CWM TAF HEALTH BOARD

Evidence from Cwm Taf Health Board – SFU 9

CWM TAF HEALTH BOARD

Response to the National Assembly for Wales Health and Social Care Committee

Follow-Up Inquiry into Stroke Risk Reduction

HSSC 2011 Recommendation	Cwm Taf - Progress Made	Further Progress Required – national or local level
Recommendation 1 We recommend that 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.	Cwm Taf Health Board and local Public Health Team contributed to the evaluation undertaken by Public Health Wales on behalf of Welsh Government, by providing a progress report on implementation of the local Stroke Risk Reduction Action Plan in March 2012. We continue to evaluate our progress locally through monitoring implementation of our Stroke Local Delivery Plan, and through broader evaluation of our Public Health programmes. We are participating in a Welsh Government Inverse Care Law programme which aims to tackle health inequalities in our communities. The focus of this work is cardiovascular disease which will include stroke.	The Cwm Taf area, covering Merthyr Tydfil and Rhondda Cynon Taff, has the lowest life expectancy of any of the health board areas in Wales. The Health Board and our partners are committed to working in partnership to tackle these health inequalities including the clinical and lifestyle risk factors involved. We acknowledge that the extent of the challenge faced requires a long term partnership commitment. As the risk factors for stroke are common to many other health conditions, including other cardiovascular disease, cancer and diabetes, we are taking an integrated approach to health promotion and recommend that this is also adopted at a national level. There should be a national awareness campaign around the risk factors and preventive actions people can take to protect themselves.
Recommendation 2 We recommend that 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 Welsh Government’s Stroke Delivery Plan was issued in December 2012. This, and Cwm Taf’s Stroke Local Delivery Plan developed in response, include actions to improve both: · the secondary prevention of stroke – the Health Board is leading the way by becoming a Smoke Free organisation in June 2012, and the Executive Board have recently adopted a policy statement built around the ‘making every contact count’ approach to ensure smoking cessation is designed into the treatment pathway of all stroke and TIA patients. - ‘brief intervention’ staff training is provided to ensure staff refer patients appropriately to programmes such as smoking cessation, weight management, alcohol reduction and exercise; - an individualised ‘Patient Passport’ is being piloted which encourages patients to recognise their own risk factors and set goals to address them, in order to help protect themselves against the risk of secondary stroke; · the treatment and diagnosis of TIA – through implementation of the TIA care bundles and proposal to introduce direct referral to TIA clinics by paramedics for low risk patients.	Locally there remain challenges around the Level 4 training of National Exercise Referral Scheme (NERS) co-ordinators to ensure stroke patients can access these services. National debate around exclusions from this service would be welcomed.
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 endarterectomies are adhered to across Wales.	TIA – TIA clinics are held on weekdays by stroke consultants or acute physicians. At weekends and bank holidays, high risk TIA patients are assessed by acute physicians and preventive treatment is initiated. The patient will then be referred to the next available TIA clinic with the stroke specialist. There is therefore, 7 day access to assessment and initiation of treatment for high risk TIA patients; however this is not always provided by a stroke specialist. Carotid Endarterectomy – round 4 of the National CE Audit, published in 2012 confirmed that Cwm Taf performs well against the clinical guidelines and had the lowest referral to treatment times in Wales, the highest rate of patients operated within 14 days of symptoms, and excellent access to follow-up appointments.	TIA pathways and services are still in need of further improvement. This will be addressed as part of the Cwm Taf Health Board Stroke Service Redesign project. The outcome of round 5 of the Carotid Endarterectomy Audit is expected in October 2013, and will need to be considered by health boards and Welsh Government.
Recommendation 4 We recommend that 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.	There is already NICE Guidance on Atrial Fibrillation. 1000 Lives Plus now has a Primary Care Atrial Fibrillation programme. The Health Board is currently planning how best to promote and implement this in GP Practices from 2014/15.	We consider that there should be a continued focus from Welsh Government on the need to improve the identification and management of AF. This is being considered as part of the Inverse Care Law Programme. Implementation of the 1000 Lives Plus AF programme has resource implications for GP Practices. Consideration should be given by Welsh Government to the allocation of resources to support this programme. It is also important to ensure that there is sufficient provision for rapid specialist assessment and treatment of AF once detected.
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 record data.	At present, the clinical guidelines for both Stroke and Atrial Fibrillation recommend screening for AF in patients who have had a stroke or TIA. However they do not mention primary prevention by screening those with stroke risk factors in primary care for AF. The opportunistic screening of all patients over the age of 65 years for AF, by checking their pulse when routinely taking their blood pressure, is being promoted through the 1000 Lives Plus Atrial Fibrillation programme, but is still optional.	The UK National Screening policy for AF is currently under review, due to report November 2013. Systematic population screening for AF is not currently recommended. National promotion and resourcing of the 1000 Lives Plus AF programme may be a way of introducing screening for a large proportion of those at risk of stroke (ie people over the age of 65), given that the risk of stroke increases with age. We also recommend that Welsh Government give consideration to how primary care Quality & Outcomes Framework (QOF) data can be meaningfully used to inform and target stroke prevention activity.

HSSC 2011 Recommendation

Cwm Taf - Progress Made

Further Progress Required – national or local level

Recommendation 1

We recommend that 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.

Cwm Taf Health Board and local Public Health Team contributed to the evaluation undertaken by Public Health Wales on behalf of Welsh Government, by providing a progress report on implementation of the local Stroke Risk Reduction Action Plan in March 2012.

We continue to evaluate our progress locally through monitoring implementation of our Stroke Local Delivery Plan, and through broader evaluation of our Public Health programmes.

We are participating in a Welsh Government Inverse Care Law programme which aims to tackle health inequalities in our communities. The focus of this work is cardiovascular disease which will include stroke.

The Cwm Taf area, covering Merthyr Tydfil and Rhondda Cynon Taff, has the lowest life expectancy of any of the health board areas in Wales. The Health Board and our partners are committed to working in partnership to tackle these health inequalities including the clinical and lifestyle risk factors involved. We acknowledge that the extent of the challenge faced requires a long term partnership commitment.

As the risk factors for stroke are common to many other health conditions, including other cardiovascular disease, cancer and diabetes, we are taking an integrated approach to health promotion and recommend that this is also adopted at a national level. There should be a national awareness campaign around the risk factors and preventive actions people can take to protect themselves.

Recommendation 2

We recommend that 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 Welsh Government’s Stroke Delivery Plan was issued in December 2012. This, and Cwm Taf’s Stroke Local Delivery Plan developed in response, include actions to improve both:

· the secondary prevention of stroke – the Health Board is leading the way by becoming a Smoke Free organisation in June 2012, and the Executive Board have recently adopted a policy statement built around the ‘making every contact count’ approach to ensure smoking cessation is designed into the treatment pathway of all stroke and TIA patients.

- ‘brief intervention’ staff training is

provided to ensure staff refer patients

appropriately to programmes such as

smoking cessation, weight management,

alcohol reduction and exercise;

- an individualised ‘Patient Passport’ is

being piloted which encourages patients

to recognise their own risk factors and

set goals to address them, in order to

help protect themselves against the risk

of secondary stroke;

· the treatment and diagnosis of TIA – through implementation of the TIA care bundles and proposal to introduce direct referral to TIA clinics by paramedics for low risk patients.

Locally there remain challenges around the Level 4 training of National Exercise Referral Scheme (NERS) co-ordinators to ensure stroke patients can access these services. National debate around exclusions from this service would be welcomed.

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 endarterectomies are adhered

to across Wales.

TIA – TIA clinics are held on weekdays by stroke consultants or acute physicians. At weekends and bank holidays, high risk TIA patients are assessed by acute physicians and preventive treatment is initiated. The patient will then be referred to the next available TIA clinic with the stroke specialist. There is therefore, 7 day access to assessment and initiation of treatment for high risk TIA patients; however this is not always provided by a stroke specialist.

Carotid Endarterectomy – round 4 of the National CE Audit, published in 2012 confirmed that Cwm Taf performs well against the clinical guidelines and had the lowest referral to treatment times in Wales, the highest rate of patients operated within 14 days of symptoms, and excellent access to follow-up appointments.

TIA pathways and services are still in need of further improvement. This will be addressed as part of the Cwm Taf Health Board Stroke Service Redesign project.

The outcome of round 5 of the Carotid Endarterectomy Audit is expected in October 2013, and will need to be considered by health boards and Welsh Government.

Recommendation 4

We recommend that 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.

There is already NICE Guidance on Atrial Fibrillation.

1000 Lives Plus now has a Primary Care Atrial Fibrillation programme. The Health Board is currently planning how best to promote and implement this in GP Practices from 2014/15.

We consider that there should be a continued focus from Welsh Government on the need to improve the identification and management of AF.

This is being considered as part of the Inverse Care Law Programme. Implementation of the 1000 Lives Plus AF programme has resource implications for GP Practices. Consideration should be given by Welsh Government to the allocation of resources to support this programme.

It is also important to ensure that there is sufficient provision for rapid specialist assessment and treatment of AF once detected.

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 record data.

At present, the clinical guidelines for both Stroke and Atrial Fibrillation recommend screening for AF in patients who have had a stroke or TIA. However they do not mention primary prevention by screening those with stroke risk factors in primary care for AF.

The opportunistic screening of all patients over the age of 65 years for AF, by checking their pulse when routinely taking their blood pressure, is being promoted through the 1000 Lives Plus Atrial Fibrillation programme, but is still optional.

The UK National Screening policy for AF is currently under review, due to report November 2013. Systematic population screening for AF is not currently recommended.

National promotion and resourcing of the 1000 Lives Plus AF programme may be a way of introducing screening for a large proportion of those at risk of stroke (ie people over the age of 65), given that the risk of stroke increases with age.

We also recommend that Welsh Government give consideration to how primary care Quality & Outcomes Framework (QOF) data can be meaningfully used to inform and target stroke prevention activity.

The Cwm Taf Stroke Action Plan includes a section with agreed actions, responsibilities and timescales for Stroke Prevention and Primary Care. This was updated in August 2010 as required by Welsh Government to ensure it reflected the new national Stroke Risk Reduction Action Plan.

Implementation of the Prevention and Primary Care actions is led by the local Public Health Team and is monitored by the Cwm Taf Stroke Steering Group, chaired by the Executive Director of Planning.

The action plan includes 3 main objectives for stroke Prevention and Primary Care, supported by a number of actions:

Objective 1 - To increase the level of awareness amongst the general population and amongst health & social care professionals of the impact of stroke and what individuals can do to prevent having a stroke.

Actions include – establishing the baseline and monitoring stroke prevalence; supporting current national awareness campaigns eg FAST; seeking ways to locally support other campaigns (e.g. Diabetes week); provision of information on primary and secondary stroke prevention and symptoms for patients, carers and health professionals; staff training and awareness

Objective 2 - To increase the uptake of healthy lifestyle choices and activities amongst those at risk.

Actions include – linking into broader health improvement initiatives such as Health Challenge Wales and the HSCWB Strategies; creating better links to current health promotion programmes for reducing cardiovascular disease and stroke, e.g. smoking cessation and brief intervention training for stroke staff, increasing physical activity and healthy eating; creating better interventions (e.g. weight management based on cognitive behavioural groups); encouraging Community Pharmacies to undertake regular medication reviews; linking in with self-care agenda and empowering patients to take responsibility for their health

Objective 3 - To increase primary and secondary prevention management and activity within primary care.

Actions include – reviewing how actively at risk patients are being managed within primary care; development of the Primary Care Stroke Pathway, supported by primary and secondary prevention guidelines, referral protocols and training; medicines management; looking at potential to collect new data (e.g. practice quit rates for smoking); investigating potential sources of funding and methods of GP engagement.

Progress against Stroke Risk Reduction Action Plan

The following progress has been made with the LHB specific actions in the national Stroke Risk Reduction Action Plan, and with Public Health Wales actions led by the local Public Health Team:

Ref	Action	Progress
2	Review opportunities to appropriately link local Health Challenge web sites, literature and activities with stroke prevention	The Health, Social Care and Well Being Team ensure that the Stroke Association is present at all appropriate events to raise awareness of the preventative measures for stroke. The Stroke Association annually attend the Big Bite event and speak to approx. 200 people, taking blood pressures and advising accordingly. They also attend Communities First health events.
4	All 22 unitary authority areas to have updated tobacco control action plans, covering the areas of: · discouraging children from starting to smoke · encouraging young people and adults to quit smoking · reducing exposure to environmental tobacco smoke	Multi-agency Smoke free Cwm Taf Strategic Action Plan 2011-2015 developed to cover RCT and Merthyr Tydfil.
7	Roll out accredited brief intervention training for smoking cessation to health and social care professionals and community workers	Cwm Taf has run 26 Brief Intervention training days. A total of 418 people have been trained in this period. Health professionals trained comprised the following groups: Primary Care 151 Secondary Care 84 Community 156
12	Identify opportunities to increase action to support sedentary adults become more physically active	A review has been undertaken of the nutrition strategies for RCT and MT areas. Multiagency workshops with a life course approach were undertaken in January 2012, as initial step in taking forward a Cwm Taf strategic approach in relation to obesity. The proposed draft consultation document will incorporate physical activity measures and will link to Active Merthyr and RCT plans and LAPA plans for RCT and Merthyr Tydfil. Creating an Active Wales - Draft multiagency strategies and action plans developed in both Merthyr Tydfil and Rhondda Cynon Taff. Available on request.
22	Ensure development and delivery of health improvement action to promote the cardiovascular health of older people in line with the Healthy Ageing Action Plan for Wales	Please see above. Increased provision of weight management support in community settings Community weight management programmes – review of current provision within the Cwm Taf community was undertaken. The current level of activity was determined, whether the programmes met NICE guidelines and also the need for further community weight management programmes and training issues. As a result a community weight management resource and support pack has been developed for community workers that include: activity ideas, nutrition resources, monitoring and evaluation ideas for use with community groups. Roll out of the resource and support pack along with behaviour change training and cooking skills for development workers and volunteers to commence February 2012.
23	Take action to mitigate the impact of extremes of weather conditions on the incidences of stroke: including training and awareness raising through Keep Well This Winter, improvements in home energy efficiency and measures that reduce fuel poverty; in addition raising awareness among health professionals and the public about protecting vulnerable people during heatwaves.	A Seasonal Flu Task & Finish Group is established each year in Cwm Taf to promote the key Keep Warm, Keep Well, and Keep Safe messages to Older People. Actions for the 2011-2012 campaign included the distribution of 60,000 Flu Jab reminder stickers via Meals on Wheels and Community Pharmacies, along with the identification of Patients eligible for the Flu Jab via medicine checks and a general promotion campaign. 3000 Flu Jab reminder Book Markers were also distributed via Library Services in Merthyr Tydfil and Rhondda Cynon Taf, including the Mobile Library Service. 150 Information bags were also supplied to the Older Persons Co-ordinator for distribution at the Merthyr Tydfil Keep Well This Winter (KWTW) event day held on 4^th November 2011. A total of 800 fleece blankets were distributed to vulnerable housebound residents to support the health through warmth message across Cwm Taf. To raise awareness of home energy efficiency and fuel poverty a one-day training course was facilitated by NEA Cymru on 7^th September 2011. This course skilled both professionals and community volunteers to be able to offer information to their local communities on financial support available including grant aid, new technologies to improve energy efficiency, problem solving for damp and heating issues and changing energy providers. Extreme heat is dangerous to everyone but especially so to older people, those living in care-homes and those in certain at-risk groups. When temperatures remain abnormally high over more than a few days, excessive heat can prove fatal. Cwm Taf Health Board has a Heat Wave plan that would come into effect if the temperature in Wales was to rise above 30 degrees C during the day and 15 degrees C during the night. Alerting levels are identified along with those residents that would be most at risk. Heat Wave advice for onward cascade is included along with symptoms of heat exhaustion and heat stroke along with further advice.
25	Seize opportunities through the pharmacy contract to encourage Community Pharmacies in supporting one health promotion campaign each year associated with cardiovascular risk (No Smoking Day; Health Challenge; Food Standards Agency Wales salt and saturated fat campaigns)	Community pharmacists will be supporting No Smoking Day on the 14^th March 2012, by running a HP campaign from 1^st- 17^th March 2012. Community Pharmacists participated in the All Wales campaign Finding the 66000 (aimed at identifying undiagnosed diabetes based on risk factors)
26	Provide information to Community Pharmacies to enable signposting services associated with cardiovascular prevention	Community Pharmacists have information on Smoking Cessation services locally, along with information relating to self help groups
27	Local Health Boards should encourage community pharmacists to carry out Medication Usage Reviews for antihypertensive drugs in support of cardio / cerebro-vascular related public health campaigns. To support pharmacists, they should consider developing templates (or aides-memoire) to include: · a section on risk reduction and what this means to patients (importance of complying with medication, alcohol intake, smoking, diet, exercise etc); · a section asking about OTC medicines, especially those with a high sodium content or that increase blood pressure (provide a list); · a section asking about medicines known to interact with anti-hypertensives (provide a list); · With respect to stroke - additional information on drugs that may cause problems (eg HRT) and how pharmacists should manage these.	Targeted MUR’s for patients taking anti-hypertensive medication were introduced by Welsh Government during November 2011. Aid-memoirs developed by Wales Centre for Pharmacy Professional Education (WCPPE)
30	Review the linkage of pertinent health improvement work (tobacco control; physical activity; food and health; older people) to health services planning for stroke services, cardiac services and chronic conditions	By ensuring a strategic public health approach to relevant health improvement activity in local strategic partnerships, including in needs assessments, strategies, plans, programmes, projects, and initiatives. This approach, through collaborative planning between public health professionals and coordination with partners, will seek to explicitly link the potential positive effects of health improvement activity to prevention and health gain within stroke, cardiac, and chronic conditions services, as will be done for other service areas and health conditions.