Together Against Stroke - A Delivery Plan for NHS Wales up to 2016

Comments on
Welsh Government Consultation
Together against Stroke: a Delivery Plan for NHS Wales

The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the Welsh Government’s consultation on Together against Stroke: A Delivery Plan for NHS Wales.

It is commendable that the Welsh Government has given a high priority to improve Stroke services in Wales.  There has been considerable progress over the past five years in this area; however, adherence to this Delivery Plan is necessary in future to ensure parity of service provision compared with the rest of the UK.

The College has the following general comments:

Stroke Units
This document only briefly mentions Specialist Stroke rehabilitation.  Management of stroke patients in a stroke unit is the only intervention that has been shown to reduce both disability and mortality.  Although all hospitals in Wales have stroke units, very few of them actually have all the essential components of a truly specialist stroke unit, as specified by the British Association of Stroke Physicians1. Development of fully fledged truly specialist Stroke Units in all Welsh hospitals is a priority, as it will have a major impact on patient outcomes.

Preventing stroke
Healthier lifestyle, improved awareness of risk factors, regular and opportunistic screening of appropriate population are all important in preventing strokes.  However, salt restriction at home, in supermarket foods and food eaten in restaurants is likely to have a big impact on the incidence of hypertension, which in turn is likely to reduce the burden not only of stroke, but also of cardiovascular disease in general.  Therefore, the importance of salt restriction needs to be stressed.

Abuse of recreational drugs is an increasing cause of stroke in young people.  Educational campaigns should be undertaken to highlight the dangers of drugs, especially cocaine and amphetamine, as causes of stroke.

To reduce the gap of stroke incidence between most and least deprived communities, it is very important also to target the ethnic minorities.  Wales, especially south Wales, has sizable ethnic minority populations, many of whom are in the lower socioeconomic group.  Smoking, hypertension and diabetes are highly prevalent in this population.  The knowledge of stroke is also very limited.  There is a need to develop a more targeted educational program for this group.

There is also a lot of evidence that rapid access TIA clinics are effective in preventing subsequent stroke and as such these should be a key part of the vision.

Detecting Stroke Quickly
The key factor in early detection is the ability of patients and their spouse/carer to recognise early stroke symptoms.  Recently, in a West Wales hospital, 35 consecutive patients were admitted after 6 hours of onset of stroke.  Clearly, there is scope for further education of lay people in early recognition of stroke symptoms.  Welsh language educational programs and posters/pamphlets may help to target the Welsh speaking population.

Experience in other centres suggests that outcome of stroke patients can be improved if specialist care is available 7 days a week.  Currently, no hospital in Wales offers such a service.  The desire for 24 hour seven day a week thrombolysis throughout Wales cannot be achieved without significant additional investment.  The consequences of offering this will be felt by paramedics, A&E, neurology/stroke doctors, radiology, haematology/neurosurgery (if there are complications).  It is impossible to offer a comprehensive service currently to the best of standards without additional support.

Delivering fast effective care
Stroke symptoms can be hard to recognise and diagnose for those not specifically trained to do so.  Some conditions, eg migraine, seizure, can mimic stroke symptoms of weakness and speech loss - stroke has many mimics and many conditions mimic stroke.  Therefore, thrombolysis (which have a very high rate of adverse effects) can be given to the wrong patients.  We would, therefore, recommend that the diagnostic process is prioritised, particularly for those who have early contact with potential stroke patients and in general medical training. Ambulance crews should be trained specifically in stroke care, and in screening.  Emergency medical services in administering a first-line response should be trained and supported in recognising symptoms, ensuring initial stabilisation, possible administration of hyper-acute therapies and communication with receiving hospitals/stroke units.

It is a laudable goal to admit all acute stroke patients to an acute stroke unit.  In reality, at present, hardly any hospital can achieve this goal consistently, mostly due to shortage of medical beds.  The only way to ensure that all stroke patients are admitted to an acute stroke unit is to ring-fence such beds.

Centralisation of hyper-acute stroke care to specialist centres may be ideal in cities, but may result in poor outcomes in rural and geographically isolated communities in some parts of Wales.  “Time is brain” after an ischaemic stroke, as patients lose nearly 2 million neurones every minute after a stroke.  It is important to deliver thrombolysis, ideally within 90 minutes and no later than 3 hours.  The enhanced training mentioned above should facilitate better triage of patients to centres best suited to their needs.

Supporting living with stroke
Currently, there is very limited Stroke specialist medical and therapy follow-up in the community.  Due to severe shortage of funds, many Trust Boards are using generic therapy staff to deliver treatment for stroke patients in the community.  Investment is clearly needed, if specialist services are to be developed in the community.

1 http://www.basp.ac.uk/Portals/2/2010%20BASP%20Stroke%20Service%20Standar...