| Previous Section | Back to Table of Contents | Lords Hansard Home Page |
Lord McColl of Dulwich: My Lords, I, too, congratulate the noble Lord, Lord Rodgers of Quarry Bank, on initiating this very timely debate. Noble Lords have already dealt with most aspects of stroke in a comprehensive and often moving way, so I shall focus on the mini-stroke, known as the transient ischaemic attack—TIA, having been put into Latin and Greek. "Ischaemic" means "holding back the blood", and this impairs the part of the brain supplied by the artery in question. The main arteries to the brain can become blocked by fatty deposits known as atheroma. "Atheroma" is Greek for porridge. It may be Greek porridge but it is certainly not like Scottish porridge.
The surface of these bits of atheroma may become roughened and covered by platelets, which are responsible for clotting in the blood. These clumps of platelets may become detached and end up in a part of the brain which stops working for about 15 to 30 minutes. In any patient, the mini-stroke always tends to present in the same way: one patient may have transient weakness of the right arm; another may have transient weakness of the left arm; and another may lose his sight for 15 to 30 minutes.
In order to shed light on the mechanisms of these transient attacks, the late Dr Knight of Guy's Hospital carried out an interesting experiment. He was an outstanding physician and an enthusiastic and inspiring teacher. He took his team of students and nurses to "Pooh Bridge" in Ashdown Forest, where Winnie the Pooh had carried out an important experiment about 100 years before. Standing on one side of the bridge, they dropped brightly painted cones into the water and established where they went. Of the 100 cones that were dropped, 31 per cent arrived at one destination and 23 per cent at another. That is a very good example of what happens in the brain. These
23 May 2006 : Column 809
clumps of platelets tend to arrive in the same part of the brain, causing the same set of symptoms in any particular patient. The treatment is simple: the patient is given a small dose of aspirin—an eighth of the normal dose—and that tends to reduce the amount of platelets adhering to the fatty deposits and so reduce the number of mini-strokes.
As has been said already, there is a tendency to regard a stroke as an incurable problem of old age, and these people do not receive the attention that they require. It is possible to limit the damage done by strokes provided that an accurate diagnosis is made within the first few hours. There are enough scanners throughout the country to make this emergency scanning possible, but the problem is that in many hospitals the scanners are used for only eight hours a day. If you tell captains of industry about that, they are horrified. The idea that huge pieces of machinery should lie idle for most of the time is an anathema to them. Some hospitals use their scanners for 24 hours a day, instead of the usual eight hours. Noble Lords will be comforted to know that St Thomas's Hospital across the river has in the emergency department a scanner which is in use 24 hours a day. That is the way to do it.
If, as has been mentioned, there is a simple blockage of an artery, that can be dissolved with the appropriate treatment. If, on the other hand, the stroke is due to a haemorrhage into the brain in substance, not a great deal can be done at that stage. But when the haemorrhage is outside the brain, just underneath its delicate covering—a so-called sub-arachnoid haemorrhage—emergency surgery is required if there has been a demonstrable rupture in the wall of the artery, which is called an aneurism. Although it is perfectly possible to arrange for everyone to have an emergency scan within three hours, as has been mentioned, there is a problem if we do not have sufficient staff to interpret the results, as the noble Baroness, Lady Barker, said.
What could be the solution to that? The radiographers could easily be trained to interpret scans. Again, however, more resources are required to train them. Then, there is telemedicine, whereby scans can be transmitted to any part of the world and interpreted by experts. I spend my holidays working on a hospital ship in west Africa. We can spread a piece of tissue on a slide and put it into a machine called a Coolscope, which is a computerised microscope. The image can be beamed anywhere in the world. We beam ours to Bristol and get the answer back in five minutes. More of that needs to be done. My noble friend Lord Swinfen and his wife run a charity promoting telemedicine in many parts of the world.
Our present mortality rate is too high, as has been mentioned; it is about 30 per cent. There is no reason why we cannot get it down to 15 per cent, as it is in many European countries and in north America, as the noble Baroness, Lady Murphy, emphasised.
Then, there is the problem of rehabilitation. There is no doubt that rehabilitation services are not nearly as good as they should be and that many patients have
23 May 2006 : Column 810
felt isolated and neglected. They know only too well that if they had expert help they could return much more rapidly to as normal a life as possible.
As the noble Lord, Lord Rodgers of Quarry Bank, pointed out, his stroke was not due to any fault in his lifestyle. However, many strokes are due to preventable conditions such as high blood pressure. I was interested to hear the noble Baroness, Lady Rendell, say that you can buy your own blood pressure machine and monitor your own blood pressure. It is easy to do, and it is very revealing. In between cases in my operating list at Guy's I went into an empty theatre, lay down on the table and wired myself up to the various monitors, including blood pressure and pulse. I then told myself to relax. You can talk to your blood pressure and bring the thing down. It is amazing. You have a measurement of your blood pressure, so you can see it. You can talk to it and teach yourself how to relax and reduce your blood pressure. I was amazed to see it come down to below 100 and the pulse below 50. I suddenly thought that if somebody came in and read those things, they would think that I needed resuscitation and probably do cardiac massage and break all my ribs. So I left the theatre rather rapidly. Those sorts of simple things are so important.
Then, there is the question of obesity. We are what we eat. It is amazing how many extraordinary diets people try, including the Atkins diet and so on. At the end of the day, however, you are what you eat and if you eat less, you will lose weight. I had a patient—a man—who was very overweight. He tried everything but it had not worked. I noticed that his wife was nice and thin, so I suggested that he should try eating the same quantity of food as his wife ate. He did not like that idea very much. Three months later I asked his wife how things were going and she said, "He's the same weight but I'm putting on a lot of weight". He was obviously getting at her to eat more.
Checking cholesterol levels and getting people to live a healthy lifestyle with plenty of exercise, avoiding smoking and excessive drinking of alcohol are other things that should be encouraged. Of course, we cannot force our views on patients. After all, we are simply advisers and in the end it is their choice.
A patient said to his doctor, "Will I live longer if I stop smoking and drinking?". "No", said the doctor "but it will seem longer". That is not true but it is true that the number of strokes can be reduced if healthier lifestyles are encouraged.
8.05 pm
Baroness Royall of Blaisdon: My Lords, I am truly grateful to the noble Lord, Lord Rodgers of Quarry Bank, for securing the debate and enabling us to discuss stroke services. The noble Lord speaks from great experience, sadly, but I particularly welcome his personal insight and all that I have learnt from his experience and courage, and that of my noble friend Lord Clinton-Davis.
It is a significant time in the development of stroke services with the National Audit Office report bringing increased attention to the opportunities available, as
23 May 2006 : Column 811
well as the challenges to deliver high quality stroke services. Indeed, I think that the NAO report has acted as a healthy catalyst for change.
Many noble Lords, including my noble friend Lady Rendell, asked why, given the scale of the problem, we have not done more to give stroke a higher priority. We should recognise that for too many years stroke was viewed as an inevitable part of getting old. We should recognise that it is only in recent years that experts have come to a consensus that much can be done to prevent and treat stroke. The growth of stroke medicine is a recent phenomenon and we welcome that.
It is important to recognise the scale of the problem. Each year more than 110,000 people in England have a stroke. Every five minutes someone in the UK has a stroke. In England more than 900,000 people have had a stroke. It is expensive to treat and there are high costs to the wider economy through lack of productivity and informal care. I understand the concern expressed by noble Lords about the NAO report. It made 10 sets of recommendations for improving stroke prevention, treatment and care. I assure the noble Lord, Lord Rodgers, that the Department of Health is committed to taking all those recommendations forward. The comprehensive response will be through a new stroke strategy currently being developed with the help of six expert project groups chaired by leading figures in the stroke world.The department is also pursuing changes ahead of this strategy; for example, through a new toolkit developed for use by acute trusts which demonstrates the benefits of improved stroke care on an individual hospital basis.
On prevention, the NAO recommended that there should be explicit references to stroke in the department's public health campaigns and that primary care trusts should ensure access to transient ischaemic attack services. The department has already included more on stroke in its websites, in campaigns such as "five-a-day", for example, which encourage the consumption of more fruit and vegetables, so that perhaps husbands and wives will both grow thinner. It also has a project group dedicated to making specific recommendations on public awareness raising and prevention issues. Indeed, this Friday, the department is running a workshop with a range of campaigning experts to produce a menu of ideas for taking this forward. There are already points available in the quality and outcomes framework for GPs about access to specialist outpatients services. Of course, they now have to monitor blood pressure on a more regular basis.
In the White Paper Our health, our care, our say, the department is committed to making a life check for everybody at key life stages. The department is working to set up pilots to explore how these will be most effective. My noble friend Lady Rendell asked about the wider use of statins. NICE has recently produced guidance recommending that people with a 20 per cent risk of cardiovascular disease should be treated with statins. We are also considering
23 May 2006 : Column 812
recommendations from the National Screening Committee about improving the detection of cardiovascular disease and diabetes at an earlier stage.
On the subject of GPs, the noble Baroness, Lady Barker, asked whether the correct protocols have been implemented. Locally, yes; but not yet set out nationally. Project groups on TIA and emergency response will make recommendations in this area. The Royal College of Physicians' stroke guidance sets out what should happen, and the Department of Health accepts the need for a further push to ensure that it really does. The department's TIA project group meets this week to set out detailed recommendations for improving rapid access in every health community. The department is also funding a campaign run by the Stroke Association to raise awareness of stroke symptoms.
My noble friend Lord Clinton-Davis spoke movingly of the need for a high standard of acute treatment of stroke and ensuring a rapid response, as did the noble Baroness, Lady Gardner of Parkes. The National Audit Office has recommended that NICE should produce guidance on delivering thrombolysis, that scanning capacity should be improved—including by providing training for stroke consultants in reading scans—and that access to stroke units should be improved. These recommendations are being taken forward through implementing the toolkit, detailed work with the professional bodies for radiologists and radiographers, and the work of a project group looking at acute care. NICE will produce guidance on managing acute stroke and an accompanying technology appraisal of alteplase, a clot-busting drug.
On post-acute support, the NAO recommended that the quality requirements of the national service framework for long-term conditions should apply for stroke patients, and that the voluntary sector should be involved in working more closely with the Government. The principles and guidelines set out in the long term conditions NSF focus on patient-centred care for people with neurological conditions and are highly pertinent to stroke. Professor Ian Philp, the national clinical director for older people, has been promoting their use in stroke care, and the department will build on this through the developing strategy. Indeed, Professor Philp also has a programme of action under way to root out ageism in the NHS and ensure dignity for life.
The voluntary sectors involved in stroke, to which I pay tribute and thank for their untiring work, including the Stroke Association, Different Strokes and Connect, already play a vital part in delivering services to stroke survivors; for example, in running conversation groups for people who experience speech problems after their stroke. Indeed, my own grandmother, who had a couple of strokes, recovered her speech when my daughter was a baby learning to speak. My grandmother had confidence to speak to my daughter, because she knew that she could practise her speech on her. They both learned to speak together. I am delighted that it worked well for both of them. All these voluntary groups are helping the
23 May 2006 : Column 813
department to frame the new strategy, and the contribution of the voluntary sector will be pivotal to implementing it successfully.
The department has already, as recommended by the NAO, brought stroke within a new unified framework for vascular disease management, with an integrated policy team across heart disease, diabetes and stroke, and Dr Roger Boyle is now the national clinical director for both heart disease and stroke. We are looking, with the Healthcare Commission and the Royal College of Physicians, at the next steps for improving stroke audit, building on the excellent basis of the sentinel audit. Already, we have agreed that the use of the FAST—face weakness, arm weakness, speech problems test—stroke symptoms protocol should form part of the Healthcare Commission's assessment of ambulance trusts.
We know what the challenges for stroke services are; the NAO report brought them clearly into focus. For example, not enough people really understand what a stroke is or would recognise the symptoms, as noble Lords have said. The noble Lord, Lord Rodgers of Quarry Bank, and my noble friend Lady Rendell were absolutely right about the need for better communication on the realities of stroke, a point that the noble Baroness, Lady Gardner, also made graphically.
The Stroke Association has recently been allocated a Section 64 grant to assist with communication. Its campaign, entitled "Stroke is a medical emergency", urges people to know the warning signs. We fully support its excellent work but we need to make more efforts to explain that a stroke is a brain attack that needs urgent medical attention. We need to ensure that people who experience a mini-stroke seek help straight away rather than risk a really serious stroke later, and that the people with them understand what is happening and how best they can help them.
Too many patients are not getting the scans they need as a matter of urgency, as many noble Lords have said. Although progress has been made, many patients still spend less than half their stay in hospital on a stroke unit, and the services are not always there to support patients and their carers when they leave hospital. Much has been said about rehabilitation, about which much more needs to be done.
The noble Lord, Lord McColl of Dulwich, will be glad to know that the department is developing a picture archiving and communications system (PACS), which will be rolled out by spring 2007 and will provide opportunities to read scans remotely—rather like what he is doing on his Mercy Ships. Stroke scanning is complex; no one form of scanning provides perfect results. As many noble Lords have said, we must ensure that the appropriate individuals are available to interpret the scans. That is why the Department of Health will include training for a range of professionals as part of the stroke strategy framework that we are developing. Safe delivery of thrombolysis will be supported by NICE guidance on the management of acute stroke and its forthcoming technology appraisal of alteplase, a thrombolytic, or
23 May 2006 : Column 814
clot-busting, drug. It will give the NHS a clear steer in the interim, building on the existing guidance from the Royal College of Physicians.
The White Paper that we published at the end of January addresses many of the issues faced by stroke patients. It aims to ensure that services are integrated and built around the needs of individuals, with more services delivered in the community or at home. It includes a new deal for carers, a commitment to integrated care plans and a range of measures to ensure that health and social services work more closely together. We must also ensure that those integrated services also address depression.
On 1 March we held a national stroke conference, attended by more than 150 people, who will begin developing a new stroke strategy. We demonstrated the toolkit that I mentioned earlier, which brings together the key actions that hospitals can take. It calculates the benefits that taking certain actions can lead to for patients and the hospital itself. It also provides examples of teams that have been through radical change and how they went about it. For example, the Royal Free Hospital used to have one of the worst performing stroke services in the country, but in five years it turned that around and in the 2004 audit it was the best in the country. I understand, therefore, the specific concern that the noble Lord, Lord Rodgers, expressed about deficits at the Royal Free Hospital. I am pleased to say that one of its stroke doctors is working with the Department of Health on its hospital care project group. That doctor will be very happy to speak to the noble Lord, Lord Rodgers, to give him a more detailed briefing about the planned service developments at the Royal Free Hospital and more widely. I will seek to ensure that that happens soon.
The noble Baroness, Lady Barker, asked about the UK Stroke Research Network. Apparently, we are giving £20 million over five years to the network, which is headed by Professor Gary Ford, a stroke physician in Newcastle who has trail-blazed thrombolysis, and who will oversee the local research networks. The network is at the very beginning of its exciting work, and I will be very happy to provide noble Lords with further details on it.
The noble Baroness, Lady Barker, also asked whether restructuring of PCTs would delay developments. The department is absolutely determined that it will not. We will do our utmost to ensure that services are not disrupted in any shape or form, but if noble Lords find that they are disrupted, I am sure that we will be pleased to hear of those instances.
I have described today just a few of the steps that we have taken in what will be a sustained and co-ordinated approach to improving stroke services. The challenge now is to spread this nationally so that all patients can benefit. We have a lot of hard work ahead of us, but I am confident that we can produce a comprehensive and effective strategy for delivering real improvements in stroke services.
23 May 2006 : Column 815
My noble friend Lord Clinton-Davis said that we needed to keep the Government on their feet. I am confident that debates such as this will indeed keep the Government on their feet and act as a catalyst to enable them to deliver even more changes.
| Next Section | Back to Table of Contents | Lords Hansard Home Page |