Health and Social Care Committee
Inquiry into Stroke Risk Reduction
SRR 11 – Age Cymru
Consultation Response
Inquiry into Stroke Risk Reduction
Health and Social Care Committee
September 2011
Introduction
Age Cymru is the leading national charity working to improve the lives of all older people in Wales. We believe older people should be able to lead healthy and fulfilled lives, have adequate income, access to high quality services and the opportunity to shape their own future. We seek to provide a strong voice for all older people in Wales and to raise awareness of the issues of importance to them.
We are pleased to respond to the Health and Social Care Committee’s Inquiry into Stroke Risk Reduction. Whilst we are not specialists in stroke physiology or care, it is an important issue for older people in Wales, as stroke predominantly affects older people. Most people who have strokes are aged over 55, and the risk of a stroke increases as you age.[1]
We have sought views from the Stroke Association in Wales, College of Occupational Therapists and local Age Cymru organisations to inform our response.
1. What is the current provision of stroke risk reduction services and how effective are the Welsh Government policies in addressing any weaknesses in these services?
Despite progress, we are still aware of examples of where people who have suffered strokes are not receiving the services they need and regional variations in the availability of services and support across Wales.
It is well documented that early treatment and intervention is the major factor in determining survival and recovery for people who have suffered a stroke. There is a far greater chance of recovery where specialist stroke services exist and where they receive prompt care from a hospital based stroke unit with a multi disciplinary team. However, there is still significant variation in specialist stroke services in areas of Wales, with rural areas tending to comparatively suffer from problems relating to greater distance from specialist provision and challenges in accessing devoted treatment services within the critical first three hours.
A multidisciplinary team approach is vital due to the benefits seen by patients with full access to physiotherapists, speech therapists, occupational therapists and social workers, in addition to medical and nursing professionals. These teams exist in some areas but are not available to patients across the whole of Wales.
Rehabilitation services are unavailable or difficult to access in some areas of Wales. Feedback received from local Age Cymru organisations, which have supported older people with mobility and speech problems following discharge from hospital, indicates that there is a lack of provision of centres and support services for people to attend in some areas.
We agree with the Stroke Association in Wales that preventing a stroke from occurring in the first place should be at the forefront of health promotion policy. Smoking, excessive intake of alcohol, obesity, poor diet and lack of exercise are all conclusively linked to stroke.
As well as continuing to promote awareness about healthy lifestyles, the Welsh Government must aim to tackle the inequalities in health which continue to lead to less favourable health outcomes for those with a lower socio-economic background. The Welsh Government should take a broader view to implementing successful health promotion interventions and campaigns, and integrate thinking with the social inequalities that come about as a result of the wider determinants of ill health which exist across parts of Wales.
The Stroke Risk Reduction Action Plan does not mention risk reduction for a person who has already experienced a Transient Ischaemic Attack (TIA) or stroke. Yet TIAs and previous stroke increase the risk of a future stroke. We note the College of Occupational Therapists point that access to occupational therapy even for those with ‘hidden’ or minimal disability can result in increased personal independence, increased potential for return to work, and decreased risk of a future stroke. These important factors must not be overlooked in the prevention of further stroke incidents for people. We believe this should be included in the action plan to ensure services are prioritised by Local Health Boards.
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?
Like the Stroke Association and other organisations we welcomed the Health, Wellbeing and Local Government Committee’s Inquiry into Stroke and the resulting publication of “Promoting Cardiovascular Health: the Stroke Risk Reduction Action Plan”. However, following publication, we are uncertain of the level of progress that has been made on implementation.
We believe that further work is required to raise public awareness of the risk factors for stroke. In order for the action plan to be effective it is essential that further investment is made to implement a wide public awareness campaign to ensure that the key messages successfully reach the public and encourage people to change their behaviours.
We support the College of Occupational Therapist’s view that in order for the action plan to be successful, long term commitment and funding is required. The cardiac networks have previously undertaken similar work, setting up projects like Active Living Projects and Obesity programmes, but unfortunately they were not able to sustain long term funding and have now ended.
It will be essential to measure and demonstrate success. Many areas have alcohol and smoking cessation programmes and people are directed toward support groups in the community. However uptake is variable and often reliant on individuals driving the schemes at a local level, and constantly reminding health professionals to refer to these schemes. It is important that older people are actively encouraged to participate in such schemes as the benefits of stopping smoking and / or excessive drinking are beneficial across all ages.
Exercise referral schemes are widespread in Wales, but appear to have variable publicity and awareness of referral mechanisms and uptake can be patchy. According to the College of Occupational Therapists, exercise professionals at the leisure centres need to be trained to a level 4 and availability of these can vary across Wales.
We would welcome a report on progress to ensure that the actions are implemented. We share the view of the Stroke Association in Wales that a review and refresh of the action plan is needed to ensure the best possible outcome for promoting good cardiovascular health and therefore a reduction of strokes in Wales.
The Healthy Ageing Action Plan for Wales (October 2005) referred to the promotion of interventions around healthy eating, alcohol use, physical activity and smoking cessation specifically in the context of older people, all of which make significant contributions to the reduction of stroke risk. We would strongly recommend that a new and updated Healthy Ageing Action Plan is developed to provide a framework and directive for multi-disciplinary partnership working towards better health and wellbeing in later life.
3. What are the particular problems in the implementation and delivery of stroke risk reduction actions?
We feel that a barrier in the implementation has been a lack of ownership. The Stroke Association in Wales has stated that despite being attributed actions in the plan, no further communication has been forthcoming to facilitate these actions and to ensure delivery.
We share the view that there has been a focus on delivery of stroke services within the acute setting, which has resulted in less focus and resources on work around stroke prevention. Whilst it is clearly important that stroke patients are given good quality interventions within hospital to ensure the best possible outcome, the whole stroke pathway needs to be taken into consideration. It is vitally important to prioritise prevention of some of the 11,000 strokes which happen in Wales each year.
This pathway should start with stroke prevention rather than the onset of stroke symptoms. We support the Stroke Association in Wales’ continued call for an overarching All Wales Stroke Strategy which would incorporate prevention, acute intervention and life after stroke rehabilitation and reablement services placing the citizen and his or her carer at the very centre of the stroke journey.
The work being done by the 1000 Lives+ initiative and supported by the NHS Delivery and Support Unit has been fundamental in improving the performance of acute stroke care across Wales.
We believe further work is needed engage of all the strategic partners. Much of the work on improving stroke services has to date centred on the clinical intervention of stroke and is firmly embedded within health. The role of local authorities in ensuring that effective prevention strategies are embedded into local strategic planning is frequently missing as stroke is seen as a “medical” problem and not a social problem with opportunity for improvement through solutions that lie within social care. The role of local government as a strategic partner in promoting preventative and early intervention programmes is vital we would like to see a stronger role for local authorities in a revised action plan for stroke prevention and risk reduction.
4. What evidence exists in favour of an atrial fibrillation screening programme being launched in Wales?
Atrial Fibrillation (AF) affects about 750,000 people in the UK and is more common in older people. The risk of stroke is five times greater in people with AF than in people with normal heart rhythm, and one of every six strokes occurs in a person with AF. Strokes due to AF are twice as likely to be fatal as non-AF stroke, more severe and have a greater need for long-term care[2].
Given the above statistics we believe that there is a case for routine screening for AF to be introduced across Wales and we are supportive of the Stroke Association’s campaign to improve awareness of AF and its link to stroke. Existing opportunities could be utilised as a way of identifying more people with AF:
· Flu clinics. Since older people are routinely called in each year for the annual flu vaccination, a simple pulse check would identify new cases of AF.
· Chronic disease clinics. The people who attend for monitoring of chronic cardiovascular conditions, diabetes etc. are at a higher risk of developing AF and will also carry a higher stroke risk. The addition of a routine pulse check to the assessment would increase the identification of AF.
Many options are available to increase the role of nursing in this area, and training to carry out manual pulse checks could easily be integrated into existing clinics at little or no extra cost to the NHS.
The existing Quality and Outcomes Framework (QOF) indicators may be one possible reason why fewer than expected AF patients are identified as they do not adequately encourage the detection of unrecognised AF. The Stroke Association recommends that pulse checks are introduced into an overall Health Check programme and we support the call for the inclusion of a new QOF indicator ‘the percentage of patients aged 65 or over who have undergone pulse assessment in the last 15 months.’
Despite the existence of NICE guidelines, and the availability of treatments to reduce the risk of stroke, many AF patients at risk of stroke are not treated in accordance with the guidelines. We support the Stroke Association’s call for NICE guidelines to be urgently updated, and for clinicians to adhere to the most recent guidance on the treatment of AF and reduce the risk of stroke by appropriate treatment.
Conclusion
We welcome this Inquiry into Stroke Risk Reduction and hope that these comments will prove useful to the Health and Social Care Committee. We would like to see a greater focus on prevention work. This does not need to be costly or resource intensive, for example including simple pulse checks into existing clinics and introducing new QOF indicators will help save lives and prevent people falling into disability as a result of stroke. We would be more than happy to provide any further information as required.