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 Carál Ní Chuilín
Mr Peter Deazley ) Department of Health and Social Services
Dr Miriam McCarthy )
I welcome Dr Miriam McCarthy, under-secretary for healthcare policy, and Mr Peter Deazley, director of secondary care. You will have ten minutes in which to make presentations, and we will have discussions thereafter. Please feel free to begin.
Dr Miriam McCarthy (Department of Health, Social Services and Public Safety):
I thank the Committee for inviting us. I will not reiterate what the previous witnesses said; they provided a good summary of their work, their view of the paper and their input to the consultation. The Department welcomes the support of the Chest, Heart and Stroke Association and Speechmatters, and their further commitment to working with us.
The strategy was put together in a participative manner with a number of clinical people and the Chest, Heart and Stroke Association and Speechmatters, and the Department thanks those organisations. Speechmatters, in particular, was extremely helpful in putting together the easy-access document, which made a huge difference for the purposes of consultation. We are aware that documents of 30 to 40 pages with a lot of text are not accessible, and the easy-access document made a real difference for people who wanted an understandable summary of the strategy. That was a huge asset; the Department appreciates the input of Speechmatters.
The Committee has seen the strategy; some members have responded to it. It is a comprehensive strategy. As Andrew Dougal said, it reflects a huge problem in society, as stroke is a major cause of death. It is the third most common cause of death, and it affects 4,000 people a year. People are left with disability because of stroke, which can affect the rest of their lives. It can affect their families and the role of their carers. The families of the 1,300 people who lose their life each year are affected. Stroke is a significant problem.
The earlier conversation focused largely on services, and I will come to those. It is also worth emphasising that a key part of the strategy is concerned with prevention. Of the 4,000 strokes each year, we estimate that around 40% are preventable. That is a huge and significant number. They are preventable by basic public health and preventative measures. The big risk factors of stroke are also risk factors for a number of other conditions. Smoking, high blood pressure and obesity are huge risk factors. We are tackling those on a public-health front and if we tackle them harder, we can prevent stroke. That is not to undermine the value of services, which are a priority, but we must not lose sight of the fundamental message that around 40% of strokes are preventable. We will continue to promote that part of the strategy. It is a particularly important message for younger people — now is the time for them to work towards preventing possible ill health.
We want the collaborative approach that we have adopted in producing the strategy — and in conducting the consultation — to continue during the development and delivery of the implementation plan. That issue has already been raised this afternoon, and the Department is committed to that collaborative approach. We only work well in major health issues when we work with voluntary and community bodies, patients and providers. It is not an isolated area, in which any one group can make the whole difference. Working together is fundamental as we make progress.
I could not agree more with the point that Jackie White made about having scrutiny over implementation. As we move towards implementation, we must have an implementation plan that sets out key timescales, and we must follow up on each aspect of that implementation. The implementation plan will take account of the input received during the consultation. Whatever the implementation plan looks like, it must be fully implemented over time, and scrutiny will play a key role.
Recommendation 4 of the strategy may — as mentioned earlier — require updating. That is valuable input. Clinical practice will change, and, in devising the strategy, the Department must recognise that standards of care for patients may change over time. The strategy, the implementation plan, and any subsequent action should reflect that.
The Department must continually evaluate the evidence. The Royal College of Physicians in London will shortly produce a document. If possible, we will include evidence from that in our implementation plan. However, if the document is released later, its evidence can still be included in our document. Therefore, we must maintain up-to-date knowledge. Similarly, the DHSSPS has a formal relationship with the National Institute for Health and Clinical Excellence (NICE), and our plan must reflect any further advice on clinical standards and guidelines released by that body. We will examine the information as it is released, because we are keen to keep up to date with the latest evidence.
The Department is devising a cardiovascular framework document — which should be available later this year — setting standards for prevention and treatment of a range of cardiovascular diseases, as well as ongoing rehabilitation and palliative care. The document examines coronary heart disease, stroke and other vascular diseases such as diabetes and renal issues. The framework will link to the overall implementation strategy. The stroke strategy is a powerful tool that has informed the development of that framework. It is important to ensure that those strands are brought together. The framework development has involved the input of users, clinicians and commissioners, and is, therefore, a valuable piece of work.
Thrombolysis is included in the strategy, supported by NICE, and formally endorsed for implementation in Northern Ireland. Our estimates, based on UK-wide data, suggest that thrombolysis could save around 13 lives a year and prevent approximately 40 people acquiring disabilities as a consequence of stroke.
Thrombolysis is of value only to a small proportion of stroke-sufferers, and, as Joe Korner mentioned in an earlier session, needs to be employed during early stages of treatment. Nonetheless, for that small proportion of people, it can make a huge difference, and implementation plans are being developed. However, although it will not happen overnight, work is underway to address outstanding staffing and infrastructure issues.
The Department will ensure that the latest evidence on early intervention on TIAs is reflected in the final document. Although the consultation period has ended recently, we will ensure that the Committee’s comments are considered during examination of the responses. The final document must outline an implementation plan, which should be available within the next couple of months. At that point, the Department will detail the structures it will establish to ensure implementation. At the moment, it would be premature to release that information.
Do you want to speak, Peter?
Mr Peter Deazley (Department of Health, Social Services and Public Safety):
No; Miriam has covered everything.
I was encouraged by what I heard during the presentation. Several issues were raised, particularly about the clot-busting treatment. I accept that it is an estimate, but it is not insignificant that that treatment could benefit 63 people.
There is always a worry that strategies can be dreamt up to cover all the bases, but that nothing actually happens as a result. That is a fear that I have. Do you view the strategy as a living and working document? Of course, no one knows what changes will occur in two-to-five years. However, if other royal colleges were to suggest improvements, or if new NICE guidelines were to be published, how quickly and easily could they be incorporated into the strategy?
Dr M McCarthy:
I appreciate the concern that a strategy could be published and that nothing would happen as a result of it. However, the days of that happening have passed. The strategy was put together because a real problem exists and needs to be addressed. We delayed its publication until we were content that the funding had been secured to ensure reasonable implementation. The Minister has secured the necessary funding; therefore, the strategy has been published with the knowledge that the money to implement it is available and that the standards will be put in place.
In some respects, clinical practice is moving quickly. Therefore, changing standards are almost inevitable — as the care available continues to improve, we need to reflect higher standards. Regardless of what measures are implemented, we need to ensure, if changes are necessary — if NICE publishes new guidelines or the royal colleges suggest improvements — that we are able to consider them. Therefore, the strategy does need to be a living document.
Many aspects will not change drastically. For example, issues that the Committee were told about this afternoon such as physiotherapy; support; speech therapy; a carers’ strategy; and access to an assessment and help are what really matter to patients and carers. Such services should continue. However, some clinical issues, such as whether someone gets an appointment within 24 hours or 48 hours may well change over time. We want to adhere to the evidence-based standards that were published by the royal colleges and by NICE. Through time, we want to reflect those standards.
Bearing in mind that the Minister has secured the finance, how quickly do you think that the strategy could be implemented across Northern Ireland?
Dr M McCarthy:
Some aspects of the strategy will be implemented more quickly than others. For example, thrombolysis treatment will require additional staffing and additional diagnostic equipment, which will take time. However, other measures can be put in place much more quickly.
A lot of the work has already been done; to some extent we are not working from a standing start. The Health Service has a lot of committed staff, and a lot of good care is being provided. We need to build on and extend what is already in place. The implementation of the strategy will be varied. We want it to start immediately, and some aspects will be visible much more quickly than others.
It is hard to be prescriptive. The difficulty is that we have not yet had the opportunity to set out an implementation plan with realistic timescales. However, we will be working on that over the coming weeks.
How would the proposal for stroke units be progressed, and will they all work as they are meant to work? One issue that has arisen during the consultation is that, even when hospitals have stroke units, patients are not admitted to them because pressures on the hospitals have led to the units being farmed out for other purposes. If the new strategy is to be meaningful, that matter must be addressed. What is the Department going to do about the situation?
I am a bit unclear about the role of a stroke co-ordinator. Establishing such a post seems to be a good idea, and I understand that people are keen to see the role developed. Will one person be appointed for the whole of Northern Ireland, or will every trust, or hospital, have its own co-ordinator? How do you envisage that working?
The Minister made an announcement yesterday about emergency services in the south-west, and people in rural areas will want to know how the new strategy will affect them. I just heard the announcement yesterday, and the Minister seems to have become caught up in the epidemic of shyness that is spreading among the Executive — he and his colleagues seem shy about coming to visit their Committees before going public with their announcements.
If a first-responder service is to work well, it must be embedded in the stroke strategy. What are the Department’s plans for a first-responder service? How will a first responder react when he or she is first on the scene to attend to a stroke victim? How will that service be equipped to deal specifically with stroke victims?
Dr M McCarthy:
The first question was about stroke units. The strategy makes a clear recommendation that stroke patients should be cared for in a stroke unit. In his eloquent summary, Mr Dougal said that he would like stroke patients to be cared for in a stroke unit for much more than 50% of their time in hospital. We are taking that on board as part of the consultation process.
We are not able to say what the final document will say about implementation. We are working on that matter, and any decision will require ministerial commitment. However, the strategy reflects the evidence that patients have a better outcome if they are cared for in a stroke unit that has skilled trained staff and the correct facilities. An awful lot of the management of a patient’s case will have to be judged by a clinician. We cannot treat everybody in the same manner. Account must be taken of particular needs, so clinicians must decide exactly how, and where, a patient is looked after, and those clinical decisions must underpin some of the work of the stroke strategy.
Nonetheless, the strategy recommends that people be looked after in stroke units. We have received some very valuable input on that matter in the consultation responses, and we must consider them before agreeing the final wording in the document. Likewise, we must take account of any input on the role of stroke co-ordinators — this is a real consultation, and we want to reflect people’s responses in the final document.
The latter issues referred to first responders and the Minister’s statement yesterday. I assume that the member was referring to the Minister’s press release on the improvements to the emergency services in the south-west.
The Western Health and Social Services Board recommended the development of first responder services in the Western Trust area. In essence, first-responder services that have been piloted elsewhere recruit trained members of the public to support and complement the Ambulance Service in the event of an emergency in their area. We tend to think of first responders as people who respond when someone collapses with a heart attack and needs to be resuscitated very quickly. Those first couple of minutes are vital. The first responders can be informed, and they carry little automated defibrillators that can restart the heart. That is one example of how they play a key role in complimenting the Ambulance Service, not replacing it.
It is hard to say what their role would be in stroke care. Most people who develop a weakness in their arm or leg, or their speech goes, are more likely to call an ambulance, to go directly to hospital, or to call their GP. I am not sure what specific role first responders would play in that situation. However, in the pilot schemes, some of the first responders have trained for particular purposes, so a lot will depend on how their roles are developed locally and on the skills and expertise of the first responders. I do not mean to be vague about that, but it will depend on how things are structured in particular areas.
Mr T Gallagher:
In many rural areas, the first-responder service will be on the scene before the ambulance. In some cases, it will arrive up to 20 minutes before the ambulance. Time is of the essence. We hope that greater emphasis will be placed on dealing with strokes. When the services are introduced, we hope that people will be aware of the stroke strategy and of what the response service can do in the event of a stroke. That is part and parcel of the type of thinking that came out in yesterday’s press release.
Dr M McCarthy:
Public awareness and information is vital.
I welcome the emphasis on prevention. Over the years, we have listened to Mr Dougal talking about prevention and about our inadequate service. Although we welcome the cardiovascular framework, I do not understand why there is so much emphasis on heart attacks always being treated as a medical emergency. Perhaps strokes are not as glamorous, yet the impact on the patient and their families is devastating. Stroke simply never seems to be up there with cancer and heart disease. Therefore, there is a lot of catch up to do.
I welcome the fact that there has been a commitment to resources, but how many beds and stroke units are needed? What is the timescale for rolling those out, because that is where people will see a difference? Workforce development needs to work in tandem with that. How much thinking has gone on?
With regard to Mr Gallagher’s point, it is important to raise awareness of the signs and symptoms of a stroke, so that people realise that it is a medical emergency. Even though it is not a heart attack and a defibrillator is not necessary, if the first responders are the first people on the scene, they will know that immediate action must be taken. It is not always an older person who suffers a stroke. We are hearing more and more about younger people having symptoms, such as sudden slurring of speech. More work must be done to raise awareness of the signs and symptoms, so that people treat those symptoms as an emergency.
Dr M McCarthy:
I agree with your comments, Carmel. Awareness is important. It is hard to know why people who have had strokes have not been given the same priority as people with heart disease. Not as many people are affected by strokes, but it is still a significant number. When I was training, there was very little that could be done to reverse the harm experienced by people who developed strokes. That was the thinking and the reality at that time.
Now, with the advent of stroke units, much more intensive physiotherapy and speech therapy, and thrombolysis, we know that there is more to be done. A key element of that is early identification and intervention. That has changed the whole climate of treatment, which is great, because it offers real opportunities to make a difference.
There are many areas of health provision for which there is never enough funding. The demands are great. The funding that has been made available will make a real difference. We expect the vast majority of that funding to go towards staffing, as it would in other parts of the healthcare budget. The workforce is the key delivery mechanism. It is hard to be specific about where those staff will be, but the Committee has already heard about the importance of workforce development, particularly for the allied health professionals. I recognise that physiotherapists and speech therapists have a key role; their importance cannot be underestimated. It takes time to develop the workforce. In answer to John McCallister’s question about implementation, we want to start that process as soon as possible. However, the lead-in for some elements will take a little more time.
I also made a point about quantifying the need. If things are going to be different, people need to know that a commitment has been made to the stroke units. It is not acceptable that patients languish in an accident and emergency department or a geriatric unit. Even some young people have ended up in geriatric wards, which is totally unacceptable. People want to know that a plan is in place for stroke units, even if it is going to take a certain length of time to implement.
Dr M McCarthy:
That is absolutely right. There need to be care pathways so that patients get to the right place as quickly as possible, that stroke units meet the standards set out by royal colleges and others, and that there are skilled staff, proper facilities, and all the other aspects that must be available for patients.
I have a question about the specialist staff required, such as speech therapists and physiotherapists. Many young people have graduated in physiotherapy but have found that no jobs are available, and have had to take lesser jobs or leave Northern Ireland entirely. Why is that happening when we are reviewing the system and examining how we treat stroke patients? Why are we allowing that to happen?
Dr M McCarthy:
I can come back to you with more of the detail on that issue. My understanding is that a number of the posts advertised require a degree of experience. It can be difficult for graduates to identify and be accepted into posts without that level of experience. However, I am not familiar with the details, and I am happy to give the Committee the information in writing.
It is the old story: how does one get experience if one does not get a job? It is a vicious circle. People have spent several years studying for those specialist positions; a number of young people have come to my offices saying that they have not been able to get jobs.
I do not wish to repeat points that have already been made. However, the workforce is a key element in the implementation of the strategy. The Chest, Heart and Stroke Association and Speechmatters made the point in their presentations about the lack of reference to carers. It is obvious that when someone has stroke, it has a big impact on their family. I would like to see a stronger reference to carers in the final strategy.
Tommy Gallagher made the point that access to thrombolysis for people who live in a rural area is crucial, particularly if it is needed within the three-hour period that was mentioned. As the Minister said yesterday, it is important that the people involved in the first-responder project are properly trained.
Will the ambulance service be involved in the working group that is being established, because, in many cases, ambulance crews will be the first to reach someone who has a stroke? In areas where there is no dedicated stroke unit, it is vital that patients are taken to hospital as quickly as possible.
Dr M McCarthy:
You are absolutely right: carers play an important role. There is a separate carers’ strategy, and we will make a stronger reference to that in the overall strategy. The two need to be linked, and we will make that point more prominent in the final document.
We have already touched on the role of first responder as regards awareness and information. The Department does not see them having a role in treatment. The administration of thrombolysis requires expertise and specialists.
I did not mean to suggest otherwise. I am referring to FAST training.
Dr M McCarthy:
First responders will play a role in informing hospital staff of the position. What is vital is getting people to hospital as quickly as possible. However, that three-hour window can be quite narrow. If an elderly person awakes to find that they have a weak leg, who knows whether it happened one hour or eight hours earlier. That poses a real difficulty.
We do not yet know the membership of the implementation group. It is fair to say, however, that in those aspects of implementation and strategy development in which the ambulance service plays a role, we like to have its representatives at the table. The service is a central player. Although I cannot be specific about who will be in the group, we always consider the input of the ambulance service wherever it is relevant. We also tend to have regular meetings with the service to keep it informed of developments.
The community and voluntary sector also has a central role, especially in raising awareness.
Everyone who has asked to speak has had the opportunity to do so. I thank Miriam and Peter for attending and addressing the concerns of members. I hope that you will take away with you the key points that have been raised and will include them in the overall review.