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From Public Accounts Committee Transcript of Evidence 8th February 2006

Sadiq Khan MP questioning Sir Nigel Crisp, KCB, Permanent Secretary and Chief Executive of the NHS, and Professor Roger Boyle, National Director for Heart Disease.

Q86 Mr Khan: One of my problems is when you are the seventh person to ask questions all the best questions have been stolen. Can I underscore the point made by Mr Clark, which is the reason why we are all a bit vexed and animated. It is not simply our obsession with the value for money point, it is that the report tells us, and you have accepted the report, that 550 deaths per year could be prevented but also 1,700 people could revert back to their normal standard of living and their life but for the recommendations so far. You can understand, I am sure, the reasons for our vexation. My first question is you explained that international comparisons are difficult and you also said, and the report says, that the number of incidents and deaths to do with strokes has gone down over the last decades. Can you explain, and I think Kitty Ussher who is not here alluded to this, why the chances of someone dying who has suffered a stroke have remained consistent compared with the chances, for example, of a heart attack, which have declined?

Professor Boyle: The numbers have declined for stoke as well, they just have not declined so fast.

Q87 Mr Khan: Exactly. The percentage of people who die post-stroke, the improvement that has been made is less good than the improvement made in better contrast to heart attack and deaths?

Professor Boyle: I think the message we have been trying to get across to you is that we need to do that effectively. We need to tackle the whole pathway right from the individual calling for help, the speed of the ambulance service, the access to the scan, the interpretation of the scan and then the application for those with a thrombotic stroke, that is an artery that concludes with a blood clot.

Q88 Mr Khan: My second question is could you give us a note setting out - over the last 15 years I would be happy with - the increase there has been or the decrease, I assume there has been an increase, in the number of CT scans over the last 15 years, the number of pre-staff like radiographers, radiologists, neuro-radiologists, stroke consultants and the rehabilitative staff for example psychologists, dieticians, physiotherapists, occupational speech therapists and social workers, those sorts of areas over the last 15 years. Is that a reasonable request?

Professor Boyle: For a lot of those staff groups the survey data is not complete.

Q89 Mr Khan: As much as you can would be useful. It provides us with a relative way of seeing in those areas how steep the graph is about improvements made. My second main issue is in the NAO paper on page five, there is a reference to the total cost - it is in table two in the second column, the second bullet point - "The total costs of stroke care are predicted to rise in real terms by 30% between 1991 and 2010". Do you accept that?

Sir Nigel Crisp: Yes, I think we do.

Professor Boyle: One of the problems we have here is with an ageing population, age being a major risk factor for stroke, you would expect the numbers to rise and therefore the cost.

Q90 Mr Khan: Exactly. Is that because more people will suffer strokes and the cost post-stroke will rise or is that because you are buying more CT scans, training more staff and having the staff working up to 36 hours rather than 12, et cetera?

Professor Boyle: Basically, I think the rate will not rise once it is adjusted for age but the volume of work that we will have to deal with will rise because we have an old population.

Professor Philp: On your point comparing where will the costs be incurred, relatively more costs will be incurred on the acute response and proportionately, therefore, less cost on the long-term burden through better treatment and reduction in long-term disability although the proportion of the total cost of a stroke episode through care is largely accounted for by the longer term costs.

Q91 Mr Khan: That is the answer I was hoping for. Can I take you on to pages 16 and 17 in the report, figures six to eight. It is quite clear that there is a huge variation in the service provision around the country. I know this because at St George's Hospital in Tooting we have a specialist stroke unit in a new wing built by PFI with a dedicated team of experts, the top ten in the country. We have access to TIA technology where the one-stop clinic would have the availability of the thrombolytic drugs that are referred to in the report. We have now more access to CT scans. Aside from your point, which I am sure you will say is because they have got a good MP, what is the other reason why places like Tooting have such a different experience to our colleagues up in the North East in particular?

Professor Philp: It is local championing. The best practice in the country - and the best practice in our country does compare with the best practice in Australia, Sweden - Newcastle, Cambridge, some centres in London and others are delivering excellent care. Our challenge is to move these from best practice because you have self-selected champions with a strong interest in the area, many of whom are at the cutting-edge of the research and building up the workforce so that we have champions throughout the country. That is the main reason why there has been differential growth, it has been the availability of local champions, including no doubt local MPs.

Q92 Mr Khan: You are right, the average time people spend in St George's is 22 days, it is still too long but going the right way. Is that good enough? That is almost an argument not for devolving power down to the trust because St George's is blessed with a great MP and a good PCT and stuff. What about the others?

Sir Nigel Crisp: A general point about performance improvement is that it is on a normal distribution of bell curve. You will have people at one end who are the leaders, you have the bulk of people in the middle and then you have got the people at the end who really are the laggards. Our task, as a system, which I think Professor Philp was saying, is to make sure that the best practice that is learned in places like Tooting is spread elsewhere.

Q93 Mr Khan: How?

Sir Nigel Crisp: Amongst over things by these sort of publications, having the strategy that Professor Boyle is leading the development of and, to some extent, by targets. Let me give you an example of something which has not yet come up which is in the GP's contract, they get paid for certain measures and for things that they do. We have now got into it something like 30 payment points that are associated with stroke which we did not have before. You are getting the incentives into the GP, you are getting the spread of best practice, you are getting clinical leadership, you are promoting what is happening in Tooting and elsewhere and you are getting those people to go and talk to other people in the country. Best practice does not spread easily, it needs all those financial incentives as well as the leadership.

Q94 Mr Khan: When should we expect to be able to have you back here and ask you the questions about the bell graph you talked about and refer to it as a significant improvement? How soon?

Sir Nigel Crisp: I think it is happening. Some of these figures, it is interesting, have changed in the last couple of years, even within this report. The people who say that they have been in stroke units and so on have shifted from 40% to 60% in three years, though if you were to invite us back in three years' time or something I suspect you would see a much better picture than that.

Professor Boyle: You mentioned the North East, in fact, one of our exemplar hospitals is in Newcastle and one our leading clinicians, who is helping us develop the strategy, is based there. One of the reasons is that it is another large hospital where you are likely to have a bigger cohort of patients to manage, more resources and easier access to the scanning and the other technology. Even there, in a big hospital, it is not easy. This individual has also been appointed to run another topic, which we have not mentioned yet, which is a UK Stroke Research Network. We have funded them with £20 million over five years to develop research networks across the country which will cover about three quarters of the population.

Q95 Mr Khan: My final two questions are that, first of all, the Chairman and Mr Curry already alluded to public awareness campaigns, and you have been given a sneak preview. One of the criticisms could well be your lack of success in your public awareness campaign. One point that Mr Curry did refer to, where there is a disproportion of sufferers, is women. To pre-empt that criticism, or to make it less stark than it will be, what are you doing to improve the public awareness campaigns?

Professor Boyle: The stroke does get a mention in pretty well every one we have done in most of the leaflets and certainly also in the work we are doing with the Stroke Association to raise awareness that a stroke is important. I think that is for the general public. I think we have got another issue which is making sure that our professional groups are also absolutely fully up to speed and that relates to your last point in terms of how do we spread good practice. We are setting up a series of attachments to the exemplar units to make sure that that good practice is spread.

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