Committee Clerk Health and Social Care Committee National Assembly for Wales Cardiff Bay CF99 1NA HSCCommittee@wales.gov.uk

Welsh Stroke Alliance c/o Dr Anne Freeman Unit 16 Bocam Park Pencoed CF35 5LJ

13 September 2013

STROKE RISK REDUCTION – FOLLOW-UP INQUIRY

Response from the Welsh Stroke Alliance to the National Assembly for Wales’ health and social care committee follow-up inquiry into stroke risk reduction

Made up of members representing multi-disciplinary expertise in stroke care and stakeholders interested in the improvement of stroke care in Wales, the Welsh Stroke Alliance (WSA) acts as a voluntary all-Wales forum to provide expert advice and support to NHS Wales, its Local Health Boards, the Welsh Government, Royal Colleges, interested parties, and other associated bodies on all aspects of stroke service delivery.

The WSA welcomes this opportunity to respond to the follow-up inquiry into stroke risk reduction, and representatives are happy to give oral evidence if required.  If you would like more information, please contact Dr Anne Freeman, Chair WSA at anne.freeman@wales.nhs.uk or on 07889976288.

Yours sincerely

Dr A. Freeman

Chair – Welsh Stroke Alliance

Overview

As part of a national drive to tackle the third biggest cause of death in Wales and the largest single cause of adult disability, the WSAwelcomes the renewed focus on stroke prevention and supports all efforts to prioritise the improvement of all stroke services in Wales.

The WSA remains well-placed to support these efforts with clinical and expert leadership in the field but, as it is currently constituted only as an affiliated group of volunteer members, do not have the resources to do so to its full potential.

As such, our overarching recommendation to the committee is that WSA be recognised by Welsh Government as the National Clinical Network for stroke and be established with appropriate managerial support, resources, and accountability in line with the established clinical networks seen across the two other major causes of death in Wales cancer and cardiac disease.

Our response

Our response is informed by our members across Wales including representatives from NHS Wales, Local Government, clinical experts, patient groups and charity organisations.

Key recommendations

1. The Welsh Stroke Alliance (WSA) recommends that a resourced National  Clinical Network for stroke be established in line with existing cancer and cardiac network models in Wales, and that appropriate managerial support, resources and governance be put in place to support the effective development and delivery of improved stroke services in line with the expectations within Together for Health: A Stroke Delivery Plan for Wales.
2. WSA recommends a programme of service development for TIA services, including effective national measurement and assurance be established as a matter of urgency.
3. The WSA recommends that Welsh Government establish clear protocols and processes surrounding the national monitoring of stroke clinical audits through a newly established National Clinical Network for Stroke
4. The WSA recommends that Welsh Government develop clear guidelines for TIA services for both high-risk and low-risk patients in line with best clinical practice and that assurance on this service development be driven through the proposed national stroke network.
5. The WSA recommends the initial work undertaken by Public Health Wales and its 1000LivesPlus Atrial Fibrillation (AF)  programme (designed to aid the management of pre-identified AF patients) be supported through the proposed NationalClinical network for Stroke to further enhance its reach and impact.
6. The WSA recommends that Welsh Government / NHS Wales consider how QOF information within Primary Care is best used by Health Boards to inform further working in stroke prevention within primary care.
7. The WSA recommends that a training and education programme of work be undertaken by the proposed clinical network on all aspects of stroke risk reduction in primary and community care, working in partnership across providers in Wales.
8. The WSA recommends a workforce gap analysis be undertaken for each Health Board and for that analysis to include all key staff required to deliver stroke care for their local populations. Further, where significant shortfalls are identified, Health Boards and Welsh Government work together and develop clear recruitment and retention programmes for stroke-trained staff for NHS Wales.
9. The WSA calls for the existing roles of Health Board clinical lead for stroke and executive lead for stroke be formally recognised, standardised and made explicit across NHS Wales. It also calls for the designation of a lead therapist and lead nurse within each Health Board.
10. The WSA recommends that Welsh Government work with the proposed National Clinical Network for Stroke to establish a robust training programme for all stroke staff in Wales and for this programme to reflect todays requirements for effective leadership in health service developments.

Discussion

The Welsh GovernmentHealth and Social Care Committee originally reported on stroke risk reduction in December 2011. In the published report were five recommendations and ten propositions from the committee. Below are a list of the original recommendations and propositions with comments from Welsh Stroke Alliance as to their current status and recommendations for further development.

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.

WSA understand that an evaluation was completed by Public Health Wales and forwarded to Welsh Government but are not aware of any subsequent action.

The WSA is disappointed this evaluation was not made available but acknowledges this was superseded by the publication of the Stroke Delivery Plan – in which Public Health Wales was involved – in 2012.

The WSA would welcome from Welsh Government steps to ensure lessons are learned from this situation, and that a robust evaluation of the subsequent Stroke Delivery Plan for NHS Wales, including the section on stroke risk reduction is put in place.

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 TIAs as they relate to stroke risk reduction work.

The prevention of strokes, including secondary strokes, is one of the six identified themes within Together for Health Stroke Delivery Plan: A Delivery Plan for NHS Wales and its Partners published in 2012.

In particular, it requires Local Health Boards to work with its strategic partners to:

- Promote better public awareness of stroke risk factors and the importance of recognising and presenting symptoms promptly.

- Work through their locality networks to plan and deliver a more systematic and coordinated approach to identifying those at risk of vascular disease and atrial fibrillation and managing that risk effectively,

- Reduce smoking, obesity and excess alcohol intake

- Implement all elements of the All Wales Obesity Pathway

- Encourage healthy schools and workplace environments to take action to reduce smoking, obesity and harmful alcoholic consumption.

WSA welcomes the inclusion of prevention, including secondary prevention, into the Stroke Delivery Plan, but remains concerned as to the structure and resources in place to support its effective implementation.  WSA recommends the introduction of a resourced National Clinical Network for Stroke to support Health Board teams in the delivery of the Stroke Delivery Plan.

In addition, the 1000LivesPlus Programme have developed a toolkit for Health Boards to monitor the services received by those patients suffering a TIA. This tool was handed over to the Health Boards for internal monitoring and improvement in line with the 1000LivesPlus methodology.

WSA are concerned that no national assurance mechanism currently exists to assess the effective application of this approach or its impact. In addition, no supportive programmes for the development of improved TIA services currently exist within Wales.

WSA recommends a programme of service development for TIA services, including effective national measurement and assurance be established as a matter of urgency.

In Spring 2014, the next round of the Royal College of Physicians Stroke Audit will once again provide external examination of our stroke services, including TIA, against these guidelines. In addition, the newly-created prospective clinical side of this audit will also monitor TIA services through its ‘spotlight’ audit scheme. The results will be made publicly available by the RCP. As with other clinical audits of stroke services, no formal national support for monitoring or further service development has been identified.

The WSA recommends that Welsh Government establish clear protocols and processes surrounding the national monitoring of stroke clinical audits through a newly established National Stroke Network.

Recommendation 3: We recommend that by April 2012 and in line with its published expectation, the Welsh Government ensures patients have access to seven day TIA clinics and that clinical guidelines in relation to carotid endarterectomise are adhere to across Wales.

WSA would like to propose a rewording of this recommendation to a “seven day TIA service” and a recognition of the clinical guidelines for both high-risk and low-risk TIA patients be incorporated into any future recommendations.  It does not feel there is clarity around the expectations of Welsh Government surrounding TIA services in Wales.

WSA recommends that Welsh Government develop clear guidelines for TIA services for both high-risk and low-risk patients in line with best clinical practice and that assurance on this service development be driven through the proposed national stroke network.

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 atrial fibrillation and clearly identifies professional responsibilities in each area.

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 then follows should comply with NICE guidelines, and further action by the Welsh Government is needed to ensure that this takes place. Compliance should be monitored through Public Health Wales’ audits of primary care data.

As these two recommendations are so closely linked, the following response applies to both. As with the development of TIA services, the strategic and coordinated development of Atrial Fibrillation services in Wales across both primary and secondary care is much needed.

Acknowledging the initial work undertaken by Public Health Wales and the 1000LivePlus AF programme, the WSA recommends this work (designed to aid the management of pre-identified AF patients) be supported through the proposed National Clinical Network for Stroke to further enhance its reach and impact.

The WSA also recommends that Welsh Government / NHS Wales consider how QOF information within Primary Care is best used by Health Boards to inform further working in stroke prevention within primary care.

The WSA also recommends that further training and education work be undertaken by the clinical network on all aspects of stroke risk reduction in primary and community care, working in partnership across providers in Wales.

Proposition 1: The Welsh Government should consider the shortfall in trained stroke physicians through the use of effective workforce planning.

A survey of stroke consultant sessions across Wales was undertaken by the WSA last year. The results of which demonstrated a significant shortfall from the number recommended by the British Association of Stroke Physicians (BASP) through their stroke consultant workforce planning document. This document provides guidance on the number of sessions of direct clinical care required each week by a consultant according to the local population served and the number of strokes admitted per year. In addition to this information, WSA is aware of the additional difficulties of recruiting to existing vacant posts.

The WSA recommends a workforce gap analysis be undertaken for each Health Board and for that analysis to include all key staff required to deliver stroke care for their local populations. Further, where significant shortfalls are identified, Health Boards and Welsh Government work together and develop clear recruitment and retention programmes for stroke-trained staff for NHS Wales.

Proposition 2: That the Welsh Government considers best practice for providing stroke leadership at Local Health Board level and develops good practice guidance to which all LHBs should adhere.

The WSA are aware that each Health Board in Wales now has a designated clinical lead for stroke as well as an Executive-level lead for stroke. 

The WSA calls for these roles to be formally recognised, standardised and made explicit across NHS Wales. It also calls for the designation of a lead therapist and lead nurse within each Health Board.

Members of WSA have sought stroke leadership training from English providers in the past and raised concerns around the ability of Wales to develop ‘in-house’ stroke leadership. Concerns around what this means for recruitment and retention of stroke staff were also raised in connection.

The WSA recommends that Welsh Government work with the proposed National Clinical Network for Stroke to establish a robust training programme for all stroke staff in Wales and for this programme to reflect todays requirements for effective leadership in health service developments.

Proposition 3: That the Welsh Government considers establishing a National Clinical Network for Stroke - across Wales.

Unlike the two other leading causes of death in Wales, cancer and cardiac, stroke does not have a clinical network to support national service development. Although some benefits may arise from working with the two existing cardiac networks in Wales (North and South), members felt strongly than a separate stroke-specific clinical network, aligned with the objectives of Together for Health – Stroke Delivery Plan would be the most effective model to support evidence-into-practice in Wales.

The WSA recommends that a resourced National Cinical Network for Stroke be established in line with existing cancer and cardiac network models in Wales, and that appropriate managerial support, resources and governance be put in place to support the effective development and delivery of improved stroke services in line with the expectations within Together for Health: A Stroke Delivery Plan for Wales.

Proposition 4: That the Welsh Government ensures that the National Stroke Delivery Plan encompasses all elements of the stroke care pathway from risk reduction through to rehabilitation and re-ablement.

The WSA welcomes the inclusion of all aspects of stroke care long the entire stroke pathway from prevention through to palliative care and longer-term management. These elements of the Stroke Plan have been reflected in each subsequent Health Board local action plan for stroke. However, it has noted the lack of reference in the document to workforce development (education and recruitment and retention).

Proposition 5: That the Welsh Government ensure that local authorities are involved and included in the development and delivery of the National Stroke Delivery Plan.

The WSA is unaware if Local Authorities were consulted on the development of the National Stroke Delivery Plan.

Proposition 6: That the Welsh Government consider new ways in which to ensure that GPs are complying with the NICE guidelines, and that patients have the information to make an informed choice. Compliance should be monitored through Public Health Wales’ audits of primary care record data.

- See recommendations 4 and 5 above 

Proposition 7: That the Welsh Government considers supporting the proposals for changes to the AF related QOF indicators, and ensure that the QOF indicators distinguish between the prescription of anticoagulation and anti-platelet therapies for AF patients.

The WSA is unaware if, or how, this has been undertaken by Welsh Government, and suggests this may be another role for the proposed stroke clinical network, working in conjunction with Welsh Government colleagues. 

Proposition 8: That the Welsh Government considers supporting the introduction and use of the GRASP-AF tool in GP practices.

- See recommendations 4 and 5 above 

Proposition 9: That the Welsh Government consider a systematic evaluation system for all part, or fully funded, Welsh Government health promotion campaigns, with the findings directly feeding into the planning and development of future campaigns. Evaluations should be shared with partners to all the dissemination of good practice and lessons learnt.

The WSA are unaware of any developments with this proposition but continues to support it.

Proposition 10: That the Welsh Government consider how the current training and development programmes for all healthcare professionals could best raise awareness and knowledge of AF.

- See recommendations 4 and 5 above, as well as proposition 2.