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Case study: How our CCG took action to reach stroke-prone patients

Case study: How our CCG took action to reach stroke-prone patients
By Awil Mohamoud
29 January 2020

North Cumbria CCG, in partnership with voluntary organisations, has been going into local communities to help prevent strokes by providing free and accessible health checks.

The NHS body identified that lots of people in North Cumbria were at risk of suffering a stroke and that far too many were being admitted to hospital after having suffered one.

Head of communications and engagement Julie Clayton tells Healthcare Leader how the CCG collaborated with the public to effectively assess the issue and introduce a bold preventative initiative.

The problem

Across parts of North Cumbria, people are significantly more likely to suffer a stroke than the national average. In one area, Copeland, they are twice as prone.

The estimated figures show that, in Copeland, 7,000 people (one in 10) have undiagnosed high blood pressure. Another 300 are believed to have untreated abnormal heart rhythms.

Part of this is down to the fact Cumbria has a ‘super-ageing population’.

‘We also have pockets of deprivation along that west coast,’ explains Ms Clayton. ‘It’s difficult in those areas if you’re making the choice between heating and eating. You may end up buying or choosing options that are less than healthy, which then continues to put you at more risk of ill health.’

‘One of the largest motivations’ for the CCG in deciding to tackle this was knowing that people were ending up in hospital for something that could be largely prevented by identifying and treating things like atrial fibrillation and high blood pressure.

The obstacle is that people must first be willing to get checked by a health professional, which is not always the case.

Ms Clayton explains: ‘I’m sure there are lots of reasons why people don’t go to their GP – everything from not thinking they are at risk to not wanting to bother the doctor. We’ve had members of the community say they are just too busy.

‘By looking at the figures, we know older men tend to not make appointments unless there is a specific problem.’


To tackle the problem, North Cumbria CCG teamed up with social change charity, Institute for Voluntary Action Research (IVAR), to establish a community project, starting with a workshop that locals were invited to attend. With the help of the Rotary Club and strategically placed adverts, they were able to guarantee a great turnout.

‘We left it up to people to decide what we could do. Everybody felt it was important that we went to the community where they are. Then it was about finding events that would take us to the right areas and people,’ says Ms Clayton.

In the end, they decided to piggy-back on two popular local events – where, in a tent, they offered a blood pressure and irregular pulse test to passers-by.

‘It was important that we were able to refer people in the most appropriate way. We didn’t want to suddenly say ‘oh that’s a bit worrying’ and to send them to their GP. So, we worked very closely with the community pharmacy.

There was one person who was worried and needed to see a health professional quite urgently, but for anyone else, we were able to refer them to a pharmacy that was near where they lived. They could then get some monitoring equipment to take home for a week and then if, at the end of that, the pharmacist felt they needed to see a GP, they were able to take all of that monitoring information with them. We didn’t send loads of people straight into primary care.’

The benefit

Together, the organisations managed to test 227 people aged 19 to 80 in the community across both events. Of those, 20% were referred to a pharmacy for a further check and, potentially, home monitoring.

The organisers also found success in their aim of reaching groups that typically find it difficult or shy away from visiting the GP.

‘We were actually quite surprised that a lot of the traders came along and had a check when things quietened down. The feedback from them was, they were running their own businesses, and they were too busy to go to the doctors at a convenient time,’ says Ms Clayton.

‘We had somebody who came and had a family member who had recently passed away and he didn’t want to go to the doctors and say ‘am I at risk’, but because we were there he came over and had a chat. We were able to give him some reassurance and other health advice and information he could take away and read.’

Beyond carrying out much-needed tests, organisers found that people benefitted from the relaxed nature of the occasion. They were able to do things like share lifestyle tips and recipes for healthy eating and have conversations with each other and an expert from the Stroke Association.

‘It’s an informal, warm and inclusive way of doing things,’ says Ms Clayton. ‘It’s not going through the front door of an NHS building and being told what to do.’

Need for change

Ms Clayton says: ‘I don’t think the NHS will be able to meet the demands placed upon it unless it collaborates and works with other partners, agencies, third-sector groups and the community.

‘There are so many great ideas and so much energy in the community, and by working together we can have more impact.’

The CCG, along with health professionals, is now looking into expanding the above approach to other health conditions.

Ms Clayton’s advice for other CCGs in a similar predicament is to ‘just get on and do it and open it up to as many different people as you can.’

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