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Health: Stroke Victims

Volume 692: debated on Monday 14 May 2007

asked Her Majesty’s Government how and when they will implement the proposals contained in the Department of Health report, Mending Hearts and Brains, in respect of stroke victims.

The noble Lord said: My Lords, at short notice and on a rather quiet day, I am very pleased that several noble colleagues are able to be present on this occasion.

A year ago, on 23 May 2006, I raised in the House the treatment of stroke victims in the light of the National Audit Office report, Reducing Brain Damage: Faster Access to Better Stroke Care, published the previous November. It was seen to be a thoroughly depressing report and, in July 2006, following its examination, the Public Accounts Committee shared that concern. Finally, late in October 2006, we had the Government’s response, which did not seriously dissent from the original National Audit Office report and broadly agreed with the recommendations of the PAC.

Given those three documents, I said in a general NHS debate in the House on 7 December that, although I conceded that there had been significant improvements in stroke treatment in the past five or six years, the tone of the Government’s response had been bland and lacked urgency. In replying, the then Minister, the noble Lord, Lord Warner, said in a reassuring way that many of my concerns were covered by Professor Roger Boyle’s report, Mending Hearts and Brains, published earlier that week. So I turn to Professor Boyle’s document in the hope that the Minister will clarify the Government’s purpose and intentions.

First, I should be grateful if the noble Lord, Lord Hunt, would explain the terms of reference for Professor Roger Boyle as the national director for heart disease and stroke and the role of Department of Health directors. Secondly, I should like to know the status of the document and to whom it was addressed. Thirdly, given the substance of the document, what has happened since it was published six months ago? Is it being implemented in, for example, a pilot? Fourthly, what is now the timetable for what Professor Boyle calls the clinical case for change, and how will the transition be handled if it gets as far as that? If I appear critical about some aspects of the document, I am agnostic about the conclusions. My focus is only on strokes and, primarily, on Professor Boyle’s document.

Once upon a time, civil servants advised Ministers in private and Ministers explained policy in public. There was a clear distinction. As a Member of Parliament, I would never criticise a civil servant by name; nor would a civil servant have been publicly exposed critically. What is the role of Department of Health directors? I assume that they are public servants, hired and fired by Ministers. Do they make and advocate policy only within the political view of the day, or do they have a degree of independence, encouraged occasionally by Ministers to fly a kite? What happens in a change of government? Do they stay, or do they go? I should like a formal definition of “directors”, perhaps from the Cabinet Office.

I should make it clear that judging by my contact with Professor Boyle through the All-Party Parliamentary Group on Stroke, he is an outstanding professional, deeply committed to solving problems. But Professor Boyle's named document is controversial and its style is puzzling. Mending Hearts and Brains and its twin, Emergency Access by Sir George Alberti, galloped into the public domain on 5 December last, the very day that the Prime Minister addressed primary care trusts. He said that the two documents were,

“a compelling and vivid account of change and why it is necessary”.

Mending Hearts and Brains is an odd document, apparently prepared in haste, with language from the industrial relations division of the department, and sometimes it reads as if aimed at 10 year-olds. It states:

“Pensioner Benny Parsons was enjoying a game of golf when the first chest pains hit him”.

His wife, Betty, “frantically” called 999. Later Benny said:

“I didn’t think I was going to make it”.

Thanks to all and sundry, Benny proudly says:

“I think that what these paramedics are doing is fantastic”.

Apart from Benny and Betty, there is Kevin, who was delighted that he had not been sent to a routine A&E department, and grandmother Mary, who was sent direct to Royal Bournemouth Hospital. “I am so lucky”, Mary said. I do not know what the target audience made of the document, but who is it meant to persuade?

Apart from the “Vision”, as it is boldly called, what is now happening? Much of the document is descriptive. There are diagrams for what is called “Hub and Spoke” care—I think they are an odd shape, given my days on a bicycle. On page 11 of the document, Professor Boyle says:

“I am currently working with a range of experts to draw up a new national strategy for stroke care”.

He continues that they will probably,

“recommend exploring models for ‘hub and spoke’ stroke treatment with round-the-clock, seven days a week access to a scanner and clot-busting drugs as well as making recommendations for improvements to the other parts of the patient journey”.

I am sceptical about yet another strategy for this and that but, six months later, what progress has been made, and when will we be told the outcome? Every strategy needs a clear objective, an assessment of resources and a staged timetable. I assume that much of the work has already been done, hence the document and the Prime Minister's speech. When is the strategy to be implemented, over what period, and who pays?

Let me briefly explain some of my anxieties. Sir George Alberti shares Professor Boyle's scriptwriter. There is nothing wrong with that because Emergency Access complements the picture. But Sir George's document starts with another vignette of what could happen if a walker in the Lake District had a heart attack on Scafell Pike. He would want, Sir George says, to be taken not to the A&E department of Carlisle hospital—by implication it lacked and would always lack the full necessary facilities—but to the state-of-the-art James Cook Hospital in Middlesbrough. He would want to be taken by road, or possibly by air. In practice, going to Middlesbrough by road is 80 to 100 miles cross-country and Carlisle is about 50 miles, partly on a motorway, so it is not axiomatic that, even when accompanied by the new super paramedics, Middlesbrough would be the natural place to go, especially in bad weather. As for a helicopter taking off from Scafell, perhaps in fog, that is not an attractive option. I do not want to score a point, but before reaching conclusions I would like to see the full picture, the practical reality of how stroke victims would be looked after in different parts of the country, urban and rural, in town centres and where the population is thin and scattered.

As for the transition, what will be done to improve existing stroke facilities and acute hospitals until the limited number of specialist centres of excellence for stroke are established? In the interim, will everything mark time, except for the new-model favoured few? Will there be no new stroke units, no more scanners, no more hospitals routinely scanning patients?

The latest figures from the 2006 national sentinel audit show that only 15 per cent of patients are admitted to a stroke unit on the same day and only 9 per cent of patients are scanned within three hours. That is simply not good enough.

Professor Boyle wrote:

“We’ve proved what redesigning services and treatment can do for heart disease. Now is the moment to capitalise on the upsurge of interest in stroke care amongst NHS professionals to do the same for stroke”.

However, redesigning services does not always work, and what matters most is the patients—the victims and potential victims of stroke. I would like to share Professor Boyle’s vision, but I need to be convinced by something rather more substantial than Mending Hearts and Brains.

My Lords, I congratulate the noble Lord, Lord Rodgers of Quarry Bank, for instituting this very necessary debate. At the present time, it is impossible to do too much to raise public awareness of cardiovascular disease. Heart disease, stroke and related conditions account for two-thirds of all premature deaths in England, as well as leaving patients with often terrible physical and communications disabilities.

The Department of Health’s recent publication, Mending Hearts and Brains, is an report by Professor Roger Boyle, the national clinical director for heart disease and stroke. In it, he refers to qualifying as a doctor in 1972 and to the limited treatments available to patients at that time. I well remember the case of my father, who first became ill with a stroke in 1969 that left him with a severely distorted face, poor co-ordination and soon, after a second stroke and a heart attack, unable to walk. As I remember it, and as Professor Boyle points out, the only treatments offered to heart attack victims were heroin to ease the pain and a defibrillator in case of cardiac arrest. As to stroke, no treatment was given to my father because stroke was regarded at that time as an inevitable consequence of old age, a more or less usual preliminary to death, although he was only 69 when the first stroke debilitated him. He suffered further strokes, but as he was basically strong, he withstood those onslaughts and suffered greatly. My father was a man of considerable intellect, an enthusiastic mathematician, a cabinet maker and a painter. After the first stroke, he was unable to do much with his hands and his painting became a kind of unintended impressionism. He lived until 1973, gradually growing more incapacitated until he was bedridden. It was a sad end for a man of his gifts, as it would be, indeed, for anyone.

Since then, things have changed for heart attack patients, and work is being done to repeat those strides forward for stroke, or as Professor Boyle calls it,

“the brain's equivalent of heart attack”.

Comparable advances for stroke have not yet been made. There are similar numbers of strokes and heart attacks, but awareness of this equally devastating condition has been slower to reach the public.

A major advance that we should all know about is the recognition of the paramount need for a healthier lifestyle. In my father’s day—he was born in 1900—people believed that a healthy diet consisted of hot meals that were home-cooked, even though they included large amounts of roasted food, fat, butter, home-baked sugar-laden cakes and pastry. These days, with our more enlightened attitude to diet, we might call these the junk foods of the early 20th century. Born and brought up in Plymouth—Cornish cream country—my father made his own clotted cream, using the whole milk from Jersey cows, as his mother had made it. For years he ate it every day. He never smoked, but the exercise he took was inadequate—short walks with an elderly dog. His blood pressure was sky-high.

We now know that over 40 per cent of all strokes could be prevented if people kept their blood pressure under control, used statins to lower high cholesterol, took regular exercise even into old age and restricted themselves to a low-fat diet of fruit and vegetables, fish and whole grains and pulses. That giving up smoking is the first rule of health should by now go without saying and the soon-to-be-in-force ban must be a major contributor to better health in the population.

Stroke needs to be treated as a medical emergency. At present, according to the national sentinel stroke audit published a few days ago, only 9 per cent of patients were scanned within three hours of stroke, and only 15 per cent were admitted to a stroke unit on the same day and only 12 per cent within four hours of arrival at hospital. Lack of early treatment is partly due to ignorance. Few people know what to look for and even if they suspect stroke, they have no idea that early treatment is essential.

By the time one reaches my age, one inevitably knows contemporaries who have recently suffered stroke. One friend of mine, a man, in spite of collapsing, was not recognised as a victim of stroke for several days, because his wife was unaware of a simple formula, first mentioned in your Lordships’ House, as far as I am aware, by the noble Baroness, Lady Gardner of Parkes, in a previous debate on this subject. She did this House and the public a great service in explaining this. She repeated the face-arms-speech test or FAST. This simple expedient requires anyone witnessing what may be a stroke to call 999, then to check if the person can smile. Has his mouth or eye dropped, as my father’s did? Can he raise both arms? Can he speak clearly and understand what you say, as my father could not? My friend is improving now, but progress is slow and might have been much faster if he had been taken immediately to a hospital where, ideally, he could have been admitted to a stroke unit and could have received specialist care from a multidisciplinary team.

A brain scan is the only way of identifying whether a patient is experiencing a haemorrhagic stroke caused by bleeding or an ischaemic stroke caused by clotting, so that appropriate action may be taken. Clot-busting drugs can reduce the chance of death and disablement in eligible patients, but they need to be given within three hours and are dangerous for patients with haemorrhagic stroke if bleeding has already taken place. More bleeding may have disastrous consequences. Therefore, rapid scanning is essential to ensure that patients receive the correct treatment.

Too few people arrange regular appointments with their doctor for blood pressure monitoring. It is worth buying oneself a blood pressure monitor and being taught to use it correctly, as a surprising number of people have no idea whether their blood pressure is low or high. One hears often of people who, on the grounds that they believe themselves to enjoy exceptionally good health, never go near a doctor and never have their blood pressure checked until they suffer an ischaemic stroke. These days, hardly a month goes by without me hearing of another victim whose brain damage might have been avoided.

I ask my noble friend whether he agrees that, in the light of Professor Boyle’s report, we need a campaign to raise public awareness of the importance of reacting to suspected stroke with speed. Would he agree, too, that the FAST technique should also be explained to everyone likely to be in the presence of a suspected sufferer—and that of course means all of us?

I am a daily reader of newspapers, yet I cannot recall a feature article published recently in any so-called quality newspaper dealing with stroke, its prevention and treatment. I may have missed such a feature, but I am very conscious of the dangers of stroke and, therefore, I am particularly sensitive to information about it and comment on it. Truly it is the forgotten disease, unglamorous and mostly afflicting the ageing, yet cardiovascular disease across the world is killing more people than AIDS, TB and malaria combined, and in England more than all the cancers put together.

My Lords, I am speaking tonight simply because the noble Lord, Lord Rodgers, sent me a note asking me whether I would speak. I did not have time to reply to the note and I thought it was better just to arrive, which is what I have done. I was delighted in listening to the noble Lord’s speech. If ever anyone has come up with a series of taxing questions for the Minister to reply to, it is the noble Lord in his speech. I had written “sceptical” on my notes just before he said that about himself, so obviously my assessment agreed with his own.

This is an interesting document. The stories it contains are part of the technique of bringing things home to people in a realistic way. Many people will be reached by those tales who would not know anything about the rest of the document at all. So they may have done a bit of good and he should think about that.

I recently had here as my guest one evening for another medical debate the president of one of the royal colleges. She was out with her husband, walking in Cumbria or somewhere like that, when he had a completely unexpected heart attack, and she saved his life then and there. We cannot all be fortunate enough to have the right person with us if we are in that situation, but it was quite extraordinary that that had happened. She was able to tell me that story when she came into one of our other debates.

The noble Baroness, Lady Rendell, of course, has repeated my bit about FAST, which I would have repeated but it bears repetition because one of the problems is that people have no idea that they are having a stroke. The article by Professor Boyle concerns both heart and stroke situations and he said that the only treatments available for hearts in 1972 were very limited. I served for 17 years on the National Heart Board and I recall a staff member retiring after 40 years at the hospital telling us that when she started the only treatment for heart conditions was bed rest. So she had been there in an era even before Professor Boyle in 1972 and you can see how there was a great element of progress from that time to 1972, and there has been a much greater element of progress here.

I have read Mending Hearts and Brains and I respect the views put forward by Professor Boyle. He has done much to help people with heart conditions and is admired for this. He says:

“I am now working to repeat those strides forward for stroke”.

I hope that he succeeds.

My first direct experience of a stroke was when my husband was affected in 2003. I telephoned him from the House that afternoon and I realised something was not right when he told me he was “not himself”. He really had no idea what was wrong. He was an experienced dentist and used to assessing patients’ conditions, but he failed completely to recognise his own.

I went home immediately and insisted that we go at once to accident and emergency. He was reluctant and did not want to waste people’s time. I insisted and we went. When Professor Boyle makes the point that accident and emergency adds a delay that can mean it is too late, this is exactly right. Kevin was not moved to the stroke ward until some six hours after arrival in A&E, which was about three or four hours after the cerebral thrombosis. The first scan was done within 24 hours but should really have been done as soon as he reached the hospital, and, of course, he should have presented earlier for treatment.

But teaching people in general how to recognise a stroke is one of the major difficulties. Speed is of the essence in treatment but the first step is to get the patient to realise that they are in need of treatment. If the patient does not start off by calling for the emergency service, then the chart setting out whether you should go to the treatment centre or to A&E is a waste of time if the patient is sitting at home and thinking “I will just see how I get on”.

I remember from my dental practice days—I might have been on the heart ward when I heard this—that patients who had heart attacks frequently thought it was nothing but a bit of indigestion, and would wait and see how they felt in an hour or two. Research was done to show that those patients who sat at home did not do well, and sometimes died before they got any treatment at all. People had then become aware of and alert to the need to call for treatment.

I repeat the reference to the FAST system, although the noble Baroness, Lady Rendell, set it out so well that I do not need to go through it in detail. It would make a big difference if we could get the message of the facial, arm and speech test through to people. Having decided that they have probably had a stroke, they must be trained to call for help within a matter of hours. As has been said, it should be within three hours. This differentiation between a bleed and clot is then an essential first step in treatment. They are exact opposites. If you are treating for one and the person has the other, that person is as good as dead. You need to know, and the whole purpose of the scan is to know what you are treating.

When Kevin had his stroke, he made a fairly good recovery, although he was much worse for 48 hours after the stroke. He recovered as much due to willpower and good care in the specialist part of the Chelsea and Westminster Hospital. He was looked after very well, but will power is an important element in recovery from stroke. I well remember when the Duke of Norfolk—Miles—had a bad stroke here, and just by sheer will power recovered his speech. He lived a good many more years—I think another seven or so. A major element is the patient’s own wish to recover.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I thank the noble Earl, Lord Howe, for his acknowledgement of the improvements that have taken place. There have been improvements: the older people’s national service framework, starting in 2001, devoted a considerable amount of that NSF to stroke; it set out a range of measures and there is little doubt that it has had a major impact. It resulted in nearly every general hospital which caters for people with strokes having a dedicated stroke unit. A recent audit by the Royal College of Physicians shows that the quality of stroke units is improving and as a result of that and of other measures that have been taken, the rate of stroke mortality is falling. For people under 65, the three-year average death rate from stroke has fallen by 23 per cent from 1993-95 to 2002-04; for people aged 65 to 75 the death rate has dropped by 30 per cent over the same period.

There is clearly no room for complacency. We have to do more. This is where the various reports that noble Lords have quoted come into their own. We need to reflect first of all on the importance of the NAO report published in 2005, which gave a very helpful series of measures that needed to be taken. That was followed by the ASSET report produced by the department, designed to inform commissioners of the kinds of services they ought to commission. I will come back to the question raised by the noble Baroness, Lady Barker, and the noble Earl, Lord Howe, about how we ensure that the service does what we want it to do. Having a commissioning model and effective commissioning will be crucial to making sure that we see a consistency of approach throughout the country. Different messages need to be got out there. It is just as important that commissioners understand what they ought to be commissioning. Professor Boyle’s report was aimed at informing clinicians of the kind of developments in service that we want to see.

The noble Lord, Lord Rodgers, asked me about the role of national clinical directors, or tsars, as we sometimes call them. I had a particular role to play when I was last in the department; I recruited the first director Mike Richards to be the cancer tsar. I remember going to see him in his office in St Thomas’s. We measured each other out and, as they say, the rest is history. I pay tribute to the tsars as a whole and to Professor Boyle in particular for the work they do. In answer to the noble Lord, they have three important remits: one is to work with stakeholders and improve the delivery of care in the service; secondly, to provide expert in-house advice to ensure developing policy takes full account of clinical issues; and thirdly, helping to spearhead change by engaging with health and social care professionals and providing visible leadership. That is their formal remit.

In my experience as a Minister, they have been invaluable in having people with professional recognition because they have all provided excellent services themselves in the health service. They come in to the department, advise Ministers and officials, work with the profession themselves and have added value to the improvement of services that they want to see. They are public servants and are employed by contract so, in the unlikely event of a change of Government, any future Government would honour those contracts. They work within the parameters of the departments but, from the statements they have made from time to time, they also exercise a degree of independence. My experience has been that seeing them walk the corridors, knowing that this expertise is on hand, has enhanced the ability of the department to get a grip on some of these very pressing issues.

The noble Lord read out some of the portraits given in the report Mending Hearts and Brains, but I thought that the noble Baroness, Lady Gardner, was right: there is a need to communicate. Yes, clinicians are very clever people and no doubt can read learned disquisitions on these matters, but, given the number of clinicians, there is also a clear case for communicating these things in an easy way, to get over to them the message that we want to give so that they fully understand the need for change. It is very important that, in getting stroke recognised as a major priority, we have clinical engagement not just from the stroke specialist, but from all clinicians who have a part to play in the provision of services and the development of policies.

As the noble Baroness, Lady Barker, suggested, the key message is that we have to ensure that the symptoms of a stroke are recognised and that the individual is got into A&E services fast. I accept what the noble Earl, Lord Howe, said. We need stroke specialists on hand 24 hours a day, seven days a week; a nine to five, Monday to Friday service will not do. That applies as much to those people who provide diagnostic tests as it does to consultant staff.

We know that we cannot deliver that in every hospital in the country. The noble Baroness, Lady Masham, suggested that there was a compromise here. I guess that, in essence, that is what hub and spoke is all about. The idea is to move to a network model in which commissioners work together to make sure that a patient is given access to the appropriate level of care and that, where highly specialist services are needed, they are provided. Also, once people are in recovery, they must be able to return to their local hospital for rehabilitation in a stroke unit. I very much accept the point raised by the noble Baroness, Lady Barker, about the importance of liaising with care homes where rehabilitation is needed for people who are resident in those establishments.

My noble friend Lady Rendell asked where we are with the national strategy. It is being prepared; what I might call informal consultation is taking place with stakeholders. We hope to publish it in the near future, after which there will be more formal consultation. The aim is to reach conclusions in the autumn. I understand the frustration of noble Lords who wish the strategy to be published, as they want to see the costs and resources. However, I think it important that we prepare the ground carefully. That is what the commissioning document was about and that is why Professor Boyle published his document, which was aimed at engaging clinicians.

We see the strategy as the final and in many ways most important part of taking forward our work, ensuring that priority is given to stroke services and that we can count on the NHS to deliver the service as effectively and consistently as possible. I understand the issue of implementation. I take the important point made by the noble Earl, Lord Howe, about the tariff and I will ensure that it is considered by the officials responsible. The role of the strategic health authorities will be very important in monitoring what is happening. We want commissioners for primary care trusts and GPs to take to heart the messages of the strategy. The role of the Government remains to ensure that that comes together in a coherent whole.

I was asked about the actual costs. I am not in a position to anticipate the work that is in the strategy, but the noble Baroness, Lady Barker, was right to identify the fact that the NAO report said that, essentially, we can make more use of our current resources by a better reorganisation of services. That was a point well made.

The noble Lord, Lord Rodgers, expressed doubt about the hub and spoke model, but there seems to be a strong clinical consensus that it is the way to go. I do not see a conflict between that model and the role of hospitals that currently have specialist stroke services. They will continue to offer specialist stroke services as now. The strategy and Professor Boyle’s report are about some of those hospitals having to offer a highly specialist service for those who have had a recent onset of stroke. We see the two concepts running together. That is really what the hub and spoke model is about. There will continue to be a valuable role for the specialist stroke services currently available in our hospitals. I accept that we have to avoid confusion or conflict.

I have used up my time. A great deal of progress has been made on PACS. I am happy to write to the noble Baroness, Lady Barker, about that. There were reports in today’s newspaper about vaccines reducing blood pressure. We will have to see how it goes in trials, then NICE will be able to assess it, or the approach by which we assess vaccines will be followed. I am not aware of evidence on the effect of mangos, but fruit and vegetables are a very important part of a preventive approach alongside exercise and the other things that noble Lords have mentioned. Obviously we are looking at scanners as a possibility.

I thank all noble Lords for their contributions. This has been a good debate and I will ensure that officials read Hansard because some very good points have been raised. I assure the noble Lord, Lord Rodgers, that national clinical directors have a valuable role. His report was directly aimed at front-line clinicians. It is part of a coherent whole that includes the NAO report, the commission report, Professor Boyle’s report and now the strategy. We are determined to build on the improvements that we have seen so that stroke is seen as a priority. We are committed to making that happen.