Health and Social Care Committee
HSC(4)-03-11 paper 2
Inquiry into Stroke Risk Reduction - Evidence from the Stroke Association in Wales
The Stroke Association in Wales welcomes the opportunity to provide written evidence to the Health, and Social Care Committee on the Inquiry into Stroke Risk Reduction.
The Stroke Association in Wales is the leading third sector provider of Life After Stroke Services. We aim to reach at least nine out of ten stroke survivors and their families within two weeks of the stroke. We are at the forefront of raising awareness of stroke and promoting the right of stroke survivors. We help people to reduce their risk of having a stroke and lobby for improvements in stroke services across the whole care pathway.
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?
1.1 Around 11,000 people in Wales have a stroke each year. However, stroke is both preventable and treatable. Preventing a stroke from happening 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.
1.2 The Welsh Government has funded a number of stroke prevention campaigns including Weigh up your Risk of Stroke, the F.A.S.T campaign and most recently with the Stroke Association; Ask First – to help prevent a stroke later campaign which focussed on the risks of having a stroke associated with having a condition called AF and / or high blood pressure.
1.3 As well as ensuring continued awareness about healthy lifestyles, The Welsh Assembly 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.
1.4 The Welsh Assembly Government needs to take a wider view to implementing successful health promotion 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.
1.5 The Stroke Association welcomes its continued partnership with the Welsh Government in delivering stroke prevention campaigns. However, these should be delivered more strategically. This can be achieved by allowing longer planning periods and more collaboration across organisations and functionalities, as well as ensuring that adequate levels of funding are available to deliver integrated campaigns.
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?
2.1 Whilst the Stroke Association cannot comment on the implementation on some of the actions attributed to other organisations, we can offer comment on how we see the overall implementation. Last year the Stroke Association welcomed the Health, Wellbeing and Local Government’s Inquiry into Stroke and the resulting publication of “Promoting Cardiovascular Health: the Stroke Risk Reduction Action Plan”. However, following publication, we have not had any further correspondence regarding implementation despite being attributed as an organisation to deliver key actions in partnership with others.
2.2 However, The Stroke Association has worked with the Health Improvement Division of the Welsh Government to implement action point 37: Conduct an awareness raising campaign ‘know your blood pressure, know your pulse; including targeted action for BME groups at greater risk.
2.3 At the Stroke Association our focus turned to AF in September 2010 when we were in the process of developing our UK wide Stroke Association AF campaign. In Wales we were given the opportunity to jointly launch “Keeping our Finger on the Pulse: why Wales must address the personal, clinical and economic impact of Atrial Fibrillation” funded through an educational grant by Sanofi Aventis and in partnership with the Atrial Fibrillation Association. This document outlined a case for action and offered analysis on the devastation that AF causes in Wales each year.
2.4 At the same time, The Welsh Government was launching “Promoting Cardiovascular Health: the Stroke Risk Reduction Action Plan” and one of the actions was to carry out an awareness raising campaign around both high blood pressure and irregular heartbeat. This coincided with our UK wide strategic drive to raise awareness of AF as a risk factor for stroke.
2.5 We decided to form a partnership to deliver a joint campaign. Ours was an AF specific campaign at UK level; however the Welsh Health Minister wanted a dual purpose approach to include high blood pressure. We set to work to integrate the requirements of The Welsh Government with our own strategic priorities and we planned and implemented a successful campaign called Ask First: to help prevent a stroke later, in March this year.
2.6 The partnership has been hugely successful and we hope to be able to work with the Welsh Government to deliver further awareness and prevention campaigns along these lines in the future.
2.7 With regard to delivery of the remaining actions, we would welcome a report on progress and an open dialogue to ensure that the actions are implemented. A review and refresh of this action plan is needed to ensure the best possible outcome for promoting good cardiovascular health and therefore a reduction of strokes in Wales.
3. What are the particular problems in the implementation and delivery of stroke risk reduction actions?
3.1 We believe the main problem with the implementation has been ownership. Despite being attributed actions, no further communication has been forthcoming to facilitate these actions to ensure delivery.
3.2 With a focus on working to remedy the failure of Wales to meet standards set out in the RCP National Stroke Audit which has been critical of Wales in terms of its delivery of stroke services within the acute setting; the work around stroke prevention has had less focus and resource, and yet it is vitally important if we are to prevent some of the 11,000 strokes which happen in Wales each year.
3.3 Whilst it is right and proper 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. This pathway should not start with the onset of stroke symptoms; rather stroke prevention should carry equal weight. This is why the Stroke Association in Wales continues to 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.
3.4 The work being done by the 1000 Lives+ initiative and supported by the NHS Delivery and Support Unit to drive up standards in stroke services has been fundamental in improving the performance of acute stroke care across Wales. The Stroke Association wholeheartedly welcomes the development of Intelligent Targets for acute, TIA, early rehabilitation stages of the stroke pathway. The implementation of these targets has been hugely successful and praise needs to be given to clinicians in the stroke community across Wales for their determination to implement this programme.
3.5 The Stroke Association is pleased to be able to support this programme and is looking forward to the work being developed on the Life After Stroke Intelligent Target and in particular any work that is going to be done to develop a Stroke Prevention Target.
3.6 Vital to implementing a successful programme of stroke improvement is the engagement of all strategic partners. The work around improving stroke services has to date centred on the clinical intervention of stroke and is firmly embedded within health. Yet, acute intervention is one part (though crucial) of the journey of a stroke survivor and the role of Local Authorities in ensuring that effective prevention strategies are embedded into local strategic planning is all too often 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.
3.7 Whilst this is an issue which affects Life After Stroke Services more so than prevention services, we would like it stated as part of this inquiry that the role of Local Government as a strategic partner in promoting preventative and early intervention programmes is vital and we would expect to see the role of Local Authorities being bolstered in a renewed and invigorated action plan for stroke prevention and risk reduction.
4. What evidence exists in favour of an atrial fibrillation screening programme being launched in Wales?
4.1 AF affects about 750,000 people in the UK and is more common in older people. AF is the most common heart rhythm disorder in Wales and it is said that AF related strokes cost in the region of £46.3 million a year.
4.2 AF means the heart is not pumping as well as it should do. The upper chambers of the heart contract and relax in an uncoordinated and irregular way because of erratic electrical activity. Irregular and fast heartbeats mean the heart does not have a chance to relax and empty properly before filling up with blood again. Blood can collect and pool and this increases the risk of blood clots forming in the blood. As a result, blood clots are more likely to form in the heart. If a clot dislodges itself from the heart it can then travel through the blood stream to the brain and can cause a stroke.
4.3 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.
4.4 AF can cause symptoms such as palpitations, breathlessness, chest pain or fatigue, but can also have no obvious symptoms.
4.5 The Stroke Association is actively campaigning to improve awareness of AF and its link to stroke. We believe that routine screening for AF should be introduced across Wales. This should not be onerous and the following existing opportunities should be considered 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.
· Flagging applied to records of all patients over 65 known not known to have AF would prompt routine checking of pulse.
4.6 The role nurses can play in detecting AF is crucial. The Stroke Association recently ran an event with the Royal College of Nursing to raise awareness regarding the role of the nurses in identifying AF. By ensuring that each local health board establishes a nurse who champions AF and its link to stroke, AF would be seen as a risk factor for stroke, not merely as a heart rhythm disorder. Primary Care nurses also have a role to play in detecting people who have AF and promptly referring for treatment. 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 the clinics listed above at little or no extra cost to the NHS.
4.7 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.’
4.8 As blood clots are more likely to form in the heart in AF, stroke may occur if a clot travels to the brain. While not everyone who has AF will have a stroke, some are at more risk than others. Some simple tools have been validated that help health professionals identify those most at risk of stroke, and a tool has been developed in England called GRASP-AF for the easy use in GP practices. The Stroke Association would like to see the use of this tool or a similar tool in GP practices in Wales.
4.9 NICE guidelines already exist for the stratification of patients with AF for risk of stroke, using validated tools. However, adherence to these guidelines is low and werecommend that a risk assessment for stroke, using a recognised tool recommended in the ESC guidelines, to be carried out on all patients with AF, and that this is reviewed at regular intervals. We call for a new QOF indicator that states ‘the percentage of patients with AF in whom stroke risk has been assessed using a validated tool’.
4.10 Anti-coagulant treatments are available for at-risk individuals. 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.
4.11 The Stroke Association calls 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. We also want to see the inclusion of a new QOF indicator ‘The percentage of patients at high risk of stroke who are receiving anticoagulants (unless a contra-indication or side-effects are recorded)’.
5. Final Remarks
5.1 The Stroke Association in Wales wholeheartedly welcomes this Inquiry into Stroke Risk Reduction and in particular the focus on Atrial Fibrillation as a risk factor for stroke. Mitigating the devastation that stroke can have on people’s lives is the basis of our work and we wholeheartedly support further attention being given to raise the awareness of the importance of stroke prevention and risk reduction.
5.2 Prevention work need not be resource heavy as we have demonstrated. Including simple pulse checks into already existing clinics and introducing new QOF indicators will help save lives and prevent people falling into disability as a result of stroke.
For further information please contact Lowri Griffiths, Head of Communications and External Affairs at the Stroke Association in Wales lowri.griffiths@stroke.org.ukor ring 029 20524400
References
Atrial Fibrillation Association, The Stroke Association in Wales (2010) Keeping our Finger on the Pulse: Why Wales Must Address the Personal, Clinical and Economic Impact of Atrial Fibrillation.
The Stroke Association (2011) Atrial Fibrillation and Stroke Policy Statement
NHS Wales (2011 / 2012) Annual Operating Framework
NICE Guidelines (2006) Atrial Fibrillation
The Stroke Association in Wales (2011) Manifesto
Welsh Government (2009) Chief Medical Officer for Wales Annual Report
National Assembly for Wales, Health, Wellbeing and Local Government Committee (2010) Inquiry into Stroke Services in Wales
Royal College of Physicians (2010) National Stroke Audit