Strokes

HC Deb 14 December 1998 vol 322 cc735-42

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Hill.]

11.53 pm

Mr. David Amess (Southend, West)

Christmas is a particularly good time of year to consider the state of the nation's health, for obvious reasons. I suppose that I am looking to the Minister to show charity in redressing what I am sure was the unintentional omission of no longer having stroke as a national priority.

Since it was announced that we would have the debate this evening, I have been contacted by a number of hon. Members. I know that the hon. Member for Crosby (Mrs. Curtis-Thomas) wanted to be in her place and that for various reasons, she is unable to be present. She is very interested in the subject. I am delighted to see the hon. Member for North-East Derbyshire (Mr. Barnes) in his place. He is a regular attender in the Chamber and I had not realised that he was the victim of a stroke this summer. Having read the newspaper cuttings, I pay tribute to him on the remarkable recovery that he has made. He is in a good position to speak about the Government's decision not to continue with stroke as a national priority.

Mr. Harry Barnes (North-East Derbyshire)

I compliment the hon. Gentleman on raising this subject. I also thank you, Mr. Deputy Speaker, for assisting me when I had a stroke, which happened on the Bench in front of me. My hon. Friend the Member for Bolsover (Mr. Skinner) and an Attendant serving the House also assisted. The events were of great personal importance and give me some insight into this issue. I am keen that the Government should pay proper attention to the interests of bodies such as the Stroke Association.

Mr. Amess

I am glad that the hon. Gentleman has made that point. Although it may be slightly embarrassing that you are in the Chair at the moment, Mr. Deputy Speaker, there is no doubt that had it not been for your good self and others, the hon. Gentleman might not be with us today.

I note that the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) is in his place and I am delighted that my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) is also here. She knows how important the subject is. I am even more delighted that the Under-Secretary of State for Health, the hon. Member for Barrow and Furness (Mr. Hutton) is to reply to the debate. He is a product of Westcliff grammar school in my constituency. We are proud that a product of a local selective secondary school has become a Minister. I am not so delighted about his politics, but I do not think that it is churlish to hope that in the coming year when we debate the future of grammar schools, he will bear in mind the great debt that he owes to Westcliff high school for boys. It is barmy to deny future generations the opportunity of the education that he had without putting something better in its place.

I regret the removal of stroke as a priority. The Conservatives' "The Health of the Nation" White Paper set two targets for stroke: one for those under 65 and another for those between 65 and 74. For whatever reason—no doubt the Minister will enlighten me—there is now just one target for heart disease and stroke combined for the under-65s only. I regret that.

Each year, more than 100,000 people in England and Wales have a first stroke. It is a little like Members of Parliament saying that they are experts because they are a father or a mother, but my father died following a number of strokes. He was a good age and his strokes went on over five years. He liked the occasional drink. The first time that it happened, as I remember only too well, my mother thought that he might have had a little bit too much to drink. We realised that something had happened to him—my nephew was present at the time—when he lost his speech. I have not had the same experience as the hon. Member for North-East Derbyshire, but I have seen my mother, who was nearly 80, caring for my father for five years. She kept him alive, but he lost a great deal of his dignity. He went to a speech therapist, but he never really regained his speech. I have witnessed at close quarters what stroke means for many people.

There are more than 60,000 deaths each year due to stroke. It is the third most common cause of death, after heart problems and cancer. Stroke is the largest single cause of severe disability in England and Wales. The estimated cost to the national health service is £2.3 billion a year. The cost of stroke care will rise in real terms by about 30 per cent. by 2023. As we all know, stroke is blockage of the supply of blood to the brain. The effects of stroke can be mild or severe. Who is at risk? There seems to be a misunderstanding that only elderly people are at risk, but young people can suffer from strokes. It has been estimated that about 40 per cent. of strokes could be prevented by regular blood pressure checks.

I pay tribute to the Stroke Association, which has been quite magnificent in briefing me closely. It is a national charity which provides practical support to people who have had strokes, their families and carers. I was privileged to be present, by sheer coincidence, at my local stroke Christmas dinner on Saturday evening and I spoke to a number of people who have suffered strokes and their carers.

I am delighted that stroke services in Southend are first class. I have no complaints about our local services and we have an excellent unit at the hospital, which takes patients in the acute phase and works through the rehabilitation process with them. After discharge, essential follow-up rehabilitation is provided by community-based speech and language therapists. Neuro-physiotherapists and occupational therapists also help, and funding is provided for a Stroke Association dysphasia support officer who, together with a team of volunteers, provides continuing support for those who have communication problems after strokes.

The service in Southend is first class, but, without being dishonourable to the Minister, I want to articulate and share with him my concerns and tackle the ministerial responses, which I do not accept. "Modernising Health and Social Services: National Priorities Guidance 1999/00–2001/02" has at page 10—for all to see, so I am not imagining it—waiting list times, primary care, coronary care, heart disease and cancer, but there is no mention of stroke.

At page 20, although the Minister will argue that it is included under coronary heart disease, it is not at all clear that stroke is accepted as a priority. That important document will direct the work of health and social services for three years from April next year, which is why I am very concerned. Stroke is the single largest cause of disability.

The Government's decision contradicts the long-term health strategy proposed in "Our Healthier Nation" earlier this year. "Clinical effectiveness using stroke care as an example" is a report by the Clinical Standards Advisory Group, an independent body which advises Ministers. The Government have drawn upon the variations in treatment and care revealed in it to support their general approach to quality in the NHS, but I believe that they have failed to address stroke-specific aspects of the report, some of which are extremely worrying.

Probably the most serious finding relates to carotid endarterectomies. Despite clear guidelines that such operations should be carried out only if complication rates are under 10 per cent., the majority of clinicians were not aware of complication rates. I am not trying to trick the Minister, but his boss, the Secretary of State for Health, described the situation as "particularly alarming" in early June. However, in a response to a parliamentary question, my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) was told that the Secretary of State will not be making any additional response to the specific recommendations regarding strokes."—[Official Report, 30 July 1998; Vol. 317, c. 514.] The national service frameworks are aimed at major disease groups and care areas where national consistency in services is desirable; my concern is that that is not being properly tackled.

I shall be brief, as I want to give the Minister time to respond. I expect him to say that making everything a priority in the national priorities guidance would mean that nothing is a priority. However, the Stroke Association is not asking the Government to step outside the priorities identified in "Our Healthier Nation"; it wants the labelling of stroke as a priority to be followed through with action. The rhetoric of Her Majesty's Government—I speak, of course, as a critic—is wonderful, but action is lacking.

I expect that the Minister will also say that stroke has not been excluded from the national priorities guidance. The section of "Our Healthier Nation" that it is claimed covers heart disease and the stroke target is, in fact, entitled "Coronary Heart Disease"—I cannot for the life of me understand why no one had the common sense to retain stroke in that section.

The Minister will say, I am sure, that the national service frameworks on heart disease and older people will deal with many issues relating to stroke. Apart from the target for accidents, however, stroke is the only target in "Our Healthier Nation" for which a national service framework is not being developed.

I commend stroke units to the Minister; excellent work has been done in Glasgow in particular. It has been shown that the chances of a patient dying can be reduced by 18 per cent., that the chances of a patient dying or requiring institutional care can be reduced by 25 per cent. and that the chances of a patient remaining physically dependent can be reduced by 29 per cent. Those results suggested that approximately 22 patients would need to be treated in a stroke unit to ensure that an extra patient survived, that 14 would need to be treated to ensure that an extra patient returned home and that 16 would need to be treated to ensure that an extra patient regained physical independence. I suspect that the vertical structure of the Department of Health has led to the downgrading of stroke.

The Parliamentary Under-Secretary of State for Health (Mr. John Hutton)

indicated dissent.

Mr. Amess

The Minister shakes his head but that is my suspicion. I have been advised that no one in the Department any longer takes an overall view of matters relating to stroke. As I said, we are approaching Christmas, so I hope that he has some good news for me.

12.9 am

The Parliamentary Under-Secretary of State for Health (Mr. John Hutton)

I am grateful to the hon. Member for Southend, West (Mr. Amess) for giving the House the opportunity, even at this late hour, to debate this important issue. He asked me a number of questions, to which I hope to respond; in doing so, I shall correct some of his misunderstandings of Government policy.

I was very sorry to hear of the death of the hon. Gentleman's father from stroke. I was not aware of that fact. He said that his mother cared for his father for some time, so I am sure that he will join me in welcoming the Government's initiative in setting up a national strategy for carers—it is important that we deal with the needs of carers in a co-ordinated way. I join him in congratulating the professionalism and dedication of national health service staff in his constituency, where, as he will know, I lived for many years—I retain great affection for that part of the country, where many members of my family still live. I am very glad also that my hon. Friend the Member for North-East Derbyshire (Mr. Barnes) has made a full recovery from his stroke.

The hon. Member for Southend, West was right that, as the UK's third-biggest killer is stroke, and as it is the largest cause of serious disability in the UK, it is a subject that affects us all. We all need to know what the risk factors are for stroke. Through the NHS and other agencies, we need well-integrated services to help care for, treat and rehabilitate patients following a stroke.

As the hon. Member for Southend, West knows from his personal experience in his family, a stroke can be a catastrophe for patients and their families. Each year, 110,000 people in the UK experience their first stroke and 30,000 have recurrences. It is estimated that about 350,000 people are severely disabled at any one time because of stroke. It is the third most common cause of death in the UK, and an important cause of severe disability. Although the majority of strokes affect older people, anyone can have a stroke at any age. The devastation that an unexpected stroke brings to the life of a younger person in particular—and to their family—can be barely imagined.

I reassure the hon. Member for Southend, West that we take the issues very seriously. The Government are committed to reducing the numbers dying from stroke, and the numbers of those suffering disability as a result of stroke.

There are three key areas where we can influence things: first, through prevention and education about risk factors; secondly, through the care that people receive—normally in hospital—immediately following a stroke; and thirdly, through rehabilitation services, which ensure that patients and their families can return, as far as possible, to the life style that they enjoyed prior to a stroke.

Strokes are a major cause of disability, and we must do everything possible to prevent and limit the burden that they impose on both stroke victims and on those who care for them. In the consultation paper, "Our Healthier Nation"—to which the hon. Member for Southend, West referred—we have selected heart disease and stroke as a priority for action, and we are proposing a target reduction in stroke mortality of at least a further third by 2010. This target is taken from a 1996 baseline.

What can people do to modify the risk of getting a stroke? Modifiable risk factors include smoking, raised blood pressure, raised plasma cholesterol and physical inactivity. Other contributory factors are excessive alcohol intake, obesity, excess salt in the diet and diabetes. Inactive people face three times the risk of stroke that people who are active face, and smokers face twice the risk. The Department of Health has been funding a major physical activity campaign called "Active for Life". This campaign highlights the relatively simple forms of physical activity—for example, a brisk walk for 30 minutes, five times a week—that can help to protect against stroke. We are spending £9 million on the campaign.

The Government have just published our White Paper, "Smoking Kills", which sets out our new proposals for implementing a ban on tobacco advertising. Together with other measures, we believe that that will be a significant step towards tackling one of the major risk factors for stroke. The commitment in the White Paper is clear evidence of our determination to address the issues raised by the hon. Gentleman. I am sorry that he did not mention the White Paper.

What about people who suffer a stroke? The needs of stroke patients span a wide variety of services. Patients who suffer a stroke will need acute care immediately following their stroke and, depending on the severity of the stroke, a programme of rehabilitation to help them optimise their independence afterwards. Stroke is a medical emergency, and the majority of patients are admitted to acute medical wards from accident and emergency departments. The aim of initial treatment is to stabilise the patient, and to reduce fatality, to reduce major disability and to prevent secondary stroke.

We are starting to see some evidence that new clot-buster drugs may improve the treatment of acute stroke. However, we need to look at further research before those drugs enter mainstream use. Nevertheless, there is a growing view that early admission of stroke cases to hospital is beneficial to ensure the patient's oxygen supply remains unimpaired and that blood glucose levels, and other aspects of metabolism, can be controlled.

The pattern of care for stroke patients is varied in England. Following the acute phase, patients may remain in acute medical wards or transfer to a stroke unit or rehabilitation facility, or have a package of rehabilitative care in their own home. The Stroke Association's recent good practice resource document, which it issued to health authorities and community health councils in September, provides practical examples of local stroke services, delivered in a range of different settings. I would certainly join the hon. Gentleman in praising the good work of the Stroke Association.

Stroke units have brought about an enormous change in the care of stroke patients. There is evidence that dedicated stroke care greatly improves outcome and reduces mortality. Specialisation of nursing staff is a key factor in a successful stroke unit. The characteristics of a stroke unit include a multi-disciplinary team; co-ordination of rehabilitation, started early; nursing integration with multi-disciplinary teams; active involvement of carers provided with the right information; discharge planning and early social work involvement; and, often, the support of a Stroke Association family support worker.

We are aware that there are different types of stroke units. They may be bricks and mortar units, in the sense that they are based in the same hospital, or they may be established through working protocols that provide care pathways for patients with stroke. We stressed the importance of care pathways in the recent guidance document, "Commissioning in the New NHS", in October. Our proposals for pathways of care will link primary, secondary and social care, where appropriate. We emphasised in the guidance that care pathways should be developed to cover a range of preventive, diagnostic, palliative, rehabilitative and other care components in an integrated programme of care.

Rehabilitation is a crucial service that gives people who have had a stroke the time and opportunity to recover properly following any treatment that they have received in hospital. We emphasised the need for rehabilitation and recovery in "Better Services for Vulnerable People", which we issued last year. Health authorities will review and propose changes to their policies for rehabilitation and recovery for older people.

Evidence from clinical trials suggests that early rehabilitation intervention leads to improved physical and functional outcomes. The first three months are the most critical period when the greatest recovery is thought to occur. In November, my Department, together with the relevant professional organisations, issued a directory of developments in occupational therapy, physiotherapy and speech and language therapy, to share and promote good practice in the development of rehabilitation and recovery services generally.

The directory contains a section on stroke that sets out working examples of the delivery of stroke services in a multi-disciplinary environment: that is real partnership in action. We issued a rehabilitation handbook in 1997, aimed at health service commissioners, giving details of good practice and quality measures for rehabilitation services.

Many of those examples illustrate another important strand in the modern, new NHS: working in partnership. This autumn, we issued landmark guidance: the national priorities guidance. For the first time, we have issued joint priorities guidance to health and social services that sets challenging targets for the next three years that all parts of the NHS and social services will be expected to meet. We are focusing on the targets that make a difference to patients. It provides the NHS and social services with a three-year planning framework, backed by the largest ever increase in resources in the history of the national health service.

Promoting independence is one of our key priorities in the national priorities guidance. The priority stresses that the partnership of timely health and social services in the community can make a crucial difference to the ability of older people to maintain or achieve independence and maintain a healthy life style.

I know that there has been some disappointment that stroke has not been included specifically as a priority. Demanding decisions will always need to be made in priority setting, but stroke has not been omitted from the national priorities guidance: it is covered under the coronary heart disease priority, which emphasises the importance of the "Our Healthier Nation" target for heart disease and stroke and the role of the national service framework for coronary heart disease in delivering national priority guidance objectives to meet that target.

We do not discount the difficulties that are often encountered by younger people who suffer a stroke. I have already mentioned the national priorities guidance priority for promoting independence. As well as applying to older people, for whom we are developing the latest national service framework, it contains a reminder that For adults of working age, statutory agencies have a responsibility to help service users and their carers of working age to stay in or regain employment where possible. The hon. Gentleman rightly referred to the Clinical Standards Advisory Group. He will know that in 1997 the Government asked the group to investigate clinical effectiveness in the NHS, using stroke as a marker condition. Its report had relevance to stroke care as well as messages about generic approaches to effectiveness.

The Clinical Standards Advisory Group made three recommendations in its report. First, it said that there should be more rigorous central collection and review of evidence, and clearer central direction as to the changes in clinical practice required. That recommendation is more than met by the proposals for a new national institute for clinical excellence, which will mean that, for the first time, patients and NHS staff will be able to turn to a single authoritative source of clinical and cost-effectiveness advice.

Mr. Barnes

My hon. Friend has made many interesting points, but why is the Stroke Association, which does such fantastic work, so upset by the failure to have specific targets for stroke? Specific targets should be ones that the Government are able to deliver easily and well, and the exercise, diet and other recommendations, which my hon. Friend mentioned and which should be undertaken to improve health, can be delivered through a good publicity campaign.

Mr. Hutton

We have set a clear target, to which I referred in my opening remarks, for reducing mortality rates from stroke by a third by 2010. We are clear about the importance that we attach to tackling instances of stroke, and we are determined to take the agenda forward positively. We are addressing the issues responsibly and setting the right priorities.

The second issue raised by the CSAG was that the implementation of centrally supported guidelines should be better co-ordinated. That recommendation is more than met by the proposals for clinical governance which will provide the local infrastructure, and national service frameworks, which will provide the national drive for selected topics. We announced last month that the next national service framework would be on services for older people. We are still considering the arrangements for taking forward the framework, but we are very aware of the increased risk to older people of suffering a stroke. The incidence of stroke rises from three people per 1,000 per year in the age group 55–64 to 20 per 1,000 people per year for those aged over 85.

I would like to make more points about the issue of stroke, how we manage the incidence of that illness and the positive approaches that the Government want to take. I reassure the hon. Member for Southend, West that we take the issues seriously and we are developing policies that we believe will address the concerns that he has raised tonight. I hope that we can work with others in the national health service and the hon. Gentleman and his colleagues on the Health Committee to take that important work forward.

Question put and agreed to.

Adjourned accordingly at twenty-two minutes past Twelve midnight.