Health and Social Care Committee

Inquiry into Stroke Risk Reduction

SRR 24 – South East Wales Regional Stroke Forum

South East Wales Regional Stroke Forum

Response to Welsh Government Health and Social Care Committee Inquiry into Stroke Risk Reduction.

The South East Wales Regional Stroke Forum consists of key managers, stroke clinicians and neurologists from the three Health Boards within the South East Wales region (Aneurin Bevan, Cwm Taf and Cardiff & Vale), the Wales Ambulance Service and the Delivery & Support Unit.   The Forum provides the opportunity for the joint consideration of stroke service issues across the Region. 

1. 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?

As required by the Welsh Government, each Health Board has a local Stroke Action Plan which incorporates Stroke Risk Reduction. 

The principles of promoting and maintaining health and wellbeing and of early intervention are also reflected in each organisation’s Strategic frameworks and programmes.

The Wales Ambulance Service NHS Trust has undertaken staff training to ensure the rapid recognition of symptoms and appropriate management of stroke patients, and has worked with the LHBs to develop pre-hospital pathways and hospital pre-alert systems, to help maximise outcomes for stroke patients. This includes the development of a TIA pathway.

Through the NHS Annual Quality Framework (AQF), the Welsh Government establishes performance targets and monitoring mechanisms for NHS Wales.  The 2011/12 AQF  has an increased focus on improving and protecting health for all, and on achieving health outcomes.

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.

Much work has progressed locally to implement the Stroke Risk Reduction Plan, including the raising of public awareness at local events.

It is considered that the Stroke Association FAST campaign has raised the profile of stroke and awareness of symptoms, and there is some evidence that it has facilitated early presentation.   It is therefore hoped that such campaigns will continue to be run in the future.

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

Identifying and targeting those at risk of primary stroke is a challenge as it may not be known that they have any risk factors. Opportunistic screening for risk factors such as hypertension and high cholesterol may therefore be helpful.

Reducing the risk of stroke requires a major change in lifestyle choice amongst the population, which is a major challenge.   Public Health Wales have recently provided training for health professionals in motivational interviewing, with a particular focus on motivating individuals to reduce their alcohol intake and to access smoking cessation services.  The impact of health promotion activities are often only realised in the long term, and  measuring the change and attributing cause and effect is difficult, particularly given the backdrop of an ageing population and increasing obesity levels.  

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

A review of the evidence on screening for Atrial Fibrillation (AF) found that active screening for atrial fibrillation does detect additional cases over current practice. However, the preferred method of screening in patients of 65 or over in primary care is opportunistic pulse taking with follow up ECG rather than systematic screening of patients. SAFE Study: Hobbs FDR, Fitzmaurice DA, Jowett S, Mant J, Bryan S, Raftery J, Davies M and Lip G. 

It is clear that patients with Atrial Fibrillation usually have a significantly increased risk of stroke. However, the level of increased stroke depends on the number of additional risk factors. If a person with AF has none, the risk of stroke is similar to that of the general population. However, many people that do develop AF also have additional risk factors and in those patients, AF is a risk for stroke.

Efforts in primary care should be centred on two groups of patients. The first are those patients known to have AF and to ensure that this is treated appropriately. The second aims at detecting news patients with AF and this should involve opportunistic testing rather than systematic screening.