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Health: Stroke Treatment

Volume 719: debated on Wednesday 30 June 2010

Question for Short Debate

Tabled by

To ask Her Majesty’s Government what steps they intend to take to ensure the efficiency and effectiveness of the treatment of stroke victims, in the light of the report of the Comptroller and Auditor-General, Progress in Improving Stroke Care.

My Lords, yesterday, I was one of 66 speakers in a debate that extended over eight hours. Today, we have much fewer speakers, but this debate may do more to the health and happiness of our citizens than yesterday’s event. On 28 May 2006, I introduced a debate on stroke victims. My text was the Comptroller and Auditor General’s report, Reducing Brain Damage: Faster Access to Better Stroke Care, which had been published the previous November. On this occasion, I turn to the successor report, Progress in Improving Stroke Care, which was published this February.

Reducing Brain Damage was damning. In the debate, I noted some limited improvements in stroke services made by the Department of Health and paid tribute, as I do again, to the Stroke Association for its research, welfare and campaigning. But the report was deeply disturbing. The House of Commons Public Accounts Committee called it “scathing” and “shocking”, adding that the neglect of stroke had led to,

“shameful lost opportunities and lost lives”.

In her reply, the noble Baroness, Lady Royall, accepted the many shortcomings in the previous treatment of stroke and said that all the recommendations would be taken forward. She said that there had already been progress. The Royal Free Hospital, mentioned by the noble Lord, Lord Clinton-Davis, and me, which had been one of the worst-performing stroke services in the country, was now one of the best. There would be a comprehensive response to the report through a new stroke strategy.

I welcomed the noble Baroness’s promise, but I was sceptical about yet another “strategy” for this and for that, which is often a plan without a timescale and is illustrated by a sunshine booklet. I did not doubt her personal good intentions, but it was on record that health officials and Ministers had previously neglected interest, perception and energy in dealing with more than 100,000 strokes a year and in providing specialist stroke services.

When the department's document Mending Hearts and Brains was published at the end of that year I was far from convinced that this was a major step forward. It included “hub and spoke” care, which for example would take emergency patients from the Lake District to Middlesbrough rather than Carlisle for an urgent brain scan.

In a further debate on 7 December 2006, I said that in answering questions about stroke, the Government’s response had been “bland and lacked urgency”, while on another occasion, 14 May 2007, I scrutinised more fully Mending Hearts and Brains, which I found to be an odd document that was easy to ridicule. But the national stroke strategy, which was eventually published late in 2007, was right in principle. Much has since been done to implement important steps. I have seen well-attended “stroke weeks” in hospitals and I was impressed by a consultation document on major trauma and stroke services for London arising from the health initiative of the noble Lord, Lord Darzi, when he was Minister. I also welcome the Stroke Research Network, which is on track.

So, looking ahead, I do not diminish the substantial improvements made during the last six or seven years from what was once a very low level of ministerial and departmental interest and involvement. In parenthesis, however, I would be concerned, following the Queen’s Speech, if the voice of patients and the role of some doctors blunted the leadership of necessary changes. It would be damaging if a decision to keep open all the existing inadequate stroke hospital units rather than use fewer fully equipped specialist centres was the result of, say, a local referendum. I hope that that will not happen and I would be grateful if my noble friend Lord Howe would reassure me.

Some of what I have said so far is essential background to the new National Audit Office report. In describing its methodology, it refers to existing documents, patient experience and a survey of the stroke networks. The authors re-ran the Royal College of Physicians’ latest national sentinel stroke audit, which states that a quarter of stroke patients are not given the best treatment as few had been admitted to an acute stroke unit within four hours, and few had been given a brain scan within three hours. Clearly, emergency stroke care varies considerably around the country. The report reminds us that stroke is one of the top three causes of death and the biggest cause of physical disability in England. It costs the National Health Service £3 billion a year. The earlier report concluded that, historically, stroke had been a low priority in the NHS, but it goes on to say that that there has now been a major change in the Department of Health’s approach, and it approves the national stroke strategy and its progress.

I do not diminish any of that, but I want to draw to the Minister’s attention some current concerns, as I am alarmed at the removal of the ring-fenced conditions to the £15 million for the year 2010-11 for the revenue grant. Why has that been done? Beyond that, I assume that the intention remains to continue with and complete the 10-year plan, and unless the Minister says otherwise, that Professor Roger Boyle will continue as the national director for heart disease and stroke.

All relevant hospitals in England now have a stroke unit, but it appears that about 40 per cent of patients are not given a brain scan within 24 hours, and that weekend and evening access is significantly more limited. That means—this is my personal footnote, but a serious one—that if you want to have a stroke, choose it during the working week, otherwise you may not survive. If you do survive, only 24 per cent of patients suffering from atrial fibrillation who are discharged from hospital are offered treatment with the anti-coagulation drug Warfarin, which is highly cost-effective. Its full use would prevent around 4,500 strokes a year and 3,000 deaths.

The audit report states that improvements in acute care are not matched by progress in delivering more effective post-hospital support for stroke survivors because there are barriers to joint working between the health service, social care and other services. In figure 15 of the report, I notice that in longer-term care, fewer than half of the patients in the survey describe favourably ongoing speech therapy as “good” or “very good”. For psychological support, only a quarter describe it as “good” or “very good”.

However, overall the report shows that the current policy is saving lives and saving money. The national strategy for stroke is starting to improve levels of service and, in technically defined terms, there has been a significant increase in “quality-adjusted life years”. As Professor Boyle said, there are no simple quick fixes. However, I repeat, the 10-year plan is crucial. I hope that the Secretary of State, Andrew Lansley, who was a long-standing and effective chair of the All-Party Group on Stroke, and my noble friend will not dissent.

Meanwhile, I strongly recommend an early meeting between Ministers and the Stroke Association to discuss and explore current and rising anxieties. The NAO was able this year to call its report Progress in Improving Stroke Care. I hope that in four years time it will not call the next report Slipping Back.

My Lords, I thank the noble Lord, Lord Rodgers, for securing the debate and I heartily endorse what he said about its importance vis-à-vis yesterday’s debate, notwithstanding the difference in attendance. I thank him, too, for his excellent exposition about the support services available to stroke sufferers and his concern about the services available to support them and their families, and especially the sustainability of such services.

I am as concerned as he is about these issues, and especially about the negative effects that some of these developments may have on families and carers. I have spoken many times in this House about carer issues and the House—and, indeed, the Minister—will be familiar with most of them. So far as stroke is concerned, carers have two difficulties which make their plight extremely serious. The first is the sudden onset of most strokes, with very little warning or time to prepare. This means that carers are even worse off than many others because they are trying to get information about help and support at a time when they and the sufferer are in most distress and most worried and are therefore less able to find the time or the attention to get in touch with helping agencies. Carers always find a difficulty with accessing information and in these circumstances it is even more of a problem.

The second major problem for carers is the length of time the caring process goes on. Unless you die during the stroke itself you are probably going to live quite a long time, sometimes with a great degree of disability and sometimes with your ability to communicate severely impaired. This means that all the problems of shortage of finance, the threat to their own health, both physical and mental, and the sheer emotional stress of caring for someone who is disabled, and sometimes suffering a change of personality into the bargain, are not only acute but chronic.

As the Public Accounts Committee report reminds us,

“it is in the months and years after discharge that … their families and carers will experience the full impact of the stroke”.

Add to that the fact that if the carer is a spouse, it is likely that they themselves are rather elderly and frail. We have to remember that as well. So support services are vital and frequently make the difference between the carer being able to continue and being unable to, however great their desire to do so.

I am the first to acknowledge that much progress has been made not only with the treatment of strokes, as the noble Lord has reminded us, but also with the support of the carers and families. The fact that there is a national strategy in position for carers as well as stroke sufferers and their families is only one aspect of the progress made. These are cross-party issues that are of concern to the whole of society. While I pay tribute to the previous Administration for the fact that carers can never any longer be ignored, as was once the case, I acknowledge too the commitment of other political parties and of individuals such as the Minister himself.

I want my intervention today to focus on two particular issues because of my experience with carers when funding was not ring-fenced and my experience of the community, charitable and voluntary sector in the provision of services. I remind your Lordships that as part of the national carers strategy £150 million was allocated to primary care trusts to provide respite care for carers. Everyone rejoiced; this was a way of getting health professionals—especially GPs, who are so important to carers—to take their responsibilities seriously and to have money specifically allocated to them to help carers. However, the money was not ring-fenced. As a consequence, only 10 per cent of that money was ever spent on respite for carers. The rest disappeared into the black holes of PCT deficits and budget problems. This is what happens if you do not ring-fence money, and it will happen to the money for stroke as well—of that there is no doubt.

In the light of that, I wonder what assurances the Minister can give that stroke support services developed by local authorities in response to the national stroke strategy will be sustained this year and in the future, now that that ring-fencing has been removed. Does he feel that the ending of ring-fencing for stroke grants sends a rather unfortunate message to local authorities—that this kind of support is no longer a top priority?

In view of that, do we need to worry about other forms of support that are made available to those in need? For example, is the £200 million given to local authorities under the local authority settlement to support carers also under threat? I would be pleased to hear the Minister’s reaction to that.

As with carers, much progress has been made with support services for stroke sufferers. Much of the improvement and innovation in these services has been spearheaded by the voluntary and community sector, such as the Stroke Association, at both local and national level. Many of these services have been funded under contract from local authorities with the ring-fenced allocation. Noble Lords will know that local authorities are under considerable pressure at present, and this is likely to get worse in the next year. If the money is not ring-fenced, the likely outcome is that services will wither on the vine. The services that you get from the voluntary and community sector are extremely good value but they are not cost-free, and unless they have that kind of support they will not go on being provided.

Let us not forget that carers often require only a very small amount of support, provided that it is given at the right time. Two hours’ respite given to a carer in a week—that is often all that they ask for, in spite of what people fear they are going to demand—will often result in the carer giving not an extra week or month but extra years of support in return. The return on a comparatively small investment is very great indeed. I have often reminded the House that it makes good economic as well as moral sense to support the families who provide the majority of our health and social care willingly and over long periods. At a time of economic stringency it is even more important to remember that, and I hope that the coalition Government will do so.

My Lords, I congratulate my noble friend Lord Rodgers on securing this debate and the National Audit Office on its excellent report showing that much needed progress has been made in improving stroke care. It is a good-news story. I congratulate also the Stroke Association on its fantastic work, which has to a large extent pushed us all into taking this issue more seriously.

Having read the report in detail, however, I have to say that it is not wholly a good-news story. One section, “Stroke patients in care homes”, set alarm bells ringing when I read it. The report argues:

“There is no single source of information on the proportion of care home residents who have had a stroke. The evidence we collected for our 2005 report suggested that at least a quarter of residents have had a stroke, although local data collected for an audit of care homes in Somerset gave a figure of 45 per cent ... About 11 per cent of stroke patients are newly admitted to care or residential homes after their stroke … The Royal College of Physicians’ guidelines recommend that nursing and care home staff should be familiar with the common clinical features of stroke and should know how to manage them; and the Strategy states that Commissioners should consider providing training on stroke to care home staff. However, there is no requirement for care home staff to be trained in the communication, mobility and other needs of stroke patients, and our interviews and case study visits revealed a lack of recognition among some care home staff that a suspected stroke or TIA should be treated as a medical emergency”.

One should add to that what is in section 3.17 of the report:

“The best way of improving the value for money of stroke care is by preventing strokes from occurring. Reducing stroke incidence requires managing the risk factors common to all vascular disease … including high blood pressure and cholesterol, smoking, unhealthy diet and lack of exercise. In March 2009 the Department announced a unified approach to the prevention of vascular disease through the introduction of the NHS Health Checks where everyone aged between 40 and 74 will be risk-assessed and, where appropriate, given information, access to services and treatment. Full rollout of the programme is expected by 2012-13, subject to the next spending review”.

But why stop at 74, particularly if, as we suspect, retirement ages are to go up still further in years to come and people will choose, for both financial and lifestyle reasons, to carry on working and having a full and independent life? Is not stopping at 74 discriminatory?

Indeed, stroke services provide one of the clearest examples of discrimination against older people. Access to specialised stroke services is considerably worse for older people than for younger. A piece of work published by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians back in 2007 showed clear evidence of an age effect on the delivery of stroke care in England, Wales and Northern Ireland, with older patients being less likely to receive care in line with current clinical guidelines. Analysing data collected for the Royal College of Physicians’ stroke audit, it found that older patients were less likely than younger patients to be treated in a stroke unit, which is very serious given that we know that admission to, and care in, a stroke unit is the single most beneficial intervention that can be provided after stroke. Only 39 per cent of patients over 85 were treated in a stroke unit, compared with 48 per cent of those under 65. Older patients were also less likely to have a brain scan within 24 hours of stroke, with only 51 per cent of those aged over 85 having an early scan, compared with 71 per cent of those under 65.

The report’s authors also say that the failure to include sufficient numbers of old patients in trials—that is a much bigger problem than in stroke care alone—has led to an evidence gap in effective interventions for those patients. This is sometimes used as a justification for limiting treatment. For example, trials of thrombolysis for stroke have included few patients over 80 years of age and the drug is therefore not appropriately licensed in Europe for patients over 80. That obviously means that the number of older people who may benefit from such treatment is limited, which is really quite serious.

Ageism was identified also by discharge from hospital: individualised care planning goals for older patients were less likely to include reference to areas of higher-level functioning, such as leisure pursuits—older people might want some leisure—driving and return to work. Older patients were also less likely to have received dietary advice to reduce fat intake and to have discussed other risk factors such as smoking and alcohol consumption. The report’s authors recommend better education of healthcare professionals, development of research programmes that test interventions in sufficiently large numbers of older people to provide clear evidence for treatment, and continuing audit that can identify where ageism persists.

There is more. Research conducted at Mayday Hospital in Croydon and published in the Postgraduate Medical Journal, and a large piece in the Daily Mail on the subject, showed serious discrimination yet again. The study assessed the treatment given to 379 patients at a rapid access clinic for suspected stroke or mini-stroke between 2004 and 2006. Although all patients experienced substantial delays, younger patients were scanned more quickly and were five times more likely than over-75s to be given a brain scan to check for bleeds. Only one in 20 over-75s was given an MRI scan, compared with one in four of those under that age. The younger patients were also more likely to be given dietary and weight loss advice, despite all the evidence showing that both groups were likely to benefit from such information. Dr Karen Lee, who led the research, said:

“A change in the attitude of healthcare professionals is needed to root out ageism”.

The Department of Health said that it was,

“determined to ensure high quality care for all, regardless of age”.

The question that this raises is important. The NAO report shows some promising progress in stroke care, which is much needed after we were lagging behind much of the world. However, if persistent negative attitudes to older people are not rooted out in healthcare, we will see discrimination against older people who have strokes—and, let us face it, they are more likely to have strokes than younger people—continue for years to come.

The former older people’s tsar, Professor Ian Philp, published his second report, A New Ambition for Old Age, back in 2006. In it, he proposed new targets and protocols for emergency responses to crises caused by falls, delirium, stroke and transient ischaemic attacks. One example is that everyone having a stroke should be seen at a specialist neurovascular clinic within one week, while the current position is that about half to three-quarters are seen by two weeks. Other scholars have been writing in the BMJ, such as Jackie Morris, who called for appropriate environments for care of older people and said:

“Although intermediate care in the NHS is expanding, it is not yet keeping pace with the rapid and continuing closure of rehabilitation beds and offers only patchy input from specialists”.

Despite general improvement, there is a real issue about stroke care for older people. The Government now have a golden opportunity, for there are to be serious evaluations of effectiveness of care and stringent examinations of the budget. If, as it seems on the face of it, not providing better stroke care to older people is in fact costly, given that they will then need greater care from social and health services in the longer term and will fail to get back to independent life, is there not a cast-iron argument for sorting this out now? Does not that fit neatly with the commitments to end age discrimination in principle, because it is wrong, and particularly in health services where evidence of a certain amount of institutional ageism appears to be commonplace?

Back in 1999, Alison Tonks, then deputy editor of the BMJ, talked about partnerships with older people to enhance core teaching and about giving older service users the power to shape the curriculum of professionals. That seems an extraordinarily good idea. In some medical schools in the United States, young students, before they begin their course, spend a month with a family where there is someone with a long-term condition, often someone who has had a severe stroke. We could learn from that and teach our students differently about what it is like to live with a disabling condition and what inputs might have improved things early on.

Will my noble friend the Minister tell this House what he thinks can be done in the short term to improve stroke care for older people in this country and how he believes ageism within health services can be dealt with in the longer term? I very much hope that he will reassure me and this House that changing attitudes in health services towards older people—stroke would be a prime example for a pilot—is high on the Government’s list of goals to be achieved.

My Lords, I start by thanking the noble Lord, Lord Rodgers, for bringing forward this debate. It is almost exactly a year since we had a debate in your Lordships’ House in which the noble Lord mentioned stroke and, indeed, his questions were answered by me. I do not expect that the noble Lord imagined that he would be addressing his questions to a Minister who, one year on, is now his noble friend. I hope that the noble Lord, Lord Rodgers, is not going to let up on his consistent holding of the Government to account for what is going to happen to stroke services and the stroke strategy.

It is not often that I do this, but I intend now to quote myself from 25 June last year. In that debate, I said:

“The noble Lord, Lord Rodgers, raised the issue of stroke, as did several other noble Lords including the noble Lord, Lord Walton of Detchant”—

whose debate it indeed was. I continued:

“He was right to point out that we have a new national framework for stroke and we are endeavouring to give it the right kind of emphasis and prioritisation that stroke requires. I can confirm that the 10-year plan is on track, that the stroke strategy acknowledges that the networks are of great benefit and that all the stroke services in England now fall within one of the 28 networks. The work of the stroke improvement programme, including the networks, will be evaluated over the next year, after which future work plans will be considered”.—[Official Report, 25/6/09; col. 1750.]

There is no question that the Labour Government took the issue of stroke very seriously, for all the reasons that have been eloquently described by noble Lords today. I think particularly of the very fair summary of the history of this issue which the noble Lord, Lord Rodgers, gave.

I suppose, then, that my first questions to the Minister are: has the review been finished, what is its outcome and what are the government plans for taking forward the strategy? Indeed, will the coalition Government be following the stroke strategy, or will they be junking it to start all over again in a year’s time? Personally, I would counsel against such a course of action, given the widespread support that the strategy has across a whole range of medical and voluntary organisations and, indeed, the involvement of many of those organisations in the creation and continued monitoring of the strategy.

However, there are some worrying signs, to which other noble Lords have already referred. On the recent decision by the coalition Government, on 10 June, to remove ring-fencing conditions from the £15 million 2010-11 revenue grant to local authorities for implementing the stroke strategy, I can only quote the excellent briefing, for which I am very grateful, from the Stroke Association. It says that in its opinion this,

“makes the risk of cuts to current support service levels even more pronounced and in need of urgent attention”.

I agree with it and would really like to know how the strategy will now be delivered at local level.

The NAO and the PAC, which noble Lords have also mentioned, recognise the risk posed to improvements in the longer-term stroke strategy services by the end of additional funding for the implementation of the national stroke strategy after 2010-11 and the current financial pressures facing the NHS and local authorities. Under these circumstances, we need a commitment from the department that these improvements will continue in the long run. Indeed, as has already been mentioned, the PAC makes a number of key recommendations on how the department can sustain and improve further the standards of service for all stroke patients across the whole care pathway, and asks for reports on progress in areas within 12 months. I agree with that and would like to hear a commitment from the Minister to that course of action. Indeed, when we were in government we regarded the work of the PAC as extremely important in helping us to deliver the stroke strategy.

However, I am alarmed at the current risks to services. The NAO report shows that 76 per cent of local authorities surveyed have used the Department of Health’s ring-fenced funding to develop services with the Stroke Association. As mentioned by my noble friend Lady Pitkeathley, the number of contracts with local authorities to provide information and support has increased from 164 in 2005 to 268 in 2009. It seems that, at current levels, one in every two patients is able to access them. Around half the local authorities have also used the funding to establish their own dedicated stroke-related jobs, such as stroke care co-ordinators, stroke-specific social workers and occupational therapists, and a quarter have used some of the grant to fund breaks for carers.

We know that there is also still an unmet need. It would seem that, at the moment, an estimated 50 to 60 services around the country could be under threat of not having their contracts renewed. This is a very serious issue. Some local authorities have already put recruitment on hold for vacant positions. I am concerned that the message being sent from the department is that this is no longer a priority for local authorities. How will the coalition Government re-establish the priority that we gave stroke, and how will they re-establish those networks that have been so important in improving the treatment of stroke across the country and for the future?

I have several other questions which the Government need to address. They relate to the issue of funding at local level. Do the Government have plans to monitor and evaluate the use of the ring-fenced funds to ensure that they continue to be a priority? Does the Minister feel that the premature ending of ring-fencing sends the message that I have already outlined—that this is no longer a priority? What on earth will they do about that? The Stroke Association and the voluntary sector have a right to be very concerned.

The Minister would expect me also to refer to FAST. The previous Government invested £10 million between 2008 and 2010 in awareness-raising activity around strokes, centred on the highly visible Act FAST campaign, which I demonstrated to your Lordships’ House twice last year. The PAC report describes this campaign as “excellent” and concluded that it,

“had improved public awareness of stroke and the responsiveness of ambulance and hospital staff”.

Given that the mantra we keep hearing is that the Government want an evidence base for the decisions that they take, I hope they will take on board the NAO’s public survey, which gives the evidence that this campaign has worked. Will the Minister confirm that the funding allocated for the continuation of the excellent Act FAST campaign will be spent? What plans does the department have to continue funding the excellent campaign to improve awareness of stroke over the medium to long term?

I am proud to have been part of the Government who transformed the treatment of stroke in this country. We made the National Stroke Strategy a priority and gave additional funding to strategic health authorities for its implementation. We ensured strong leadership at a national level with a national clinical director for stroke and the new NHS Stroke Improvement Programme. Progress was aided by the inclusion of implementation of the National Stroke Strategy of the NHS operating framework as a tier-1 “must do” national requirement. I am pleased that the tier-1 status continues to be there in the revised operating framework that this Government have just published. I hope that that is not just for this year, but for the duration of the strategy. Is that the case?

We know that the best way to reduce the human and economic cost of stroke is through prevention. I put it on record that I remain to be convinced that the coalition Government are taking seriously their commitment to issues of public health. The prevention of stroke is key to the whole of the Government’s public health drive. Smoking cessation, obesity campaigns and swimming are all linked to how we prevent stroke in the future. How will the Government’s work to prevent stroke happen in the current financial climate and given the freeze in advertising? Having a policy which just says that we are going to prevent stroke by doing the following things, but are cutting the budget that allows us to communicate that, makes it not at all a useful commitment. It is meaningless. It is important that we hear what the Minister has to say on that.

Finally, what does the moratorium on reconfigurations mean for stroke services? Following consultation, Healthcare for London planned to introduce eight hyper-acute stroke units, all of which it hoped would be up and running by April 2011. However, I have to ask, what is the future for these centres? The Secretary of State has said:

“I am fulfilling the pledge I made before the election to put an end to the imposition of top-down reconfigurations in the NHS … As part of this, I want NHS London to lead the way in working with GP commissioners in their reconfiguration of NHS services. A top-down, one-size fits all approach will be replaced with the devolution of responsibility”.

We have heard this many times before. However, this has potentially extremely serious implications for stroke services in London, which are beginning to deliver an absolutely excellent first-rate service which is saving the lives of Londoners. As someone who lives in London during the working week, I would like to know what would happen to me now if I had a stroke. Would I end up at one of these centres or have they now been reconfigured out of existence? I suggest that we probably need to keep a very vigilant eye on the future of stroke services.

I apologise for speaking in the gap. I did not know whether I could be here. However, it would be remiss if I were not to mention the debt that some stroke sufferers owe to the authorities of this place. I am one of them.

My Lords, I being by congratulating my noble friend Lord Rodgers on securing this debate and giving us the opportunity to discuss the important issue of treatment and care for people who have had a stroke. I found much to agree with in all that he said. Stroke is a devastating condition that has an enormous human cost. It is our third biggest killer. Every year some 110,000 people in England have a stroke. A million people have had a stroke and a third of them have moderate to severe disabilities as a consequence. It is the largest single cause of adult disability and often has shattering consequences for families and carers. There is also a major economic dimension to stroke since the cost to the economy runs into billions of pounds every year. Indeed, the National Audit Office, whose recent report we are considering, estimates that in 2008-09, stroke had direct care costs of £3 billion within a wider economic cost of about £8 billion.

The Government welcome the National Audit Office report of 2010 which identifies significant and positive changes in the provision of stroke treatment and care since its report in 2005. As my noble friend said, it shows that acute care is improving with specialist stroke clinicians now available in all hospitals, and concludes that action taken since 2005 has improved value for money. That is very welcome news. However, as has been pointed out by a number of noble Lords, the NAO also identifies areas for further improvement—for example, in post-hospital care to match the progress made in acute care. It is clear that there is still more to be done. My noble friend Lady Neuberger drew our attention to several key items on the agenda. Before coming to future work, I pay tribute to the multidisciplinary teams in the NHS and social care whose energy and commitment are making the stroke strategy a reality. Charities, too, such as the Stroke Association, Connect, Different Strokes and Speakability have contributed a great deal to the significant improvements that have been made.

What are we doing? We are working with NHS Improvement to develop the accelerating stroke improvement programme to achieve in this current year further, faster improvement across the whole care pathway. This will help address issues that the NAO highlights and will support the NHS and its partners to make the necessary improvements. Five strategic health authorities have held events to start implementing this programme and arrangements are in hand for the remaining five to do so.

One of the key components of stroke treatment is for all patients who require it to have timely brain imaging. The stroke best-practice tariff encourages this, and direct admission to a stroke unit also improves outcomes. A stroke-skilled workforce is vital. The department has supported development of the stroke-specific education framework which, through the UK Forum for Stroke Training, will contribute to assuring the quality of stroke training. More stroke-specialised physicians have been trained and we are planning more training places in the coming year. We continue to work with the Care Quality Commission, Skills for Care, NHS Improvement, the ambulance service and local government to develop systematic ways of enabling all staff who look after people who have had a stoke to be stroke skilled.

Working with the CQC, we will support action to improve training opportunities for those caring for stroke survivors in residential and nursing homes. Many more stroke survivors could benefit from high-quality early supported discharge, which can improve outcomes. Stroke care networks and local authorities need to work together with commissioners and provider trusts to ensure that this part of the pathway continues to develop. The accelerating stroke improvement programme will be supporting this.

Stroke is a vascular disease and, as well as smoking and high blood pressure, its risk factors include an irregular heart rhythm called atrial fibrillation, or AF, which can be detected from the pulse. Some 12,500 strokes a year are thought to be attributable to AF. Improved diagnosis and treatment would prevent around 4,500 of those strokes annually and work is in hand to raise awareness of AF in both primary and secondary care, and to explore opportunities to improve this situation.

Quality, as ever, is key, and the House may wish to know that the National Institute for Health and Clinical Excellence has today published a quality standard on stroke as advice for the Secretary of State to consider. NICE quality standards provide a description of high-quality care across a care pathway, and I very much welcome NICE’s work in this area.

My noble friend paid tribute to the Stroke Association, as do I, and asked whether Ministers will meet it. I understand that my honourable friend the Minister responsible for stroke, Mr Burns, is planning to meet the Stroke Association in the reasonably near future.

The noble Baroness, Lady Thornton, spoke very powerfully about the Act FAST campaign. It has been evaluated in some detail and has proved to be very effective in raising awareness of the signs of a possible stroke and the need to treat it as a medical emergency. In addition, analysis of calls to 999 found that in the first four months of the campaign there was a 55 per cent increase in stroke-related calls. Qualitative research among healthcare and social care workers found that the public campaign has done a very good job of educating them about the signs of stroke and the need for urgency. The noble Baroness raised concerns about the funding allocation for the Act FAST campaign. She knows that as part of the efficiency measures announced by the Government all communications activity has been frozen, but we will make the case for exemptions where we believe that we have robust evidence, can generate a strong return on investment—if I may put it that way—and achieve measurable benefits to the nation’s health. I am absolutely sure that my honourable friend Mr Burns will have this issue fairly near the top of his list for the reasons that she stated.

The noble Baroness and my noble friend Lord Rodgers expressed concern about reconfiguration. The Government are clear that they do not expect reconfiguration to stop, but wish to ensure that plans are locally owned by residents, patients and particularly clinicians. Some areas have chosen to implement the national stroke strategy through proposals for significant reconfiguration of stroke services. NHS London has developed detailed plans in this regard. Those proposals are due to be discussed at forthcoming meetings to ensure that all stakeholders agree with the approach. I also have a note here about Greater Manchester. If the noble Baroness would like the details, I will gladly write to her.

My noble friend Lord Rodgers and the noble Baronesses, Lady Pitkeathley and Lady Thornton, expressed worries about the premature ending of ring-fencing for the stroke grant and about the message that this sends. It is important to note that the funding itself has not been cut. For 2010-11 it has been protected, unlike that in many other areas of local and central government as we tackle the deficit. The decision to remove the ring-fencing is consistent with the approach of the Department for Communities and Local Government, of the Treasury and of local government itself. The decision to remove ring-fencing was not taken lightly. The Government's view is that in this very challenging period for public finances it is important to give local government flexibility in local decision-making and in the delivery of front-line services, including social care. The local authority circular that accompanies the grant describes clearly the kind of services that local authorities might want to commission and provide using this funding. Local authorities are required to make a return to the department confirming that expenditure of the money has been incurred under the terms and conditions set out in the local authority circular.

As I expected, the noble Baroness, Lady Pitkeathley, spoke powerfully about the role of carers. The Government recognise that being given breaks from caring is one of the top priorities of carers when it comes to the support that they want. We are committed to using direct payments to carers and better community-based provision to improve access to respite care in particular. The noble Baroness is absolutely right that experience has shown that involving stroke survivors and their carers from the outset in the development of services is essential if those services are to match individuals’ needs and expectations. The grants have provided local authorities with an opportunity to focus attention on a group of people in the community who have very specific needs. Enhancing the quality of life and degree of independence of stroke survivors indirectly supports their carers and families as well.

It has always been clear that the grant money was for a three-year period, during which local authorities would have the opportunity to put in place service provision for stroke survivors and their carers. We anticipate that local authorities will endeavour to incorporate approaches that are proven to offer value for money into their longer-term plans.

Time is against me and I will probably have to write to noble Lords whose questions I have not answered. I say to my noble friend Lady Neuberger, in response to the key point that she raised, that age discrimination, as with other forms of unfair treatment, has no place in the health and social care system. The National Service Framework for Older People published in 2001, explicitly rejected age discrimination in health and social care, and Equality Act will give legal force to this.

The noble Baroness, Lady Thornton, asked when we would respond to the PAC report. We will do so on 8 July.

Finally, I thank the Comptroller and Auditor General and his staff for producing their stroke care report. As it says, there are clear patient and economic benefits from having a fast emergency response and early access to stroke units. We intend to ensure that the improvements that the report acknowledges continue, and we will support further progress so that our stroke services become among the best in the world.

House adjourned at 6.59 pm.