In Gateshead, we have a 10% higher than average mortality rate for stroke and about 10% more admissions for stroke than the England average. The prevalence of strokes in Gateshead is 2.2%, compared with 1.7% in England as a whole.
We knew that one of the ways to tackle stroke death and emergencies was to focus on primary prevention. That meant better diagnosis of atrial fibrillation (AF) – notably we didn’t use any risk scoring for stroke at that time – and addressing the fact that local GPs seemed reluctant to prescribe anticoagulants; it was often felt that warfarin prescribing was a specialist decision for secondary care to make.
For both of those problems we needed to improve education and confidence among primary care practitioners.
Gateshead CCG decided to focus on reducing stroke risk in patients with AF, with case finding and anticoagulant prescribing for patients at high risk.
What we did
The CCG’s initial contact with the Stroke Association arose from discussions on moving secondary prevention clinics from secondary to primary care, which laid the foundations for our future joint working. We were keen to collaborate with the charity to maximise the impact of their campaigns and to use their experience in working with the public to enhance our work on stroke prevention.
Our first step was to organise training on stroke awareness, and on how our local stroke services worked. We asked our local stroke team and the Stroke Association to lead an update session at one of our area’s regular education half-days.
Education sessions happen around six times a year – every local practice shuts for an afternoon and the PCT pays for staff cover while we run a training session on a particular clinical area for GPs, nurses and practice staff.
We followed this initial session with regular updates on using CHADS2 risk scores, safe prescribing of warfarin, ECG interpretation and risk stratification.
Throughout the year we encouraged practices to promote the Stroke Association campaigns including the Act Fast campaign, which educates the public on recognising and reacting to stroke symptoms. The charity provided campaign materials – namely posters – which were well designed and saved us time and money.
We also worked with the Stroke Association to ensure practices used its Ask First publicity materials, which highlighted the importance of identifying anyone with undiagnosed AF.
The charity helped us provide an education session at my practice’s patient forum, which included a presentation on stroke prevention and services available to those affected by strokes.
Alongside our work with the Stroke Association, we developed a local enhanced service for practices to screen patients over the age of 65 for pulse irregularities when they attended for their flu jab – 30 out of 34 practices took part, and practices were paid £2 per patient screened.
We ran a local incentive scheme, which paid all 34 practices up to £2.05 per patient
for taking part in risk stratification. This involved practice clinicians and staff attending our regular training half-days, taking part in audits and surveys and undertaking a wide variety of clinical improvement projects.
All 34 practices in our locality decided to use the Grasp AF toolkit to find patients at high risk of stroke.
It works by searching for any Read codes that might indicate AF, such as ‘pulse irregular’, and produces a list of patients whose notes need to be reviewed.
The CCG provided IT support to enable each practice to download the toolkit and run the searches. We also gave our practice managers training on using it.
The second stage of Grasp AF allocated a CHADS2 stroke risk score to each patient. We reviewed the records of every patient who was at high risk of stroke to ensure they were receiving appropriate anticoagulation therapy.
Patients were then invited to attend an appointment with a GP to discuss their risk of stroke and the benefits of anticoagulant therapy.
Working with a charity in this way was a new experience for us as a CCG. We got fantastic support from the Stroke Association for our projects and access to high-quality educational and promotional materials.
The joint education programme with the Stroke Association for patients and clinicians helped raise the profile of our prevention work, and we hope that the links made between individual practices and the Stroke Association will lead to more joint working in the future.
Working together with a charity helped both sides achieve their aims.
We have also worked with the British Heart Foundation, a much larger charity, which paid the salary of one of our heart failure nurses. It’s a little different working with a charity who has given you funding, as it wants to be clear its funding is meeting its needs as well as yours.
We had to be adaptable to changing circumstances – midway through the project, we were asked to select contracts to be commissioned through any qualified provider. We chose anticoagulation services in order to increase capacity, to accommodate the expected increase in referrals.
Some of the work on stroke was more thanks to the NHS than the third sector. The local Cardiac Network, the North of England branch, was helpful on Grasp AF – providing experts to give education sessions and educational materials to support clinicians in prescribing warfarin. There are 28 Cardiac Networks across Britain, all run by NHS Improvement.
At the end of nine months, the total number of patients with recorded AF had risen by 96 patients – from 3,235 to 3,331.
We think the true number of new patients identified was much higher, as many practices removed or put into past problems the AF diagnosis from patients where AF had resolved or had been an incorrect diagnosis.
The number of patients at high risk of stroke (CHADS2 score >1) prescribed warfarin rose from 1,175 to 1,269, a rise of 8%, and referrals to the anticoagulation clinic rose by 11%. Many patients had previously not been prescribed warfarin or had any documented contraindication or record of declining warfarin, and this number reduced from 533 to 215 – a fall of 60%.
The Grasp AF toolkit does not remove patients who have AF that has resolved, meaning it is not possible to have for all patients at high risk to be prescribed warfarin or have a record of contraindication or declining warfarin.
Before our project 16 practices did their own ECGs, only six of which could send electronic copies for cardiologist interpretation. We now have 24 practices providing in-house ECGs with access to cardiologist interpretation of ECGs through ‘advice and guidance’ on Choose and Book.
The pulse irregularities LES was a success, with 15,504 patients having their pulse checked and 765 new irregular pulses identified.
Unfortunately, we were not able to say how many of these 765 patients went on to be diagnosed with AF – the LES did not ask practices to collect this data.
Lastly, in June, I accepted on behalf of the CCG the 2012 Life After Stroke award from the Stroke Association for our work.
Hopefully this award will help both patients and clinicians locally build on the good work we’ve started in this area.
While we know that working with bigger charities with more funding might entail more compromise or negotiation, we will look to increase the number of charities we work with as our experience with the Stroke Association has been very rewarding.
Dr Steve Kirk is a GP in Gateshead and vice chair of Gateshead CCG