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Transient Ischaemic Attacks

Volume 587: debated on Wednesday 5 November 2014

It is a pleasure to serve under your chairmanship, Mrs Riordan. I am glad to have the opportunity to debate transient ischaemic attacks, or TIAs. They are also known as mini-strokes, but we should be careful with our terminology, because a TIA is a serious matter; it is a warning of a possible future stroke. Because it is a serious matter, I am a bit perturbed that no one is sat on the Government Front Bench. I hope that the Minister will join us shortly. A possible future stroke could kill or incapacitate someone temporarily or permanently, and the risk is greatest in the first few days after a TIA. In fact, one in 12 people will go on to have a stroke within a week of a TIA, yet TIAs are often not taken seriously by members of the public and are sometimes not recognised by health staff.

We have known for some time, however, that dealing with TIAs urgently can prevent future strokes. In fact, research published in The Lancet in 2007 indicated that 10,000 strokes a year could be prevented if all TIAs were treated urgently, but that still does not happen. Those strokes could be prevented, people could avoid serious disability and the NHS could save a huge amount of money.

I intervene only to apologise most profusely for not being here at the start of the debate. We checked with the Doorkeeper following the Division and were advised that a quarter of an hour would be added and that this debate would start at quarter to 5. I would never be so discourteous to the hon. Member for Warrington North (Helen Jones). I really am extremely sorry, but that was the advice that we received. We were only next door.

Order. The sitting was suspended at 4.15 pm, but Members were back shortly after the vote. The rules are that we start again as soon as the Minister, the Member who proposed the debate and the Chair are back. As long as three Members are here, we can resume, which we did, and the debate finished at 4.38 pm. Helen Jones began her debate then.

I of course accept the Minister’s apology. I am sure that she would not be deliberately discourteous to any Member of the House.

Part of the reason why action is not being taken is that public awareness of TIAs is low. A 2012 poll for the Stroke Association found that few people understood the symptoms. In a recent survey of people who had experienced TIAs, the association found that 44% had no knowledge of TIAs prior to having had one and, astoundingly, 61% did not know that it was a warning sign of a possible future stroke. Those were people who had already had TIAs, so it is unsurprising that a third of people take no action following a TIA. Others do not realise that it is a medical emergency and wait for appointments. Astonishingly, the Stroke Association found that a quarter of the people surveyed did not take any action even though they had had TIA symptoms more than once. People may not know where to go for help, and some think that nothing can be done.

When people do seek help, however, it is fair to say that the service that they receive is variable. The all-party group on stroke heard from two former patients, one of whom had been treated quickly and efficiently, but the other had had the opposite experience. The Stroke Association found that while many people have a great deal of praise for how they were treated and for the care provided by health care staff—it is important to put that on the record—16% felt that they were not taken seriously and 25% said that their symptoms had been misdiagnosed. One person at the all-party group meeting had actually heard a paramedic say those classic words, “It’s just a funny turn.” Another person told the Stroke Association:

“Our GP has told us not to bother to attend GP surgery or A and E as it is not worth it for TIAs.”

Another said:

“I had numerous TIAs that were misdiagnosed as migraine.”

Such comments are worrying, particularly given that parts of the NHS deal with the matter well and show great examples of good practice. The south-western ambulance service, for example, has pioneered direct referral of suspected TIA patients to a TIA clinic. It has invested in training its staff and all ambulances carry details of TIAs, of the referral pathway and, importantly, information for patients. I have also heard a great deal about what has been done at Southend university hospital, which went from having a Monday to Friday TIA clinic to having an online rapid referral system, using new technology, that helps GPs and health care staff to assess patients and to transmit information directly to the clinic or even to the consultant’s mobile. It trained more clinical staff to do ultrasounds and changed the protocol for MRI scans, so that patients can be accommodated in between the normal list. As a result, its service operates seven days a week and sees all high-risk patients within 24 hours and others within a week, as recommended. That service saves lives and enables tests to be done and treatment to be begun on the same day. If that can be done in Southend, it can be done elsewhere. The first problem is actually getting patients to realise that they need treatment.

I thank the hon. Lady for giving way, and I appreciate her bringing this matter before the House. The Government run the FAST campaign, which covers symptoms similar to those of TIAs. Could the issues be addressed through that campaign? The Government, officials, GPs and families could use it in the same way. That might be a way forward.

The hon. Gentleman takes the words right out of my mouth. I was going to put it to the Minister that the FAST campaign has been excellent and has raised awareness of stroke symptoms and of the need to call an ambulance. We need to extend the campaign to TIAs, because people still wait for treatment or do not access it at all. There are also people who go to the wrong person for treatment, such as an optician, because they mistake their symptoms for something else.

Investment in staff training is vital, in particular for front-line staff, because TIAs are difficult to diagnose. Often when a patient is seen, their symptoms have gone and health care workers rely on reports of what happened. It is also true that TIAs can mimic other illnesses, such as epilepsy, migraine or visual disturbances, which is all the more reason why front-line staff—the first point of contact for patients—should be trained to recognise the symptoms. We must also ensure that referral systems are in place, so that people can access treatment rapidly. I hope that the examples I have given show that it is possible to meet the guidelines contained within the national clinical guidelines for stroke, so that people can be treated quickly and easily. However, the Stroke Association found that 22% of people wait more than a week for their first appointment, which is quite outside what the guidelines recommend.

The provision of information is absolutely vital. The Stroke Association’s report, “Not just a funny turn”, contains many examples of people who have changed their lifestyles and diet after being given proper information following a TIA, so that they hugely reduce the risk of a future stroke, but that does not always happen. Some 40% of people say that they are given little or no information following an attack, and some 50% do not know about the risk of a possible future stroke. The report contains some worrying comments. One person says:

“After TIA I had no support or advice or information… I didn’t know about risk of stroke—was not told this by anyone.”

I find that profoundly shocking. It is not even a case of spending a lot of money; it is simply about having information to give to patients. What will the Minister do to ensure that that actually happens?

My next point, which the Minister and I have debated with regard to stroke, is about the provision of emotional support after a TIA. Like a stroke, a TIA is an event that someone does not expect or plan for. Many people lack support afterwards, but with support they can make changes that reduce their future risk. Some people feel that they need counselling, others simply want to talk to someone who has experienced a TIA and others want to be in contact with patients’ groups or organisations such as the Stroke Association. If people are given the right information, they can do all that, but the information is often not given to them at all. That, too, could be done with little expense.

We have some good care in the national health service—some excellent care—but it is patchy. I want to hear from the Minister how she plans to raise public awareness of TIAs and to extend the FAST campaign to cover them, as the hon. Member for Strangford (Jim Shannon) said.

What will be done about training front-line staff so that we bring everyone up to the level of the best? That is a difficult matter. We cannot blame staff for misdiagnosis if they are not trained properly. We need to train them. What will be done to ensure rapid access to treatment everywhere in the country, not simply for those who happen to be lucky and live near an excellent hospital? The NHS works best when its organisations co-operate and learn from one another. We need to ensure that that co-operation takes place.

Finally, what will the Minister do to ensure that people get the right information following a TIA, as well as support afterwards to deal with the emotional issues and to help change their lifestyles to lessen the risk of stroke in future? That would be a sensible investment for the NHS. It would ensure not only that we saved a great deal of money, but that we prevented a great deal of disability and heartbreak and even deaths.

I look forward to hearing the Minister tell us what is to be done about the important issue of TIAs. We could save lives if we invested in it properly.

Once again, my apologies to the hon. Member for Warrington North (Helen Jones) for missing the first two minutes of her contribution, because of a misunderstanding on our part.

The hon. Lady is a great expert on the subject and, as she said, we have debated it in the past—in fact, it was the subject of the first debate that I responded to as a Minister, about a year ago. It is good to see her commitment. As the chair of the all-party group on stroke—she is one of Parliament’s great champions of the issue—she also takes great interest in transient ischaemic attacks. The debate is timely, because it was world stroke day last Wednesday, which this year focused on the impact of stroke on women.

As ever, I will try to respond to as many of the points that have been made as I can, but the matter is obviously the responsibility of the NHS. In a debate of this nature, I always undertake to draw to it the attention of the key people in NHS England, in particular the national clinical director—

I am sorry to interrupt, but Ministers are in the end responsible for what happens. If they are not, there is no point in them being Ministers. A huge bureaucracy has now been set up, but it is still open to a Minister to pull the strings to ensure that the things that need to be done are done. I hope to see the Minister doing that.

I note the hon. Lady’s comments. NHS England is the lead on the subject, because it is ultimately a clinical matter. I always draw the attention of our clinical leaders to the views of Parliament and, where I need to underline them, I of course do so, but it is also important to recognise that in a large organisation the views and leadership of senior clinicians are vital. I will refer to that.

The Minister is gracious to give way, but I am sorry, I had to intervene at that point. The clinical details are not in doubt. We know what works and what best practice is; the problem is that best practice is not always followed.

I note the hon. Lady’s comments.

Turning to the Act FAST campaign, when people have a TIA, getting medical attention quickly is key, as the hon. Lady said. Ensuring that the general public are familiar with the signs and symptoms is important. Public Health England continues to run the highly impactful Act FAST stroke awareness campaign, which covers similar signs to those of a TIA—I note that she is right to draw the distinctions—and the simple message to call 999 if such signs are witnessed. The campaign was run again in March this year, and new adverts feature an Afro-Caribbean man to underline the fact that people from some ethnic groups, whether south Asian, African or Caribbean, are at higher risk of TIA and stroke than others. PHE plans to run the adverts again later in the financial year. Over the summer, the Stroke Association also ran a campaign to raise awareness of TIA, “Not just a funny turn”. It was welcome and many of us saw it.

The hon. Lady also referred to front-line staff and to raising awareness of signs and symptoms. Act FAST and the Stroke Association’s campaign were aimed at public and professionals alike to ensure that everyone acts swiftly. PHE plans to run its adverts, which do not only face the public, again before April 2015.

In addition, NHS England has produced a resource for clinical commissioning groups, to support them in setting and delivering on the level of our ambition to reduce premature mortality. TIAs form an important part of that. The resource includes information on the most high-impact interventions that CCGs can consider commissioning to reduce premature mortality, and TIAs fit into that description. One such intervention is to increase the proportion of patients suffering a TIA treated within 24 hours from 71% to 100%. Let us recognise that TIAs sit right at the core of all the resources being distributed to our front-line staff and produced by NHS England.

NHS England has also been working with the 111 service to ensure that the protocols and triaging systems on the phone lines are used to identify as many people with stroke and TIAs as possible. We recognise that there is more to do and that such work is ongoing.

On getting patients the treatment that they need, quite a lot of work is under way in many parts of the country to reorganise services. That involves reconfiguring care for patients with TIAs as well as acute strokes. For example, in Birmingham and the black country, Warwickshire, Surrey and Sussex standards for TIA care have been set and services are being redesigned to ensure that patients with high-risk TIA can be seen and managed within 24 hours.

The reorganisation of vascular surgery services into a smaller number of higher-volume units is also improving the efficiency of the provision of surgery for TIA. There have been huge improvements in TIA patients’ access to neurovascular clinics in recent years. That is important because, as the hon. Lady said, we know that the risk of stroke in the first four weeks after a TIA can be as high as 20%. It is vital that people are seen urgently and their symptoms investigated, and that a management plan is put in place.

The hon. Lady said that services can be inconsistent. We want to ensure that we work towards making all services as good as the best, but part of that work is to define what the best standards are and to disseminate best practice. I will talk about some of the ways in which that is done.

The 2012 national clinical guidelines for stroke recommend that patients who have had a TIA are seen, investigated and treated in a neurovascular clinic within one week. A few years ago, such clinics were relatively unusual and waiting times could run to weeks or months. Information from the latest Sentinel stroke national audit programme organisational audit published in 2012 shows a picture of real improvement. According to the audit, 100% of trusts in England, Wales and Northern Ireland now have a TIA or neurovascular clinic, with a median of 20 clinics held in each four-week period. There has been a really big improvement in access to those clinics.

The same audit also said that there are very few areas of the country where a high-risk TIA patient would need to wait more than a week, and that over half of high-risk in-patients could be seen the same day, seven days a week. We are waiting for an update of that audit, which is due to be published quite soon. I hope to see further improvement.

In the mini-exchange I had with the hon. Lady at the beginning of my contribution, we touched on best practice. The strategic clinical networks are important for that. They bring together clinicians from across health care settings and the wider health and care system in 12 geographic areas. The SCNs share best practice and promote initiatives on their core service areas, which include cardiovascular disease. The networks hold regular meetings to enable communication and information sharing. As an MP for a London constituency, I saw the benefit of bringing that clinical excellence to bear in the reorganisation of stroke services in London. Such work is ongoing, to make sure that best practice is disseminated around the country.

One problem I am aware of—I suspect the hon. Member for Warrington North (Helen Jones) is as well—is that TIAs pass in two or three minutes and there is no real understanding of what is happening among friends, relatives or others who are close by when they occur. The hon. Lady is trying to push for raising the level of awareness, and I am sure the Minister would wish to achieve that as well. How can we better achieve that within the Act FAST campaign? That was what I was hoping the Minister would set out.

I am happy to put that issue on the agenda for my next meeting with Public Health England, which puts together such campaigns. We all wish to raise awareness of the symptoms of a lot of different conditions, but one has to be realistic about how many public information campaigns we can run and how those can be organised. However, I am happy to have that discussion with Public Health England, because we are pleased with the way in which the Act FAST campaign has been received. There is clearly something to build on. I also know that the Stroke Association feels strongly about the issue. I am happy to discuss it and perhaps feed back in due course.

Hon. Members might be interested to know that the National Institute for Health Research has recently funded research on TIAs to look at the pathways taken by patients, from symptom onset to specialist assessment. That research found that factors contributing to delay included incorrect interpretation of symptoms and failure to involve the emergency services. The research is something else we can build on in order to understand what needs to be put in place so that we can do better.

Work is under way, and I am happy to look at what has been said today about public information. However, we have made a really good start. The picture for stroke care is also really improving. Sometimes I respond to debates on issues where we have not seen improvements of the kind that I set out on specialist clinics and surgery. We can see some real momentum, so it is case of building on that and on awareness of symptoms. I pay tribute to the work of the Stroke Association and its report. I saw the “Not just a funny turn” campaign over the summer, which I thought was well judged and was put across well. It did a good job of attracting publicity to stroke and TIA, so I congratulate the association on the campaign.

I hope that what I have said will reassure the hon. Member for Warrington North that the Government and the NHS both recognise that it is vital to ensure that people who have had a TIA receive the right treatment and care to help them to recover. I have not touched on the issue of psychological support, which was the subject of our debate last year, at which time there were encouraging signs. I will write to her about how those have been built upon over the past year and whether we have continued to make progress.

The picture is improving, but we recognise that there is more work to do. I congratulate the hon. Lady on keeping this issue very much at the forefront of Parliament’s attention. As ever, I congratulate the hon. Member for Strangford (Jim Shannon) for contributing to this debate on health in the way in which he always does. We are all keen to see the best possible services for people to ensure that TIA care is of the highest quality and that we minimise the number of people who go on to suffer a stroke.

Question put and agreed to.

Sitting adjourned.