Health and Social Care Committee

Inquiry into Stroke Risk Reduction

 

SRR 20 – Cardiff and Vale University Health Board

 

 

 

NATIONAL ASSEMBLY FOR WALES HEALTH AND SOCIAL CARE COMMITTEE

INQUIRY INTO STROKE RISK REDUCTION

 

 

The following paper outlines the current arrangements relating to stroke risk reduction within Cardiff and Vale University Health Board, and responds to the specific points raised by the Health and Social Care Committee.

 

There are national strategies tackling some areas of the Stroke Risk Reduction Partnership Action Plan (as part of the Stroke Service Improvement Programme Action and Implementation Plan 2010/11-2014/15), and a number of local initiatives have been established to support national progress.

 

Wales' first specialist Stroke Prevention Clinic was started at the University Hospital of Wales in 1995. In Cardiff & Vale, there is now a daily transient ischaemic attack (TIA) service and high risk TIAs are seen within 24 hours during the week days. Over weekends and holidays such patients are seen in the Medical Assessment Unit & subsequently reviewed in Stroke Prevention Clinics. Cardiff & Vale UHB has prompt access to investigations such as CT/MRI, Carotid Doppler & echocardiogram and has excellent vascular and neurosurgery support.

 

In Primary Care, the Quality and Outcomes Framework (QOF) was introduced as part of the new General Medical Services (GMS) contract. The QOF has four domains. Each domain consists of a set of indicators, against which practices score points according to their level of achievement. The Clinical domain has 86 indicators across 20 clinical areas (e.g. coronary heart disease, heart failure, hypertension. These indicators cover most of the risk factors for stroke. The QOF has incentivized GPs to actively seek and manage stroke risk factors.

 

The Cardiff and Vale Public Health Service is increasing links with primary care (both Division of Primary, Community and Intermediate Care and Independent Contractor Services) and also with neighbourhood groupings of partner organisations. The provision of a comprehensive stroke reduction plan is complex, and the neighbourhood structure will provide an opportunity to establish whether strategies are implemented effectively and to identify gaps in current provision. It is important to recognize the importance of General Medical Practitioners, Public Health and secondary care services working in close partnership to gain a full picture of services provided for stroke risk reduction. The primary, community and public health service summary is grouped in terms of the current interventions for different “risk factors”.

 

 

 

SUMMARY OF CURRENT SERVICE PROVISION

 

Smoking Cessation

 

General Practitioners

Within the Quality and Outcomes Framework (QOF) there are a number of indicators to identify smokers and also to encourage smoking cessation by offering advice/interventions. These interventions are targeted at high risk groups (CHD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar disorder and other psychoses). In addition to this, practices have a responsibility to record the smoking status of patients aged 15 and over as part of the QOF records and information requirements.

 

Many practices offer in-house smoking cessation services. There is significant variation in referral rates on to Stop Smoking Wales Services, the reasons for which need further exploration.  All practices in C&V obtained maximum QOF points in 2010/11 in relation to the identification of high risk patients and the provision of smoking cessation advice.

 

Primary Care

Pharmacy advisers within the Division of Primary, Community and Intermediate Care work with community pharmacists who are strongly encouraged to support National No Smoking Day.

 

Local Public Health Strategic Framework

This provides support for national campaigns e.g. National No Smoking Day, Smokebugs.

 

Actions for 2011/12 involve leading the development and implementation of the Tobacco Control Cardiff Action Plan and the Smoke Free Vale Action plan. Work has been undertaken to support the Welsh Government Tobacco Control Action Plan for Wales (e.g. smoke-free UHB entrances) and also to enable the referral of pregnant women and pre-operative orthopaedic and breast service patients to specific smoking intervention services.

 

Other ongoing initiatives include :-

 

 

In addition, further action is required to address alterations to the community pharmacy contract, variable referral rates to Stop Smoking Wales and targeting “hard to reach” groups.

 

 

Alcohol

 

General Practitioners

Alcohol is included in the QOF as part of lifestyle advice offered to newly diagnosed hypertensive patients and within mental health reviews. Training has been provided on brief intervention with respect to alcohol use, and is provided in some local practices.  Further work is required to ensure timely referral on to secondary care and voluntary sector services.

 

 

Local Public Health strategic Framework

Work is ongoing to develop a strategic context for a Cardiff and Vale Alcohol Action Plan.  The Public Health service is leading on the delivery of a local plan including education for teachers and youth workers, development of the school nursing role, involvement in implementation of the “brief interventions” training programme and continuation of an alcohol awareness programme for UHB staff.

 

 

 

 

Physical Activity

 

General Practitioners

Physical activity is encouraged in lifestyle advice given to newly diagnosed hypertensive patients

 

Primary Care

Partnership work at neighbourhood management team level is developing.  The Cardiff West neighbourhood management team has a number of initiatives in the formative stages, encouragingpartnership between health and council leisure services, which will if successful provide links between partner organizations to encourage physical activity. These initiatives are intended to complement the current National Exercise Referral Scheme and Physical Activity and Health Initiatives, and will encourage physical activity in individuals with sedentary lifestyles and no current identified morbidity.

 

Local Public Health Strategic Framework

Current initiatives include the Cardiff Healthy City Programme, Cardiff Physical Activity and Health Delivery Plan and the Vale of Glamorgan Food and Physical Activity Framework.  The planned focus for service users in 2011-12 is within areas of deprivation, and to encourage walking and cycling. These will be in conjunction with partner organisations, and the Public Health service will provide advice and support on healthy urban planning principles and health impact assessment in the development of local plans. Physical activity is also encouraged within the organization.

 

Further work is required to ensure consistent service provision across the whole of the UHB and to ensure that user charges do not create a disincentive for participation.

 

 

Food and Health

 

General Practitioners

The prevalence of obesity in the UK is at least 21% in men and 23.5% in women.  As part of QOF, practices have to produce a register of patients aged 16 years and over with a BMI>30 in the preceding 15 months.  In the QOF year 2009/10, there was a large variation in recorded obesity prevalence in Cardiff and Vale, ranging from 4.2% to 18.2%. The highest prevalence still falls short of the national figures, suggesting there is still significant work to be done in identification.

 

Dietary advice (low cholesterol/ weight reduction) is offered as part of lifestyle advice for newly diagnosed hypertensive patients, and dietary advice is provided as part of the QOF requirements for mental health reviews.

 

 

Primary Care

A work programme to target older people work was developed in the UHB by the dietetic service, enabled by Welsh Government funding. A variety of courses have been developed and piloted, including short course to raise awareness of the importance of nutrition and two accredited courses for health workers.  This work is now being rolled out across Wales and continued funding has been made available for another 12 months to run additional courses in Cardiff and the Vale.

 

The course above introduces a nutrition awareness tool and provides advice on the management of nutritional problems.  The work is focussed on under-nutrition and maintaining a balanced diet. The other dietetic capacity grant work with younger ages is focussed on healthy lifestyles (e.g. MEND).  Again, it is hoped that this work can be progressed at a local level by partnerships developed in Neighbourhood  Management Teams.

 

Local Public Health Strategic Framework

Actions for 2011-12 include leading on the delivery of the Cardiff Food and Health Action Plan 2008-11, the Vale Food and Physical Activity Framework and Action Plan and the Cardiff Healthy City Programme. Additionally, work will be undertaken to improve the food environment in local areas across the social gradient through the implementation of the Appetite for Life Action Plan and the food element of the Healthy Schools Programme.

 

Public Health practitioners have been instrumental in supporting the dietetic advice work done with nursing and residential homes and with providers of care for the young, in association with the community dietetic team.  Communication and engagement with some high risk groups remains a challenge

 

 

 

Hypertension

 

Primary Care

The QOF requires GPs to identify and treat hypertension. At diagnosis a cardiovascular risk assessment is undertaken and interventions in terms of diet, smoking, exercise and alcohol are undertaken (Primary Prevention of CVD).  In 2009-2010, the mean prevalence of hypertension in Wales was 15.5%, and in Cardiff and the Vale, prevalence ranged from 3.5%-18.6% (some of this variation is accounted for by widely varying practice demographics)

 

Atrial Fibrillation

 

General Practitioners

The QOF requires GPs to treat AF with anticoagulation/antiplatelet drugs. There is no current requirement within QOF for screening for AF. It is estimated that 1% of a typical practice population will be in AF (UK). The Wales average is 1.69% and the range in C&V 0.3%-2.5% (2009-10 figures), some of which can be explained by demographic variation. AF is associated with a five fold increase in risk of stroke.

 

 

 

How effective are the Welsh Government’s policies in addressing any weaknesses in stroke risk reduction services?

 

At the all Wales level, these have been only partially effective. Due to a lack of trained specialists, TIA patients are not always assessed promptly, thus missing opportunities to prevent major strokes. Although there has been investment in supporting the management of acute stroke, there has been no central funding to develop stroke risk reduction services, and stroke physician numbers in Wales lag behind the rest of the UK.

 

The provision of services to reduce the risk of stroke is a complex area as the summary above demonstrates. There are a wide variety of services – some targeted at certain groups - and it is difficult to ensure that services truly target the most at-risk groups.

 

The strategies tend to be implemented at a high level, and there is limited control of resources at local level, other than those areas which are covered by the GP GMS contract and are provided at a very local GP practice level.

 

 

 

 

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?

 

This provides a useful strategic framework to ensure that organisations are aware of general responsibilities, although the consultant body in Wales do consider that local stroke specialists had little input into the plan. The Stroke Risk Reduction Action Plan addresses a wide range of actions for primary prevention.  It does not, however, include a section on secondary prevention which should be addressed.

The challenge lies in ensuring that services are provided to all those at risk and are able to target high risk individuals and populations.  The strategic nature of the document means that resources are controlled at a level which is remote from certain populations.

 

The neighbourhood management model offers the opportunity to use local knowledge and partnerships to provide services at “ground level”.

The Action Plan points (14) and (15) relate to the National Exercise Referral Scheme.  It is a requirement that capacity is maintained for NERS which has funding agreed for the next three years.  Is ongoing funding assured for this service?

The physiotherapy profession has been developing its relationship with NERS services locally and this has proved useful in terms of supporting the links between hospital based exercise progressing to lifestyle based exercise undertaken in local communities.

It is apparent that further work and publicity is required to ensure sustained public awareness of stroke risk factors generally.  Informal research within the UHB has demonstrated that even among active and motivated health professionals, there was a lack of awareness of the overall campaign.  The inquiry process will have the opportunity to address this within a wider population, but from the perspective of those in primary care, it is apparent that more needs to be done to increase public awareness.

 

What are the particular problems in the implementation and delivery of stroke risk reduction actions?

 

From the evidence provide above, undoubtedly, the greatest challenge lies in achieving sustained changes in awareness, attitude and lifestyle among the general population, and in high risk groups in particular. 

 

The delivery of many objectives is hampered by a lack of specialist clinicians and by resource constraints generally.

 

By its very nature, stroke extends across not just the whole healthcare spectrum, but also across a range of other public services and agencies, and service co-ordination is therefore also a major challenge.  This has however been improved within healthcare through the establishment of integrated health boards.

 

 

 

 

What evidence exists in favour of an atrial fibrillation screening programme being launched in Wales?

 

Atrial fibrillation (AF) is a very important cause of stroke, especially in very elderly patients. One in six strokes are due to AF. Anticoagulation reduces the risk of stroke by at least 60%1. Therefore, identifying patients with AF and commencing eligible patients on anticoagulant therapy is likely to reduce the burden of stroke significantly.

Local QOF data shows a wide variation not wholly explained by demographics. This would suggest that a programme to screen for AF will increase identified prevalence. Given the significant stroke risk associated with AF this would be beneficial.

 

Reference:

 

 1. Hart R G, Benavente O, McBride R, and Pearce L A. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med. 1999;131: 492-501.