Health and Social Care Committee
Stroke risk reduction - follow-up inquiry
Evidence from Stroke Association – SFU 10
National Assembly for Wales Health and Social Care Committee
One day inquiry into the implementation of the recommendations made during the Stroke Risk Reduction Inquiry in 2011
Written evidence to support oral evidence session to be held on
23rd October 2013
Stroke Association
National Office for Wales
Unit 8, Cae Gwyrdd, Green Meadow Springs Business Park,
Tongwynlais,
Cardiff, CF15 7AB
Tel: 02920 524400
www.stroke.org.uk
Working for a world where there are fewer strokes and all those touched by stroke get the help they need.
Registered Charity No. 61274
Overview
This Inquiry provides us with an opportunity to remind ourselves that stroke is the third biggest killer in Wales and is the leading cause of adult disability. It is the second biggest killer world-wide and yet Wales is the only country in the UK which does not have an over-arching strategy.
In 2006, The Royal College of Physicians reported that Wales was one of the worst places in Europe to have a stroke. Since then, central Welsh Government financial investment in improving stroke services over the last seven years has been minimal, and improvement has relied largely on the commitment of those working within the stroke community.
In responding to this call for evidence, the Stroke Association has consolidated its position following discussions with stroke survivors, colleagues who work within the health and social care setting on a day-to-day basis and with clinicians who are seeking to deliver and drive improvements in stroke services across localities in Wales. We have also carried out an initial audit of each Local Health Board’s Stroke Delivery plans.
In summary, our concerns about the implementation of the recommendations made by the committee inquiry in December 2011 are as follows:
· Anonymity and lack of leadership of those with responsibility for accountability within Welsh Government and Public Health Wales – leading to lack of ownership for outcomes.
· Severe lack of resources and capacity to deliver next tranche of improvements.
· The need to develop an overarching Stroke Network to give structure and support to the stroke community in Wales.
Recommendation 1
We recommend that the Welsh Government undertake a full and robust evaluation of the implementation of the Stroke Risk Reduction Action Plan, Involving all stakeholders. The evaluation should be published, and the results used to inform the development of the National Stroke Delivery Plan
It is with regret that, once again, we have to submit evidence to the National Assembly’s Health Committee outlining our concerns that there is a clear lack of leadership in the delivery of the recommendations outlined so clearly in the December 2011 report. In the past two years, neither Welsh Government nor Public Health Wales have made any co-ordinated approach to evaluate the original 40 recommendations made in the 2010 Risk Reduction Action Plan. The Stroke Association has not been consulted even though it is one of the main Third sector delivery partners included in the plan. Whilst we accept the Minister’s acknowledgement that many of the recommendations have now been incorporated into the NHS Five Year Stroke Delivery Plan, we would argue that many of the original 40 recommendations are yet to be evaluated for impact and we would implore the Health committee to put pressure on the Welsh Government and Public Health Wales to carry out recommendation 1 – that is to:
“undertake a full and robust evaluation of the implementation of the Stroke Risk Reduction Action Plan, involving all stakeholders”
This evaluation would provide the benchmark and should be cross referenced to the now live national Stroke Delivery Plan and to the individual Local Health Boards’ Stroke Delivery plans.
Key to this is the importance of laying the overarching responsibility for this activity at the door of the Health Minister’s department. Furthermore, we would recommend that the Minister incorporates this work into the role of specific officers who will be responsible for holding all stakeholders to account in delivering the agreed outcomes.
At a time when health and social care costs are spiralling and the NHS is under severe pressure due to an increasing burden of poor health, never has prevention activity been so important. It is unfathomable that the Stroke Risk Prevention Action plan has laid idle year on year and that inaction is passed off in the argument that one delivery plan supersedes another.
We welcome the inclusion of prevention activity as a key tenet of the Social Services and Wellbeing Bill and we will be seeking to monitor the benefits of this as social services take on this area of responsibility. Social services, like public health, have a key role in both primary and secondary prevention. Collaboration between agencies will be fundamental in easing the burden of stroke amongst the population in Wales.
An example of best practice in this area comes from Ysbyty Cwm Rhondda where a pilot model has been developed that enables Community Occupational Therapists (COTs) to ‘in-reach’ into hospitals to identify patients whose discharge they can support. Patients are seen jointly by the in-hospital and Community OTs allowing them to share goals, ensure a smooth transition and facilitate better communication with the patient at the centre. Patients are able to get home earlier and identify ways to lessen their chances of suffering a secondary stroke and start working to make changes in their lifestyle faster than they would otherwise.
Recommendation 2
We recommend that the Welsh Government includes within the National Stroke Delivery Plan clear references to the prevention of secondary strokes and the treatment and diagnosis of TIASs as they relate to stroke risk reduction work.
We welcome that this recommendation has been included in the National Stroke Delivery Plan. However, nine months since the launch of the plan, there are no clear indications of how the recommendation is being implemented across Wales. Lack of financial and human resources is also a concern; please refer to comments below.
Recommendation 3
We recommend that by April 2012 and in line with its published expectations, the Welsh Government ensures patients have access to seven day TIA clinics and that clinical guidelines in relation to carotid endarterectomies are adhered to across Wales
In relation to the two recommendations above, an initial audit of the Health Boards’ Stroke Delivery plans reveals that preventing non-communicable diseases are high on the agenda and there is much reference to smoking cessation, tackling obesity and reducing alcohol and substance misuse. We welcome all of these actions as they will undoubtedly improve population health.
However, these recommendations specifically address stroke prevention in relation to TIA and the delivery of carotid endarterectomies. Upon reading the local action plans it appears that many health boards lack the staff capacity and resources to target specifically the deficiencies which surround the diagnosis and prompt referral to these clinics and procedures.
At this point it is important to note that many improvements have been made in the delivery of stroke services across Wales. However, only so much improvement can be made through re-aligning procedures. A time comes when the next tranche of improvements can only be made through the allocation of resources to attract a highly skilled and motivated workforce who can make real inroads to saving lives and preventing strokes. It is unrealistic to expect the growth of seven day TIA clinics given the allocation of resources available to run such services comprehensively across Wales.
There is a serious and real concern amongst the clinical community in Wales that the severe lack of resources is impacting upon the ability to research and innovate. This in turn is resulting in an inability to attract the highest calibre practitioners into stroke services. This lack of capacity and resource results in growing pressure that inevitably impacts upon prevention services.
Recommendation 4
We recommend that the Welsh Government develops clear guidance for primary care and community resource teams on the diagnosis, treatment and management of AF and clearly identifies professional responsibilities in each area.
When the original Stroke Risk Reduction Action plan was published in 2010, the Stroke Association delivered its Atrial Fibrillation (AF) awareness campaign in partnership with Public Health Wales. Since then we have contributed to ensuring that the dialogue on AF is maintained through the work of the Cross Party Group on Stroke. Additionally, the Stroke Association has also developed a practical implementation in partnership with community pharmacies. In fact, in September 2013 we launched a stroke risk factors awareness campaign that includes screening for high blood pressure and irregular heart beat (including AF) with an independent corporate chain of pharmacies.
We understand that as part of the 1000Lives+ programme, Public Health Wales has developed an improvement initiative for Atrial Fibrillation (AF). To date it has proven challenging to secure a dialogue with the relevant personnel involved in this programme to highlight the benefits of the campaigning work we have undertaken and explore potential areas of collaboration. We will continue to pursue collaboration in this area, but, given the limited level of dialogue and the available evidence, we cannot offer further comment on the effectiveness of this activity in relation to this recommendation.
Recommendation 5
We recommend that the Welsh Government ensures that pulse checks are offered as standard to patients presenting stroke risk factors when attending primary care, Any necessary treatment which them follows should comply with NICE guidelines, and further action by the Welsh Government is needed to ensure that this take place. Compliance should be monitored through Public Health Wales’ audit of primary care record data.
There is an argument that whilst pulse checks fall outside of the Quality Outcomes Framework (QOF), only the most pro-active GPs will offer pulse checks as standard practice. The Stroke Association would like to see the Welsh Government working to influence QOF in relation to opportunistic pulse checking so that those presenting with stroke risk factors in primary care, be given a pulse check alongside a blood pressure check. This would significantly help with the detection of AF which places individuals five times more at risk of having a stroke.
It is encouraging that the Betsi Cadwalader Health Board’s draft Stroke Delivery plan includes an action for ‘GPs to carry out pulse tests on all patients to screen for AF via an addition to the screening template to ensure automatic pop – up’. It will be of much interest to learn whether this particular health board is successful in implementing this action. Similarly, despite not being currently included as a QOF staple, it will be revealing whether GPs in north Wales deliver this simple screening mechanism. We look forward to learning the outcomes of increased detection rates and corresponding actions in relation to stroke reduction in this particular region.
As stated above, the Stroke Association is continuing to work with Community Pharmacy Wales and with individual pharmacy chains to encourage them to provide blood pressure and pulse checks. We are also collaborating with pharmacies to ensure Medicines Use Reviews incorporate stroke prevention messaging for those who are on medication for hypertension and atrial fibrillation.
In addition, we are collaborating with Public Health Wales in the development of a an on-line stroke risk reduction calculator as part of the Health Checks for the Over 50s programme. We maintain that there is a role not only for GP surgeries, but also for community pharmacies in delivering the practical implementation of high blood pressure, pulse and wider health checks as part of the Health Check Wales programme. This area warrants further investigation and we will continue to drive this agenda forward.
Propositions
As well as making five robust recommendations as part of its report, the Health Committee also made 10 additional propositions. The Stroke Association welcomes each and every one. The most significant being the development of a fully funded Stroke Network. The proposition is for a joint network – however, we would advocate that, given the level of need, stroke warrants its own protected infrastructure.
We also want to highlight that the role of social services is key – both to primary and secondary stroke prevention. We very much welcome the scope of the Social Service and Wellbeing Bill setting an onus on Local Government to develop prevention services and we look forward to continue to contribute to and learning about the detail of this area of the Bill as it develops. In the meantime, a number of the Local Health Boards’ Stroke Delivery plans outline the importance of having social work representation at their multi-disciplinary team meetings and there is certainly an opportunity to develop terms of reference for social work involvement in secondary prevention. Again, we look forward to seeing this area develop as per our earlier example from Ysbyty Cwm Rhondda.
Research evidence[1] recognises that for the prevention and reduction of stroke to be effective, it is required to adopt a life-course approach. Therefore, in line with co-production principles, the Stroke Association continues to maintain that stroke prevention programmes, as part of reducing health inequalities, can only translate into tangible outcomes through longitudinal strategic collaboration of multidisciplinary agencies that include the NHS, social care, education and economic development.
In conclusion
Whilst this document raises many areas for improving leadership and accountability, we would like to close by acknowledging the work of the NHS Delivery Support Unit (DSU) for its continued drive to improve stroke services in Wales. The leadership from DSU has been instrumental in bringing this overarching programme for improvement to the forefront.
Similarly, we wish to acknowledge the co-ordinated work that is being developed across Wales by the Wales Stroke Alliance and the wider stroke community. It is worth noting that improvements in stroke services in Wales have been achieved by sheer will and professional determination and, in the absence of dedicated new resources. However, the recommendations from the Stroke Risk Reduction plan and the programme of work contained within the Stroke Action plan are unlikely to be implemented successfully unless clear leadership and appropriate resources are provided both nationally and at local level.
The Stroke Association calls for the Welsh Government and Public Health Wales to take the lead nationally in making the necessary investment in stroke prevention to avoid new strokes and achieve better outcomes for stroke survivors across Wales.
We believe that a fully resourced stroke network with clear leadership would be a logical first step, coupled with the participation of stroke survivors in local and national stroke prevention awareness raising campaigns. The Stroke Association looks forward to continuing working in this area as a key Third sector partner.
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