Health and Social Care Committee

HSC(4)-05-11 paper 5

Inquiry into Stroke Risk Reduction

National Assembly for Wales

Health and Social Care Committee Inquiry into Stroke Risk Reduction

Submission from: Dr Anne Freeman on behalf of

WELSH STROKE ALLIANCE

About us

The Welsh Stroke Alliance is an umbrella organisation encompassing professional bodies, NHS Wales, third sector organisations and patient representatives, all of which have an interest in taking stroke services forward within Wales.

It aims to:

• Facilitate the rapid and continuous improvement in stroke care in Wales.

• Ensure correct standards are set according to national guidelines, recognised best practice, and emerging research.

• Identify gaps in service provision and recommend solutions, highlighting and sharing areas of best practice.

• Act as an all Wales forum and provide expert multi-disciplinary advice and support to NHS Wales, it’s Local Health Boards (LHBs) the Welsh Assembly Government, Royal Colleges, interested parties, and other associated bodies on all aspects of stroke service delivery.

• Be the expert reference group for the Stroke Delivery Group of NHS Wales, identifying constraints and solutions to specific clinical and operational challenges, and reporting on progress in improving stroke services in Wales.

• Scrutinise, challenge, and develop clinical practice in stroke across Wales.

Background: Stroke Risk Reduction

• Stroke is the third biggest killer in UK and is the greatest cause of significant adult disability.
• With an incidence of 2 per 1000 per year, it is a condition that creates huge personal and financial burden.
• Traditionally considered a condition of the elderly, it is now recognised that one-third of strokes occur in children and working age population.
• It accounts for around 5-6% of the NHS budget in UK every year and additional billions of pounds spent on community and social care.
• Whilst there has, over the last 2-3 years, been a successful drive to improve the acute care of stroke patients, preventing strokes occurring is now one of our top priorities.
• Stroke is treatable and stroke is preventable and the relevant action must be taken to ensure as many strokes as possible are prevented each year.  The biggest risk factors are still smoking and hypertension though Atrial Fibrillation is now attracting much more attention as a causative condition where prompt treatment can have an immediate effect on risk reduction.

Stroke Risk Reduction: A three-pronged approach

The evidence suggests there are three main areas to review for effective population stroke risk reduction:

· Lifestyle issues

o Including obesity, smoking, alcohol habits, and sedentary lifestyles.

o To reduce these stroke risks, it will take at least 5 to 10 years to alter patterns of behaviour across a population. Although this principle has been acknowledged and has been included in the Stroke Risk Reduction Action Plan it has yet to become a reality and therefore a longer-term, generational, policy commitment encompassing areas outside of healthcare needs to be implemented as soon as possible.

o This should include education and awareness at schools and the workplace

o Lifestyle issues must be addressed through exercise programs, smoking cessation and more robust targeting of alcohol-related illness.

o Obesity campaigns and healthy nutrition must be considered.

o A clear remit needs to be given to Public Health Wales to address these issues.

· Vascular risks

o Such as diabetes mellitus, high cholesterol, and high blood pressure, all of which can be detected, controlled and modified by good management by patient and healthcare professionals.

o These risks would require an effective detection and management regime within NHS Wales, including supportive mechanisms to encourage self-detection and self-management.  

o A performance target should be considered for QOF attainment in general practice.

o Consideration should be given to a ‘Know your Numbers’ (blood pressure, pulse, cholesterol) public awareness campaign, allowing more informed life-style choices.  

· Specific stroke risk

o Such as carotid stenosis, atrial fibrillation, and hypertension which can be seen as areas where more speedy reductions in stroke incidence can be achieved by appropriate assessment and treatment.

o To affect this possible ‘low-hanging fruit’ of stroke risk reduction, a clearly defined national programme of service delivery needs to be put in place, with responsibility for monitoring delivery held centrally. The Delivery and Support unit may have a role in doing this.

o The Stroke Risk Reduction Action Plan was published in 2009 and all Health Boards were requested to address this in their stroke Action Plans. A central mechanism for monitoring its implementation should be put in place. We need to monitor progress from each LHB.

o TIA is now considered to be a medical emergency and should be dealt with as such. A significant number will develop stroke within 2 weeks and timely assessment and management within 24 hours of symptom onset can minimise risk of subsequent stroke. This needs to be a 7 day service.

In addition to these three wider areas of stroke risk reduction, it must be remembered that stroke in the younger age population has a different risk profile and includes, amongst others:

o Recreational drug abuse

o Pregnancy

o Thromboembolic diseases

o Lupus anticoagulant

o Carotid dissection

o Rarer causes (including conditions such as Fabry’s disease, Cadasil, etc.)

These need to be managed in the appropriate settings

Consideration for BME groups, and their increased risk of stroke, must also form part of any overall stroke risk reduction plan.

A significant reduction in stroke incidence will not be achieved overnight but delaying action now will delay eventual positive gains in stroke risk reduction.