Scotland’s independent think tank
Scotland’s independent think tank

From FAST to BE FAST – James Bundy

Introduction  
Public Health campaigns serve a crucial role in promoting healthier behaviours and improving health outcomes. These initiatives aim to disseminate information to raise awareness about health risks and encourage positive behavioural changes. For example, campaigns targeting smoking or excessive alcohol consumption aim to prevent health issues by prompting individuals to quit smoking or moderate alcohol intake. Similarly, campaigns like CPR awareness and FAST (Face, Arms, Speech, Time) for stroke recognition aim to empower individuals to respond effectively in medical emergencies in the hope of saving lives.

Assessing a campaign’s effectiveness involves evaluating its impact on public perception and healthcare systems. Demand-side outcomes include public awareness, information retention, and overall satisfaction, while supply-side outcomes focus on intervention received, equitable provision, and performance improvements within healthcare systems.

The efficacy of public health campaigns lies in their ability to prevent the onset of illness and minimise fatalities through proactive measures. The main purpose of this article is to explore if Scotland’s FAST (Face, Arms, Speech Time) stroke public health campaign is effective, and if it can be improved upon.

Stroke public health campaign
In essence, the purpose of a stroke public health campaign is to save lives by seeking to change people’s behaviour when a stroke is suspected. Stroke is a medical emergency and requires rapid medical attention; therefore, any stroke public health campaign must prioritise seeking emergency medical treatment quickly.

Due to this requirement of quick treatment, a stroke public health campaign must also seek to educate the public about stroke symptoms. If a stroke cannot be identified early due to a lack of knowledge within the general population, then emergency medical attention will not be sought, with potentially devastating consequences. It is also important to note that stroke can happen to everyone (and anyone could be asked to respond to somebody else having a stroke), meaning that the stroke public health campaign must be aimed at everyone in the general population.

An effective stroke Public Health campaign must result in the following:

  1. An easy to remember message whilst containing key information regarding stroke (symptoms and the need to call 999).
  2. Funding for this message to be repeatedly seen on different channels
  3. A successful increase in awareness across the public about stroke symptoms and the need for emergency help.
  4. The public being satisfied that the campaign is giving them the information they need to act accordingly when stroke occurs.
  5. An increase in people receiving the emergency treatment they need on time after suffering a stroke.
  6. Ensures that all stroke sufferers get access to emergency treatment. The campaign cannot prioritise some forms of stroke over others.
  7. Ultimately, that lives are saved.

Does FAST work?
To help us determine if FAST is an effective public health campaign, before considering if it can be improved, we will briefly analyse the above bullet points.  

  1. An easy to remember message whilst containing key information regarding stroke (symptoms and the need to call 999).

FAST is an easy to remember message. At its core is the three most common symptoms of stroke (drooped face, arms struggling to be raised, and slurred speech) and the importance of time, highlighting the need to call 999. The requirement for quick, emergency treatment is re-emphasised by the use of the acronym, FAST. Therefore, FAST does contain key information on stroke symptoms and the need to call 999 in an easy to remember format.

  • Funding for this message to be repeatedly seen on different channels

Research shows that without repetition, knowledge of the FAST campaign amongst the general public fades over time. If the purpose of the campaign is to increase stroke recognition, and to prompt quick treatment when a stroke occurs, then this implies that the FAST campaign must be repeated and on different platforms. 

Unfortunately, this is currently not happening in Scotland. In 2023, England and Wales re-launched a FAST stroke public health campaign. Northern Ireland re-launched one in 2021. In Scotland, however, there has been no FAST stroke campaign since before the COVID-19 pandemic. Even in the Scottish Government’s 2023 Stroke Improvement Plan, the footnote for the FAST stroke public health campaign is a link to the Chest, Heart, and Stroke Scotland website, an independent charity.[1]

Knowledge of stroke symptoms within the Scottish general public, and the need to call 999 if you suspect a stroke, is likely not reaching its full potential due to a lack of Government backed stroke Public Health campaign.

  • A successful increase in awareness across the public about stroke symptoms and the need for emergency help.

Whilst FAST is easy to remember, does it help the general population understand the symptoms of stroke and the need to call 999?

A paper published in 2013 titled, ‘The impact of the UK ‘Act FAST’ stroke awareness campaign: content analysis of patients, witness and primary care clinicians’ perceptions’, highlighted mixed results. Positively, the paper concluded that “The majority of stroke patients reported being aware of the campaign overall (n = 14/19) at the time of experiencing the stroke.” However, only “Two patients reported being influenced by the campaign”. The paper then went on to say: “The majority of patients who were aware of the Act FAST campaign reported that the campaign had no impact on stroke recognition or response (n = 11/14). Some patients commented on the mismatch between the severity of advertised stroke symptoms and the stroke experience…A mismatch between expected and experienced symptoms was reported to prevent the recognition of stroke.” Even more worryingly, “One witness reported a negative impact of the campaign due to misdiagnosis leading to delay”.

Another paper titled, Can people apply ‘FAST’ when it really matters? A qualitative study guided by the common-sense self-regulation model’, published in 2019, noted that “Despite clinicians reporting that the campaign improved stroke awareness, they assumed that this awareness had little, or no effect on patients’ and witness’ response behaviour. One of the limitations of this study was that patients experienced a variety of symptoms, which were often not in line with those depicted by (the) campaign.” This paper also noted that “It was also common for participants to lack association between the symptoms they observed, and the symptoms presented in the campaign.” It also highlighted that for “Two of the youngest participants in their 40s, (they) felt that they failed to correctly identify that they were having a stroke because they did not associate themselves with the campaigns, or their own, representation of a stroke.”

The biggest limitations regarding the FAST campaign, however, is that it does not contain all symptoms of stroke, which can result in misdiagnosis and a delay to emergency treatment.

 Various research papers have come to a similar conclusion. One paper noted that a “Significant limitation of the ‘Act FAST’ campaign, however, is that the acronym excludes any reference to the symptoms of sudden visual loss, which may be a manifestation of embolic disease either in the anterior or posterior circulation…If patients with vision loss are not aware that this can be a symptom of stroke, they may not present in the first place.” [2]

Another paper concluded that “FAST identified 69% to 90% of strokes but missed up to 40% of those with posterior circulation events.”[3] An article published on BMJ Journals in 2014 stated that “the most common symptoms among false negative patients were speech problems, nausea/vomiting, dizziness, changes in mental status and visual disturbance/impairment”.[4]

Within this measurement, it is safe to say that the FAST stroke public health campaign has had mixed success. For many sufferers of stroke, they were aware of the FAST campaign when their stroke occurred. This is a positive. However, academic research shows that it has had little impact on how people respond to a stroke. To the contrary, the inability to associate with the FAST campaign (through severity of symptoms and age difference) potentially stops people seeking emergency medical treatment immediately. Additionally, the research shows that the lack of stroke symptoms within the FAST campaign has resulted in delay to emergency medical treatment.

The inability to associate with the campaign and the restrictions of stroke symptoms within the FAST campaign, show that Scotland’s stroke Public Health campaign is failing to get people to call 999 when some strokes occur, highlighting that it is not reaching its full potential.

  • The public being satisfied that the campaign is giving them the information they need to act accordingly when stroke occurs.

Critical to any Public Health campaign is members of the public feeling that they have the information they need to look after their health, or the health of a loved one.

In December 2023, the Stroke Association made a post on their Facebook page which asked people: “Did you have a stroke without FAST symptoms?”.[5] There was over 500 responses to this post. Here are a sample:

  • “My husband died at the end of June aged 53 with an undiagnosed stroke. He attended his GP nearly two weeks before as he had taken a really bad turn at work. Loss of balance, cold sweats, violent vomiting & blurry vision. He asked if he had suffered from a mini stroke, was assured no and advised to get his eyes tested. Out shopping eleven days later he took really ill again with the same symptoms he had attended his GP with but this time his speech was really slow too and an ambulance was called. They refused to attend initially as he passed the FAST test and he wasn’t having chest pains. We called back and insisted on an ambulance and he was then taken to hospital and seen by a triage nurse. My daughter and I reiterated to her that my husband had suspected he had had a mini stroke less than a fortnight before but yet again he passed the FAST test and was left in the hospital corridor for 5 ½ hours before taking the full-blown stroke in front of myself and daughter. This was on the 25th June and Tony passed away on the 29th June.”[6]
  • “I’m an Orthoptist in an Eye Hospital. Many of my stroke patients only have vision problems (double vision, eye movement problems or vision loss) with no FAST signs or symptoms. In fact, many of them delay going to hospital because they don’t think they’ve had a stroke”.
  • “No FAST signs. Loss of my peripheral vision, tiredness, and memory problems! Left untreated for over 8 months while waiting to see an ophthalmologist!”

These are just three testimonies of separate incidents. All highlight that treatment was delayed, either by the patient not going to the hospital or medical staff ruling it out, because symptoms were out with of the FAST campaign. On top of showing how FAST can restrict examinations carried out by medical staff, it highlights that there is some level of dissatisfaction within the general public about the FAST campaign.

  • An increase in people receiving the emergency treatment they need on time after suffering a stroke.

The FAST campaign has undoubtedly resulted in some victims of stroke receiving emergency treatment they needed on time. Without the FAST campaign, more people in Scotland would be dying from stroke. Yet, as highlighted earlier, the FAST campaign does not include all symptoms of stroke. In some cases, this means individuals, fully aware of the FAST campaign, do not seek emergency treatment because they do not think they are having a stroke, or that their symptoms are not part of an emergency situation. In other cases, it means stroke is ruled out by medical staff, resulting in treatments being delayed. Both of these scenarios, which we know are happening through research and personal testimonies, indicate that the FAST stroke public health campaign may be playing a role – in some cases – in stopping, or at least slowing down, the emergency treatment that stroke patients should receive.

On a brief note, it should be highlighted that the FAST stroke campaign is also the basis of the test that call handlers use to try and detect stroke. In Public Health Scotland’s Stroke Improvement Programme 2023, it reads: “All emergency calls are triaged using the Medical Priority Dispatch System (MPDS). SAS call handlers assign a diagnostic code and call priority (represented by a response colour) to each incident. Once the call priority has been determined SAS 25 dispatchers will identify and allocate a SAS resource as soon as possible. For any call suggestive of stroke, callers are taken through performing a screening ‘Face, Arm, Speech Test’ (FAST).”[7]

With ample evidence that FAST does not contain all symptoms of stroke, does it make sense that the test used by call handlers to try and detect stroke is so restrictive? Answering this question in their Programme, though not directly, Public Health Scotland say: “Lack of diagnostic sensitivity risks missing a stroke which could benefit from time critical thrombolysis, whilst over diagnosis leads to unnecessary deployment of emergency resources which are then unavailable for other urgent cases.”[8]

This contribution from Public Health Scotland highlights a real concern about expanding FAST. It could increase the number of people wrongly thinking they are having a stroke, taking limited emergency resources that could be used for proper emergencies. This is something that needs serious consideration.

  • Ensures that all stroke sufferers get access to emergency treatment. The campaign cannot prioritise some forms of stroke over others.

Following directly from above, it is clear that the status quo does not result in all stroke sufferers getting equal access to emergency treatment. If your symptoms are out with the FAST campaign, then there is less chance that you will get emergency treatment. This means that the FAST campaign is failing one of the key requirements of a Public Health campaign: the equitable provision of intervention. The results of this failure can be devastating. A paper published in Emergency Medicine Australasia put it bluntly: “Upon patient presentation at an ED (Emergency Department), missed identification and appropriate categorisation of stroke patients results in longer waiting times, delays in treatment, and in some cases potentially irreversible damage.”[9] The current inequality of emergency treatment for some stroke victims – due to the limitations of FAST – is resulting in some people in Scotland losing their lives prematurely.

  • Ultimately, that lives are saved.

For the most part, FAST has saved lives. It has increased awareness of the three most common symptoms of stroke, and the need for ‘fast’, emergency treatment. Yet, this essay has highlighted some research and examples which suggest that FAST could actually be preventing ‘fast’ treatment. With a FAST test ruling out stroke, either by the patient, call handler, or medical staff, treatment is delayed. Research from the Scottish Parliament Information Centre implies that 8-10% of strokes could be missed by the FAST campaign/test, implying that these situations are not rare.[10] If that is the case, then it means that despite all the improvements that the FAST campaign has helped bring forward, there are some serious shortcomings that are resulting in some Scots losing their lives prematurely.


The Alternative – FAST to BE FAST  
One alternative to FAST is BE FAST, which incorporates Balance (a loss of balance) and Eyes (Eyes struggling to focus) as potential symptoms of stroke. There are two key advantages to BE FAST. Like FAST, it is easy to remember and re-emphasises the need to ‘be fast’ when you suspect a stroke. Unlike FAST, however, it contains five symptoms of stroke rather than three. As highlighted earlier, “the most common symptoms among false negative patients were speech problems, nausea/vomiting, dizziness, changes in mental status and visual disturbance/impairment”.[11] Incorporating Balance and Eyes to the FAST acronym, therefore, includes two of the most common symptoms associated with strokes which were missed by FAST. In theory, therefore, BE FAST should be able to identify more strokes, but noting the concerns of Public Health Scotland, it could also result in an increase in false positives, putting additional strain on emergency department resources. [12]

Whilst research into the effectiveness of BE FAST is immature, there are some encouraging signs. One paper published in 2017 concluded that “The 14.1% of stroke patients who would not have been identified by FAST alone was reduced to 4.4% with the addition of these 2 symptoms (BE-FAST; z=7.62; 95% confidence interval, 2.99–6.098; P<0.0001).”[13] There is one key weakness with this study, however: it was retrospective. That means everyone in the study was confirmed to have suffered a stroke. Therefore, what this research paper does is confirm that by broadening the test, you would detect more symptoms of stroke. What this paper does not do is determine the impact of ‘false positives.

However, there is one recent study, published by the Australasian College for Emergency Medicine, which aims to examine the impact of the ‘implementation of the BE FAST stroke screening tool at the Emergency Department and determine whether its usage improved timely stroke detection.’ This paper was published in January 2024 with the summary that “Patient outcomes were improved after implementation of the BEFAST stroke triage tool. More stroke patients were identified upon presentation to the ED, and in a timely fashion. For those with a stroke diagnosis, time-critical interventions can take place earlier, allowing patients to return home sooner, and with less disability.” Whilst this is only one study it is highly encouraging and should prompt further investigation.

However, we should not be looking at the stroke public health campaign in isolation. We must consider it alongside ways we can improve stroke screening tools, understanding that broadening the Public Health campaign will expand sensitivity, training needs, and potentially, the use of limited resources. The BMJ Journal published in 2015 goes on to say, “Without screening tools and training to improve the identification of patients with less common stroke symptoms, inequity of available stroke care for patients will remain, particularly for patients with posterior stroke.”[14]

The research into the effectiveness of BE FAST, in comparison to FAST, is encouraging, though at its early stages. Scotland should be at the forefront of this research but understand that simply adopting BE FAST is not enough. By including more symptoms of stroke, a BE FAST stroke Public Health campaign should result in greater awareness of stroke symptoms amongst the public, resulting in more people seeking emergency treatment if they suspect a stroke. For this outcome, however, such a campaign would need funding to be consistently repeated. On top of this, further funding is required to invest in training and technologies used by call handlers and medical staff to detect stroke.

Seeking to improve knowledge of stroke symptoms amongst the public and promoting an equality of access to intervention by expanding the symptoms within the stroke Public Health campaign, and further seeking to improve efficiency of intervention by investing in training and technology is the correct approach for Scotland.

Conclusion
Prevention lies at the core of public health campaigns. By seeking to promote positive behavioural change, campaigns can either seek to discourage certain behaviours; prevent the development of long-term illness; or prevent fatalities in emergency situations. Public health campaigns for emergency situations must be easy to remember, contain key information, emphasis the requirement to call 999, and target the general population.

Whilst FAST is easy to remember and contains key information, there are many shortcomings:

  1. The lack of funding from the Scottish Government to advertise the FAST campaign will mean that public awareness is not as high as it could be.
  • It has been noted that whilst stroke survivors were aware of FAST, they found it difficult to associate with the campaign. There were various reasons for this: symptoms were not as severe as the advertising suggested; they believed they were too young to suffer a stroke; or their symptoms were not contained within FAST.
  • By not including more symptoms of stroke, the FAST campaign is failing to provide an equitable provision of medical intervention. If strokes occur with symptoms that are out with the FAST criteria, there is a higher risk that the stroke will become fatal due to the lack of timely medical intervention. This is because people will either not seek emergency treatment or because medics will rule-out the possibility of stroke.

Whilst research into BE FAST is immature, the results were promising:

  1. BE FAST (Balance, Eyes, Face, Arms, Speech, and Time) is easy to remember and contains even more key information.
  • Initial evidence from a live-setting showed that “Patient outcomes were improved after implementation of the BEFAST stroke triage tool. More stroke patients were identified upon presentation to the ED, and in a timely fashion. For those with a stroke diagnosis, time-critical interventions can take place earlier, allowing patients to return home sooner, and with less disability.” [15]

One concern regarding the implementation of BE FAST is the potential to increase the number of ‘false positives’ in an emergency medical setting, but this concern must be balanced and considered alongside the ‘false negatives’ we know are happening due to the restrictions of FAST.

I am acutely aware of the pain and suffering that follows a ‘false negative’. My 53-year-old father, Anthony Bundy, passed away following a fatal, undiagnosed stroke. At every stage he sought medical help (GP, Call Handler, Paramedic, and Triage Nurse), a stroke was ruled out. The reasons for ruling out a stroke were as follows: My Dad was too young; my Dad did not have risk factors (he did not smoke, he was not overweight, etc); and, my Dad’s symptoms were out with FAST. A stroke being ruled out meant that my Dad was prevented ‘proactive’ or ‘fast’ treatment, which ultimately cost him his life.

This is the cost of a ‘false negative’ diagnosis for stroke. It is unacceptable for the Scottish Government to continue with the status quo, knowing that it is resulting in stories like my Dad’s, when there is a ready-made alternative in the form of BE FAST. Yes, regular funding would be needed to run a new stroke Public Health campaign constantly. It would also need investment in training and technology to improve stroke detection in medical settings to reduce the pressure of ‘false positives’.

Yet, these investments would result in the Scotland stroke Public Health campaign being closer to fully fulfilling its objectives: Sharing information with the public that could save their lives, or the life of a loved one; making sure the information is consistently available in many forms; allows the public to act accordingly when they suspect a stroke; an increase in the equality and quality of the provision of emergency medical treatment for stroke; and ultimately, save lives.

Now is the time for the Scottish Government to take the lead on stroke awareness and consider adopting BE FAST as Scotland’s public health campaign.

James Bundy is a Scottish Conservative Councillor for Falkirk North. After the sudden death of his 53-year-old Father in June 2023, following an undiagnosed, fatal stroke, James and his family have been campaigning to expand Scotland’s stroke campaign from FAST to BE FAST.


[1]Stroke Improvement Plan 2023’, Scottish Government. 2023. Available at: https://www.gov.scot/publications/stroke-improvement-plan-2023/pages/6/

[2] ‘Is the ‘Act FAST’ stroke campaign lobeist? The implications of including symptoms of occipital lobe and eye stroke in public education campaigns’, Journal of Neurology, Neurosurgery & Psychiatry. 2015. Available at: https://jnnp.bmj.com/content/86/7/818

[3]BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic’, American Heart Association. 2017. Available at: https://www.ahajournals.org/doi/10.1161/STROKEAHA.116.015169

[4]Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review’, Emergency Medicine Journal. 2021. Available at: https://emj.bmj.com/content/38/5/387

[5]Facebook post by the Stroke Association in December 2023 https://www.facebook.com/TheStrokeAssociation/posts/pfbid02vexka1vbXtZLoFn1tseg737aphMun2RfzxfYzT59gVHAGz7toM9DjTXw5EAg2Ekal

[6] This contribution was from my mother, Selena Bundy.

[7]Scottish Stroke Improvement Programme 2023: national report, Public Health Scotland. 2023. Available at: https://www.publichealthscotland.scot/media/20499/ssip-june2023-english.pdf

[8]Scottish Stroke Improvement Programme 2023: national report, Public Health Scotland. 2023. Available at: https://www.publichealthscotland.scot/media/20499/ssip-june2023-english.pdf 

[9]Time is brain, so we must BEFAST: Improving stroke identification and triage in a rural emergency department’, Australasian College for Emergency Medicine. 2024. Available at https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.14369

[10]Briefing for the Citizen Participation and Public Petitions Committee on petition PE2048: ‘Review the FAST stroke awareness campaign’ , lodged by James Anthony Bundy’, Scottish Parliament Information Centre (SPICe). 2023. Available at: https://www.parliament.scot/-/media/files/committees/citizen-participation-and-public-petitions-committee/correspondence/2023/pe2048/pe2048_spice_briefing-(2).pdf

[11]Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review’, Emergency Medicine Journal. 2021. Available at: https://emj.bmj.com/content/38/5/387

[12]Scottish Stroke Improvement Programme 2023: national report, Public Health Scotland. 2023. Available at: https://www.publichealthscotland.scot/media/20499/ssip-june2023-english.pdf

[13]BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic’, American Heart Association. 2017. Available at: https://www.ahajournals.org/doi/10.1161/STROKEAHA.116.015169

[14]Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review’, Emergency Medicine Journal. 2021. Available at: https://emj.bmj.com/content/38/5/387

[15]Time is brain, so we must BEFAST: Improving stroke identification and triage in a rural emergency department’, Australasian College for Emergency Medicine. 2024. Available at https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.14369