Preventative medicine is a large part of the GP's role and explaining the importance of this to patients is a daily event. In stroke, we know that blood pressure control is crucial and diabetes, smoking and obesity are other important factors which can load the dice and affect the risk of stroke in an individual. Of course age and family history are fixed risks that can mean the variable ones become even more important.

At the end of last year the Department of Health produced a document on stroke that was very interesting. Much of the controversy has been about the introduction of 'stroke centres' which will provide speedy diagnosis and management around the clock to try to improve outcomes. Less newsworthy is the fact that about 30,000 of the 110,000 strokes that occurred last year happened in patients who had a heart condition called Atrial Fibrillation (AF). This is quite common (1.4% of the population but 10% of the over 80s) and it causes an irregular pulse that makes the formation of tiny clots in the heart more likely. In fact patients with AF are four times more likely that those with normal rhythms to have a stroke. AF usually causes absolutely no symptoms at all and so part of the challenge is to find these patients and then try to reduce their risk of stroke.

Finding new patients with AF
GPs and Nurses can do their own screening on everyone who attends the Surgery. But taking a pulse and finding if it is irregular is something that anyone can do. If there is any doubt then the pulse can be checked by a Nurse or a Doctor and if necessary a confirmatory ECG can be done. We know from work elsewhere that there are about 60% more patients with AF than we are aware of and we want to identify and help them.

Treatment
The best treatment in most cases is to use warfarin (the clot-stopper) and sometimes to control the heart rate. Warfarin is very effective but it does have drawbacks. Firstly it makes bruising and bleeding more likely because it slows down natural clotting. In some patients there is a balance of risk that suggests avoiding warfarin is the right thing to do - but these cases are relatively rare. There is no doubt that these are 'rock and hard place' decisions because in 1000 patients we know that six will have bleeds (with occasional fatalities) and yet 30 will have strokes. As GPs, our dilemma is that our warfarin treatment could rarely cause death and yet not treating is generally much more likely to cause death or disability - and yet this might be seen by the public as 'natural'. A frequent compromise is the prescription of Aspirin which may save 12 strokes but the contention is that we should warfarinise more patients.

Why not warfarinise more patients with AF?
The decision here weighs up a lot of factors.  The risk of falls and subsequent bleeds, difficulty in getting the warfarin dose blood tests and uncertainty about whether patients will take the warfarin reliably are reasons quoted frequently by GPs. Occasionally the risks of treatment are given more emphasis than the risks of not treating although sometimes it is clearly right not to treat.

Plan
Patients and their relatives need to be aware of this balance so that mature decisions can be made. We now have a computer programme that can predict the annual risk of stroke while the patient is sitting in the Consulting Room. We know patients are more concerned about stroke than heart attack so this will be powerful personal information that will influence the decision that the patient and GP take together. Furthermore the patient information is also checked by a local Cardiologist who gives an emailed response within a day based on the information supplied. This is a new move which will support both GPs and patients in difficult decisions. In Primary Care we need to make the blood testing easier and have this done in the home by someone who specialises in just warfarin. He or she can then help patients be clear about dosages possibly even using a portable machine in the home.

As GPs we are fortunate to have the trust of our patients. We want to be open about the risks and benefits of warfarin and we feel that sharing the annual risk of stroke, Cardiologist support and offering convenient home testing will shift the balance towards more warfarin and less strokes. The Cardiac Czar tells us that 18,000 of those 110,000 strokes could be prevented across the country. Much suffering and cost could be saved through this honest open debate.

 

Click here to see our "take the pulse" poster

Click here to see Dr Havards presentation

Click here to view a draft of "The Auricle" online tutorial

 

 

 

 

 

 

Stephen ‘Jumbo’ Felton (pictured with Nurse Lynn Williams) comes from a long line of smokers. He has 8 brothers and 7 sisters, all of whom have smoked. Like so many, he started as a teenager but this was not behind the bike sheds but in a hospital ward! ‘I broke both legs in a car accident when I was 15 and was in Ipswich Hospital for three months on traction. I started smoking on the ward with two or three cigarettes a day and by the time I left I was a 20 a day man!!' Everybody on the ward both staff and patients smoked and the windows had to be kept open to clear the air!

 

He has worked out that at today’s prices he has spent £64,000 on tobacco! The real $64,000 question is why quit now? The imminent public ban is a factor for many considering stopping smoking but Jumbo hated needing the cigarettes and was worried about his health. ‘I tried to quit on my own before but always failed. I got so desperate I would have mugged an old lady for a cigarette!’ Last year he got the help of the Saxmundham Health Group Practice Nurse, Lynn Williams. ‘She spent a lot of time understanding what smoking was like for me and then chose some patches out of several alternatives. She has supported me through it and I found it much easier than I thought and am really pleased to have done it. There is no going back now!’

 

The Practice have designed and produced a badge which is presented to all the successful quitters. ‘I stubbed it out with Saxmundham Health’ has proved popular and got other smokers interested. ‘It is as much a medal as a badge’ said Dr John Havard, partner at Saxmundham Health. ‘We are really proud of all our quitters and Lynn who motivates and supports them so well’. We have produced leaflets for children about smoking and obesity because these two issues are the big killers of tomorrow.’ The Practice is also trying to build a Health and Social Care One Stop Shop which is continually rebuffed by the local Primary Care Trust. ‘We have now found a way through grant and subsidy, in which the building could be cost-neutral for the PCT but they are still unable to give the go ahead despite initial unanimous PCT Board approval.’ After four years of battling the Practice are still determined to succeed. Dr Havard is not bitter ‘If you remain reasonable but resolute then patient improvements will win through in the end. Jumbo has offered to help persuade officials using his chainsaw but we prefer him as an ambassador for smoking cessation!’

 

 

 

Lynn's acheivements (and those of our quitters) have been recognised nationally in the Nursing Times

 

 

 

 

Saxmundham Health Group have designed and produced badges for patients who manage to quit smoking. The ‘I stubbed it out’ emblem is evocative and it also carries the Practice’s logo.

 

 

Nurse Lynn Williams awards a badge to Beryl Lee who gave up smoking this year after nearly 50 years of cigarettes. ‘I didn’t think I could do it but Lynn was such a support that it was much easier than I expected’ she said. ‘My house is now a no smoking house and many of my friends and family are quitting too. At today’s prices it is frightening to think I spent just under £64,000 on cigarettes – what a waste!’

 

 

‘Helping patients to stop smoking is one of the most effective things we can do as GPs’ stated Dr John Havard who is the senior partner in Saxmundham. ‘Lynn Williams is one of the most successful smoking cessation nurses in the county and we want to do everything we can to help her. The badges may seem a bit of a gimmick but many patients are justly proud of giving up smoking and welcome the chance of encouraging others.’

 

The Practice is also trying to discourage teenagers from taking up the habit and the EADT featured their teenage ‘text’ leaflet about both smoking and obesity in EA Life recently.

 

The public ban due in the summer is a big incentive for all age groups to quit now but younger smokers seem more resistant.

 

The Strategic Health Authority has set tight smoking cessation targets for our region and the PCT are working on these across Suffolk. Dr Havard commented 'It is refreshing to be in step with PCT priorities'

 

If you would like help to stop smoking contact your Practice or the Suffolk Stop Smoking service on www.suffolkstopsmokingservice.co.uk or 0800 0856037