Brain Injury Rehabilitation (Frenchay) (Hansard, 5 December 1990)

§ Mr. Michael Stern (Bristol, North-West)
Frenchay health authority covers a substantial area to the east of Bristol, but it touches on my constituency in two respects. First, many of my constituents already look to Frenchay as an alternative provider of services to their home district of Southmead or the Central Bristol and Weston district. Many more are looking forward to the more consumer oriented and more varied pattern of service that will inevitably develop in the three districts as a result of the Government's health service reforms next year. Secondly, a major part of Frenchay's provision for mental handicap is at Stoke Park hospital, which lies within the boundaries of the Bristol, North-West constituency, as does the independently funded Burden institute. It is likely that the staff of those two highly respected institutions would be the principal providers of the proposed service in respect of brain injury rehabilitation.
Despite a rapid increase in knowledge of the nature and rehabilitation of acquired brain injury around the world in the past decade, rehabilitation facilities and the study of rehabilitation techniques in the United Kingdom are sparse and unevenly distributed. The south west region has one small unit which serves only Cornwall. Wessex region has four in-patient general rehabilitation facilities, but no dedicated brain injury service exists in the south west or adjoining regions. I believe that there is no comprehensive organisation for the management, study and treatment of brain injury anywhere in the United Kingdom.
As a result, no accurate data exist in the United Kingdom on the actual incidence of severe head injury. By "severe" I mean that defined as causing post-traumatic amnesia of more than 24 hours. Evidence shows that the outcome of treatment of serious brain injury is far from optimum and is capable of improvement by way of increased personal independence and reduced job loss. However, those optimum outcomes tend to be available only as a result of prolonged intensive rehabilitation.
For more than 10 years a partnership of consultants and research scientists at Frenchay hospital and the Burden neurological hospital and institute have been working on designing a model service for brain injury management and rehabilitation. The model is based not only on information and advice from successful centres in the United States of America, other parts of Europe, Israel and Australasia and on wide consultation with professionals in rehabilitation of all kinds throughout the United Kingdom, but on a considerable body of personal experience built up in the district. The resulting service is, to say the least, impressive.
A few years ago, a layman such as I would not have thought possible the advances in medical science that the use of sophisticated computer techniques and advanced learning programmes, overlaid with the detailed experience in the treatment of brain injuries, have brought about. Links have been established with other local units in respect of particular elements in the treatment programme. For example, the Bristol royal infirmary conducts assessments and offers clinical follow-up facilities. There are also links with clinicians working with the brain-injured elsewhere in the south-west. So far, 427 however, facilities have not been developed in line with scientific advances, and the lack of any specialised in-patient rehabilitation facility has meant that the consultants and research scientists have not been able to achieve for the victims of brain injury what they know can be achieved and what international experience has shown can be achieved.
In 1989, Frenchay health authority applied for special medical development funding for a head injury rehabilitation service, but its bid was unsuccessful in competition with bids from other medical areas. I understand, however, that the Department is still interested in funding a model head injury rehabilitation service, and it is on that basis that the authority has prepared and submitted a further proposal.
The authority has proposed a centrally funded model brain injury rehabilitation service with independent scientific evaluation of its effects in terms of economic quality of life and cost-effectiveness over a five-year period. It is intended that initially the service will provide skilled treatment, rehabilitation and follow-up for all those with brain injuries in the northern part of the South West regional health authority area, but I am sure that many of the members of the team which has developed the service share my view that demand will rapidly stretch beyond the sub-regional area that it was originally intended to cover.

§ Mr. Jonathan Sayeed (Bristol, East)
Does my hon. Friend agree that, like recovery from brain injuries. their assessment and treatment is a slow process and that we should therefore need a minimum trial period of five years for the Department properly to investigate any system?

§ Mr. Stern
My hon. Friend has hit on one of the most important aspects of the problem. The authority's proposal can be made to work only if it is allocated an appropriate trial period. The five-year period has been chosen because recovery is slow and the medical and social outcomes can be assessed only after a lengthy period has elapsed. A period of less than five years would fail to produce data of clinical value.

§ Mr. Jack Aspinwall (Wansdyke)
I congratulate my hon. Friend on securing an Adjournment debate on this important subject. Is he aware of the interesting situation that has developed in respect of Headway, an organisation which is very active in the Frenchay and Bristol areas, and which works hard to encourage the kind of project that he has proposed? I hope that my hon. Friend will take into account the many representations that have been made to him and to me. In the past few weeks, I have received more than 100 such representations from my constituents.

§ Mr. Stern
My hon. Friend has drawn attention to an important aspect of the case. I applied for an Adjournment debate partly because, like him, I had received a large number of representations from families and friends of people who had suffered brain injuries, and who are aware of the scope for additional work to be done.
It is accepted in Frenchay's application that the service would not necessarily be restricted to the needs of the head-injured. Many of the techniques developed so far could be applied to other forms of disability such as severe encephalitis and the effects of anoxia. However, the service could not be adapted to meet the needs of patients who 428 have suffered strokes or the victims of progressive neurological diseases, and it would be concerned, at least in its initial stages, with adults rather than with children.
Finally, I should mention that the proposal, once implemented and evaluated at the end of the five-year period, would ideally fit into the pattern of provision of service that will develop as a result of the Government's reforms. There is a clear intention that a properly evaluated service will be offered through the contracting system to purchasing health authorities not just in the sub-region but beyond it, and what I am therefore inviting my hon. Friend to consider this evening is a permanent addition to the range of services offered by the national health service which, once initially funded, will not require further special funding.
A consultant at the Burden neurological institute has drawn my attention to a paragraph in the original Beveridge report of 1942 which pointed out the need for a national health service to encourage rehabilitation, and which stated: Rehabilitation is a new field of remedial activity with great possibilities, but requiring expenditure of a different order of magnitude from that involved in the medical treatment of the nation". I commend the proposal to my hon. Friend and look forward to his reply. First, however, I give way to my right hon. Friend the Member for Northavon (Mr. Cope).

§ Mr. John Cope (Northavon)
Frenchay hospital is situated in my constituency and in the past 16 years I have got to know it quite well. I know some of the consultants and other staff at the Frenchay and Burden hospitals who are involved in the treatment and rehabilitation of those with head injuries, about whom my hon. Friend the Member for Bristol, North-West (Mr. Stern) has been speaking. The proposal that my hon. Friend has supported today has important potential which deserves the closest study from my hon. Friend the Minister. I am sure that he will look at it carefully and I hope that he will consider it sympathetically.

§ The Parliamentary Under-Secretary of State for Health (Mr. Stephen Dorrell)
I congratulate my hon. Friend the Member for Bristol, North-West (Mr. Stern) on introducing this subject on the Adjournment. The idea that he has drawn to the attention of the House has clearly aroused considerable interest in the Bristol area. My hon. Friend is right to bring the matter to a wider audience because in so doing he draws attention to what I shall seek to demonstrate is recognised to be one area in the national health service in which further improvement is necessary. The proposal which has been prepared by the Frenchay district health authority and which my hon. Friend has espoused in this short debate suggests an interesting way forward, to which I hope to be able to respond in a friendly spirit, if not in a concretely positive spirit immediately.
My hon. Friend suggested that the Department should accept the proposal from the Frenchay health authority that a sub-regional brain injury rehabilitation unit should be developed in the authority, which would not only form the basis of improved care in the immediate area around Frenchay but could provide research and expertise that could be applied elsewhere in the health service. That is a powerful case, to which we react with interest, but also 429 recognising that, within the context of the health service, such a submission must always enter immediately into the competition for resources which is a necessary part of the management process.
In terms of our analysis of the problem, there is no difference between myself and my hon. Friends, or between myself and the Frenchay health authority. This is clearly an issue that needs to be addressed, and in bringing it to the attention of the House this evening my hon. Friend has done a service nor merely to the residents of Frenchay but to a wider audience.
I think that my hon. Friend would accept that he has been addressing the specific problem of rehabilitation after the immediate acute phase of treatment has been attended to. It is important to distinguish between the treatment of the acute condition and the post-acute rehabilitation service.
In the context of the acute care of people suffering from head injury, the health service has a good record. The victim of a motor accident or any other incident leading to serious injury can, in the immediate phase after the injury, expect from the national health service quality of care that is second to none. The care gives the patient a good chance to stabilise his condition and enter a rehabilitation phase. The immediate control of the acute symptoms of a head injury is something that the national health service does well, and that pattern repeats itself in the course of other treatments under the NHS. Treatment of acute-phase post-injury is of a high quality throughout the country.
The problem that my hon. Friend highlights relates not to the acute phase immediately after an accident, but the long-term rehabilitation when the patient's condition is stabilised and there is potential to set him on the road to recovery. As I have already acknowledged, that is where the record is less good. The problem is not purely esoteric, applying only to a small number of patients, but involves a significant part of health care provision. It is a serious problem, which each health authority should address.
My hon. Friend rightly said that statistics are unreliable, but such estimates as are available suggest that, in the average district health authority, there are each year 20 new cases of severe disability and 45 new cases of moderate disability arising from brain injury. Even after six months, five of the 20 severe cases and five of the 45 moderate ones still display substantial disability. The cumulative effect of that on the resident population in an average district health authority means that each authority contains between 250 and 350 survivors of accidents or other causes of brain injury with severe disability. In each health authority district, the problem is of substantial if not large proportions, and one that each authority must address.
Precisely because our care of the acute condition is relatively good, there has tended to be a rise in the number of those likely to benefit from the type of rehabilitation care for which my hon. Friend argued this evening. Therefore, the issue is not purely esoteric. Clearly, potential benefit is available if proper rehabilitation is provided because it is beyond dispute that, where that is provided, the improvement in the patient's condition can be considerable. When proper support is provided, it is 430 possible to see dramatic transformations in the expectation of a patient and his carers and supporters in the immediate post-acute phase.
We acknowledge that the rehabilitation service falls below the aspirations that most of us have for it. It would be hard to do otherwise, because two recent reports, one from the Royal College of Physicians and the other from the Medical Disability Society, have drawn attention to the lack of specialist facilities for the rehabilitation of brain-injured patients and to the likelihood that they will find themselves in an inappropriate place for the care that they need. There is a risk that patients will find themselves in a mental handicap or mental illness hospital, or bed blocking in an acute hospital. None of these are proper places for high quality rehabilitation.
The two reports also highlighted deficiencies in the training of staff and drew attention to the lack of out-patient and day-patient facilities, so it is clear that the infrastructure of the rehabilitation service is not all that we should like it to be.
The news is not uniformly bad, however. There are places in the NHS, notably the Rivermead centre in Oxford, where there is high quality rehabilitation care. Some authorities use quite well-known facilities in the private sector to provide rehabilitation.
The Department has already taken some steps to try to improve basic provision, notably by providing funds for the charitable organisation that my hon. Friend the Member for Wansdyke (Mr. Aspinwall) mentioned: Headway. We also support the development of Oakwood house in Stockport and the work that it is doing in co-operation with the Leonard Cheshire Foundation. So we have supported the development of rehabilitation care facilities in the voluntary sector.
We recognise that further action is necessary. As my hon. Friend the Member for Bristol, North-West said, even in the days of Beveridge it was suggested that the NHS should be a three-legged stool—we should emphasise prevention and rehabilitation as well as treatment. The rehabilitation leg for brain-injured patients is not yet as good as we should like it to be.
What steps do the Government intend to take to put right this acknowledged weakness? We are considering whether to invite model schemes of the type that Frenchay has put forward. Before doing so, however, we should first consider how high a priority to attach to the rehabilitation of brain-injured patients in the health service. At any given moment, there are always opportunities to improve the quality of the health service, but any proposal to improve the rehabilitation of brain-injured patients will have to take its place in the competition for resources in any given year. It might be decided that it was a longer-term priority.
Our first decision, which we have not yet taken, is to determine whether the improvement of rehabilitation facilities for brain injured patients is a priority that we can tackle in the next financial year. If we decide to invite applications, we would invite from each health authority development schemes to treat brain-injured patients. If such an invitation is issued, I have no doubt that Frenchay would put forward its scheme. I have had a brief look at that scheme and, plainly, it has been well thought out. My hon. Friend the Member for Bristol, North-West referred to its genealogy.
The scheme is well established and its ideas are the result of considerable background knowledge of the field. Therefore, it would be a strong runner, but it would not be 431 right for me to commit myself to accepting that proposal rather than one of the other runners that I have not yet had a chance to examine in the paddock. It is right to decide, first, whether the priority can be addressed next year. Secondly, if we decide to address it, we must ensure fair competition between the proposals that are submitted by health authorities.
My hon. Friend the Member for Bristol, North-West has drawn attention to an important matter, and even if we do not address it next year, we shall clearly have to address 432 it at some time. The proposal that he espoused is a useful contribution to the debate about precisely how services in that field should develop. When the Secretary of State is able to say that he intends to fund some model schemes, the Frenchay proposal will be considered seriously and sympathetically by whoever has the opportunity to improve facilities.