The National Assembly for Wales
Health and Social Care Committee Inquiry into
Stroke Risk Reduction
Submission from the Royal College of Nursing, Wales
September 2011
ABOUT THE ROYAL COLLEGE OF NURSING (RCN)
The RCN is the world’s largest professional union of nurses, representing over 400,000 nurses, midwives, health visitors and nursing students, including over 23,000 members in Wales. The majority of RCN members work in the NHS with around a quarter working in the independent sector. The RCN works locally, nationally and internationally to promote standards of care and the interests of patients and nurses, and of nursing as a profession. The RCN is a UK-wide organisation, with its own National Boards for Wales, Scotland and Northern Ireland. The RCN is a major contributor to nursing practice, standards of care, and public policy as it affects health and nursing.
The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies.
Health and Social Care Committee Inquiry
into Stroke Risk Reduction
Submission from the Royal College of Nursing, Wales
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?
The current provision for people at risk of stroke is predominately though the general health promotion services provided by primary care GP services. These services vary between individual practice and LHB area. In considering the introduction of health checks of the over 50s this could be a useful area to focus on.
Within the Annual Quality Framework 2011-12 there are specific targets for stroke acute care, rehabilitation and Transient Ischemic Attack (TIA). There are however no specific targets around stroke prevention.
Following a TIA people may receive risk reduction advice from a stroke prevention clinic, this is sometimes Nurse led and patients will often be referred back to primary care services to monitor blood pressure and receive follow up treatment. This service however is not universal and it would be worth reviewing the differences between Local Health Boards.
Specialist Nurses offer a dedicated point of contact and advocate for patients. The funding derived from the WAG 2008-2009 enquiry led to each health board submitting improvement plans. An increase of stroke specialist nurses in each health board was a result of the funding and around 13 (this figure is not whole-time equivalent) nurse specialists are employed across Wales (with the exception of Powys). In Cwm Taff and Torfaen the role bridges primary and secondary care but elsewhere the role is restricted to the acute sector.
Currently there is no position for a Consultant Nurse for stroke services in Wales. A Consultant position allows for the strategic development of services. This vastly different compared to England and Scotland which currently have over 20 Consultant Nurses for Stroke.
There are also private clinics which offer Blood pressure and cholesterol tests and aim to assess cardiovascular risk.
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?
There is anecdotal evidence to demonstrate that public awareness of the symptoms of stroke and the correct response of dialling the emergency services has risen. However more could be done to inform the public of the benefits of lifestyle change, healthy eating, stopping smoking, monitoring cholesterol and blood pressure. The risks are often seen to relate to cancer and cardiac events and not stroke.
The Risk Reduction Plan almost entirely focuses on raising public awareness. Whist this aim is laudable and necessary there are specific steps that the Welsh Government could take to reduce risks and raise awareness. More could also be done to involve specialists in stroke in Wales in the implementation and progress of this plan (a network approach).
In England health communities, led by the Heart and Stroke Improvement Programmes in England have been developing work on stroke prevention. Joining up prevention includes information on stroke prevention through better identification and treatment of both atrial fibrillation (AF) and transient ischaemic attack (TIA).
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Atrial Fibrillation (AF) a type of irregular heartbeat and is the most common heart rhythm disorder in Wales. AF undermines patients’ quality of life and is responsible for around a quarter of all strokes. It imposes a heavy burden on the NHS in Wales, with AF related strokes costing health and social care in the region of £46 million a year. There are specific actions relating to this that the RCN is calling for:
© A specialist nurse should be championing AF detection in each LHB.
© GP services in each LHB area should have knowledge of how to refer patients with AF and the importance of this.
© Practice nurses and HCSWs may need education in stroke risk reduction. Even if this is provided by the LHB the employees the GP may not be released to attend. LHBs could examine this provision and need in their area.
© The Chronic Conditions team in each LHB should consider AF as a chronic condition.
© Prompt treatment is needed for people once AF has been diagnosed.
What are the particular problems in the implementation and delivery of stroke risk reduction actions?
Lack of Ownership by the Stroke teams and Primary care teams is an important factor in the implementation and delivery of risk reduction actions. Clinical Champions would be able implement actions readily and be able to monitor effectiveness.
Evidence from Millar 2010[1] suggests that nurses are the most likely professional group to take prominent leadership role in the primary and secondary prevention of strokes. Millar emphasises the importance of prevention on all inpatient and outpatient units and establishing workplace staff health promotion programs to reduce modifiable stroke risk factors, given the increasing incidence of stroke in younger adults.
At present there is a lack of training and education opportunities in Wales for Stroke for medical and nursing and therapy staff at all levels.
What evidence exists in favour of an atrial fibrillation screening programme being launched in Wales?
AF is an important cause of stroke especially in the elderly patients. Anticoagulation reduces the risk for stroke by 60%.
Screening could be carried out cost effectively by the nursing/ primary care team. This could simply be done by carrying out manual pulse checks when doing other routine work for example during flu clinic or routine health check.
We would recommend the Committee examine the service recently developed in Cwm Taff. An AF Specialist Nurse is developing a nurse led clinic and works closely with Cardiologists and Stroke Physician. Referrals come from Primary Care and from within the Hospital.
Other area of best practice from which evidence may be drawn are the SAFE project study - a small study which investigated the role of practice nurses systematically screening practice population or the pilot study conducted by 2 arrhythmia nurse specialists in North Wales looked at integrating manual pulse checks into a routine chronic conditions clinic within General Practice[2].
Wright et al .2006[3] found that a cluster randomised trial in the North of England to implementation evidence based guidelines improved the quality of primary care for atrial fibrillation and TIA. The intervention included evidence based recommendations, audit and feedback, interactive educational sessions, patient prompts and outreach visits. Implementation led to 36% increase in diagnosis of AF and improved treatment of TIA.