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Health: Stroke Care

Volume 734: debated on Monday 30 January 2012

Question for Short Debate

Asked by

To ask Her Majesty’s Government what plans they have to address variations in health and social care support for people after stroke identified in the Care Quality Commission’s special review, Supporting Life After Stroke.

My Lords, I respectfully draw noble Lords’ attention to the fact that, except for the noble Baroness, Lady Wheeler, and my noble friend the Minister, speeches are limited to three minutes.

My Lords, I am delighted to have secured this debate on the key issue of support in the community for people who have had a stroke and their carers. The Care Quality Commission report, Supporting Life After Stroke, was published a year ago this month, following a landmark special review by the commission, which charted what was happening in every primary care trust area in England.

I do not have a record of when I proposed the debate, but clearly patience has paid off. In fact, one year on and in the lead-up to the Government's promised spring White Paper on social care, consideration of the report's findings and proposed actions is timely indeed: both to address the widespread concerns about the impact that the major changes to the NHS will have on the huge progress that has been made in recent years; and to highlight the need for care pathways to address the need for long-term support for stroke survivors and not just help in the immediate period after hospital discharge.

Before moving to the report's findings, it is worth briefly providing a word of praise for the much beleaguered CQC itself. The special review is an incisive, excellent piece of work—precisely the type of national review report that the CQC should be undertaking—setting out a range of actions for service providers, commissioners and central government from its locally based assessments. However, there is doubt about the amount of meaningful follow-up work that has been done by the commission and indeed whether it will be able to undertake such review work in the future—but I will come back to that later.

For the record, I give the stark facts about stroke. Stroke is the third biggest killer, the largest single cause of severe adult disability in the UK, and the second major cause of dementia. There are about 110,000 strokes and 20,000 TIAs—that is, mini-strokes—per year in England and approximately 300,000 people are living with moderate to severe disability as a result of stroke. Stroke is also one of the most expensive conditions, with direct care costs to the NHS of £3 billion a year within a wider cost to the economy of £8 billion.

The central message of this debate, nearly five years since the start of the implementation of the 2005 national stroke strategy, is that there must be no turning back, no brake on the enormous progress that has been made and that we must keep up the momentum. As a carer of a severely disabled adult who most certainly would not have survived his major brain haemorrhage without the immediate care and treatment measures outlined in the strategy being in place, I can personally testify to the life-saving effectiveness of the strategy in the area where I live, and pay tribute to the marvellous skills of ambulance and hospital nursing, physiotherapists and medical staff in getting him through. We know that, as a result of the national strategy, that excellent early treatment experience is replicated in many stroke centres across the country. But we also know from the 2011 national stroke audit undertaken by the Royal College of Physicians that huge variations in standards of acute care still need to be addressed.

Similarly, the CQC report on community-based care for stroke survivors once they have left hospital found significant variations across England in the extent to which they are supported to cope with life after stroke. In many areas, the report found that people were unable to access the services they need when they need them. Early supported discharge, focusing on intensive rehabilitation in the home rather than in the hospital, was available in only 37 per cent of areas; 32 per cent of PCTs failed to commission physiotherapy in the community across the whole of their area; in 48 per cent of areas, people waited an average of two weeks until receiving speech and language therapy—vital lost days in a such a critical enabler to living and coping with stroke.

The CQC also found major problems with people and their carers accessing services and support after hospital discharge; information packs not easy to follow or not including information about local services; carers not given information about local carer support or befriending schemes; information not available in relevant community languages other than English; helpline staff not trained to deal with people with communications problems such as aphasia; and, most common, a named contact for support which did not look across health, social and community care.

However, the overall CQC message is that, despite the problems it identified, much has been achieved in improving post-hospital support and many of the building blocks necessary to achieve a transformation in care are now in place. In the words of the CQC, the report shows that the barriers to effective care after transfers home can be overcome and improvements made to which can help people both to recover from and cope with life after stroke. The report reinforces my message about keeping up the momentum and ensuring that it is not lost in the light of the threats to improvements in post-hospital stroke services from substantial cuts to local social care budgets and the impact of the reorganisation of the NHS.

The CQC recommendations cover a wide range of actions to address the variations in service provision that it found. These include PCT service improvement plans to address the problems and, most importantly, to ensure that services are adapted to individual needs, such as for people who have little or no support from carers or family members, people in care homes, people with aphasia, and people from black and ethnic minority communities. From my experience as a carer, often battling to ensure that the various support services actually happen and join up, I shudder to think what happens to the many stroke survivors living on their own.

The authors of the CQC report highlighted the importance of the NHS stroke improvement programme and the 27 stroke care networks that operate at regional level. They have a key role to play in helping to improve longer-term stroke support in the weakest performing areas, and I hope that the Minister will be able to give reassurances that funding of the networks will continue following the current review period.

It is clear from the problems highlighted in the report—and the CQC stresses this—that strong national leadership and support will continue to be needed for the foreseeable future to support the changes in the longer-term stages of the stroke care pathway envisaged. I hope that the Minister, in his response, will be able to reassure the House that the national Commissioning Board will commit to ensuring that the key elements of the national strategy are incorporated into future guidance to commissioners of stroke services and that it will also ensure that the strategy continues to move forward to meet the challenges ahead.

On the question of leadership at national level, the Department of Health’s continuing failure to appoint at least an interim national clinical lead for heart disease and stroke following the resignation of Sir Roger Boyle has caused much concern and has led to precisely the leadership vacuum that we must avoid at this critical transition phase. Moreover, the number of staff in the vascular team at the department has also significantly declined during this time. Meanwhile, there are still national clinical directors for other major areas such as cancer, diabetes and respiratory disease. Can the Minister explain how the Government justify not filling the heart disease and stroke post, even on an interim basis? How is this leadership role currently being undertaken, and how will he ensure that the Commissioning Board has the expertise to advise and deliver on stroke strategy without it?

In the time I have left, I have some key questions for the Minister arising from the report. First, I understand that the CQC’s remit has changed since publication of this report and that the review team working on stroke has been disbanded. In the absence of the proposed targeted CQC inspections, as well as training and support for the weakest areas, how will the Minister ensure that all PCTs, now in their clusters, have reviewed the CQC local assessments and are implementing action plans? Is this the last stroke review that the CQC will undertake?

Secondly, consistent and authoritative data on stroke care once people leave hospital is vital to gauge what progress is being made. How will information on the quality and standard of stroke services be monitored and reported in the future, and will more information be collected on post-hospital stroke care and support?

Thirdly, I am sure that the Minister will join me in recognising the valuable work undertaken by the voluntary sector in providing stroke support services. I refer in particular to the Stroke Association, although I should also like to give a quick plug for the amazing work of my local TALK charity in Surrey for stroke survivors with aphasia. However, the removal of the ring-fenced conditions from last year’s £15 million government grant to local authorities, combined with local authority budget cuts, uncertainties over NHS funding and future commissioning arrangements, will seriously threaten the viability and provision of services in the future. How will the Government ensure that local authorities provide adequate support for voluntary organisations and networks providing such vital community support for stroke recovery?

Fourthly, I draw your Lordships’ and the Government’s attention to the publication in May of the Stroke Association’s forthcoming Daily Life survey as part of Action on Stroke Month. It is the largest survey of the life experience of stroke survivors across the UK. I am sure that the Minister will want to commit to working with the Stroke Association on the outcomes to ensure that the long-term support that stroke survivors need are improved.

I end with a hobby-horse of mine concerning stroke. We were told rather authoritatively by a number of medical, nursing and social care staff, and well-meaning others, that there was a two-year “real” improvement window in stroke care—in other words, if improvements to impaired movement, paralysis or speech loss had not occurred by then, that was how it was going to be. That is a common myth and it is not true. With the right support and care, stroke can be, and often is, a long journey of small, continuing improvements—to memory, to motivation, to speech, to thought processes, to the ability to live with disability and to finding ways of enjoying a good quality of life. That is why making progress in strong and continuing support for stroke survivors in the community and addressing the current variations across the country is so important. I look forward to the contributions to the debate and to the Minister’s response.

I am very grateful to the noble Baroness, Lady Wheeler, for securing this important debate. I declare an interest as chairman of the ARNI Trust, which deals with rehabilitation after stroke. The noble Baroness has reminded us that stroke is now ranked as the largest single cause of disability among adults in the United Kingdom. About a third of a million people are now living with moderate to severe consequential problems, and in the brief time allowed I want to touch on one new initiative concerning them.

I was privileged early last year to visit a community centre serving a wide area. Inevitably, among those who come every day just to chat, dine or use its amenities were a considerable number of stroke survivors. I was there to open a unique new stroke facility, which has been pioneering a novel approach developed by the ARNI Trust, and this is the use of fitness trainers. I have to say that hitherto I had thought of fitness trainers as well-muscled young men and women hired at some expense to put city executives through their paces. However, these were rather different. Each had undergone a rigorous course in teaching exercises suitable for stroke victims. They are not physicians or physiotherapists, of course, and the techniques that they teach are simple but innovative ones which relate to the daily life-needs of their patients. I shall give an example.

Many stroke survivors will tell you that they dread falling over because getting up unaided is usually impossible. At home, they often ring the emergency services to assist them, the alternative being possibly to lie on the floor for many hours until a carer arrives. The staff of the centre that I mentioned spend many thousands each year on hiring professional paramedics to turn out when a stroke victim has fallen over while there. This is a legal requirement. In the new facility, the fitness trainers teach a novel and safe technique, currently the subject of a clinical study by a group from the University of Exeter and Plymouth University. It is called IGO—“I get off the floor”. Patients who have learnt it can get up unaided. It has been so successful that the centre now saves some £8,000 each year in paramedic costs, and the disabled people whom I interviewed are delighted with the new-found independence that such techniques can bring.

These trained fitness professionals are now teaching these techniques throughout the country, often in the homes of the stroke disabled, for there is evidence—and the noble Baroness, Lady Wheeler, touched on this—that some stroke victims can continue to make improvements long after conventional wisdom suggests. I have met many who have been able, after training in these techniques, to discard walking aids, and one has been mobilised out of his wheelchair.

Finally, evidence suggests that quite properly the vast majority of funding available for stroke nationally is directed towards the acute phases. In my view, a small funding adjustment towards long-term needs would lead to a greater emphasis on functional exercise after stroke.

My Lords, I thank my noble friend not only for securing this debate but for the wide-ranging way in which she introduced it. Her personal experience as a carer enriches our debates, and it is on the care experience that I want to focus in the few moments available to me.

I want to bring to your Lordships’ House Olivia, who looked after her husband, Ronald, when he suffered a massive stroke. She said:

“He spent four months on a stroke ward where little was done to rehabilitate him; he was lucky if he got 10 minutes of physio a day and even less input from speech and occupational therapists”.

She felt that the care he was receiving was so poor that she would take him home, and she thought that she would be better off doing that. Within days of taking him home, she felt that his condition had improved, and Ronald also received support there from district nurses and a physiotherapist. Olivia had to fight to get information and support. She said:

“It took months to determine what help we might be entitled to. I was passed from department to department, we were subjected to assessment after assessment and review after review, answering the same questions over and over again, the various departments procrastinating over every decision”.

She is still convinced that she made the right decision to care for Ronald at home, but the lack of support for her meant that she had to give up paid work to care, and suffered then from stress and depression, providing round-the-clock care. The impact of both people losing their incomes forced them to sell their home and go into sheltered rented accommodation. Your Lordships may think that that is an extreme example but it is not. It is a common experience in some families.

One of the great difficulties about a sudden onset condition such as stroke is that carers have little time or opportunity to plan for caring responsibilities. Intensive support, or reablement as we often call it now, following hospital discharge, can make the difference between a more rapid recovery and the need for ongoing long-term care. Not only is it crucial to support the independence of the stroke sufferer but for family members, too. Many families can juggle short periods of intensive caring and ongoing lower levels of support with paid work. They are very willing to do that, and to juggle it with other family commitments. But the lack of rehabilitation services can extend the length and intensity of the caring responsiblities of families. Evidence from Carers UK shows that many families are at risk of longer-term penalities: falling out of work and risking isolation, ill health and financial hardship.

In addition to support with personal care and mobility, stroke survivors often experience communication difficulties and changes in behaviour. That, too, can lead to stress and strain in the caring relationship. When the Minister responds, I hope that he will acknowledge the importance of caring families and address specifically the latest developments to support the Olivias of this world, as well as the Ronalds, who are the sufferers, particularly in respect of the unacceptable variation in levels of support available to them.

My Lords, this debate is the latest in a series of short debates in which the House has explored the causes and consequences of stroke. Of today’s list, three—the noble Baroness, Lady Rendell, the noble Lord, Lord Clinton-Davis, and I—spoke at the first of them on 23 May 2006, arising from the pioneering National Audit Office report Reducing Brain Damage: Faster access to better stroke care.

The noble Lord, Lord Clinton-Davis, and I drew from our personal experience as victims—a term I do not like, but it is used. For my part, I was not physically disabled but my speaking, reading, writing and comprehension were severely affected. I needed two and a half years of speech therapy to recover my capacity, and longer for my confidence.

In her ministerial reply in 2006, the noble Baroness, Lady Royall of Blaisdon, gave a sympathetic response, saying that the hospital to which I had been taken following my stroke five years earlier used to have one of the worst performing stroke services in the country but that it had been turned round to one of the best.

I say that because stroke had been grossly neglected by the NHS until the late 1990s. Since then the perception of stroke has been transformed and I pay tribute to the Stroke Association as it has played an important campaigning role. I also pay tribute to Sir Roger Boyle for his leadership of the national stroke strategy. I am sorry that he has felt unable to continue his role during these turbulent NHS times. Among unfinished business is to ensure that GPs can recognise and take seriously the symptoms of stroke in a patient and to contribute towards the rehabilitation and care of stroke victims.

In reading the 2010 stroke sentinel audit reports, I have found no reference to GPs and only one in the Care Quality Commission report, in passing, on the role of GP consortia in the new commissioning procedures. I would be grateful for the Minister to bring up to date this aspect of the national stroke strategy—involving GPs in stroke—and explain where responsibility will lie on completion of the current Health and Social Care Bill.

I greatly welcome the initiative of the noble Baroness Lady Wheeler, in putting forward this debate, and I hope that we shall have further occasions in the House to maintain the momentum of change.

My Lords, I thank the noble Baroness, Lady Wheeler, for her timely question. People up and down the country are concerned about the standards of care there will be for people with long-term conditions in a reformed NHS. It is hoped that a quality standard will be commissioned by NICE over the next Parliament.

My husband had a stroke sitting in his armchair watching cricket; our previous Black Rod had a stroke in bed. It can happen at any time. I am pleased that there have been improvements in recent years, but could these be at risk? People are living longer post-stroke with a higher level of need. More than 900,000 people in England are living with the effects of stroke, with half of them being dependent on other people for help with everyday activities.

Early intervention of speech and language therapy is crucial and has a direct impact on the length of stay in hospital and the outcomes for the patient. However, anecdotal evidence shows that many speech and language therapists’ posts are becoming frozen or lost, and budgets are being cut by between 9 and 33 per cent. More than one-third of people have persistent speech, language or communication problems after a stroke. Patients are sometimes left over a weekend with no food or fluids with a sign on their bed, “Nil by mouth”, and forgotten if they have not been assessed by a speech therapist. Hospitals must do better. Patients with dysphagia are at risk of serious complications, developing respiratory infection or pneumonia, and suffering from undernourishment and dehydration.

Prevention, if possible, is the best option. People with atrial fibrillation—irregular pulse—are five times more likely to suffer a stroke. A quality standard will raise awareness of the condition among commissioners and GPs. Everyone should be taught to take their pulse and to help others do so. Children could learn this at school and could then check their parents. Information on AF and stroke prevention should always be available. Taking blood pressure with a BP machine will not show an irregular pulse.

The CQC's special review identified a number of areas that service providers and commissioners could focus on to drive improvements. Work at national level could support these improvements. I hope that the Government will put this into practice.

My Lords, I, too, congratulate my noble friend Lady Wheeler on instituting this timely and needed debate. In recent years, as the Care Quality Commission's review points out, attitudes to stroke and treatment for stroke have improved enormously, with better access to specialist stroke units, greater use of thrombolysis and improved working across care and social services. People are able to leave hospital earlier and receive rehabilitation when they return home. Despite this progress in recovery, data collected by the national sentinel stroke audit have shown that it is after that return home that people tended to feel abandoned. More than half had unmet needs for care and more than half wanted more information about strokes. The audit found that 48 per cent of PCT areas had a two-week average wait for community-based speech and language therapy, even though one-third of stroke survivors experienced communication problems after stroke. It is on this aspect of rehabilitation that I will concentrate briefly today.

Complaints from stroke survivors included a failure to find what help could be got, a failure to be “treated like a human being”, and of a lack of respect for people's dignity, which came about through a failure to understand another culture. One woman stroke survivor had difficulty communicating because although she spoke English her mother tongue was Urdu. We have heard much lately about the desirability of immigrants who come to the United Kingdom learning our language, but here we are not talking about learning English but about speaking it to a high level of comprehension and being understood. The woman who was an Urdu speaker could speak English and no doubt read it but not confidently when she needed to take information from the printed word or from rapidly imparted speech.

Only a third of the areas covered provide information in languages other than English. Audio and DVD access is available to stroke survivors only in one-fifth of cases. Many services provide limited support and information only for people of working age, despite stroke being the largest cause of disability in adults and particularly in older people. With three main foreign languages and 16 main immigrant languages spoken in the United Kingdom, surely the time has come to remedy the situation of stroke survivors by providing those who require it with the requisite information in translation, for example, into Urdu and Bengali among others.

Good information about what stroke is and what can be done is often still lacking. The national stroke strategy, now three years old, recognises that people's needs require regular reassessment so that changes can be taken into account. A review should take place six weeks after someone has left hospital, and again after six months, and PCTs should set out that the people who have had a stroke and their carers should be involved in these reviews. Only one in 10 of the information packs given to stroke survivors mentions the reviews, or people's right to ask for a reassessment if their needs change. Many must be unaware that the reviews should take place. How much more obscure and difficult to follow are the details of reassessment for those who have to struggle through information in a language that is at the best of times difficult for them.

My Lords, I, too, welcome the opportunity that the noble Baroness, Lady Wheeler, has given us to discuss this subject. I was a member of the Public Accounts Committee in 2006 when we received the National Audit office report, and again in 2010 when we reviewed the progress of that report. It is concerning to think that some of the concerns of the Public Accounts Committee in 2010 were picked up in the CQC report. I will pick up on one or two of them.

We in the Public Accounts Committee said:

“The Department lacks evidence about what types of post-hospital support and long-term care are most effective for stroke patients and does not have a clear plan as to how such care should be funded”.

I hope that my noble friend this evening will be able to assure us that that has been taken on board, particularly in the light of the changes to the health service. Also, despite 11 per cent of stroke patients being newly admitted to care or residential homes after their stroke, there is little understanding of what services stroke patients need in these settings. As a former constituency MP, I know not only that stroke is life-changing but how much more so it is when somebody one day has a stroke at home and never goes back to that home, instead going into nursing or residential care. I hope that that group of people will not be forgotten and that my noble friend will address them as well.

There is also the question of the joint care plan, which is picked up in the CQC report, and particularly, as part of that care plan, the need for regular reviews. I think the point was very well made about this two-year cut-off point. In fact, the CQC report shows that those plans which incorporate the structure of six-week reviews and six-monthly reviews are not only ongoing but that the best quality care is usually delivered as well. Yet we see that only two-thirds of people had six-weekly reviews, 44 per cent had six-monthly reviews and only one in 10 information packs given to patients on discharge mentioned the reviews at all.

At the UK stroke forum in December last year, the Secretary of State for Health announced that work will begin this year on the development of an outcomes strategy for cardiovascular disease. Will the outcomes strategy for cardiovascular disease replace or complement existing national strategies, such as the stroke strategy? How will it focus on the areas most in need of improvement, such as longer term care and support for stroke survivors? I hope that when he replies my noble friend will also be able to tell us what progress has been made on the development of the outcomes strategy for cardiovascular disease.

My Lords, I thank my noble friend for promoting this debate. I know only too well that a stroke can have devastating effects. Often, it kills. It can often lead to serious disability, mental and physical, and it can disrupt families. The commitment to long-term support is vital, as is the training of carers in suitable cases. The Government should indicate their unwavering support for the recommendations of the CQC report, and there should not be wide discrepancies in the country in the care of stroke sufferers. In my experience, physiotherapy is an absolute must, yet it is not always available on the scale necessary or sometimes not at all. Speech and language therapy and rehabilitation are too often woefully inadequate. Local services should be more widely known. So many organisations—PCTs, adult social services and providers—have a substantial role to play, which should be recognised much more widely.

There is so much to say about this and I thank my noble friend Lord Rodgers. He and I have suffered from this. Unfortunately, there is so little time to say everything, but this scourge demands a much more positive response from the Government. They should recognise how valuable this work is. I join with others in paying tribute to the Stroke Association for the work that it has done in focusing upon the essential issues.

My Lords, I, too, congratulate my noble friend Lady Wheeler on picking an opportune moment for this debate and on her concentration on after-stroke care. If you talk to clinicians involved in stroke, they say that the treatment you get immediately has a major effect on what may happen later on, so I want to concentrate on the situation in London. Many noble Lords will know that in London 6,000 people a year suffer a stroke. London is the region that has done most to improve its management of acute stroke. In the past, if you had a stroke in London, you could have been taken to any one of the 38 hospitals which have an A&E department. This fragmented care meant that too many patients were not getting the care and rehabilitation they needed. Over the past two years, London has reorganised stroke care. If you suffer a stroke now in London, you are taken rapidly to one of eight specialist hyperacute units capable of delivering the highest quality care from an expert team of clinicians. Following this, you will receive specialist, multitherapy rehabilitation care and ongoing medical supervision in one of 24 new stroke units.

The results show a dramatic improvement. The new arrangements will save between 300 and 500 lives a year with a commensurate reduction in disability. London has moved from a poorly performing system to one which is now not just the best stroke system in the UK, but is comparable to the best in the world. Dame Ruth Carnell, the chief executive of SHA London, has many things to be proud of but, in my view, none more than driving the reconfiguration of the stroke services across London.

I need to declare an interest when advising the House that Barnet and Chase Farm Hospital’s acute stroke unit, based on Spruce Ward at Barnet Hospital, is the first unit in London to be accredited as meeting all the standards set by the London cardiac and stroke networks.

The noble Baroness, Lady Wheeler, drew our attention to the CQC report, which reminds us of the need to ensure an equal focus is given to the development of stroke services outside hospital, and I support that. As ever, the rehabilitation end of the pathway is getting less attention than the acute, but it is important that stroke care is given uniformly, and I ask the Minister to take on board that inequality. Is the London model of hyper and acute stroke services one that the Government are minded to replicate and encourage across England and Wales?

All those who suffer this awful and possibly life-changing illness deserve the very best acute services. As the CQC says, the further extension of this superb treatment and care in supporting their lives is essential.

My Lords, there is no question that the 2010 national stroke strategy has heightened the knowledge of stroke across the country, but there is still evidence of gaps in long-term provision.

I will concentrate on aphasia, which is an outcome, among others, that my daughter still suffers from 15 years after having a stroke. Aphasia can take the form of people not being able to speak at all or having only a few words; others can no longer read, write or use numbers. All the evidence shows that services are not planned with the needs of people with aphasia in mind.

There are currently about 250,000 people in the UK with aphasia. However, statistics are notoriously difficult to collect. This is illustrated by the findings of the Care Quality Commission. Only 7 per cent of adult social services departments reported including people with aphasia in designing stroke information. Eighty-one per cent of PCTs have not tried to estimate how many people with aphasia live in their area. All this is further compounded by the fact that communications disability is not a recognised disability and so is not monitored. People with aphasia are invisible. A simple solution would be to monitor how many people have aphasia at the time of the stroke, at discharge from hospital and when under the care of social services.

Key to the provision of services for people with aphasia are the voluntary bodies, and I want to refer to one specific organisation, Connect, of which my daughter is a board member. Connect is a charity for people living with aphasia, which offers information and support for carers and health professionals. Crucially, it recognises people with aphasia as experts and as such has pioneered innovative ways of working in partnership with people with aphasia. It aspires to enhance and extend statutory service provision once statutory services end and offer the opportunity to re-engage with life beyond services. This is in addition to the provision of a statutory workforce and a passionate and highly skilled workforce of volunteers supporting service development and delivery. At the same time it aims to reduce costs for national services by reduced visits to the GP as a result of improved mood, greater self-esteem and increased social participation as well as reduced dependency on speech and language therapy, enabling earlier discharge from statutory services.

It is not all about specialist rehabilitation, important as that is, but sometimes about low-cost, accessible, creative, peer-led activities such as drop-in, befriending and awareness provided by a third sector organisation. However, real support is required to help organisations such as Connect and the Stroke Association continue to provide these vital services in the long term. Stroke is not a one-off event but a life with complex disabilities.

My Lords, I congratulate my noble friend Lady Wheeler on being patient enough to allow this debate to take place tonight. I thank all noble Lords who have taken part in this debate.

When Andrew Lansley was appointed to the Cabinet by David Cameron in May 2010, we might have expected that the new Health Secretary would take the trouble to introduce himself to the leading players in his department. I have to say that this was not the case. Sir Roger Boyle, who had been toiling away as the Government’s national director for heart disease and stroke for more than a decade, did not actually meet the Secretary of State until just before he parted company with the department. As someone who judges the success of something by the action that is taken, not by the rhetoric, I think that that is decidedly unimpressive.

Sir Roger Boyle was appointed as national director for heart disease in March 2000. He led the implementation of the National Service Framework for Coronary Heart Disease, which led to a 50 per cent cut in deaths from heart attacks. That has been in the news very recently. He published the National Stroke Strategy in December 2007, and indeed was working on the implementation of that stroke strategy when he left the department last summer. My question to the Minister is this: I understand that Sir Roger Boyle has not been replaced. If he has not been, why not? Indeed, what does that say about the priorities of the department on the issue of stroke?

It is a pity that Mr Lansley did not make more of an effort to find out what Sir Roger was up to. He would have learnt some important lessons about the NHS and what it had achieved without the benefit of the market revolution that is being ushered in under the NHS reforms before the House.

The second question I would like to ask the Minister is what future, therefore, will the national stroke strategy have in a reformed NHS, and who will be responsible for its implementation under the proposed new system?

My third question picks up the points made by my noble friend Lady Wall. It concerns whether something as successful as the London stroke strategy could be replicated and how that would be achieved. I make no apology for repeating the question that I have been asking, on and off, at every opportunity over the last year or so, because I think that so far we have not received a satisfactory answer. The London stroke strategy was achieved through a London-wide strategic plan driven by clinical co-operation. I would like to know how, and in what timeframe, such a strategy would be possible under the new levels of decision-making bureaucracy and, some might even say, fragmentation that are being proposed by the new Bill.

Would there be a great risk that the clinical competition that allowed the London strategy to move forward, if it were to be an economic or financial competition, would have to be based on the failure of some centres, to allow others to emerge as winners? That is my understanding of how things would have to move forward. I hate to say this to my noble friend Lady Wall, but it seems at present to be less rather than more likely under the new regime.

I thank all noble Lords who have covered what seem to be all conceivable questions about the matter of stroke, and I look forward to the Minister’s reply.

My Lords, I am delighted that the noble Baroness, Lady Wheeler, has been successful in securing a debate on stroke care, and I thank her for introducing the subject so ably. As demonstrated today by the number and quality of contributions made by noble Lords, it is an area of great interest and one that it is vital to keep in the public eye. I shall do my best to cover as many issues that have been raised as I can, but I shall write to those noble Lords whose questions I have not been able to cover.

Stroke care has witnessed huge improvements over the past few years and many thousands of people have benefited. Stroke patients are getting treatment that is faster and better than ever before and data suggest that improvements are continuing. I pay tribute to the work of Sir Roger Boyle during his time as national clinical director. The latest data show that over 80 per cent of stroke patients are spending the majority of their hospital stay on a stroke unit, and the management of high risk transient ischaemic attack patients has also improved by 20 per cent since 2009. Access to immediate brain scanning has improved considerably and more patients are receiving thrombolysis giving them a better chance of regaining their independence following a stroke. There has been the very successful campaign to raise awareness of stroke—the Act FAST campaign.

We want the progress underway to continue but we also know, as was pointed out by the noble Baroness, Lady Pitkeathley, that we need to do more to improve support for people after stroke. As we acknowledged when the Care Quality Commission published its report last year, there is still more to do in ironing out the variations in stroke care, particularly in the support provided to patients when they leave hospital.

The noble Baroness, Lady Wheeler, asked about monitoring of outcomes with the benefit of robust information. At a national level, our focus on outcomes through the NHS, public health and adult social care outcomes frameworks sets out the areas we want to improve. Stroke specifically features in two parts of the NHS outcomes framework in terms of reducing premature mortality and in recovery from major illness.

Noble Lords will be interested to hear that the stroke indicator on recovery has been developed in collaboration with several organisations, including clinicians, academics and the NHS. The indicator, based on the modified Rankin scale, will assess the patient’s recovery from stroke after six months. It will provide an incentive for the NHS and social services to work together, getting the right services in place so that when patients leave hospital they have the support they need to make the best possible recovery. I hope that that reassures those noble Lords who are afraid that care will be fragmented. This outcomes framework will drive services in the opposite direction.

The social care outcomes framework is helping to gauge the progress made by local services and drive up standards across the country. One of the areas this framework covers is reducing the need for care and support and delaying dependency. This will help people to live healthy independent lives and properly manage any health needs. Local authorities will be able to compare their services with those of other authorities around the country and make improvements based on what has been proven to work elsewhere, integrating care and working together to provide care that suits individual patients. For stroke survivors, this means providing access to the kind of support that they need to enjoy the best possible quality of life after their stroke.

Building on the national stroke strategy, the NICE quality standard for stroke, which has been mentioned by a number of noble Lords, has been developed with patients, commissioners and leading doctors. This provides an authoritative definition of what high quality care for stroke actually means. They are the measures of quality that matter most to patients and the NICE quality standard for stroke recognises the key role that rehabilitation plays in making sure people can live their lives as fully as possible after their stroke.

My noble friend Lady Browning suggested that there is perhaps inadequate understanding of what patients need in care settings. The NHS, through the stroke improvement programme and the 28 stroke networks in England, is working to make sure that stroke care improves at all stages of the patient pathway. The stroke networks connect different organisations and teams that have roles to play when someone has a stroke so that patients can be sure of co-ordinated management from the moment they are first in touch with a doctor or nurse and throughout their lives as a stroke survivor. This whole approach takes the needs and wishes of stroke survivors and their carers into account when delivering these services. I should like to reassure the noble Baroness, Lady Wheeler, about funding of the networks. Funding is in place for 2012-13. The future of the networks is being actively considered as part of the development of the NHS Commissioning Board.

The stroke improvement programme and the stroke networks have made good progress in getting the stroke strategy up and running, and they have done the same with the NICE quality standard. Patients now see better acute care as a result of both. Attention is now being focused on improving care for patients who have left hospital. The accelerating stroke improvement programme was developed specifically to improve care in areas where progress needs to be made faster and is looking at improving post-hospital and long-term care. The stroke improvement programme, working with the stroke networks, is delivering this.

Accelerating stroke improvement is concentrating on four key areas of post hospital care: that is, providing early supported discharge; making sure patients and carers have a joint care plan on discharge from hospital, which was mentioned by my noble friend Lady Browning; making sure stroke survivors have a review six months after leaving hospital; and making sure psychological support is provided for those who have mood, behaviour or cognitive disturbance.

One example of where a stroke network has been working well with commissioners to improve access to stroke community services is south London. Through the ASI programme, the network has developed a service specification for early supported discharge and community services, and has helped commissioners to make the case for change. What is more, analysing data from the CQC review, the stroke network was able to identify areas that needed to do more in the provision of post-hospital services. This has resulted in one of the care trusts commissioning a stroke community rehabilitation service, which is an excellent example of how the CQC review has actually driven improvements in services.

A number of questions were put to me. The noble Baroness, Lady Wheeler, asked about clinical leadership in this area, a point also raised by the noble Baroness, Lady Thornton. The replacement of the National Clinical Director for Heart Disease and Stroke is being considered as part of the development of the NHS Commissioning Board, but I would just say generally that improving stroke services is a priority for the Government, and there should be no doubt about that. It is a priority against which we shall hold the NHS Commissioning Board to account. Tackling premature mortality from stroke is an area for improvement in both the NHS outcomes framework and the public health outcomes framework.

The noble Baroness, Lady Wheeler, mentioned the Stroke Association, and again I pay tribute to its work. My officials meet its representatives on a very regular basis. The local stroke networks are working with clinical commissioning groups and PCT clusters to ensure that improvements are made in stroke services, including those recommended by the CQC. I was asked how improvements in quality will be monitored. There are two audits running this year. The Sentinel Stroke Audit and SINAP will both publish their results, which will help commissioners and providers of stroke care to monitor and improve their services, helped by the local stroke networks. The noble Baronesses, Lady Wall and Lady Thornton, asked whether we agree with the hyper-acute model that has been adopted in London. We certainly acknowledge that the reconfiguration of stroke services in London has produced very good results. The Stroke Improvement Programme works through local stroke networks, which are responsible for disseminating good practice across the country. They have done so with the London example very much in mind and, indeed, other examples where reconfiguration has delivered better stroke care.

The noble Baronesses, Lady Masham, Lady Gould and Lady Rendell, my noble friend Lord Rodgers and the noble Lord, Lord Clinton-Davis, all spoke of aphasia services and speech and language therapy. Stroke survivors should receive care and support from staff with the skills and competence to meet their needs, ensuring that those with communication difficulties such as aphasia have opportunities to return to a full life back in their communities. A good example of working with those who have aphasia is the Access to Life project in Cornwall, run by Connect. Twenty people with aphasia have been trained to provide one-to-one support to others with aphasia at home or in hospital, which helps those with aphasia grow in confidence in the way they communicate, and so reduces their risk of social isolation, a point well made by my noble friend Lord Rodgers.

The noble Baroness, Lady Rendell, spoke about entitlement to reviews and reassessments. Patients should have reviews at six weeks and six months. The NHS outcomes framework will include an indicator in the recovery domain to ensure that patients are reviewed at six months, as I have mentioned. The noble Baroness, Lady Pitkeathley, referred to the needs of carers. Carers play a critical role in ensuring that stroke survivors enjoy the best possible quality of life. Local authorities, working with PCTs, should together make sure that appropriate services are available to support both stroke survivors and their carers. Health and well-being boards will in the future have responsibility for ensuring that these local needs are met. The noble Baroness, Lady Gould, asked about support for third sector organisations. It is for local commissioners to decide how to use the third sector in providing stroke services, but many local authorities and PCTs commission such services from organisations such as the Stroke Association.

We want our stroke services right across the pathway to match the very best in the world. As I have said, huge improvements have been made to that end, but significant improvements still need to be made. I have given a couple of examples of what is being done to address this, and there are many more examples from around the country of services continuing to improve. But we are not stopping here. Identifying how we can deliver better outcomes in cardiovascular disease, including stroke, is a key task. This is one of our biggest killers and causes of adult disability. That is why my right honourable friend the Secretary of State for Health recently announced the development of an outcomes strategy for cardiovascular disease, building on existing strategies and the national service framework. I hope that the noble Baroness, Lady Wheeler, will see this as good news.

The aim of the strategy is to create a joined-up approach across the NHS, public health and social care to improve outcomes for patients with CVD, which includes stroke survivors. This will mean even more stroke survivors living active and fulfilling lives.

Sitting suspended.