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Health: Stroke Survivors

Volume 792: debated on Thursday 28 June 2018

Question for Short Debate

Asked by

To ask Her Majesty’s Government what action they are taking to improve the provision of long-term rehabilitation for stroke survivors.

My Lords, I thank noble Lords and the Minister for giving up time for this debate. I remind your Lordships of my registered interest as the chairman of the stroke charity ARNI, Action for Rehabilitation from Neurological Injury.

We know that in the UK over 150,000 people have a stroke annually. But happily, people do not die nearly so often from stroke as they used to. In fact, some 85% of those who suffer a stroke survive it. They do so because: first, there is a greater recognition out there of what a stroke looks like, and the importance of immediately calling the emergency services; secondly, ambulances get stroke victims to hospital more quickly; and thirdly, when they are there, hyper-acute stroke units can carry out rapid diagnoses, first-class scanning and excellent treatment.

The net result of this upsurge in the welcome ability to save lives is that we have a very large number of stroke survivors. In this country, some 1.2 million people are living with the effects of stroke at any one time. It is the biggest disabler of all. It is those people whom I want to discuss this afternoon for, if the clinical treatment of stroke patients has been a great success story, sadly, helping them to live as near normally as possible afterwards has not been so.

Rehabilitation starts typically with physiotherapy and, if required, speech therapy. It begins for most people in hospital; they then continue as out-patients or receive treatment at home, but it is very much time limited. The health watchdog, the National Institute for Health and Care Excellence, has produced guidelines based on recommendations by the Royal Society of Physicians, which suggest that patients should receive 45 minutes of each therapy that they need every weekday, for as long as their disabilities require it. This is a huge ask of course but, typically, we are told that stroke survivors average the equivalent of just 16 minutes per day of physiotherapy, 12 minutes of occupational therapy and 12 of speech therapy. Moreover, on leaving hospital, many have to wait six weeks before community therapy, such as it is, is initiated. The Stroke Association says that, at this stage, many are forced to pay for private care.

One-quarter of all strokes in the United Kingdom happen to people of working age, and one-fifth of these are under 45. Stroke therefore reduces employment prospects for the future for its sufferers, with all that means for society. It has a knock-on effect for family and friends involved in a patient’s care and who are usually, of course, unpaid in this role. The estimated aggregate costs of stroke are a substantial £25 billion. There is still a commonly held misconception, however, that people cannot significantly recover from the effects of having a stroke and that they are stuck with whatever mobility they have after hospitalisation and its consequent physiotherapy for the rest of their lives. However, well-established evidence shows that neuroplasticity of the brain can be utilised to augment recovery, leading to better function and action control even some years after the stroke has happened.

Stroke-specific physical training, applied at home, which targets upper and lower limb deficits can be the key to a better quality of life and for readmission to employment. In short, active approaches where patients are highly involved in their own rehabilitation and do many hundreds, sometimes thousands, of specific repetitive actions can lead to positive neural adaptation, whereas those where survivors are merely the recipients of predominantly traditional therapy are much less likely to do so.

It is precisely these active interventions which my own stroke charity, ARNI, does so well and with such heartening results. ARNI was created in 2001 to ensure that there is a growing body of qualified exercise instructors available for stroke survivors. They go into homes to help people to rehabilitate and we now have more than 100 therapists and professional instructors across the country, many of them running group classes as well.

This kind of rehabilitation works with people of all ages, including those whose strokes happened some years before. Here is the testimony of John Scrivener, an elderly former paratrooper who suffered a massive stroke in 2012, losing the use of his left arm and leg. Two years later he was introduced to ARNI’s exercise techniques at which he works hard and regularly with his instructor. He says:

“I can now go up and down awkward steps with no handrails. I have no difficulty in going into strange environments and I can even get up unaided from the floor. I am astonished by the changes that have made such a difference to my life”.

The broadcaster Andrew Marr has said publicly and often how ARNI’s exercise regime helped him enormously after his own stroke and gave him better gait, balance, grip and strength, the better to be able to cope with his arduous public life.

Last year I saw Harry Baker, then 16 years of age, start his rehabilitation with my charity. He had significant limitations and could hardly lift his hand. A year later, after determined and repetitive special exercises, he has improved so much that he has had the confidence to join a martial arts class, where I witnessed his agile kicking and dextrous handling of a football. The appalling and depressing effects of a stroke, probably the result of a sports injury, were felt deeply by this teenager whose social life was reduced to zero. Normal life beckons for him once again.

One simple ARNI technique reported at the World Stroke Congress has improved the lives of hundreds of patients and saved many thousands of pounds in public funds. It is called “off the floor” and enables stroke-impaired patients to get up from a fall by themselves. Typically, before learning it, many would lie immobile for hours or, often with huge embarrassment, had to rely on calling 999 for paramedics to help get them back up.

Stroke survivors rely on charities like my own for this kind of long-term rehabilitation because it is not available from any other sources. I pay tribute to the Stroke Association, which last year began its £2 million project of Life After Stroke grants, having been sponsored as the Royal Mail’s charity of the year. These grants of £300 each can enable longer-term rehabilitation such as that which I have mentioned to take place. We badly need two things: first, the recognition that disabilities caused by stroke can be much improved by techniques such as those I have described, and secondly, grants from public funds to make this happen. As always, such investment will save money even in the medium term by reducing the number of people who are expensively re-hospitalised by injury or physical decline, by reducing their reliance on the ambulance service, and by reducing the burden on carers. Above all, it will help to give survivors of all ages back the dignity of being able to live more normal lives physically and socially, and even the ability to return to the world of work.

We are extremely good at dealing with the immediate effects of stroke, but now we must deal just as effectively with its long-term effects as well.

My Lords, I declare an interest as co-chair of the All-Party Group on Modern Languages. I quite understand if, at this point, other noble Lords wonder if I have wandered into the wrong debate, but please bear with me as I hope to convince noble Lords that there is an important link between the recovery of stroke victims and languages. This is borne out by robust research and has the potential to bring significant benefits to patients, as well as leading to some cost-effective decisions for the NHS.

In January this year, the All-Party Group on Modern Languages heard from a panel of experts on the cognitive benefits of learning a second or subsequent language. The panel comprised, among others, the neuroscientist Dr Thomas Bak of Edinburgh University, who is president of the cognitive disorders research group of the World Federation of Neurology. His main clinical research interest is the relationship between language, cognition and the brain. He was accompanied by Dr Dina Mehmedbegovic from University College London’s Institute of Education. She is developing interdisciplinary work with neuroscientist colleagues to provide a broader evidence base for advocating the cognitive benefits of lifelong language learning.

The bottom line is that people who speak more than one language recover cognitively from strokes more successfully than those who do not. In Dr Bak’s study of 2015:

“The percentage of patients with intact cognitive functions post stroke was more than twice as high in bilinguals than in monolinguals”,


“bilingualism emerged as an independent predictor of poststroke cognitive impairment”.

For the sake of clarity, I emphasise—with Dr Bak’s authority—that the word “bilingual” in this context means simply having the ability to communicate, not having a perfect command of a language. His detailed findings included that 40.5% of bilinguals had normal cognitive functions after a stroke, compared to only 19.6% of monolinguals. Looking at that the other way round, he found that that only 49% of bilinguals had cognitive impairment after a stroke, compared with 77.7% of monolinguals. This research was reported in 2015 in the American Stroke Association journal. A further significant finding was that late acquisition of another language has a similar protective effect to early acquisition. It is never too late to start learning another language in order to benefit in this way.

Research has also examined the impact which learning and using more than one language had on delaying the onset of Alzheimer’s and other forms of dementia, and found that it can indeed cause a delay of four to five years, including for vascular dementia, which is the type caused by strokes. Similarly with aphasia, a common language disorder caused by brain damage such as stroke, bilingualism leads to less severe impairment and better recovery. This finding was reported by Paplikar et al earlier in 2018. Dr Bak is involved in a project in Scotland, in partnership with Alzheimer Scotland and Edinburgh University, and supported by an ESRC grant. It is called Lingo Flamingo, and teaches languages to Alzheimer’s sufferers to improve their cognitive resilience.

Will the Minister consider supporting a similar initiative in England and Wales for stroke survivors? Drs Bak and Mehmedbegovic argue that, by increasing multilingualism in the population, we could expect to reduce the incidence of dementia, saving billions of pounds. I understand that the current total cost of dementia care is around £26 billion a year. Exactly the same argument can be made for the long-term treatment of stroke survivors, and I hope that the Minister will agree to take this proposition back to the department.

As always in scientific research, there are some discrepancies in findings across different studies, but on this proposition—that learning and using more than one language improves long-term recovery after a stroke—there is now converging evidence from different studies, different populations, different countries and even different continents that supports the conclusions that I have highlighted. However, to transform the research findings into practical policy, we need to change the general attitude towards language learning in the UK. I am pleased to say that, following the APPG meeting that I referred to earlier, Nick Gibb, the Schools Minister, requested further details of the research for the Department for Education to consider. The DfE’s interest of course lies in the cognitive benefits of language learning for children, of which there are also plenty, although not for elaboration in today’s debate. However, the Minister here today will, I hope, be sufficiently interested and intrigued by my contribution also to want to follow up this innovative research and find out more.

Dr Bak says that,

“promoting language learning and use is one of the cheapest, simplest and most effective means of improving cognitive functions across all ages”,

and he points out that the work of the Lingo Flamingo project is scalable, so if funds were available for a pilot project for stroke survivors, he could have it up and running within months. This would be a fast and measurable initiative. Is the Minister tempted to find out more and would he like me to arrange a meeting for him with Dr Bak?

My Lords, I say to the noble Lord, Lord Lingfield, that it is an absolute joy to take part in this debate with him this afternoon.

Following on from the noble Baroness’s comments, I can recount that about 20 years ago a lady called Mary Anne MacLeod Trump woke up in a hospital ward in New York following a stroke. Most of her nurses thought that she was speaking gibberish, but she was very lucky because one of her nurses was Irish and knew that she was speaking Gaelic. In fact, Mrs Trump had been born on the island of Lewis in Scotland and, unlike her son, did not routinely speak gibberish—it was just the effects of a stroke—and she recovered. The noble Baroness is quite right.

The noble Lord, Lord Lingfield, set out for us the state of stroke care in England and Wales today. However, one point is so obvious that he did not make it: we have a national health service and, consequently, we are in a uniquely good place to gather information about the detection, diagnosis and treatment of stroke and about people’s recovery from it. That is something that we often overlook but it is very important. Just in the last 10 years or so, the work that the noble Lord, Lord Darzi, has done in London in reorganising stroke services has had a measurable effect. Our National Health Service is able to measure, at scale, the effectiveness of new thrombolytic or clot-busting drugs as they come in. That is why we have a real forward steal on the rest of the world in this highly complex area.

In another place back in December, MPs talked a lot about the development of mechanical thrombectomy —I am pleased that I got that out; it is not the easiest word to say. It is a marvellous step forward in the acute treatment of stroke. The ability of surgeons to remove clots and stop further neurological damage makes an immense difference to patients and their recovery.

We are, unfortunately, able to have a 24 hours a day, seven days a week, service in only very few places. Like the noble Lord, I am very lucky to be living up the road from St George’s Hospital: we are okay. Other places are not. The ambition, surely, ought to be to make that service available at specialist neurological centres around the whole country, and easily accessible to the majority of the population as soon as possible.

A particular problem with thrombectomy is that it requires the input of several different medical disciplines, specifically surgeons and others who are not normally part of a stroke response unit. Far be it from me to accuse the NHS of territorialism, but getting surgeons to change their ways is not the easiest thing to do. I ask the Minister, therefore: will thrombectomy services be commissioned via specialist commissioning, and if the provision of the service requires redesign and redefinition—not just of the services but of the medical roles in the team—how that will happen? Does he believe, as I do, that STPs may well face a real battle to get so many people from different disciplines to change the way they work?

My understanding is that the department has not yet decided to refresh the stroke strategy; it is relying on the 2013 cardiovascular disease outcome strategy. Does the Minister believe that that is an adequate way for the department to require the NHS to look at some pretty significant changes among staff?

I also refer the Minister to the experience of some MPs who looked at provision in their local areas. They mentioned the tension between university hospitals and district general hospitals. It requires the might not just of NHS England but the department to look at this problem.

My next point is on research. We have one centre of excellence in research—certainly in thrombectomy—which I think is the University of East Anglia. It is one of several across Europe. I am a Liberal Democrat spokesperson and am therefore bound to ask what the Government are doing to make sure that, post Brexit, research and research collaboration continue? I know that the Royal Society is looking across the piece at the impact of Brexit on research, taking an unbiased and pragmatic view of it. I simply ask the Minister to tell us how the Government will keep an eye on that.

My third observation is that in 2016 Stanford University reported remarkable results from a very small-scale study—about 16 patients—on the use of stem cell therapies. These are often considered to be wonder solutions to quite an array of neurological conditions. I would not go that far: there is a lot to be done by neuroscientists before they realise the potential of stem cell therapy in all sorts of conditions, but principally such neurological diseases as Parkinson’s and possibly Alzheimer’s. If and when those trials are replicated on a larger scale and get to a further stage, where they might lead to some form of therapy, will the NHS build on its track record of work in stroke treatment by taking advantage of such developments?

On the question of rehabilitation, much of what the noble Lord, Lord Lingfield, said pointed to a system in which we have highly skilled staff but not enough of them. We have highly skilled therapists, physiotherapists and nurses—I have been in awe of the ones I have had to deal with—but we need to enable them to impart information first to care workers and secondly to family members, who are there in that golden six-week gap in which recovery can be advanced if people know what to do. To what extent are we asking our NHS acute staff, as part of their duty of care, to pass on information to carers to make sure that they can be there to assist and improvise with things which work?

What do the Government intend to do about the collection of data on post-acute service provision as part of the overall stroke strategy? The bulk of stroke recovery happens in the weeks and months afterwards.

The difference between acute provision and community provision would be that acute provision will help you deal with a physical deficiency, and a community service will help you deal with a lack of confidence. For most people, life after a stroke means living with a lifelong lack of confidence, but that can be aided, helped and treated.

We have done a lot in this country of which we should be proud, but with clever thinking we could do a lot more.

My Lords, I too congratulate the noble Lord on securing this debate and on his informative speech. This is a key opportunity to focus on rehabilitation—that is, life after stroke. Like me, he is a strong admirer and supporter of the Stroke Association on stroke research, prevention, treatment, care and support. As usual, I am grateful for its briefing in support of this debate and for the key background documentation from the Lords Library.

I have spoken on a number of occasions about the importance of renewing and updating the 10-year national stroke strategy, which ran out last year. It has taken time but the strong and determined national campaign for this has resulted in the association and others from across the healthcare system now working closely with NHS England on a national plan for stroke.

There is no doubt that, despite the huge progress in the reorganisation of acute stroke care services as a result of the 2007 strategy, post-hospital support, rehabilitation and ongoing long-term community support for stroke survivors is an area that has seen least progress. It is vital that this be a declared ambition of the new plan and given urgent priority. Can the Minister update the House of progress on the national plan and a timeframe for its development and publication?

As we have heard, stroke is the fourth-largest single cause of death in the UK and is the largest cause of long-term disability. It results in over half of all stroke survivors having some form of disability. With major strokes disability is often profound and severe and, in this context, perhaps I may digress slightly and mention haemorrhagic stroke. Some 85% of strokes are ischemic strokes. Only 15% are brain haemorrhages and there is currently no acute treatment for them, despite their being associated with the most serious strokes and the worst patient outcomes. It is a significantly underfunded area of research into prevention, treatment and rehabilitation and I make a special plea for the Minister to look at this issue.

It is relevant to consideration of whole care pathways and long-term support for stroke survivors, especially those with the severe disabilities that result from a brain haemorrhage. It is also relevant to me as my partner is hemiplegic as a result of a major haemorrhage 10 years ago. He benefited from the early days of the FAST campaign and the successful reorganisation of London stroke services, which was referred to by the noble Baroness, Lady Barker. This meant that he received the emergency and stabilising care and treatment in hospital he needed within the four-hour period. Ten years on, I am pleased to say that he has a very good quality of life, lives well and is a part of the community. I single out four key basics that have led to that outcome for him.

The first is a good, reliable package of personal care, including washing and dressing, and a domiciliary agency that, overall, provides a good service with a regular team of care workers who we both know and trust. The second is a strong and active connectivity through the local community centre, with its excellent stroke support group, and other voluntary sector support. The importance of staying in touch in keeping well cannot be overemphasised as the key to rehabilitation. The third is weekly assisted disability exercise support through a local charity, which helps maintain his limited walking ability. It is not physio but movement exercises by trained assistants. Fourthly, he has the home adaptations and the disability aids he needs, such as a profile bed and splints, plus a power wheelchair, which means that he can get out and about locally on his own. I also add to the list his amazing assistance dog, who has made such a huge contribution to his mobility, independence and confidence, and pay tribute to the charity Canine Partners for its work in training such dogs and supporting disabled people in this way.

Of course, many other elements are involved in supported care at home, such as GP and primary care support, but the current support available is under huge pressure, as noble Lords have pointed out. We know that it is medical and reactive rather than proactive and focused on rehabilitation and staying well—on wellness rather than illness, as the Committee on the Long-term Sustainability of the NHS put it.

The noble Lord, Lord Lingfield, cited the Royal College of Physicians national guidance 2016 as the gold standard. It calls for stroke survivors to have,

“at least 45 minutes of each appropriate therapy … for as long as they are willing and capable of participating and showing measurable benefit”.

Hospital patients typically receive only one-third of that: the equivalent of 16 minutes a day of physio, 16 minutes a day of occupational therapy and 12 minutes a day of speech therapy. We know that, in the community, those therapies mostly have to be self-funded or obtained in the private sector.

The NHS RightCare Pathway included in the Library pack cites earlier RCP guidelines on what should be expected of NHS commissioners, which are clear and unequivocal. The guidelines stress:

“Commissioning organisations should ensure that their commissioning portfolio includes the whole stroke pathway from prevention (including neurovascular services) through acute care, early rehabilitation, secondary prevention, early supported discharge, community rehabilitation, systematic follow-up, palliative care and long-term support”.

It is vital that more CCGs and the STPs commission services that meet what is set out in the guidance. I should like the Minister to respond to that.

As all speakers have stressed, stroke is a recoverable condition. Many stroke survivors see improvements physically, communicatively and cognitively for months and years afterwards. The often-repeated adage that I heard when my partner first had a stroke—sadly, from both the public and some professionals—was that stroke improvements will not take place after two years. That is wrong. Improvements can and do happen with the right motivation, support and help along the care pathway.

I ask the Minister some questions on this issue. First, will he comment on the large regional variations in the availability and quality of community services for strokes shown in the latest national stroke audit? Secondly, will he comment on the unacceptably high waiting times for starting speech and language therapy post hospital—two months in some of the worst performing areas? Thirdly, will he comment on the 12-week waiting time for psychological support for stroke survivors across the country—up to five months in some areas, when the target is two weeks? Fourthly, will he comment on the action being taken to deal with CCGs which, despite the strong national guidance, are not commissioning ESD to provide intensive, multidisciplinary stroke-specialised rehabilitation and support for patients, carers and families? Forty per cent of patients should be eligible for this, but do not receive it. These are key questions, and I look forward to the Minister’s response.

It is small wonder that 45% of stroke survivors say that they feel abandoned when they get home from hospital, lacking in confidence, information and support. I can certainly relate to that. Fifty-one year-old Philippa Haslehurst, who had a stroke four years ago, received just two NHS sessions of physiotherapy and occupational therapy before having to pay for private treatment. She said:

“I felt like after a couple of rehabilitation sessions, the NHS had wiped its hands of me. I had made hardly any progress and I was still dealing with the debilitating after-effects of my stroke. If it wasn’t for private physio, I wouldn’t be walking now, let alone be back at work. I believe physio saved me”.

I also ask the Minister about the personalised care plans that stroke survivors are supposed to receive for their ongoing post-hospital treatment, care and support, and the findings of the recent Neurological Alliance survey that over 70% of patients are not offered one. Surely this should go hand in hand with the ESD plans for personal and domiciliary care support and generally to ensure that patients are discharged into a safe environment. Can the Minister also explain what action is being taken to ensure that all CCGs commission the six-month post-hospital review of stroke survivors’ progress and problems? Less than a third of stroke survivors receive this review and only half of all CCGs actually commission it. NHS RightCare guidance includes follow-up annual reviews, which are obviously needed if a patient’s progress is to be monitored effectively.

As the noble Baroness, Lady Barker, said, one of the key issues arising from this debate is the lack of post acute-stroke data in comparison with that for acute care. We need strong and consistent data on the provision of the different types of therapy, treatment and rehabilitation as well as on measurable patient outcomes; its lack is seriously hampering progress in this area. Can the Minister outline what work is being done and will the recommendations in the national stroke plan include ensuring that this key aspect is addressed?

This has been an excellent, thoughtful and wide-ranging debate, despite having few contributors, while we wait for the national stroke plan to be finalised and for the publication of the social care Green Paper, now promised for the autumn. I hope that the Government will recognise that prioritising effective rehabilitation for stroke survivors will achieve significant long-term savings across the health and social care system as well as being of huge benefit to stroke survivors themselves.

My Lords, I congratulate my noble friend Lord Lingfield on securing this debate. As the noble Baroness, Lady Wheeler, has just pointed out, it has been short but sweet—rather, we have had a small cast list but a high quality of output. The experience of the noble Baroness and that of her partner has been invaluable, while the noble Baroness, Lady Barker, asked some searching questions, which I shall attempt to answer. The noble Baroness, Lady Coussins, will be amused to learn that in my briefing it states of her, “Does not normally ask health questions”. I am absolutely delighted that she is here, because hers is a perspective that we have not had before. I hope that it is not the last time that we see her taking part in a debate of this kind, and I shall come to the very interesting ideas that she mentioned. Along with other noble Lords, I recognise and applaud the work of charities like ARNI, while my noble friend also referred to the Stroke Association, Canine Partners and others. They make a valid and vital contribution to care in this area.

We have talked about the impact of stroke. In England some 80,000 people a year are being admitted to hospital. We also know about the impact that strokes can have not only on the lives of sufferers themselves, but also on their families, friends and carers. The statistic that stroke leaves half of those affected with a disability is a sobering one. We know also that the difficulties are not just physical. As we have discussed, they include communication difficulties, psychological cognitive fatigue and others. Indeed, stroke is the leading cause of complex disability, as well as the fourth largest cause of death, which is why it has quite rightly been the focus of successive Governments.

It is worth saying that major improvements have been made in stroke prevention, treatment and outcomes since the publication of the 2007 strategy, for which the then Labour Government deserve much credit. I shall highlight one or two of those outcomes, because they highlight some of the questions which have been asked. Over the past 20 years, the 30-day mortality rate has dropped from 30% to 13.5% in 2015-16. There is now better compliance with the occupational therapy standards, from 56% to 83%, while physiotherapy standards have risen, along with speech and language therapy. However, it is notable that even with speech and language therapy, where compliance has doubled, it remains at less than 50%, which goes to the heart of some of the points about variations in provision which noble Lords have pointed out. While improvements have been made, it is clear that a lot more needs to be done.

As several noble Lords mentioned, one way that we can improve rehabilitation is to get the care right in the first place. The noble Baronesses, Lady Barker and Lady Wheeler, mentioned mechanical thrombectomy, which is highly effective at preventing severe disability. The statistics are interesting: for every 100 patients treated, 38 will experience a less disabled outcome than with the best medical management—an extraordinary improvement—with 20 more achieving functional independence. Having national coverage is clearly important, and I will come on to how we try to achieve that.

The noble Baroness, Lady Wheeler, talked about how her partner had benefited from Public Health England’s Act Fast campaign. That is reducing the amount of time between someone having a stroke and arriving at hospital. The campaign has been going for about nine years now, during which 5,365 fewer people have become disabled as a result of a stroke, saving the equivalent of 12,200 quality-adjusted life years. This is quite an achievement for a public health campaign. The third area on the acute side where big improvements have been made, and which noble Lords have spoken about, is the centralisation of services, including hyper-acute stroke services. The noble Baroness mentioned the work which our colleague, the noble Lord, Lord Darzi, did in London. Because of that, a significantly higher proportion of patients are receiving care compliant with the guidelines and processes. That alone has delivered a 5% relative reduction in mortality at 90 days, another significant improvement.

Those things are at the acute end, but the topic for today is rehabilitation. As has been mentioned, there are over 1 million stroke survivors. Not only do half of those have a disability but half are also living with four or more co-morbidities. The question is: how do we get their lives back on track? We know that rehabilitation delivers better outcomes, improves quality of life and reduces health inequality. It also provides good value for money; it is the right thing to do on every level. It is also important to approach this with an optimistic mind set. As noble Lords have pointed out, stroke can be a recoverable condition, with survivors continuing to improve for months after their stroke.

We know from stroke survivors and the charities that represent them, and we have heard today, that they need early and ongoing rehabilitation and support. The testimony of the noble Baroness, Lady Wheeler, and her partner brought this to life. This includes holistic reviews of progress; a personalised care and support plan which is regularly updated; the provision of information; the availability of the right therapies; and so on. This obviously has to happen in the acute setting but, more importantly, it needs to happen in the post-acute setting as well.

My noble friend Lord Lingfield and the noble Baroness, Lady Wheeler, talked about the stroke working party guideline of 45 minutes, but they also said that that is being missed all too often. What are the Government doing about it? The governing document has been the strategy which began in 2007, which has now been replaced with the stroke programme board, established in March this year. It is chaired by the national medical director of NHS England and the CEO of the Stroke Association and is developing a costed stroke plan to address the challenges of prevention, service reconfiguration, optimising rehab services, workforce development and data. I do not have a date at this time, but I shall endeavour to write to the noble Baroness and other noble Lords with that.

The board is looking at some changes. It has been said, quite rightly, that there needs to be seven-day availability of the right workforce. We need to make sure that nurses, therapists and other medical staff are there round the clock. As we know, there is some silo thinking on clinical expertise in the NHS. As the noble Baroness, Lady Barker, pointed out, the availability of mechanical thrombectomy is hampered by a shortage not just of skilled neuroradiologists but of other trained consultants. Reconfiguration can deal with some of that, but we need to do more to deal with it at a national level.

Through the work of the programme board we intend, first, to include stroke-specific plans within workforce strategies and to support integration across care settings. Secondly, we will establish training pathways from other medical specialties to increase the interventional neuroradiology workforce. Thirdly, we will include experience in stroke medicine early on in the undergraduate curricula of foundation medical training programmes, to encourage early career choices to pursue stroke training.

The noble Baronesses, Lady Barker and Lady Wheeler, also talked about the need for better data. That is absolutely right, and is happening in a couple of ways. First, a new national clinical audit of cardiovascular disease prevention in primary care is being instigated. Secondly, in reference to one question that was put, we are making sure that the research strategy of the NHS will address key evidence gaps in stroke, particularly around post-acute care. I shall certainly take away the suggestion by the noble Baroness, Lady Wheeler, about a specific type of stroke and the under-resourced or under-researched nature of it.

Much of the funding for research comes through the National Institute for Health Research—a domestic source, although this issue is international in scale. As for Brexit, following our exit from the European Union, we are looking to achieve participation in the next iteration—the successor programme to Horizon 2020. Third countries are already participating, so it is within our grasp, as was set out in the Government’s Collaboration on Science and Innovation: A Future Partnership Paper.

On commissioning, which was also mentioned, NHS RightCare: Stroke Pathway was published in October 2017 and is the governing document. We need to ensure that the guidance that includes information about early supported discharge and community provision is adhered to. I do not know what the mechanisms are by which we will improve compliance, some of which is quite good and some, frankly, too low. That is a topic of work for the programme board. I shall write to noble Lords with its ideas on how it intends to make that bite, so that there is CCG compliance in commissioning frameworks.

Finally, we need a different approach to rehabilitation, one that is collaborative and integrated across health, social care and, critically, the third sector. In addition to rehabilitation, stroke survivors need a very broad set of services, including spasticity services, psychology, orthoptics, pain and continence services. As we have also heard, stroke survivors often need help with housing adaptations.

We have, therefore, three goals to achieve this rehabilitation revolution. First, we must make sure that there is proper commissioning of stroke specialist rehabilitation of the required intensity seven days a week for stroke victims through their in-patient stay, as recommended by the clinical guidelines. That will be driven by NHS England. Secondly, we must ensure that stroke survivors have access, within 24 hours of discharge from hospital, to a stroke specialist rehabilitation service that can provide support for the early discharged patient at the same rehabilitation intensity as stroke unit care, seven days a week. Thirdly, we need to develop a national service specification for the structure and process of stroke specialist rehabilitation services provided immediately after discharge, including early supported discharge, that describes appropriate staffing levels and, critically, addresses rurality. We must not only set those guidelines but make sure that they are complied with.

I shall briefly answer questions where I have not yet had a chance to do so. My noble friend Lord Lingfield asked about grants from public funds to rehab charities. Local authorities do that kind of work through their social care function. I am not aware of what CCGs and the NHS itself do, but I will endeavour to find out what support is available.

The noble Baroness, Lady Coussins, took us on a very interesting journey into the power of language, and second languages. I knew about its benefits for dementia sufferers, but not about its benefits for stroke sufferers. I shall certainly be happy to find out more about the scheme and whether we can help. It sounds like a fascinating idea; considering the annual cost of stroke, and what the cost of educating children in a second language at school would be, the cost-benefit analysis looks quite good. It is something to think about, and I am glad that my right honourable friend Nick Gibb is enthusiastic about it.

The noble Baroness, Lady Barker, asked about stem cell and gene therapies. It is a really good question. We have a fantastic network of biomedical research centres, funded by the National Institute for Health Research. I do not know if she has had the opportunity to visit any of them but I thoroughly recommend it. Sometimes we are a bit hard on ourselves in this country in asking ourselves whether we really have access to cutting-edge, world-leading therapies in cancer, stroke, cardiovascular, or whatever. This is where it happens—where the translation from lab to the clinical setting happens. People here are among the first in the world to get these therapies. I thoroughly recommend seeing that, and if the noble Baroness were to get in touch I would be delighted to recommend a suitable one. We have the opportunity to be involved in this field, and a good track record in it.

Finally, the noble Baroness, Lady Wheeler, asked several questions. I hope that I have responded to most of them. If I have not, I will of course follow up with a letter.

I close by once again thanking all noble Lords for their contributions. It has been a fascinating and useful debate. With the programme board in place, I think that we have the opportunity and the leadership to make sure that we improve stroke services. We are in the happy position of knowing what is necessary; now, we need to deliver it. I am sure that, working together, we can start to transform rehabilitation care so that it is of the intensity required and provides a lifeline to stroke sufferers.

Sitting suspended.