Stroke: Aftercare

Despite the ever-present threat of strokes, the reality is that for many years research has been underfunded in comparison with other devastating and debilitating conditions such as cancer. In 2016, research by the Stroke Association revealed that just £48 is spent on stroke research per patient compared with £241 on cancer research. We need more funding for both those serious conditions. The already challenging situation has now been compounded by the devastation that the covid pandemic has had on many charities’ fundraising capabilities, meaning that millions of pounds have been lost. That has reduced their ability to continue their work and carry out critical research.

Strokes are incredibly prevalent in the UK, with one striking every five minutes, meaning that it is a leading cause of adult disability. It is therefore vital that sufficient funding is in place not only to research the causes behind the condition and help to identify preventative measures, but to support our national stroke programme, including the aftercare and rehabilitation services.

Research such as the recent study announced by the Stroke Association—the largest of its kind in the world—to investigate a possible link between covid-19 and life-threatening strokes is crucial. In particular, the report states that stroke patients who have had coronavirus may be younger and experience more severe effects of the stroke as a result, including death. It is an incredibly timely and important study that will need to be supported, given that the charity’s own research director said that the research was

“just the tip of the iceberg.”

Now more than ever, the national stroke programme needs to be given the support and funding that it requires to ensure that it can continue its vital work and deal with the rising number of cases in the UK. I therefore urge the Minister to do all she can to look again at this issue and to push her Department to ensure that the national stroke programme and associated aftercare and rehabilitation services receive increased funding that will help to meet both existing and growing demand on NHS stroke provision.

My story is not unique. We need to do more to stop this happening again, and I think that we can. It is about investment in prevention, treatment and care. In my constituency and, I am sure, in many other rural areas, it would be achievable to invest in more early diagnosis and treatment. We need good prevention, so that TIAs—transient ischaemic attacks—and blood clots can be spotted early. We have to be proactive. In turn, of course, that pays for itself, because early prevention lessens the load on the NHS.

The two main issues that we have in Norfolk remain the lack of thrombectomy services and the unequal provision of post-stroke care and support, in particular affecting my constituents in North Norfolk. I have campaigned for more services at Cromer Hospital—an early diagnosis ward would help enormously—but such services could be improved in so many of our community hospitals throughout the country. There is simply little point in my constituency having an ambulance that will take more than an hour to get to Norwich. We have to put in place the processes and procedures to treat in that precious golden hour in which recovery chances are so improved. I understand that Cambridge is to receive a mechanical thrombectomy trial—why not Norwich?

I would love to see real investment in physiotherapy, occupational therapy, and speech and language therapy for early supported discharge. A lot of encouraging work is under way nationally, in the national stroke programme and in the rehabilitation space, and I thank the Minister for that. I hope that the suggestions in this debate will be helpful and driven forward, so that we may level up pockets of the country where people are behind the curve to ensure that everyone has the same level of success after suffering a stroke.

Back home in Northern Ireland—I presume it is the probably the same here—we have regular adverts. Chest, Heart & Stroke has an advert on UTV that tells people what to watch out for, and it is really helpful. Can the Minister confirm whether the mainland has the same number of adverts? They tell people what to look out for. To take up the point made by the hon. Member for North Norfolk, time is of the essence when someone has a stroke. It is what people do in those minutes afterwards, regardless of whether they have the qualifications or just want to do something that helps, because time is absolutely critical.

I recently watched something on TV. It was a clip of a darts match in which a player is having a stroke. His face distorts, and he loses all power in his arm. Seeing that take place in real time has shocked me, because it really brought home the issue that pertains to those who have had a stroke, as well as what can be done in that short time. We need to incorporate a greater awareness of the warning signs. Getting help quickly makes the difference between a fast recovery and a slow one. Can the Minister tell us what has been done to raise awareness among the general public?

I said that I know people who have had strokes and who have recovered quite well. Indeed, a friend of mine had one a while ago and is now back to almost 95%. It is incredible that someone can have a stroke and recover so quickly. In Northern Ireland, over a third of strokes happen to people over the age of 69, and 50% to people over the age of 60. However, it is not uncommon, unusual or unique for those under that age to have a stroke. What has been done among all those groups? Those who are most at risk must be aware of the signs and symptoms.

The hon. Member for Bromley and Chislehurst was absolutely right to refer to long-term personalised care. I am asking things that have perhaps been asked before, but I am quite sure that the Minister will be able to reiterate and to assure us on that, and on the national stroke programme and the lessons learned and the changes that can provide better protection, raise awareness and ensure that we improve health for everyone in this great United Kingdom of Great Britain and Northern Ireland. I know that the Minister has no responsibility for Northern Ireland, but I look to her, as always, for a response to the queries we have all put forward. It is important, not only for me, as my party’s spokesperson on health issues, but for all of us to know that we are improving long-term care and help following strokes for those who need it.

One challenge I always found was the pressure to get people out the hospital door and discharged quickly. To actually re-educate somebody’s mind and body to synchronise and work together in a new way takes time, and therefore ensuring that there is that investment in time is really important. We also cannot push somebody because they become tired, so we have this really delicate balancing act of timing.

It is different for absolutely every patient, but as they go through that journey, they need that specialist support. I will give an example. They may be discharged home, but we know that so many people, once they go home, will just sit in a chair, as opposed to carrying on their rehabilitation. Or perhaps, even when getting up from the chair, they will take the short cut of pulling themselves up, increasing their muscle tone, which is detrimental, as opposed to, say, using a proper Bobath method of facilitating their muscles. That makes a real difference how this issue is approached, and therefore the paucity of stroke rehab specialists must be addressed, making sure that that skill mix is there, but also with the right level of training. That is crucial.

I ask for more training around stroke rehab for GPs and in the community in particular. A community physio may deal with respiratory patients, musculoskeletal patients, neuro patients. We want neuro physios in the community through an extension of specialist rehab centres moving into the community while keeping that clinical case load. We also want the same clinicians along a patient’s rehab journey. It is not easy for clinicians to relay information about a patient simply, so following them into the community could be a different way of doing that as opposed to the silos of our institutions that we currently see.

One other thing is really important. We know that stroke is for life, and therefore we need to ensure that the services are there for a substantial amount of time. I have raised the issue of the six-month review, which is far too long to wait—an individual may plateau or even regress in their care. Regular intervention is really needed and, if someone has plateaued or regressed when they could have been progressing, they should be brought back into more specialist care, even if that is residential care, to help them take that step forward again and get that continuity that is needed. If we do not put in those interventions, clearly the impairments experienced by someone will deepen, which will create pressures that will show themselves elsewhere in the NHS or the social care system. Therefore, that investment is so important for people as they are recovering from stroke.

There is clearly so much to be done. I really welcome the call for an APPG and would be happy to serve on such a group should it arise, but as we are currently reimagining healthcare, this is a real opportunity to put the patient’s need at the centre of a stroke service and ensure that we sustain that for the rest of their life.

I praise and pay tribute to all the silent carers of covid, who have been helping their loved ones who have suffered a stroke, and who have had to negotiate through the care pathways alone. I thank them for everything they have done. I thank all the carers and health professionals who have done everything they possibly can during covid to help those who have been suffering in silence in their homes, in out-of-hospital care.

I ask that we look at strategic, long-term recruitment for these professions to meet the needs and demands of England, and that we look at how we can develop a much more joined-up and cohesive post-stroke recovery plan, because where the process also breaks down is where someone who is in a hospital in a local authority is discharged into another local authority, where the care pathway has to pass from one council to another and from one NHS trust to another. It is very difficult to maintain a pathway that delivers and communicates that, even to your GP, so those complex pathways tend to break down at the rehabilitation level. I ask that we look at having a stroke passport that those who have recovered might take with them—a physical copy that they can take to any healthcare professional, so that they can see their records and so that there is a clear understanding of where that survivor has come from. That would ease and speed the process of recovery as new carers take on the rehabilitation of that survivor.

I thank hon. Members for being here today and for considering the complex nature of the debate. I hope that we start an all-party parliamentary group—I would have to join as well—to continue raising this important issue in the House.

The most recent Sentinel Stroke National Audit Programme data for April 2019 to March 2020 shows that only 41% of patients received a recorded six-month post-stroke review, and just over a third of applicable patients received recommended levels of physiotherapy or occupational therapy. Less than a fifth received the recommended levels of speech and language therapy. As hon. Members put it in different ways, those figures are clearly not good enough. It needs to be emphasised that that poor record is from before the pandemic.

There were concerns before the pandemic about the shortage of specialist stroke consultants. Figures from Kings College London showed that almost half of hospitals had a shortage of specialist stroke consultants, with 48% of hospitals in England, Wales and Northern Ireland having at least one consultant vacancy in the previous 12 months or more. To pick up on the comment by the hon. Member for Beaconsfield (Joy Morrissey), the Stroke Association called on the Government and NHS England to make stroke medicine a more attractive proposition for junior doctors to specialise in, as well as the other specialities, and drew attention to the need for nurses and rehabilitation. Can the Minister update us on the number of consultant vacancies and say what steps are in place to introduce a plan to deliver the staffing levels that we so clearly need?

It is clear, from what everyone said, that we need to go further and faster to provide support for stroke survivors. Further investment is vital to ensure equitable access to services, avoid digital exclusion and improve health outcomes, to stop the kind of disparities that we have heard about. We must end the postcode lottery. It is so important that, no matter where you live, you get access to the same quality stroke support services, which are consistent with clinical guidelines. I hope the Minister will address the issues that Members have raised, and will set out what steps the Government intend to take to support more survivors of strokes.

The prevention and treatment of stroke is a key priority for the NHS. Despite the many challenges presented by covid, the stroke programme has continued to support regional delivery. In some areas, we have accelerated implementation because it is such an important area. As of 1 April, there are now 20 integrated stroke delivery networks operating to support the national stroke service model. Those networks have patient voices and public voices, which it is quite important to let everybody know, because this does need to be patient-driven, and people need to know that they are being heard. ISDNs bring together key stakeholders in stroke to deliver a joined-up, whole pathway transformation through the integrated care systems.

I am sure that my hon. Friend the Member for Bromley and Chislehurst knows that such an ISDN is now operational in his constituency. They will be responsible for delivering optimal stroke pathways based on best evidence, which he referred to. They will ensure that patients who experience a stroke and, so very often, quite debilitating outcomes from it, receive excellent care from pre-hospital, through to rehabilitation and then life after stroke.

There is good evidence that stroke units delivering hyper-acute stroke care 24/7 enable the NHS to achieve ever-improving outcomes. Receiving high-quality specialist care in well-equipped, well-staffed hospitals is the optimum, and 90% of stroke patients will receive care in a specialist stroke unit. More patients will have access to disability-reducing treatments of mechanical thrombectomy and thrombolysis; combined with increased access to rehabilitation, that will, hopefully, deliver long-term improvement and a more seamless pathway.

As we heard from my hon. Friends the Members for Bromley and Chislehurst and for Beaconsfield, navigation of all the different systems is really part of the challenge as well. My hon. Friend the Member for North Norfolk will be pleased to hear that Norfolk and Norwich is one of the new pilot areas for non-neuroscience centres that will work towards the delivery of thrombectomy.

Delivering the right treatment quickly will lead to the best outcomes. We see that with ischemic strokes: busting the clots has become increasingly effective using the right drugs and treatments. All stroke units in the UK can deliver intravenous thrombolysis. Early diagnosis by stroke specialists, followed by early thrombolysis, has been transformative in stroke care.

Thrombectomy is a procedure used to treat some stroke patients, and there is evidence that, where used appropriately, it will reduce the severity of disability. Thrombectomy is available in 22 centres, with two further non-neuroscience centres under development, of which the Norfolk and Norwich centre is one. The expansion of these services is in the long-term plan, with plans to increase the workforce who are able to perform the procedure. Owing to training requirements, that is currently restricted to neuroradiologists, which is a challenge, so we have worked with the General Medical Council to develop a credentialling programme. That will hopefully enable the acceleration of training to a wider cohort of medical professionals, such as radiologists, cardiologists and neurosurgeons.

On rehabilitation services, if the stroke patient has had a hyper-acute treatment they will need early therapy, as we have heard from so many hon. Members. That needs to be delivered by physio, speech and language therapist specialists, and should be accessible within 24 hours. We have heard of the challenges. Long-term rehabilitation is also best undertaken locally, so that people do not face the challenges of chasing around for the service—that also supports the family, who are often vital in a patient’s journey—and to enable the assessment of the appropriateness of homes by occupational therapists and others. We do not want reviews every six weeks, every six months and annually. We want reviews to be patient-led, which I think is what the hon. Member for York Central was driving at.

The integrated community stroke service model has been developed by clinicians, experts and charities, whom I thank for the help that they have given us. To ensure that evidence-based care is being delivered, we have worked with them to address the variation across the country, which is a problem. The stroke rehabilitation pilots mobilised in 2020 are implementing an integrated community stroke service that will enhance care path- ways, including psychological support and vocational rehabilitation. Recognising that everybody’s needs are different is very important, as is delivering personal, needs-based stroke rehabilitation to every stroke survivor, in their home or place of residence.

We have funded the Stroke Association during the pandemic to provide the Stroke Association Connect service. Stroke rehabilitation pilot sites are also testing improved data collection.

The hon. Member for Stockport will be pleased to hear that we have turbocharged research, calling for more research into stroke areas, because evidence-based research is really important. Building on the rehabilitation pilot initiative, we will launch the new stroke quality improvement for rehabilitation later in 2021. Working closely with integrated stroke delivery networks, that will help address variation. Combined with funding for quality improvement projects and expansion of community data, we will then expand. In addition, the national stroke service model, due for publication in late spring, will support that service. The Government have initiated the biggest recruitment drive for allied health professionals in decades, including speech and language therapists and occupational therapists.

I want to give my hon. Friend the Member for Bromley and Chislehurst a couple of minutes to respond, but in conclusion, I hope I have demonstrated that this is a serious issue. I know the stroke community will have heard our discussion. I would welcome the opportunity to discuss the subject more fully, when there is time for me to go over some of the developments and ambitions we have to ensure that we impact the lives of people with strokes. We can give them significant benefits, we can benefit the NHS and, as my hon. Friend said, we can bring people back the best way that we can.