Health and Social Care Committee
Inquiry into Stroke Risk Reduction
SRR 9 – Cwm Taf Health Board
1. What is the current provision of stroke risk reduction services and how effective are the Welsh Government’s policies in addressing any weaknesses in these services?
a) Stroke Risk Reduction in Cwm Taf
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 WAG to ensure it reflected the national Stroke Risk Reduction Action Plan.
Implementation of the Prevention and Primary Care actions is being led by the local Public Health team, and Professor Jonathan Richards, Professor of Primary Care and Locality Clinical Director.
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; writing out to all Cwm Taf community pharmacies and GP practices to provide information to support new ‘Act Fast’ campaign; 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; seeking to engage with GP practices and community pharmacy by feeding back to practices with available practice level and all-Wales data; 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
- The local Public Health Team have supported national work to establish baseline information, and a monitoring mechanism which will enable robust comparative measures for Cwm Taf on TIA and stroke incidence and mortality.
- The Public Health Strategic Framework for Cwm Taf Health Board has been agreed, and submitted to the Welsh Government. This takes a results based accountability approach, under the 10 headings of Our Healthy Future. (including tobacco control, physical activity, and healthy eating) and the effective management of vascular risk.
- 13 stroke staff from both sites have been trained in brief intervention for smoking cessation, ie training staff to motivate people to stop smoking.
- Availability of the Exercise Referral Scheme has been promoted to encourage referrals of those at primary risk of stroke, and training is being explored to be able to offer Level 4 provision.
- A Primary Care Vascular Risk Reduction group has been set up, to explore how to systematically identify and manage risk
- Campaigns: the public health team have been involved in campaigns (Act First and Act Fast) and were involved in planning for the Diabetes Cymru diabetes week in June to identify the “missing 60,000”.
b) Effectiveness of Welsh Government Policies
It is noted that risk factors for stroke are generally the same as for other vascular disease and are being addressed utilising the Cardiac NSF. However as the SE Wales Cardiac Network notes in its latest report :
“Whilst most primary care practices score highly on the GMS Quality and Outcomes
Framework and have registers for CHD, stroke, hypertension, diabetes, smoking, atrial
fibrillation, heart failure and obesity, the precise extent to which all practices identify
and monitor all high risk patients is currently difficult to assess until Informing
Healthcare provides the long awaited single national risk stratification tool.”
Atrial Fibrillation is an additional risk factor in stroke and it is notable in the updated Cardiac NSF that the previous chapter on AF has been changed to address arrhythmia and there are no longer recommendations regarding AF.
Services for AF assessment for stroke prevention remains poorly developed. In Wales the GRASP-AF initiative to assist primary care that was introduced in England does not seem to be supported.
TIA is a recognised risk factor for subsequent stroke. TIA assessment services have been enhanced as part of the All Wales Stroke Improvement Collaborative which will facilitate stroke prevention and their development and evaluation supported by the intelligent targets process. These were first reported in July 2011, thus it is too early to assess progress.
Rapid access requires primary care to be able to utilise electronic referral and 7-day services for specialist TIA assessment are not possible with current staffing and access to radiological investigation.
The Health Board is working with WAST on protocols for direct referral of TIA patients by paramedics to the TIA Assessment Clinics.
2. What are your views on the implementation of the Welsh Government’s Stroke Risk Reduction Action Plan and whether action to raise public awareness of the risk factors for stroke has succeeded?
The Stroke Association FAST campaign has raised the profile of stroke and awareness of its symptoms, and there is some evidence that it has facilitated early presentation.
The recent event to promote pulse and blood pressure checking to prevent stroke had a limited impact and would need more support.
The Cardiac NSF includes education to people at high vascular risk of cardiac symptoms and that should be adjusted to include stroke symptoms.
The plan mentions linking stroke awareness to various existing programmes (i.e. Healthy Aging and Communities First) but the success of such ventures is uncertain.
3. What are the particular problems in the implementation and delivery of stroke risk reduction actions?
Stroke specific programs are required, as outlined elsewhere, which may need separate funding streams.
Motivating people to change their behaviour is always challenging, hence the Brief Intervention training run by the local Public Health Team
4. What evidence exists in favour of an atrial fibrillation screening programme being launched in Wales?
The SAFE study (Hobbs et al Health Technol Assess 2005; 9(40).) was acknowledged by NICE guidelines (Dewar et al Heart 2007; 93:25–28.) to demonstrate that:
“In terms of a screening programme, that the only strategy that improved on routine practice was opportunistic screening, rather than targeted screening. As atrial fibrillation commonly occurs in association with risk factors, such as hypertension, diabetes and ischaemic heart disease, opportunistic assessment of such patients for the presence of atrial fibrillation may be prudent, especially as such patients are often seen for checkups in primary care.”
Using the annual flu vaccination program has also been described as providing a low cost high impact opportunity for AF screening.
30 seconds of manual pulse palpation for irregularity, followed by ECG confirmation is the most efficient method of case identification that has been assessed.