HC Deb 22 May 2002 vol 386 cc356-66

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

7.17 pm
Mr. Jim Cunningham (Coventry, South)

I thank the Speaker's Office for granting me this important debate. I am grateful for this opportunity to raise the issue of the support services available to the victims of strokes.

Let us first be clear what we are talking about. Each year more than 100,000 people in England and Wales have a first stroke. About 10,000 of them are under retirement age. There are 200 strokes each week in those under 55, and there are close to 60,000 deaths due to strokes each year.

Stroke is the third most common cause of death in England and Wales after heart disease and cancer. It accounts for more than 8 per cent. of all deaths in men and 13 per cent. of deaths in women in England. The cost of stroke to the nation in terms of health and social care is estimated to be more than £2.3 billion. That is 5.8 per cent. of total national health service and social service expenditure. The total cost of stroke care is expected to rise in real terms by around 30 per cent. by 2023.

Most important for the purposes of this debate, stroke is the largest single cause of severe disability in England and Wales, with 300,000 people being affected at any one time. About a third of people who have had a stroke die within a year, a third make a good recovery and a third are left with a serious disability.

Over the last 20 years, a number of small, randomised controlled trials for stroke units have been conducted. These trials show that stroke units reduce mortality and disability compared with management in acute general medical wards. No other treatment for stroke has demonstrated such large benefits. It is imperative that all victims of stroke, no matter where they live, be treated in a stroke unit. That is just not happening at the moment.

The Royal College of Physicians sentinel audit has shown that only 26 per cent. of patients are accessing such treatment. Even those hospitals that have a stroke unit often have insufficient beds to accommodate all their stroke patients. That means that some patients are treated in general wards just paces away from the specialist care that they need. In Coventry, we are fortunate to have a stroke unit at the Walsgrave university hospital. However, it is estimated that at least five people continue to die each day and seven require institutional care because they could not receive care in a specialised unit.

I welcome the Government's commitment to improving the care of those affected by stroke as laid out in the national service framework for older people. I particularly welcome their commitment to stroke victims receiving treatment from specialist stroke teams in designated stroke units. The framework, which has been endorsed by the Stroke Association, provides an excellent care standard for victims of stroke. Should any of those near and dear to me suffer stroke, I would rest easier knowing that their care was based on that outlined in the document.

The first milestone in the implementation of the framework has already passed—by last month, every general hospital should have had a plan in place to introduce a specialised stroke service. That is where my concerns about the Government's approach to stroke services begin, because progress towards that milestone is not yet known. I take this opportunity to ask my hon. Friend how the Department of Health is monitoring progress in this area and what mechanisms it intends to use to ensure that the milestone is reached. It is vital that hospitals that have yet to introduce a plan are supported and, dare I say it, compelled to introduce one.

We should welcome the publication of the national framework, but the Government must do more. I am concerned that no resources have been made available for hospitals to pump-prime stroke units or to increase the size of a unit to accommodate all patients. Obviously, the success of stroke units depends on adequate staffing of the multi-disciplinary team, ideally comprising specialist nurses, a specialist physician, a speech therapist, a dietitian, a clinical psychologist, a pharmacist and a social worker. It is essential that the Government ensure that there are sufficient numbers of therapy staff to support stroke victims in making the best possible recovery. Health care professionals need to be encouraged to specialise in those fields.

Strokes primarily affect older people, and with an ageing population we can expect their incidence to increase in coming years. I welcome the work that the Government and the Stroke Association are doing on stroke prevention. I particularly welcome the Stroke Association's work on stroke prevention in the Afro-Caribbean population. Afro-Caribbean people are twice as likely to have a stroke as those of European origin, and are more likely to have their first stroke at an early age. Although research is under way to try to explain that, the Stroke Association is not waiting for the results, but is conducting a major campaign to raise awareness within the community. It should be congratulated on that initiative.

It is important to recognise that investment today in adequate stroke units across the country will reap huge rewards in the future for individual patients and the public purse. There is a danger, however, that stroke is seen only as an older person's condition, especially as the stroke standard is contained within the national service framework for older people. A significant number of younger people and children suffer, and will continue to suffer, from strokes. It is vital that the needs of young people are acknowledged and that appropriate treatment and support is available to them as part of a comprehensive stroke service. The Stroke Association has raised concerns with me about the extent to which the stroke standard is being applied to the care of younger patients. How does the Minister's Department plan to ensure that young stroke victims receive specialist care?

I reiterate the importance of this subject. We are all aware of the demographic time bomb, and if we fail to take action now, we are storing up huge problems for the future. Although I hope that the prevention programmes in place today will reduce the numbers who fall victim to stroke, realistically we must expect more and more stroke patients over the coming years. Patients of the future are entitled to expect the best possible care—that is, through being treated in a stroke unit.

I have some questions for my hon. Friend. How is the Department of Health monitoring the progress of hospitals' plans to introduce stroke units? What is the Department doing to encourage health care professionals to specialise in the field of stroke care? What plans does she have to provide assistance for existing stroke units to expand? What is the doing to encourage health care professionals to specialise in stroke care? What plans does she have to provide assistance for existing stroke units? Finally, how does her Department plan to ensure that young stroke victims receive specialist care? Stroke victims across the country await the Minister's response.

7.24 pm
Mrs. Claire Curtis-Thomas (Crosby)

I start by offering warm congratulations to my hon. Friend the Member for Coventry, South (Mr. Cunningham) on securing this important debate. As he said, stroke affects thousands of people in this country every year and affects some families more than others. I welcome his support for the Stroke Association, which does a great job in my community and in communities throughout the United Kingdom, not least in providing sometimes very distressed family members with vital information when they need it most, sometimes when consultants are too busy or no specific consultant is available to advise on stroke. The association is there to help people and to guide them through a very troubling time.

Difficulties sometimes start in hospitals where patients are not placed in appropriate facilities—a stroke unit is not available and they have to go into general wards—and may continue long after the patient is discharged, sometimes into communities without appropriate facilities for people with stroke and perhaps an absence of physiotherapy services as well. In our community in the north-west, care is sporadic. I endorse the sentiments expressed by my hon. Friend and ask the Minister to reassure us about the implementation of the stroke plan, with particular reference to hospitals and stroke units.

Some hospitals are engaging in research activity on stroke. That is welcome. A local hospital, Aintree university hospital, has such a research facility. I recently visited it, and was delighted to hear that the stroke unit had received £1 million for research. I thought that that was rather a small amount of money for one year, and asked how it had been spent over the course of the year. I was told that it had been spent over a period of six years. One million pounds over six years does not a lot of research make. There is a desperate need to do far more research, because intervention and good management can lead to a good prognosis for many people who endure a stroke.

However, the argument is not just about money—it is far more complex than that. There is an acute shortage of appropriately qualified and motivated individuals who want to embark on work on this condition. Will the Minister touch on the initiatives that her Department is engaged in, first, to make more research funding available for people interested in stroke and in developing good outcomes for stroke victims and, secondly, to stimulate the clinical world's interest in stroke?

I want to say a few words about educating the public on what they can do to minimise susceptibility to stroke. Far too few people understand that salt is a significant factor in stroke, as is hypertension. Although we have started to educate the public on both those factors, far more work remains to be done. Unfortunately, it is often only when people have suffered a stroke that they discover that they could have taken several simple measures to reduce their risk. Will the Minister tell me what has been done to improve the information available?

7.28 pm
The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears)

I commend my hon. Friends the Members for Coventry, South (Mr. Cunningham) and for Crosby (Mrs. Curtis-Thomas) for securing and contributing to this important debate. The management of stroke is an important aspect of health care, and I welcome the debate, not least because it gives me an opportunity clearly to explain the Government's policy and how we are helping to make progress in this crucial area.

Stroke is an illness in which part of the brain is suddenly severely damaged or destroyed. The result is loss of function of the affected part of the brain. It usually causes weakness and paralysis of parts of the body, and in some cases, disturbance of vision and of speech. Stroke is the United Kingdom's third biggest killer and largest cause of serious disability.

During the 1990s, death rates from stroke fell by just over a third, having been falling continuously since the 1960s. However, although the figures have been coming down for several years, in 2000 the figure still stood at 19.9 deaths per 100,000. Although the majority of strokes affect older people, they can affect people at any age, and the consequences of a stroke for a young person are especially devastating.

My hon. Friend the Member for Coventry, South asked what was happening about strokes and young people. The standards set out in the national service framework for older people apply equally to services for young people. They are not exclusively for older people. It is the responsibility of each coronary heart disease team and primary care trust to work together to ensure that they develop services that are appropriate to younger people. Involving patients in designing those services will help to make them more accessible and responsive. The health service often puts people into categories, such as older people or younger people, and the right services are not always available. That is particularly true of adolescents, who find that the services available are often not appropriate to their needs. Involving those patients will be a key consideration.

The Government are committed to reducing the number of disabilities and deaths that result from strokes. We are making changes and improvements in access to, and delivery of, effective care and treatment. That includes the key priorities of prevention and education about risk factors. It also relates to the care and rehabilitation services that people receive immediately following a stroke, which make a difference to the quality of life that stroke victims experience.

On funding, substantial new investment in health and social care services was announced in the Budget. The NHS will receive an annual average increase of 7.5 per cent. above inflation over the next five years. That represents an increase of about £34 billion and is the highest sustained growth in funding that the NHS has ever received. There will be a similar increase over the next three years of 6 per cent. in real terms for social services, which are just as important to people who suffer strokes as acute medical services.

My hon. Friend the Member for Crosby made the important point that the problem is not just one of investment; we also have to consider the capacity of the staff who work in the system. We are acutely aware that we need to boost the number of staff who are available to treat people in the NHS. The NHS plan makes it clear that we need a huge increase in consultants across the board if we want to have a consultant-led service. The target was initially set at 7,500 extra consultants by 2004. The recent Budget announcements have allowed us to roll that target forward and we now want to recruit at least 15,000 more doctors—consultants and GPs—over the 2000 baseline by 2005.

We are not just providing more doctors. Between September 2000 and September 2001, the number of qualified nurses employed in the NHS increased by 14,400, which is about 4.3 per cent. However, the Budget has allowed us to forecast a further increase of 35,000 more nurses by 2008. Again, we are trying to get qualified staff into the system as soon as possible.

Therapists are particularly important for people who have suffered strokes because they help with their rehabilitation. There will be 6,500 more therapists and other health professionals working in the NHS by 2004. There will also be an extra 4,450 training places. In the past, we failed to invest in training people in the system or we cut training places. The therapists will include physiotherapists, occupational therapists and speech therapists, who are particularly important for stroke victims. Many of the stroke victims I met said that had they received speech therapy at an early stage in their treatment, their quality of life—in particular their communication with their families, friends and neighbours—would have been greatly enhanced.

I recently met an elderly lady who had recovered from a stroke. Before her stroke, she used to get a great deal of pleasure from completing crosswords, which formed a large part of her life. Following her stroke, she lost the ability to spell, which left a big hole in her leisure time. I managed to enrol her in classes for literacy and spelling, and she is well on the way to being able to complete crosswords again. The NHS would not necessarily have thought of providing her with educational support to ensure that her skills went back to the levels at which they were before she suffered her stroke. It is important that we are more imaginative about the services and links that we provide for rehabilitation.

We want to deliver a patient-centred service. That is a big challenge for us—nowhere more so than in services for people who have suffered strokes. We have a 10-year programme to provide extra investment and to reform the service. We need to increase capacity but we also need to look more creatively at the services that we provide. However, the extra funding will help us to deliver the national service framework for older people, on which clinical services for strokes will be centred.

We want to ensure that patients can return as far as possible to the lifestyle that they enjoyed before their stroke. Work on the national service framework will help us to achieve that. Many of the policies that we are developing, such as helping people to give up smoking, promoting healthy eating, encouraging people to increase their physical activity and reducing the number of overweight people, especially those who have problems with obesity, will help to reduce the incidence of stroke and to tackle heart disease.

It is important to prevent and limit the burden that strokes impose on the people who suffer them and, crucially, their carers. A huge responsibility is put on the families and friends of those who have had a stroke. We recognise that in the White Paper "Saving Lives: Our Healthier Nation", in which we identify heart disease and stroke as priorities for positive action to improve prevention. We set a target to reduce stroke mortality by at least a further third by 2010, using 1996 as a baseline. We are trying to build on recent reductions in mortality from strokes, and we have set a challenging target to reduce that even further.

Although we might reduce the number of people who have strokes, we must not forget that stroke victims still need a wide variety of services. Some people need acute care immediately following their stroke. Depending on the severity of the stroke, they will need a programme of rehabilitation to help them optimise their independence afterwards. Services for older people, especially stroke victims, were not always the most attractive parts of the health service and did not necessarily draw in clinicians. I am pleased to say that that is changing and we are developing good doctors, consultants, nurses and therapists who are committed to team working when helping stroke victims. I have seen evidence showing that when rehabilitation services work together, they have a huge impact on someone's quality of life in years to come. That intervention has to be at the earliest possible opportunity. If we leave problems for a long time, there is a corresponding reduction in the quality of life. Ensuring that different members of the team work together, and work quickly, is a priority.

Clearly, stroke is a medical emergency. 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 reduce the risk of fatality; to reduce the prospect of major disability; and to prevent secondary strokes, which happen far too often and affect someone's quality of life enormously. The development of stroke services—the team working—has brought about an enormous change in the care of stroke patients. There is growing evidence that dedicated care improves outcome, reduces mortality and is cost-effective. Specialisation of nursing staff is a key factor in a successful stroke unit.

The latest development of stroke care was contained in the national service framework for older people, published in March last year. That sets specific standards and milestones, to which my hon. Friend the Member for Coventry, South referred. It establishes the development of integrated stroke services and improvements in the delivery of stroke care as a priority. I am pleased to say that the NHS priorities and planning framework for 200203 reinforces the high priority given to delivery of the milestones set in the national service framework. The health service used to have a wide range of priorities—probably far too many, in fact. Having a smaller number of priorities should enable the NHS to deliver better on the targets that we set, and stroke care is one of those high-priority targets.

Mr. Jim Cunningham

Will my hon. Friend say more about numbers of social workers? How many specialist units have been established and where are they? My hon. Friend knows that provision throughout the country is patchy.

Ms Blears

I understand my hon. Friend's concern about the inconsistency in the way in which the units have been established. I understand that the results of monitoring will be available later this summer, so in the next couple of months we should get a clear picture of where services have been established, where they are planned but not yet up and running, and where we need to ensure that they are provided.

I know that the way in which monitoring will be carried out in future is a particular concern. In future, strategic health authorities will monitor the performance of acute trusts and primary care trusts in delivering the national planning priorities. Therefore, there will be a performance management route through the system, so that we can see where things are happening, and, where nothing is happening, take action through investment and creation of services on the ground. In future, the levers will be at strategic health authority level, rather than in the centre at the Department of Health. That is part of our drive to ensure that while the Department does not micro-manage the service, the service is managed according to the national standards and frameworks that we set. I assure both my hon. Friends that the matter is covered in the national priorities and planning framework and that it will be performance-managed to ensure proper performance in every community.

The aim of the stroke standard is to reduce the incidence of stroke in the population; to ensure that those who have had a stroke have prompt access to integrated stroke care; and to take action to prevent strokes, working in partnership with other agencies where that is appropriate. We are determined to ensure that people who have had a stroke have prompt access to diagnostic services; that they are treated appropriately by a specialist stroke service; and that subsequently they, with their carers, participate in a multidisciplinary programme of secondary prevention and rehabilitation.

Recently, I visited a beacon stroke service in the south-west which is attended by people who have had a stroke and their carers, so that they can learn together about the action that they can take to maximise the extent of rehabilitation and the mobility, speech and basic skills regained by the person who has had the stroke. I met an incredibly impressive husband-and-wife team who, as a result of their involvement with the stroke service in their area, resolved to set up a self-help group in their community. The stroke service was able to help them to set up this entirely new group, which could go on to help others in the community. I was impressed by that close collaboration between people who had had strokes, their carers and their wider family. That provides a good model for us.

The standards in the national service framework will be supported by wider action and development work on the elimination of age discrimination; the delivery of person-centred care through the single assessment process, which will apply to older people across health and social care, so that in future those involved in social care are involved in assessment as well as the NHS; the delivery of intermediate care services to promote faster recovery from illness and to prevent acute hospital admissions; and improving access to appropriate specialist care in the best hospital environments. Each of those standards has a contribution to make to the care of stroke patients.

Mr. Cunningham

Does my hon. Friend intend to speak about the Afro-Caribbean community—an issue that was drawn to my attention a couple of weeks ago? I am sure that she is aware that the Esaba Afro-Caribbean women's group in Coventry was involved in a pilot scheme during stroke week, which was last week.

Ms Blears

I am aware that certain groups in our community are particularly susceptible to certain conditions. A challenge facing all of us—not only those involved in stroke services but everyone involved in NHS provision—is to make sure that services are accessible, responsive and appropriate to the needs of a far more diverse and varied community than before.

The constituency group my hon. Friend mentions provides evidence of the way in which dramatic changes to services can be achieved when patients, their carers and their families are involved. The people with the best ideas for change are usually those who are at the sharp end—they know their illness better than any expert specialist, because they live with it every day. My Department is developing the expert patient programme, which covers a wide range of conditions including arthritis, diabetes and stroke. That programme will help to develop patients' skills in helping themselves and others. My hon. Friend's constituency group provides an excellent illustration of the way in which local people can influence the shape of health services in their community. I undertake to find out details of that project and to feed them into the development of policies within the Department.

The milestones for action were set from April this year. They are being monitored now and we should have the results very soon, which will enable us to see where specialised stroke services have been established. By April next year, all hospitals will have to have established clinical audit systems that ensure delivery of the Royal College of Physicians clinical guidelines for stroke care. By April 2004, PCTs will have to have linked with local specialist stroke services to ensure that general practices can identify, manage, treat and refer through agreed protocols. In that way, we will establish services at all levels—primary care, secondary care, and rehabilitation and community care—thus providing a seamless service for people with stroke.

Mrs. Curtis-Thomas

Recently, and to his great misfortune, a member of my staff succumbed to a second stroke, having had his first four years ago. Unfortunately, his prognosis is extremely grim. The problems he has experienced are familiar to me because this awful affliction has affected several members of my family.

From meeting this man's family and others, I have become concerned about the fact that when stroke strikes, people who have never been in that position before have no idea what type of services they can expect. This dear man is expected to leave hospital very shortly—the hospital can do no more for him, nor can physiotherapy—and his wife feels that she has been abandoned. She desperately wants to look after him at home, even though that will be extremely difficult, but she believes that social services are likely to tell her, "We're terribly sorry, but that's not an option. Your husband has to go into care because we're not prepared to fund the support that you need at home."

What can I say to that woman? Can I say, "If you want to nurse your husband—our dear friend—at home, you can do so and you will have the support of social services", or is there a class of individual who will invariably be consigned to a nursing home—

Mr. Deputy Speaker (Sir Alan Haselhurst)

Order. The hon. Lady cannot make a second speech during an intervention.

Mrs. Curtis-Thomas

I apologise, Mr. Deputy Speaker. I hope that my hon. Friend the Minister is able to respond to the case that I have outlined.

Ms Blears

My hon. Friend gives a poignant illustration of the difficulties that people experience when seeking post-hospital care. The introduction through the national service framework of the single assessment process, which involves the NHS and social care, should ensure that people do not fall through the net. Closer integration and working between those two arms of the service will be key. In some circumstances, the assessment may indicate that residential care is the appropriate course of action. I have no knowledge of the personal circumstances of those involved in the case my hon. Friend describes, but in some cases residential care is appropriate. What is important is that the family, the carers and the person who has had the stroke are involved as far as possible in reaching what are extremely difficult and important decisions.

The involvement of specialist nurses is also important, as experience of other conditions such as cancer has shown. Macmillan nurses are able to assist people with home care, and the principles that govern their activities are equally applicable to a range of different conditions. Specialist help from people who have a wide range of knowledge and previous experience can help to guide and shape the services that should be established. Certainly, stroke services are not as well developed as cancer services, which have been in place for many years, so we need to look at developing them.

We have just embarked on a 10-year programme on the national service framework stroke standard. As it develops, I hope that fewer people will have a first or repeat stroke because there will be early identification and preventive action, and that there will be general advice and support on how to reduce risks; access to specialist stroke services, based on best evidence; better care and better outcomes to reduce death and disability from stroke; co-ordinated rehabilitation to improve people's chance of regaining independence; and support for carers.

As I said, it is important that standards in the national service framework for older people inform services provided for younger people in an age-appropriate setting. We are acutely aware that the organisation of stroke care across the country remains variable, and there is still much to do to ensure that services are consistent and that people can access them. In Coventry, there are 10 beds in a dedicated stroke unit at University Hospitals Coventry and Warwickshire NHS trust, supported by a stroke co-ordinator, a consultant leader and a professor of age-related medicine, which represents good progress.

Approximately 1,000 patients a year are admitted to that hospital with stroke-related disease, but only 30 to 40 per cent. of them go through the dedicated unit, which has a very high occupancy rate. It is recognised that that low coverage of at-risk patients is not desirable, so more efficient use of beds is being examined. However, the stroke co-ordinator's role ensures that all patients admitted to hospital with stroke-related disease receive appropriate care, although there is more work to be done on getting people into the specialist unit. The primary care trust in the area is running an experimental national programme for stroke care called Smartcare, which aims to smooth out the early identification of stroke and the management of treatment across primary and secondary care. It tries to make those processes seamless so that people do not fall through the net. The two-year programme has already begun and we hope to learn national lessons from it.

I hope that my hon. Friends the Members for Coventry, South and for Crosby agree that the Government are committed to improving services for all NHS patients, including those who have had strokes. We have invested substantial extra funds in the NHS and intend to invest even more over the next five years. For people with stroke, initiatives such as the national service framework will do much to drive up standards of care. The improved standards will apply to stroke patients across the country, whatever their age.

I am delighted that my hon. Friends have raised this issue, which is of great concern to patients and their families. As I said, we have made progress, but we have a long way to go before we can be proud of services in every part of the country. However, shining a light on something which, in the past, may have been a Cinderella service is welcome; it can do nothing but good, draw clinicians and researchers together, and help to make the service a priority. When good teamwork and specialist clinicians are involved, there is evidence that the outcomes for people who have suffered a stroke are a lot better than many of us may expect in the early days. I am therefore delighted that my hon. Friends have participated in our debate, and I hope that they accept that we are making progress on aims that we all share.

Question put and agreed to.

Adjourned accordingly at seven minutes to Eight o'clock.