HSC(4)-09-11 paper 4

Health and Social Care Committee

Inquiry into Stroke Risk Reduction Services - Written evidence from the Minister for Health and Social Services

1. This paper provides the Committee with evidence on the: epidemiology of stroke / transient ischaemic attack (TIA) in Wales; broader policies aimed at reducing risk of stroke; actions to tackle key risks for stroke; awareness raising activity; and future developments.

Stroke and TIA in Wales

2. Strokes are a major cause of adult disability in Wales and one of the most common causes of death. Although stroke is predominantly a disease affecting older people, it can affect people of any age.

3. There are over 65,000 patients on the GP stroke / TIA register in Wales, which equates to approximately 2% of the population[1]. In 2009/10, the rate of emergency hospital admissions in Wales with a stroke as the primary diagnosis was 118.08 per 100,000 population. The rate declined between 2002/03 and 2007/08 (from 151.89 to 122.70), saw a rise in 2008/09 (130.76) but fell again in 2009/10 (118.08).

4 Mortality figures also show an encouraging downward trend with regard to deaths from stroke. In 2009, 97 per 100,000 of people aged 65-74 died of stroke. This is well below the Health Gain 2012 target of 135 per 100,000.[2]

Broader Welsh Government action to reduce the risk of stroke

5. Reducing the risks of stroke continues to be a priority for the Welsh Government and is a key element of our broader approach to tackling cardiovascular disease risks. For example, the Cardiac Disease National Service Framework for Wales (2009) clearly sets out requirements in relation to cardiovascular disease prevention, risk assessment and management.

6. More recently, the Welsh Government tasked Public Health Wales with mapping existing services across Wales which assess people at risk of cardiovascular disease, such as stroke, and the management of these risk factors. Using the outcome of this exercise, Public Health Wales was asked to make recommendations on how these services could be made more systematic and coordinated. These recommendations have been received recently and my officials are preparing advice on these for me to consider next steps.

7. The 1000 Lives Plus Programme is also making a contribution through its work to improve TIA services and the reporting of key clinical data. The effective and prompt management of people who have a TIA or mini stroke will reduce the number of strokes in Wales. A recent national clinical audit showed that people are not accessing surgical intervention following a TIA and we are taking action to work with Local Health Boards to address this. I expect to see significant improvements over time.

8. Broader work on improving the health and wellbeing of older people, arising out of the Strategy for Older People, plays a part too. For example, the Welsh Government supports the Healthy Ageing Programme (HAP) delivered by Age Cymru. This is a health improvement programme which supports and delivers initiatives such as Keep Well This Winter (KWTW), physical activity programmes and medication awareness. These initiatives make a clear contribution to reducing the risks of strokes in older people.

Stroke Risk Reduction Action Plan

9. The Welsh Government issued Welsh Health Circular (2007) 58 which emphasised that tackling stroke is one of the top priorities for the health service in Wales. Local Health Boards were required to review stroke services and put formal action plans in place to map the journey to achieving compliance with national standards by 2015.

10. The following Welsh Health Circular ((2007) 082) required an assessment to be made of gaps in the availability of local and national resources or services that sought to reduce the risk factors for stroke. The resulting Stroke Services Improvement Programme included an action to address stroke risk and was taken forward by the National Public Health Service for Wales as one of the work streams of that programme.

11. The work stream’s report “Promoting Cardiovascular Health: The Stroke Risk Reduction Action Plan” was developed in 2010, with the aim of pulling together and strengthening existing actions. It focused on primary prevention but took into account that risk reduction applies to the entire stroke care pathway.

12. The Plan took a population level approach, including actions to raise public awareness of the risk factors for high blood pressure, atrial fibrillation, TIA and stroke. The plan also included links to specific individual level interventions such as the National Exercise Referral Scheme and included the contribution of community pharmacies to run public health campaigns, signpost to risk reduction services and undertake reviews of medication where appropriate. All actions referenced within the plan were scheduled to be completed by March 2012.

13. Progress with implementing the actions within the Stroke Risk Reduction Action Plan has generally been positive, with a large number of initiatives contributing to the overall picture. There are a limited number of instances where actions have been placed on hold or superseded by subsequent developments. A number of actions have continued and developed beyond their initially scheduled completion date.

Welsh Government Action to reduce Specific Risk Factors for Stroke.

14. The Welsh Government’s public health strategic framework, Our Healthy Future, sets out the agenda and actions required to improve health and wellbeing in Wales. Five of the ten priority outcomes identified in Our Healthy Future have a direct correlation with reducing risk factors for cardiovascular disease and stroke:-

· Reduced smoking prevalence;

· Increased participation rates in physical activity;

· Reduced unhealthy eating;

· Improved health at work; and

· Reduced health inequities.

15. In addition, the National Prevention and Promotion Programme has identified areas of public health action which can have a high impact on the utilisation of health and social care resources within a three to five year timeframe. These areas included reducing the burden of tobacco use and alcohol misuse and effective management of vascular risk, all of which are relevant for stroke risk reduction.

16. These public health priorities are reflected in the specific actions of the Stroke Risk Reduction Action Plan. However, activity to target these risk factors extends beyond the actions within the Stroke Risk Reduction Action Plan and some key developments are set out below.

Blood pressure

17. Recorded prevalence of high blood pressure as noted in the Welsh Health Survey 2010 is 20%. GP contacts provide the opportunity to identify and manage high blood pressure and other risk factors such as smoking, cholesterol levels and irregular heart rhythms. The Quality and Outcomes Framework (QOF) for General Practitioners promotes and rewards proactive systematic care in these areas. Local Health Boards provide quality assurance of the QOF process and work with GP practices to minimise variation and improve outcomes. The proportion of patients whose blood pressure has been reviewed continues to increase, and for patients with a history of stroke or TIA over 88%[3] have a record of blood pressure managed to the target level. The Primary Care Information Set provided Local Health Boards with comparative information to identify opportunities for further work in this area.

18. Guidance from the National Institute for Health and Clinical Excellence advises that implementation of hypertension guidance has the potential to deliver significant savings[4]. Adherence to the recommendations will cost more in drugs, but this is far outweighed by the predicted number of cardiovascular events (heart attacks and strokes) that will be avoided if hypertension is better controlled.

Tobacco

19. The Welsh Health Survey 2010 noted that around a quarter of adults (23%) report that they currently smoke. Tobacco exposure increases a person’s risk of a range of conditions, including stroke and cardiovascular disease. The risk increases with the number of cigarettes smoked. For many people, quitting smoking is the single best thing they can do to improve their health.

20. Action to tackle the harm caused by smoking remains a priority for the Welsh Government. One of the key themes in Our Healthy Future is to further reduce smoking and exposure to second hand smoke. To take this forward we recently consulted on a draft Tobacco Control Action Plan, which builds on our programme of measures to discourage young people from starting to smoke and to support smokers who want to give up. It also promotes smoke-free environments, but particularly aims to protect children and reduce inequalities in health. The Action Plan aims to drive down smoking prevalence levels to 16% by 2020. We are currently considering the responses to the consultation on the draft Tobacco Control Action Plan for Wales and will launch the revised Plan in December.

21. The Welsh Government supports the Stop Smoking Wales service, delivered by Public Health Wales. Smokers who wish to quit can contact Stop Smoking Wales for guidance, advice, information and free access to counselling and support groups across Wales. The Stop Smoking Wales annual report 2010/11 noted that approximately 16,000 people contacted the service during that year.

Obesity (including diet / salt intake and physical activity)

22. The Welsh Health Survey 2010 noted that around 3 in 5 adults (57%) were classified as overweight or obese, including around 1 in 5 (22%) classified as obese. The Survey also noted that around 3 in 10 adults (30%) reported meeting the guidelines for physical activity in the past week.

23. The All Wales obesity pathway outlines the four tiers of services directed at preventing and managing weight and obesity. The preventive work is supported by Change4Life, the social marketing component of the Welsh Government's broader response to help people achieve and maintain a healthy body weight. Change4Life is a fully integrated programme which seeks to set the right conditions for behaviour change, accurately target information at at-risk families and develop an on-going relationship with them. Change4Life initially targeted families with children and over 13,000 families are registered in Wales. This October, Change4Life is being extended to cover adults more generally and I am proposing that it will cover alcohol misuse from Spring 2012.

24. The Welsh Government continues to deliver interventions aimed at improving the diet of the population, including reducing intakes of salt and saturated fat. Current work includes developing guidance on healthier food and drink provision for public sector settings such as hospitals, leisure centres and youth settings, which will be published shortly.

25. The National Exercise Referral Scheme (NERS) includes obesity and stroke patients, in line with the Royal College of Physicians’ National Clinical Guidelines for Stroke (2008) which in the section on rehabilitation recommends that ‘after stroke, all patients should participate in aerobic training unless there are contraindications unrelated to stroke’. Over 23,000[5] patients were referred between 1 April 2010 and 31 March 2011. The NERS evaluation published in 2010 confirms the cost effectiveness of the scheme. Using Quality Adjusted Life Years (QALY) as our measure of effectiveness gave a cost per QALY of £12,111, well within the NICE threshold of £20,000-£30,000.

Alcohol

26. Alcohol can be both a risk factor and a preventative measure for stroke. Binge drinking and heavy alcohol consumption increase a person’s risk of high blood pressure and of ischaemic and hemorrhagic strokes. However, drinking small to moderate amounts of alcohol may have a positive effect on stroke risk by increasing HDL cholesterol and decreasing the blood’s clotting tendency.

27. The Welsh Health Survey 2010 noted that around 2 in 5 adults (44%) reported drinking above the recommended guidelines on at least one day in the past week, including around a quarter (27%) reporting binge drinking. Our Substance Misuse Strategy for Wales – Working Together to Reduce Harm 2008-2018 - gives a high priority to tackling alcohol misuse. An implementation plan includes a range of actions specifically targeted at tackling alcohol related harms. As part of the Implementation Plan, the Welsh Government is delivering a combination of both population and individual level interventions such as brief interventions to address the harm caused by alcohol.

28. Evaluations of brief interventions have consistently shown them to be one of the most effective approaches to reducing problem drinking. The Welsh Government will continue to promote opportunities for alcohol brief intervention in primary and secondary care.

Atrial Fibrillation

29. Population based national screening programmes available in Wales, as in the rest of the UK, are based on expert advice provided by the UK National Screening Committee (UK NSC). The UK NSC’s current policy position is that it does not recommend screening for atrial fibrillation. However, this position is currently under review and due to be completed by March 2012. Welsh Government and Public Health Wales are members of the UK NSC and will be kept informed of developments.

30. However, evidence has shown that timely management of Atrial Fibrillation benefits patients and reduces the risk of stroke. As part of 1000 Lives Plus, the Primary Care Quality and Information Service has designed a guide to support practices to provide care in line with the best available current evidence. This work includes early identification and management of symptomatic and asymptomatic atrial fibrillation.

31. Practices are currently being invited to engage in the Atrial Fibrillation improvement work as part of a series of locality-based learning events.

Campaigns and activity to raise awareness of cardiovascular disease and stroke risk factors

32. The need to raise awareness among the population of the risks associated with cardiovascular disease, including stroke, is a key element of Welsh Government activity. This is reflected in the Programme for Government, which includes a commitment to deliver an annual campaign over the term of this Government, to tackle the five biggest public health priorities in Wales (obesity, smoking, teenage pregnancies and drug and alcohol misuse).

33. A number of initiatives have already been put in place to raise awareness of the key risks. In April 2008 the Stroke Association ran a Wales-wide campaign, in support of Health Challenge Wales, as part of its efforts to raise public awareness around the symptoms of stroke. Adverts were published in twenty weekly newspapers encouraging people to act quickly if they suspect someone is having a stroke by using the FAST test. The Stroke Association reported a 3.5 fold increase in people recognising the FAST test after the one week campaign. In addition, the ‘Weigh up the risk’ radio campaign, run in January 2009, aimed to highlight that maintaining a healthy body weight could decrease high blood pressure and cholesterol levels, reducing the risk of stroke.

34. The Public awareness campaign ‘Ask First’ was delivered in partnership with the Stroke Association in March 2011. The campaign consisted of radio adverts and testing events in Corporate Health Standard network workplaces, plus posters in pharmacies, bus stops and GP practices.

35. We have also put in place a number of awareness raising issues aimed at specific target audiences:-

Workplace settings

36. The Welsh Government and Public Health Wales provide information to employers on cardiovascular risk through Healthy Working Wales employer engagement events, e-newsletters and e-bulletins. Employers are also sign-posted to the support materials of partner organisations, including the British Heart Foundation and the Stroke Association.

37. As part of the ‘Ask First’ campaign, 15 stroke prevention days were held with employers, including Admiral Insurance Group, Tata Steel, HSBC, John Lewis, Lloyds TSB and GE Aviation, and black and minority ethnic groups across Wales. Over 500 individuals were tested for high blood pressure and Atrial Fibrillation.

Educational Settings

38. Basic preventative messages are best introduced at an early age if we are to change behaviours, and the environment must support those messages. The Welsh Network of Healthy School Schemes (WNHSS) provides the framework for a whole school approach to health, which incorporates action on the risk factors for stroke. Over 99% of maintained schools are working as part of WNHSS and we are currently extending the approach to pre-school settings.

Future Developments

39. Current Welsh Government policies have sought to reduce the risks associated with cardiovascular disease, including stroke, by focusing on the main risk factors, including tobacco, diet, physical activity, alcohol and blood pressure.

40. Stroke risk reduction continues to be a priority for the Welsh Government in the context of improving cardiovascular health in general and the health and wellbeing of older people. Whilst significant strides have been made, we recognize that further action will be needed during the coming years and this is reflected in the Programme for Government.

41. For example, the Welsh Government has made a commitment to instigate a programme of annual health checks, led by GPs, practice nurses, pharmacists and other health professionals, for everyone over the age of 50. Health checks could also be an important mechanism for identifying and addressing potential issues in the context of stroke risk reduction at an earlier stage. Officials are currently undertaking initial scoping work and I will shortly be considering initial options for delivering health checks for people over 50.

42. Issues of stroke risk prevention and reduction will also form an important part of future developments and will feature in the National Stroke Delivery Plan for 2011-12 to 2015-16, which the Welsh Government is developing. This will set out the results we want for the population of Wales for tackling stroke and guide and direct action by the NHS. As part of this work, I will be looking carefully at what strategic leadership and partnership working is needed in the future to support the NHS in achieving my aims for reducing the numbers of stroke and improving the quality of stroke care.

[2] Source: Chief Medical Officer Annual Report 2010

[3] General Medical Services contract, Quality and Outcome Framework Statistics for Wales 2010-11 (September 2011)

[5] Based on NERS programme management information