minutes.
We have heard many comments, including comments based on personal experience from the hon. Member for Braintree (Mr. Newmark). I wish the family well. I am sure all of us would want to do the same.
My hon. Friend the Member for Vauxhall (Kate Hoey) again pointed out with regard to the consultation the important work that takes place at St. Thomas’s and at Guy’s. I also commend St. Thomas’s hospital, which Members consider to be their local hospital. The work that is done by Dr. Holmes and his team is excellent.
The hon. Member for Leeds, North-West (Greg Mulholland) looked in particular at BME groups and how checks are being made. Efforts are being made to target that population in particular so that they go for those all-important health checks. Most Members have been gracious enough to say that that is good work. We are continuing down that line.
Points have been raised by Members covering many situations. Out-of-hours services were again raised by the hon. Member for Westbury. Imaging was mentioned, as was the importance of out-of-hours work and seven-day-a-week, 24-hour imaging. It is critical that that happens. We are looking at the development of the professions and the training that will be required to achieve that. Incorporating telemedicine in the way the hon. Gentleman mentioned is important. Many areas are starting to do that.
It is critical, as we continue with the 10-year strategy, that stroke is a No. 1 priority for the NHS, providing extra funding and establishing the local stroke networks. We are firmly aiming at a revolution in stroke services over the next few years, which I believe we will see. The House will work together on that important issue. Members will be aware that it is important that all the matters that have been raised are addressed, but the consultation, the reconfiguration and the specialist units will continue. I thank Members for their contributions to the debate today.
Question put and agreed to.
That this House has considered the matter of stroke services.
Sitting suspended (Standing Order No. 20).