HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
10 April 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Mr John McCallister
Ms Sue Ramsey
Mr Andrew Dougal ) Northern Ireland Chest Heart and Stroke
Mr Joe Korner ) The Stroke Association
Mrs Jackie White ) Speechmatters — Part of The Stroke Association
The Chairperson of the Committee for Health, Social Services and Public Safety (Mrs I Robinson):
I welcome Andrew P Dougal OBE, chief executive of Northern Ireland Chest, Heart and Stroke Association, Jackie White, chief executive of Speechmatters and Joe Korner, director of communications for The Stroke Association. The Committee is looking forward to hearing what you have to say. You will have 10 minutes for your presentation, after which the floor will be open for members to ask questions if they so desire.
Mr Andrew Dougal ( Northern Ireland Chest, Heart and Stroke):
Thank you very much, Chairperson. This is a great opportunity for Northern Ireland Chest, Heart and Stroke Association. For 30 years, stroke and aphasia have been Cinderella illnesses that have not been tackled effectively by the Health Service. An opportunity to do so now exists.
As Committee members know, stroke occurs because of a clot or a bleed in the brain. More than 4,000 strokes occur in Northern Ireland each year, resulting in approximately 1,400 deaths and 1,400 people being left seriously disabled.
Each year in Northern Ireland, strokes cost the Health Service £80 million. The cost to the economy as a whole is £200 million. Strokes are the leading cause of aphasia and disability in the community.
The people whom we spoke to during our consultation exercise are impassioned, and they were empowered by that consultation. Indeed, my colleagues in Speechmatters argued for an easy-access document so that the consultation paper could be easily understood by stroke survivors and their carers. More than 150 individuals replied to the questionnaire in that document — that is extremely positive.
At the request of the Department of Health, Social Services and Public Safety, the two voluntary organisations hosted four conferences throughout Northern Ireland. Up to 300 stroke survivors and carers attended those events — that again was extremely positive, and many people asked us what was going to happen as a result of the process. We hope that the Health Committee will persuade the Department that additional, positive resources must be provided for stroke survivors and carers.
The feedback included: the need to improve the quality of life for stroke survivors; the need for partnership between service users and voluntary agencies and an end to the postcode lottery for services. In many centres in which there have been stroke units for years, there are excellent services. However, services are extremely poor in many areas — for instance, Downpatrick and Coleraine — where there are no stroke units.
Having a stroke unit is not sufficient. For example, there is no point in having a stroke unit that caters for only half of the number of people who suffer strokes. Stroke units catering for all stroke patients are needed so that each person in hospital has the same opportunity to benefit from such a unit.
We must focus on the stroke strategy and monitor its implementation. A workforce model must be developed for the delivery of stroke care.
Our four consultation events produced 10 key demands. Stroke must be treated as a medical emergency — that approach is long overdue. Transient ischaemic attacks (TIAs) — mini strokes — are often predictors of stroke and must be treated as medical emergencies and with the same seriousness as stroke. All stroke patients must be taken to a stroke unit immediately — at the consultation events, many people told us that they had been obliged to hang around accident and emergency departments or were sent to various wards before being admitted to the stroke unit, where they then received good care. Those people could have done without the trauma of being transported from one place to another.
All stroke survivors, and their carers, must be given psychological and emotional support — that cry was echoed in every meeting we had. All stroke survivors must receive a seamless transition from hospital to home, and they must be given comprehensive information, the lack of which was a universal complaint — in many instances, patients, families and carers were not told that a stroke had occurred.
All stroke survivors must receive rehabilitation and long-term support in the community. It is no good if care finishes after three or six months. Improved services for stroke survivors must include respite care for their carers and a proper carer’s assessment. Carers are entitled to an assessment, and, at our consultation events, few carers reported having had one — at the meeting in the La Mon Hotel and Country Club, when asked, no one put up their hand.
There is a grave need for guidance and support in financial matters and in financial planning. A family in which someone suffers a stroke — especially if it is the breadwinner — experiences unbelievable devastation. For 20 years, we have been attempting to reduce the time required for occupational therapists and for the Housing Executive to carry out home adaptations. Firm targets must be set and adhered to. Carers must also be made aware of the available services.
All services provided to stroke survivors and their carers must be consistent and equitable throughout Northern Ireland — I cannot emphasise that enough. Stroke survivors must be told about developments in stroke care, and they must have an opportunity to participate in, and benefit from, discussions about them.
My colleague, Jackie White, from Speechmatters will now take over.
Mrs Jackie White (Speechmatters — Part of The Stroke Association):
I want to talk about the key recommendations that we want the Committee to consider in relation to the final stroke strategy.
For both of our organisations it is fundamentally important to raise stroke awareness. We call on the Minister and the Department to provide a properly financed “stroke is a medical emergency” campaign. The people of Northern Ireland have a right to such a campaign, and it should be developed in partnership with non-statutory stakeholders such as Northern Ireland Chest, Heart and Stroke and Speechmatters, which is part of The Stroke Association. The creation of an awareness-raising group would work well at co-ordinating the campaign.
We want the final strategy to recognise that life after stroke is important. Dermot Ferris, a stroke survivor and a member of Speechmatters — Part of The Stroke Association, described his experience by saying that stroke is like an octopus: physiotherapists, occupational therapists and speech and language therapists each do their things; half swimming upstream and half swimming down. There seems to be no collective onus to get it right because each is too engrossed in his or her own wee scenario. That was Dermot’s description, and he is with us today.
We want a life-after-stroke recommendation to be included in the strategy, because we believe that there should be specific recommendations covering community-based speech and language therapy, physiotherapy and occupational therapy.
In addition, the role of emotional and peer support, conversation groups and so on — often provided to a high standard and in a cost-effective way by the voluntary sector — should be included. Stroke survivors are extremely clear; rehabilitation is crucial to their recovery. Without adequate rehabilitation, many people lose their role in the family for longer than is necessary. Few survivors return to employment, and many lose the ability to communicate. In some regions, the length of waiting lists for such services is unacceptable. Many stroke survivors have experienced inadequate access to services that are pivotal to their rehabilitation.
We want the final strategy document to acknowledge the role of the voluntary sector. It should highlight the important work of the voluntary sector; including Speechmatters — Part of The Stroke Association, and Northern Ireland Chest, Heart and Stroke; that supports stroke survivors, their carers and their families.
We believe — and stroke survivors have told us — that that work is vital to thousands of people with post-stroke communication and emotional difficulties. Many of our service-users describe the services provided by the voluntary sector as an absolute lifeline after stroke and want that sector to continue to operate those services.
It is important to focus on the implementation and scrutiny of the strategy. We are concerned that there is insufficient information about the Department’s proposed method of implementation, both regionally and within each health and social care trust. We hope that a transparent-partnership approach, involving the voluntary sector and, importantly, stroke survivors, will be adopted. They must be informed of developments in stroke care and have opportunities to contribute to those developments. Speechmatters — Part of The Stroke Association and the NICHSA will work hard to offer time, support, energy and expertise to the Minister and the Department during implementation and are keen to be represented on any implementation bodies.
The scrutiny of the implementation of the stroke strategy is arguably as important as the recommendations. Speechmatters — Part of The Stroke Association, and Northern Ireland Chest, Heart and Stroke, are firmly committed to working in partnership with the Minister, the Department and other stakeholders to oversee the implementation of that strategy.
In Northern Ireland today, 12 people will suffer a stroke: four will recover, four will have permanent disabilities and four will die. We urge the Committee to help us ensure that the stroke strategy reflects the needs of stroke survivors, their families and their carers. Improvement in prevention, care and rehabilitation will reduce the social and financial cost of stroke and help rebuild thousands of lives. By acting on our advice, the Committee can improve the quality of life for stroke survivors, their carers and families, and ensure equity across Northern Ireland. If we can, we must remove the postcode lottery once and for all. We can help reduce the number of people who suffer strokes, die of strokes — and increase the number who fully recover.
Mr Joe Korner (The Stroke Association):
The only thing I want to add to both those eloquent presentations is that we are excited by the strategy. Although there are bits that we would like to improve or strengthen, and we have concerns about its implementation, it represents a great step forward. It also represents a consensus among the medical side, the voluntary side and the Minister. That is really important.
Our experience across the UK is that it is consensus for change in the treatment of stroke that drives things forward. We want to be very involved in forging consensus, which must also include the allied health professionals and researchers. The strategy and consultation process have given us a strong platform to move forward and radically improve stroke services throughout the very long care pathway.
I forgot to mention one area in which we have been campaigning for some years: the use of clot-busting drugs to combat stroke. Such drugs have been available in the United States for ten years and I have seen them in action. Since then we have campaigned for their use here. They are referred to in the Minister’s draft strategy and we welcome that. It is essential that such drugs should not be available only from 9.00 am to 5.00 pm, Monday to Friday, which amounts to a lottery. There must be access to the drugs on a 24/7 basis, and therefore, access to CT scanning on a 24/7 basis, as occurs in other centres throughout the United Kingdom.
Thank you for your in-depth presentations. The meeting is open to questions from members.
How does Northern Ireland compare with the rest of the UK regarding the number of people who die from stroke and how people are treated? You seem have a problem getting information from the Department: have you found that there has been lack of co-operation or lack of partnership? Please tell us: it is important that you make your points to the Department and that it works with you. I would encourage such an approach.
Tell us about the financial costs of stroke. If the number of strokes were reduced, would that free up money to be spent on rehabilitation?
Mr J Korner:
I can answer the question on comparison between Northern Ireland and the rest of the United Kingdom. Northern Ireland was in advance of the rest of the UK in the introduction of stroke units — specialised wards with expert staff: doctors, nurses, speech and language therapists, physiotherapists and occupational therapists.
Survival and disability rates in Northern Ireland compare well with those in England. Scotland, which has had a stroke strategy for several years, is ahead of England and Northern Ireland. In Wales, progress has been slow, and work is ongoing there to catch up with the rest of the United Kingdom and introduce stroke units across the country. Only half of the hospitals in Wales have a stroke unit.
A stroke strategy was launched in England last December. Its recommendations are similar to those in the Northern Ireland strategy, and much work has been ongoing to implement them.
The figures that we gave for death and disability are up to date. However, if comprehensive stroke units and clot-busting treatment were to be introduced, the number of deaths and people left with severe disability could be reduced. A saving could potentially be made. However, implementing that type of strategy would involve up-front investment; particularly in reorganising services. If CT scanning were to be made available 24-hours a day, staffing and ambulance issues would be involved. However, that investment is worth making; both for the health benefits and because, down the line, it will reduce long-term costs to the economy and to the Health Service in Northern Ireland.
We have been involved with the Health Service for 25 years, and the Department has been helpful in giving us information. Since 1989, we have run a series of conferences for the Health Service in order to persuade it to improve treatment of stroke, and although the Department has agreed to do so, that agreement did not develop into either policy or strategy, which concerned us.
However, in spite of that, individual physicians, nurses and other health professionals went ahead and, without additional resources, established stroke units in most hospitals in Northern Ireland — and it is to those people that we want to pay tribute today. Nevertheless, it will be great to have a strategy now because it would have been good if we had had one when we started on this road in 1989.
Our relationship with the Department during the stroke strategy consultation has been extremely positive, and I do not say that lightly. Money was made available quickly to fund the vital listening events, so that people’s voices were heard. People who are usually forgotten were brought together to comment on the document. I hope that that positive relationship continues with the implementation and scrutiny. I am hopeful, too, that our partnership throughout the process will continue.
Mr Gallagher and I attended an event recently and found it very worthwhile. I pay tribute to the magnificent work that the voluntary sector does in this area. It is hard not to argue positively for your key points. I was with one of your conversation groups in my constituency in Newcastle yesterday morning. It was interesting to hear their views on a variety of issues, even access and transport; issues with which many people have had to deal suddenly. Some are just thrown into that situation in almost the blink of an eye.
One of the issues that came to the fore — and Mr Dougal touched on it when he spoke of support ending in perhaps three to six months — was that stroke survivors continue to improve, and not in just three to six months. Group members said that they were still improving six or seven years after their event. How does that fit into the strategy? The phrase “long-term support” was used, but, realistically, for how long can stroke victims be supported?
Over the years, once the statutory services end, it is the voluntary sector that has been left to take over. After the three- and six-month periods, the Northern Ireland Chest, Heart and Stroke Association and Speechmatters take over. We are available for as long as people need us. People have been members of our stroke schemes for 10 and 15 years, and we are there to help them. We do not expect the statutory sector to be available to stroke sufferers forever. However, we believe that we can provide services much more cost-efficiently than the statutory sector. Therefore, when it is deemed that the statutory sector can do no more, the voluntary sector is there to take on that work — and that fact must be recognised by Government. People cannot simply be abandoned after six months — there must be support.
Health trusts fund our schemes by 47% on average. We would like more schemes and more extensive support. In recent years, Northern Ireland Chest, Heart and Stroke has been introducing physiotherapy into stroke groups. If those Health Service resources were available to our groups, that would help to continue rehabilitation. In any survey, when a stroke patient is asked: “If you had money in your pocket, how would you spend it?”, time and again the answer is: “To buy myself more physiotherapy.” What are needed, therefore, are physiotherapy; and, if aphasic, speech therapy.
It would make a huge difference if we had those resources and if people were seconded into the listening groups and into Northern Ireland Chest, Heart and Stroke clubs, perhaps for one morning a week in each area. Those professionals would be dealing with a group of patients rather than working with patients on a one-to-one basis, and would therefore be achieving multiple rather than single benefits. That is the view of Northern Ireland Chest, Heart and Stroke.
Stroke survivors often tell us that they continue recovering for years. The problem with a very evidence-based medical establishment is that measurable improvements in mobility or in speech are sought. However, a person’s recovery rate slows down as the time since their stroke passes. Therefore, one issue that we face is whether it is possible to measure how much someone improves as a result of a particular service, and that is why, traditionally, speech and language therapy or physiotherapy often stops after three or six months. Quite often, that is not solely a clinical judgement; it is also a financial judgement. It is affected by the availability of physiotherapy or speech and language therapy. I suspect that, if the workforce in those areas were increased, people would get those services for longer, and physiotherapists and speech and language therapists would make different assessments.
Another issue is the huge impact that stroke sufferers’ emotional and psychological state has on their ability to recover. Even though it may not be possible to show an improvement medically in someone’s speech or mobility, the psychological importance of being in a stroke group or a communication group is extremely important. The benefit of that is not easily measured in medical terms, but it is hugely measurable in what stroke survivors tell us. They are able to say that they are still improving after six or seven years because they are in an environment in which that improvement can be discussed, validated and supported by the professionals who work for our organisations and, of course, by the other stroke survivors. That peer support is so vital.
It is important to remember the need to be person-centred when dealing with this. One size does not fit all, so we cannot say that a person has made as much of a recovery as they are going to after six months, and that we are going to direct our resources to someone else. I thank Mr McCallister for taking the time to visit one of our conversation groups. Certainly, our members are telling us that, after four years, they have the confidence to speak a little bit, and, after five years, to speak a little bit more. Who are we to say that we are going to stop working with them and move on? Any approach must be person-centred and must deal with people as individuals.
I was in a shop recently and I met a woman in her 60s whose speech was difficult to understand and I discovered that she had had a stroke. That lady had the confidence to start shopping again and try to make contact with people, and it was possible to understand her if one listened carefully.
However, it made me reflect upon how much depression and related issues are suffered by people who perhaps led a very active life until the day they became a stroke patient. I am interested in knowing how many people are affected in that way, and what backup is available to help them through depression or other mental health issues that they may suffer, and which may add to their problems.
It is estimated that approximately 30% of stroke survivors will suffer from clinically defined depression. There is a range of reasons for that, such as the trauma of having suffered a stroke and the subsequent loss of independence that is a reality for so many people. There may also be physical changes in the brain that can contribute to range of different mental states, such as changes in cognition. Most stroke survivors’ experience is that they have very little support in that respect.
The Royal College of Physicians recommends that there should be psychological support in a stroke unit. That is very rare in practice, and where it does exist it is not available for long enough for a proper assessment of people to be made. Often, people’s depression will last beyond their stay in hospital — it may develop when they return home or even three months after they have been at home, for example. The type of psychological assessment that you are referring to is very rare. Peer support — the emotional and informal support that that provides —will be people’s main source of support. We must not diminish the importance of that; however much more could certainly be done.
It is important, and welcome, that psychological support has its own recommendation in the draft Northern Ireland stroke strategy. We aim to strengthen that and also to assess the requirement for psychological and emotional support in the longer term.
Are there statistics to show that people may go on to commit suicide?
We do not have such evidence. Indeed, there is a paucity of evidence regarding the social and emotional impact of stroke. For example, we suspect that a higher number of stroke sufferers’ relationships break down, but we do not have the evidence to say that for certain. The Stroke Association is keen to investigate the social aspects of the impact of stroke. We are trying to raise funds to conduct a needs survey on the matter.
There must also be a mood assessment. One of the criteria of the Royal College of Physicians’ audit is that people should have their mood assessed before leaving hospital. Sadly, very few people have that assessment. That is a basic requirement, and it is essential that it is part of the implementation of the strategy. Before a person is allowed to leave hospital, their mood should be assessed.
I welcome your positive attitude towards the strategy, and I agree that there should be a transparent, partnership approach to its delivery. We will make that point to the departmental officials in the next evidence session. The only recommendation that you appear to disagree with is recommendation 4 regarding the neurovascular clinic. Will you give us your feelings on that recommendation?
It was said that not every area has a dedicated stroke unit. Research shows that patients of all ages benefit from being cared for in such a unit. However, because of a shortage of available beds and resources in general, obviously not everyone is looked after in a stroke unit. Does the strategy go any way towards addressing that problem?
No. Indeed, that is one of the issues that we raised in our submission to the Minister. We even challenge the Royal College of Physicians’ recommendation that people should spend at least 50% of their time in a stroke unit; 50% is a totally unambitious target and must be improved. Stroke units are extremely beneficial.
My view — and the view of Northern Ireland Chest, Heart and Stroke — is that a patient in a bed in a general ward takes up as much resources as he or she would if that bed were in a stroke unit. Therefore, why not have fewer beds in the general wards and more in the stroke unit? The cost would be the same, but it would be much more effective for patients to be in stroke units rather than languishing in general wards.
In the past, many under-65s who had a stroke were consigned to general wards where, perhaps, the physicians were not that interested or where a team approach was not taken. Those people suffered badly; but that situation is changing. Rather than people who have had a stroke being scattered in general wards throughout the hospital, additional beds should be put into the stroke units. Those beds will cost the same as if they were in a general ward but the treatment will be much more effective.
Recommendation 4, which concerns TIA, is out of date. Research into TIA is moving very quickly. Professor Peter Rothwell — the foremost TIA expert in the UK, who is based in Oxford — developed the scoring system for assessing risk following TIA.
If an individual has a TIA, they are potentially at very high risk of having another stroke. TIA is the only pre-warning that another stroke may be suffered. An individual is at highest risk in the first 48 hours following a TIA. The ABCD2 score assesses that risk; scores range from one to six and if the score is six or seven, the patient is at very high risk of having a stroke within 48 hours. The key is to catch those people and reduce their risk — usually through surgery on the carotid artery which gets clogged up.
One can look at the carotid artery by using an ultrasound scan or an MRI scan. If that is done quickly, strokes can be prevented, which will save heartache, trauma and NHS money. That is why this is a crucial issue.
The latest evidence suggests that people who are at high risk need to be seen within 24 hours to get access to high-quality imaging — an MRI scan if possible — and get them into surgery, if necessary, within a week. There is economic evidence that suggests that it is best that everyone who has had a TIA is transferred to a clinic within 24 hours regardless of the risk. Although that is the most cost-effective way, the practicalities are difficult. The National Institute of Clinical Excellence (NICE), which has examined the issues and issued its guidance for consultation recently, suggests that anyone with an ABCD2 score of four or above should be seen within 24 hours and have access to MRI scanning. That accords with the English stroke strategy.
That is the latest thinking, and our view is that the recommendation was based on evidence from six months or a year ago and only requires updating. However, that is not to underestimate the challenge of putting that type of emergency response to TIA into practice.
All of the witnesses have mentioned therapy, and that the service is not as good as it could be. There are workforce-planning issues regarding physiotherapists in that although the Health Service trains a certain number of physiotherapists, one third of graduates cannot find employment in the Health Service. The problem is that, despite the resources that are spent on training, service delivery is still coming up short. Do you recognise that problem as regards physiotherapy, and does it extend to speech therapy?
As regards physiotherapy, I have heard that there are people who are unemployed after they finish training. If the Government allocated extra money to voluntary organisations, we could make effective use of the services of those physiotherapists to continue the mobility rehabilitation of stroke clients in our groups. That would be a positive initiative.
In many cases, it has been brought to our attention that many of the waiting lists for speech and language therapy for people with aphasia exist because of vacant posts — there are not enough highly-qualified speech and language therapists who have the necessary expertise in their career to provide the service.
Steps to change that, by increasing the number of available places at the University of Ulster to train the speech and language therapists in Northern Ireland, have not impacted yet. Our members are describing long waiting lists for speech and language therapy, which could be because of workforce planning.
Is there a plan to increase the number of training places?
Some time ago, there was a plan and the number of places did increase. However, I have not heard anything recently to suggest that there will be a further increase in the number of places.
There is still work to be done to determine the correct ratio of physiotherapists or speech and language therapists to stroke patients. There are different views on the level of intervention that is required in the stroke unit and once people are back in the community. Therefore, there is still a lot of workforce planning to do. For example, the Chartered Society of Physiotherapy is campaigning across the UK because there are so many unemployed physiotherapy graduates.
A big problem throughout the UK is that trained physiotherapists do not get employment, perhaps because budgets are squeezed. In some areas, not enough people are being trained. However, there is also not enough available in budgets to employ people who have already graduated and to bring them up to the level of specialist skill that is required to enable them to support people who have had a stroke.
Another important matter with regard to that is that many speech-and-language therapists, who may, traditionally, only have treated people with speech and language difficulties, now treat people who have swallowing difficulties after having a stroke, which can be life-threatening. That is where investment is being made. Obviously, when people have a life-threatening condition, it must be focused upon. However, if someone has lost their speech as the result of a stroke, investment must be made towards helping that person to regain as much conversation as possible; otherwise, he or she is lost to the economy, will never be able to work again and will probably lose his or her role in life completely. That matter must also be examined.
I welcomed the consultation, which has offered a great opportunity to improve the service. It has enabled the Committee to respond, to endorse the comments that has been made by the witnesses today and, indeed, to provide its own comments.
I attended the event in the La Mon Hotel and Country Club. Listening to the people there was a humbling experience. None of us listens enough. Mr Dougal mentioned the need for social and psychological support. Many said that they just want to be treated as whole people; not simply to be addressed with, “And how are we today?” When they are screaming inside, people do not really want to hear what their problems are because they must get on with one thing or another.
Mr Gallagher and others raised the issue of workforce, which I want to tease out at another time with the Department. How is the workforce matched up in order to ensure that the correct number of physiotherapists, speech therapists, and so on, is available?
I strongly agree that stroke must be treated as a medical emergency. The situation with regard to heart attacks has progressed, but that has not been the case for stroke. Treatment for heart attacks is great. However, I could have a stroke tomorrow, and although the service is great, it is patchy. Rather than ask a question, I simply want to reinforce the comments of the witnesses, especially when departmental representatives are listening.
The situation could be much better and it must be improved. Although clot-busting drugs are available, there is no point in treating stroke as a medical emergency when people are not able to get scans or have access to those drugs; and where there is no stroke unit in which they can be taken in order to get physiotherapy and other treatment quickly.
Earlier, the Committee heard the figures for the number of people who have strokes in Northern Ireland; those who die as a result; those who recover, and those who are left permanently disabled. Physicians sometimes refer to that as the rule of thirds but, in fact, that rule can be broken.
The strategy points the way on how to break that rule. If more people were treated in stroke units, the mortality rate could be reduced dramatically. If between 10% and 20% of people who could benefit from clot-busting drugs and thrombolysis were treated, that would dramatically reduce the number who are left with severe long-term disabilities as a result of strokes. Therefore, we could all be part of the consensus to break that rule of thirds. It is hoped that in five or 10 years’ time, we could come to a similar venue to talk about fewer strokes and different outcomes for the majority of people who have them.
As we have said in the past, stroke has been a Cinderella illness — it has been neglected for decades. I appreciate that the Minister has acquired additional money for strokes. However, that money will not, in any way, begin to compensate for decades of neglect. That bolsters the argument for huge, new resources to be directed towards stroke services, which have been neglected for decade after decade.
I want to ask a closing question. How much would it cost to provide clot-busting drugs to treat the number of strokes that happen each year?
The National Audit Office carried out an analysis in England of the number of lives that could be saved and the reduction in disabilities that could be achieved through introducing thrombolysis. That report indicated that, although there is an initial set-up cost, and investment is needed, 1,000 lives could be saved in England over the course of a year. Therefore, as you can see, the treatment could have a dramatic impact.
Unfortunately, thrombolysis is of benefit to a minority of people who have strokes. There are many reasons why people are excluded from the treatment. Sometimes, it feels as though one is talking about a special group of patients, but that is not the case. Those patients are the thin end of a very important wedge. If we introduce clot-busting treatment, we will drive improvement in the whole acute service.
One cannot introduce clot-busting treatment unless one has a good acute stroke unit. There may be one or two centres in Northern Ireland that would be able to deliver 24-hour hyper-acute care. People will need to be repatriated to their local hospitals, and the implementation strategy must ensure that they will be repatriated to the best possible acute-stroke unit. Although only a minority of patients can be treated using thrombolysis, that treatment will be the wedge that will drive improvement throughout the whole sector. That is why we are talking about long-term support; we want to ensure that the back end of the wedge also receives the improvement that will happen at the acute end.
It is hard to say exactly what the savings will be. If we save more lives, we might increase the number of people who survive, but who have disabilities, and there are costs associated with that. However, the National Audit Office’s report is perhaps the best reference source for the types of cost-and-benefit analyses on thrombolysis.
Therefore, you are saying that clinicians must support the identification of people as being likely to benefit from the treatment. It is the same as the use of beta interferon for MS sufferers; it will benefit some patients, but not others. Basically, the clinician would decide whether the person would benefit from using the drug.
Yes, they would. There are various issues. The drug can only be administered within three hours of the onset of the stroke, which means that a patient who calls an ambulance after three hours would not be considered for the treatment, unless he or she was part of a trial to see whether it would be effective after three hours. There are many exclusions. At present, the treatment is licensed only for people aged between 18 and 80, for example.
Some hospitals in the USA, Canada and Glasgow report that more than 20% of their patients are being treated. Therefore, if we get the system right, we can really increase the benefit of the treatment.
I thank Jackie, Andrew and Joe for coming to the Committee and giving us an insight into strokes and Speechmatters.