Health and Social Care Committee

Inquiry into Stroke Risk Reduction

SRR 5 – Welsh Therapies Advisory Committee

Welsh Therapies Advisory Committee Response to HSC Committee Inquiry into the Stroke Risk Reduction Action Plan

General Introduction

The Welsh Therapies Advisory Committee (WTAC) welcomes the opportunity to contribute to this consultation.  WTAC is the statutory body that advises the Welsh Assembly Government on issues relating to therapies.  The professions it represents are Arts Therapies (Art, Music & Drama), Dietetics, Occupational Therapy, Orthoptics, Physiotherapy, Podiatry, and Speech & Language Therapy.

This response combines those of the All Wales Dietetic Managers and All Wales NHS Physiotherapy Managers Committees as National Specialist Advisory Groups that contribute to the advice provided by WTAC and the therapy profession with the most significant involvement in Stroke Risk Reduction. 

Diet and Nutrition play an important role in the health of the population. Dietitians support a reduction in health inequalities through enabling and supporting people to access a healthy balanced diet.  Rates of obesity are increasing and there are still inequities in being able to access an affordable, nutritious diet and there is a lack of supporting knowledge and skills.  There is a wealth of evidence demonstrating the positive relationship between the uptake of a healthy balanced diet and good health throughout the life course.  A healthy balanced diet contributes to a reduction in cardiovascular risk, including stroke.  Research suggests that improved diet could reduce CVD and cancer deaths by a third, thus improving life expectancy and general health and well being.

Physiotherapy skills are required throughout all stages of the stroke pathway and are essential as part of the acute and rehabilitation phases of treatment and management.  Physiotherapists also contribute to the risk reduction services, particularly in relation to cardiac rehabilitation and health promotion as part of a holistic physiotherapeutic management of patients who may be at risk of suffering a stroke or having already survived a stroke and need to decrease the potential risk of having a further stroke.  Exercise is crucial and physiotherapists use exercise as part of their treatment programmes.

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?

Stroke reduction is encompassed in the general public health strategies, in particular ‘our healthy futures’ as part of the universal health improvement plan.  Reducing unhealthy eating is a priority within this plan and also within the obesity pathway. Dietitians are key to taking this work forward, in particular through providing training in community settings to improve knowledge and skills around good nutrition.  The dietetic WAG capacity grant has been key to providing increased dietetic capacity to undertake this work and take forward the recommendations in the WG policies. The Dietetic capacity grant targets 0-25 and has this year broadened its focus to include older people. It has developed a standardised approach for accredited nutrition training across Wales, promoting consistent nutrition messages and contributing to preventing nutrition related disease.  The work that dietitians have undertaken as part of this grant scheme has been proven to be effective (through external evaluation by Glyndwr university) and now needs to be incorporated into mainstream dietetic service provision through provision of an ongoing funding stream. Consideration also needs to be given to extending the scheme to incorporate the working age population, in particular working age men, who are a priority group for stroke risk reduction.

The dietetic capacity grant deals with prevention of ill health, it is important to note that there are no dietetic services targeting lifestyle management in the secondary prevention of stroke and the obesity pathway mapping exercise undertaken by health boards has highlighted a lack of multidisciplinary services at level 3 to support lifestyle management in people with complex obesity.

The Stroke Risk Reduction Action Plan targets Primary care where there is limited involvement of physiotherapists for this patient group.  Physiotherapists do, however, refer patients directly to the NERS programmes from secondary care.  Patients referred to physiotherapy services for other interventions, e.g. musculoskeletal disorders, receive advice on exercise and healthy lifestyle including smoking cessation as part of their care.

Implementation of the Welsh Government Stroke Risk Reduction action plan whether action to raise public awareness of the risk factors for stroke has succeeded?

There has been a variety of campaigns to raise public awareness of stroke, through Welsh Government as well as third sector organisations.  Whilst we feel these have been successful it is important to ensure that messages do not get confusing for the population.  Having a healthier lifestyle through smoking cessation, reducing unhealthy eating and increasing physical activity will benefit the population through reduction of multiple conditions including cardiovascular disease, obesity, diabetes, cancers.  We need to keep the primary prevention message generic to improve health rather than target messages at individual specific conditions.  These generic messages are promoted through Health Challenge Wales and the Change for Life campaign and continued use of the Change for Life campaign should be endorsed.

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

Action area 1. It is important that all community groups working to address health inequalities have a basic level of nutrition knowledge so they can support people in achieving a healthier diet.  Training being developed in this area needs to link with the dietetic capacity grant training to ensure that communities first staff has the relevant skills and knowledge around nutrition.

Action area 9. The expansion of the capacity grant to older people will support awareness raising of nutrition and the prevention of problems associated with under nutrition in the older population.  This work will not directly support the stroke prevention agenda and consideration needs to be given around investment in training capacity to support the working age population.

Action area 10. Publication of the All Wales Obesity Pathway has provided information against which health boards can map their services.  A group of Welsh Dietitians are now working with the Health improvement team to develop a weight management programme that can be delivered by leisure services and third sector organisations.  This will give the general population (estimated 52% of whom are overweight or obese) the opportunity to access evidence based programmes to help them make lifestyle changes to manage their weight and so reduce their risk of cardiovascular disease.  Continued support from Welsh Government will be required to enable the full potential of this accredited programme to be achieved and to improve access to weight management services across Wales.

Action Areas (14) and (15) relate to the National Exercise Referral Scheme.  Physiotherapy Managers fully support the use of this scheme but are concerned that the increasing demand put upon it may exceed capacity as NERS is used increasingly for a range of pathways (back pain, cardiac, COPD, falls etc) to good effect.  The danger may be development of waiting lists for this service or creating an over reliance that cannot be met though existing capacity

In addition Physiotherapy Managers are aware that funding for the NERS scheme has only been agreed for a fixed period understood to be 3 years.  It is unclear what would happen should this funding either not be extended or made permanent.

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

Training for NERS professionals is essential and regular review and update of training modules is required.  This needs to be undertaken across Wales to ensure equity of provision and access for people at risk.

The Stroke Risk Reduction Action Plan addresses a wide range of actions to prevent stoke in the first place.  Physiotherapy Managers noted that it does not, however, include a section on dealing with risk reduction for a person who has suffered a stroke.  Including something on this will provide an opportunity to ensure stroke risk reduction is a priority for health professionals in primary, community and hospital based settings.  Physiotherapists would be key professionals who would play an active part in this.  If included within the Action Plan and referred to by the Committee, it will mean Health Boards and Public Health Wales will need to demonstrate success as part of performance management.

Action Area 16. The healthy schools part of the action plan should now be extended to include the new preschool healthy schools scheme so there is a co-ordinated approach through the care settings. Also consideration should be given to incorporating nutrition education programmes into the flying start schemes around Wales so that nutrition is addressed with families at the earliest stage.

Consideration also needs to be given to expanding guidance to leisure services on the food provided in their catering outlets to ensure it promotes the correct health messages and enables people accessing leisure facilities to have a healthy diet.

Finally, the hardest part of any risk reduction programme is demonstrating success.  The professions note the high level evaluation measure and timeline associated with the Stroke Risk Reduction Action Plan.  Many of the dates in the timescale section have already passed.  The Committee may wish to scrutinise this area and consider ways in which improvements can be demonstrated.  The Action Plan should provide a performance management tool to check that activities have been undertaken but no report on progress against the 40 action points in the plan has been seen by the profession to date.

WTAC would be happy to provide support if additional information is required regarding this response.

References

NICE Public health guidance 25 Prevention of Cardiovascular disease

Food and Well Being: Reducing inequalities through a nutrition strategy for Wales. WAG / Food Standards Agency 2003

Our Healthy Future: WAG 2009