We work with all registered patients to minimise their risk of having a stroke or a “mini-stroke” or Transient Ischaemic Attack (TIA).   We use clinical scoring systems to help patients understand their own measurable risk of a stroke and then work with them to address known risk factors, such as smoking, drinking alcohol, poor diet, high blood fats, diabetes and lack of exercise.  We also screen all patients with known risk factors, inviting them in writing to our Vascular Risk Screening Programme for a clinical assessment.  We provide services to help people, such as Smoke Stop clinics, and advice about recognising the signs and symptoms of stroke.

Patients with specific risk factors, such as atrial fibrillation and congenital heart disease, will be closely monitored and their GP will work with hospital specialists to agree personal plans for each patient.  Most of our patients choose to be referred to Derriford Hospital neurological or cardiac departments but other service provider choices are available.

For patients who are in hospital following a stroke, we work with the hospital stroke team to plan their discharge, especially any home modifications that might be required.  Patients will be discharged with an agreed rehabilitation and treatment plan to meet their individual needs and the GP will help monitor progress, amending the plan where necessary.   The team will support the family and carers and work to meet their needs in caring for the patient.

Depending on the needs of the patient, a range of support and care is available for people at home.  Some patients will return home with support from the hospital’s stroke discharge team for up to six weeks.  The team consists of occupational therapists, physiotherapists, speech & language therapists and a nurse, with support from a clinical psychologist.  Patients who need general nursing care at home will be part of a community based support team that cares for patients with a range of conditions.  The team communicates weekly and has close communication links to prevent or treat any issues as they arise.

Patients will be encouraged to participate in local voluntary groups and day centres and the GPs will refer patients to specific services where necessary.  The GPs will also work with patients to minimise the risk of a repeat stroke or TIA by providing specific support based on the patient’s individual circumstances and focusing on their risk factors.

All patients who have had a stroke or TIA are reviewed twice a year by their GP.  Patients will also be invited to be part of the annual seasonal flu programme, with the vaccination being given at the surgery or at home if necessary.