National Assembly for Wales

Health and Social Care Committee

Stroke risk reduction - follow-up inquiry

Evidence from Aneurin Bevan University Health Board University – SFU 5

ANEURIN BEVAN HEALTH BOARD

 

The Health and Social Care Committee Inquiry into Stroke Risk Reduction

Report on progress against the recommendations from the  2011 Report

 

Issues highlighted

Linkage with Delivery Plan

Progress made against the Stroke Inquiry Report

Stakeholders were not consulted on the risk reduction action plan

 

Yes

·         A key objective of the Delivery Plan is to engage stakeholders on risk reduction through LSBs.  This will ensure appropriate population outcomes are identified within Single Integrated Plans and that the actions of all partners are clearly set out, monitored and measured.

 

·         There is a continuous process of engagement with patients, staff and stakeholders to inform stroke services re-design.

 

There needs to be greater awareness and ownership among the people who will be delivering the actions

Yes

·         ABHB is working with partners through LSBs to implement local action to prevent stroke.

 

·         The risk reduction actions of partners are set out in Single Integrated Plans and are being measured and monitored using indicators/targets aligned to the health and well being themes.

 

·         ABHB is working through locality networks (NCNs) to plan and deliver a more systematic and co-ordinated approach to identifying those at risk of vascular disease and atrial fibrillation and managing that risk effectively. 

 

·         There is a PHW Consultant in Public Health Medicine on the Stroke Board to ensure risk reduction is a key feature of the Delivery Plan.

 

Concerns around the implementation, leadership, management and monitoring of the Stroke Risk Reduction Action Plan

 

Leadership and management of TIA/stroke services

Yes

·         There has been engagement of a wide range of stakeholders/clinical staff in discussions regarding Stroke Services Re-design.

 

·         The PHW Consultant in Public Health Medicine and the NCN clinical lead for cardiovascular disease are working through the Stroke Board to provide leadership for the implementation and monitoring of stroke prevention actions within the Delivery Plan.

 

Stroke boards needs to have a comprehensive membership which should include representation from local authorities.

 

·         The Stroke Board within ABHB has comprehensive membership, including a local authority representative from Social Services

Local authorities should be involved in the development and delivery of the Delivery Plan and especially in relation to the prevention of secondary strokes.

 

 

·         Local authorities are involved in setting the strategic direction for stroke risk reduction through their involvement in the LSBs.

 

·         There is local authority representation on the Stroke Board and at NCN levels to ensure a more integrated approach to operational delivery at local level.

 

The Delivery Plan should look at the full stroke pathway from risk reduction through to diagnosis, treatment, rehabilitation and prevention of secondary strokes.

Yes

·         ABHB have reviewed current stroke services and used outcome indicators to inform the local Stroke Delivery Plan.

 

·         The Stroke Board has been implementing the 1,000 Lives Plus care bundles to reduce the morbidity following a stroke and facilitate quicker functional recovery and discharge home.  Separate work streams have been set up on acute care, early rehabilitation and TIA services.

 

·         Secondary prevention has been included in the Delivery Plan

 

·         The ABHB Delivery Plan includes stroke telemedicine to improve timely access to thrombolysis for appropriate patients.

Development of robust workforce plans which link public health, local authorities and primary and secondary care providers, to ensure that there is a consistent and effective delivery and support provided to patients.

 

 

·         ABHB has held a series of workshops on re-design options to deliver “Best in Class” Stroke services with the aim of providing “World Class” Stroke services.

Establishment of Joint Cardiac-Stroke Networks in order to provide a co-ordinated leadership to ensure consistency in stroke risk reduction services throughout Wales

 

 

 

·         ABHB is not aware of discussion between Welsh Government and the existing South Wales Cardiac Network in terms of establishing a Joint Cardiac-Stroke Network

TIA

 

 

Lack of public and professional awareness about TIA and its severity.

Yes

·         ABHB will be working together with partners to raise awareness of the symptoms of Stroke/TIA and the importance of accessing WAST/medical care promptly, using the FAST test.  This is supported by the TV public awareness campaign “Stroke - Act FAST”

 

No action stated on early detection and treatment of transient cerebral ischaemic episodes or atrial fibrillation

 

Yes

ABHB has initiated a number of actions within the Delivery plan on early detection and treatment of TIA and AF including:

 

·         Work with GPs to raise their awareness of symptoms

·         GP reception pathway based on “FAST” roll out

·         Public awareness of stroke risk factors and the importance of recognising and presenting symptoms promptly

·         Use of TIA and AF intelligent target bundles in order to improve compliance

·         TIA Quality and Productivity (QP) pathways offered to GP practices.

·         Use of the 1,000 Lives Plus/PCQIS “How To” Guide on early detection and management of AF

·         Consensus and shortlisted options to deliver a single admission point for the hyper-acute stroke service which should enable direct admission for patients with suspected stroke and achievement of stroke bundles.

  • QP TIA pathway - the pathway is based on the national stroke bundle. In terms of update – practices didn’t have to undertake the pathway but many did – anecdotally compliance with the national TIA bundle has improved markedly – ABCD2 scoring especially

 

TIA’s not being recognised as medical emergency

Yes

·         ABHB will be reviewing public health education campaigns as part of the Stroke Delivery Plan

·         ABHB will continue to work with GPs to raise their awareness of TIA symptoms

·         ABHB will continue work on the GP reception pathway based on “FAST” roll out

·         ABHB will work with partners (e.g. Stroke Association) to promote public awareness of stroke risk factors and the importance of recognising and presenting symptoms promptly

 

People need to seek medical attention early (TIA) – raise awareness like chest pain

 

Yes

·         ABHB will be reviewing public health education campaigns as part of the Stroke Delivery Plan

·         ABHB will work with partners (e.g. Stroke Association) to promote public awareness of stroke risk factors and the importance of recognising and presenting symptoms promptly

·         ABHB will continue work on a GP reception pathway based on “FAST” roll out and consider modelling on the Cardiac Network Chest Pain Awareness project

 

Barrier may be resourcing to the development of a 7 day TIA service – staffing and equipment

Yes

·         ABHB is looking at options for development of 7 day TIA service

·         ABHB is re-designing the service to ensure appropriate management of patients not diagnosed with a stroke (e.g. TIA)

RCP state that patients who have a TIA should have carotid endarterectomy within 48 hours of the attack. There can be a 2 week wait in Wales.

 

Work ongoing with Vascular Surgeons.

 

Atrial Fibrillation

 

 

 

A clear need for improvement  in the identification, diagnosis and treatment of AF

 

 

All practices in ABHB 2013-2014 being offered QP AF pathway based on 1,000 Lives Plus AF pathway

  • The GRASP AF is not being introduced in practices in ABHB. It has been developed in England and there is a cost to implementation – however Audit + has developed an AF module which is very similar. Practices are to be offered the AF pathway as part of QP this year and will need to use this software if the undertake the pathway.

 

A greater need for public and professional awareness surrounding risk factors (including AF) for stroke

 

 

·         ABHB will be reviewing public health education campaigns as part of the Stroke Delivery Plan

·         ABHB will work with partners (e.g. Stroke Association) to promote public awareness of stroke risk factors and the importance of recognising and presenting symptoms promptly

·         Primary care staff (i.e. GPs, Practices Nurses and Health Visitors) trained in multi topic brief intervention – smoking cessation, alcohol misuse, obesity.

·         ABHB are developing and rolling out a Smoking Dashboard as part of the GMS Variation Project

 

Opportunistic pulse checks

Yes

·         The “Healthy Heart” cardiovascular risk assessment programme includes a radial pulse of all patients screened and refers patients with irregular pulse for GP follow-up

 

  • ABHB is exploring options for primary care nurses opportunistically undertaking pulse checks (e.g. flu clinics, chronic conditions clinics) and are awaiting results of pilot scheme in Carmarthen

 

  • Raising awareness –w e have developed a poster in surgery for receptionists – similar to MINAP poster – plans to roll

 

 

Follow up of pulse check is reflected in patients healthcare records to ensure effective management of the condition

 

 

 

  • Pulse checks – GPs will often check pulses opportunistically as there is no official programme.

 

Effective monitoring of treatment of AF

 

 
  • Rate of identification of AF – we have this data as part of QOF and if practices undertake the QP pathway we will be able to see if the incidence is increasing.

 

Prevention of primary and secondary strokes

 

 

 

A need for an improved emphasis on preventing strokes following a TIA or initial stroke

 

 

ABHB has 24/7 TIA advice service  for primary care physicians

 

ABHB has daily TIA clinics during the week days where patients are seen promptly in accordance of RCP guidelines.

 

ABHB also has hot slot clinics where high risk patients are seen within 24 hours.

 

ABHB has got on site vascular facility where all TIA patients will have vascular imaging done on same day. And if vascular occlusion been identified then arrangements are in place to be referred to vascular surgeons on same day.

 

ABHB provides the Information back to primary care physicians with plan and guidance on same day

 

Risk reduction was not mentioned for a person who has already experienced a TIA or a stroke

 

 

Almost all TIA patients’ risk factors will be checked and discussed.

 

Baseline electrocardiogram will be done in all patients to exclude AF

 

Where risk factors been identified, advice and follow up is provided to patients

 

Leaflet information is provided to patients on various issues related to TIA.

 

Additional information: Considerations for Welsh Government

 

·         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

·         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

·         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 endarterectomies are adhered to across Wales

·         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.

·         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 record data.

·         The shortfall in trained stroke physicians

·         Establishing Joint Cardiac-Stroke Networks across Wales

·         Ensuring that the National Stroke Delivery Plan encompasses all elements of the stroke care pathway from risk reduction through to rehabilitation and re-ablement

·         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.

·         Consider how the current training and development programmes for all healthcare professionals could best raise awareness and knowledge of AF

·         Supporting the proposals for changes to the AF related QOF indicators and ensure that the QOF indicators distinguish between the prescription of anti-coagulation and anti-platelet therapies for AF patients.

·         Supporting the introduction and use of the GRASP-AF tool in GP practices.

·         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 allow the dissemination of good practice and lessons learnt.

·         Produce a progress report on “seek opportunities to provide a national co-ordinated approach to introductory public health/community health development training to Communities First staff”.

·         Inform the impact of the Welsh Network of Health School Scheme. It provides the framework for a whole school approach to health and that includes action around stroke risk factors.