Cardiovascular Disease (CVD) affects around seven million people in the UK and is a significant cause of disability and death.
Atrial Fibrillation (AF) is the most common cause of an irregular heartbeat. It often causes no symptoms but people with AF are five times more likely to suffer a stroke, and people who suffer an AF-related stroke are more likely to die or suffer severe disability than any other type of stroke. However, treating AF with anticoagulant (blood thinning) medication reduces the risk of stroke by up to two thirds.
Despite the serious impact of AF, many people are unaware they have the condition, and even when diagnosed, many are untreated. NHS Digital estimates that there are more than 147,000 people in England with AF and at risk of stroke who are not receiving anticoagulation. Indeed half of all people with known AF who suffer a stroke have not received anticoagulants before their stroke.
The NHS has announced a £9 million investment to fund a demonstrator project to test out new ways of providing treatment to people with AF. In 23 Clinical Commissioning Groups (CCGs) around the country, specialist anticoagulation pharmacists or nurses will work with GPs to identify and treat up to 20,000 people with high-risk AF who are not currently taking anticoagulants. It is estimated this work could prevent up to 700 strokes within this period and approximately 200 deaths from stroke.
We have worked with a number of organisations, including Public Health England, the Academic Health Science Networks (AHSNs), NHS RightCare and the British Heart Foundation, to design this programme.
In a nutshell, how will it work?
Specialist anticoagulation pharmacists or anticoagulation nurses carry out an in-practice review of GP records to case-find people who have already been diagnosed with AF, but are not receiving optimal treatment. The specialist anticoagulation pharmacist or nurse will discuss these patients with the GP, using a virtual clinic, and recommend a treatment plan for the patient. The GP will then discuss this with the patient, using shared decision-making skills, and they will jointly decide on the best course of treatment.
Selection of CCGs
23 CCGs have agreed to take part in the programme based on deprivation levels and QOF attainment rates (AF001). We wanted to target CCGs with low attainment of AF001, as these CCGs will have high numbers of patients who have been diagnosed with AF who are not being treated and managed optimally. Areas of high deprivation have been targeted, using data from the Indices of Multiple Deprivation 2015.
The CCGs taking part are:
- NHS Barnet CCG
- NHS Bradford City CCG
- NHS Brent CCG
- NHS Camden CCG
- NHS Chorley And South Ribble CCG
- NHS Croydon CCG
- NHS Enfield CCG
- NHS Great Yarmouth And Waveney CCG
- NHS Greenwich CCG
- NHS Haringey CCG
- NHS Harrow CCG
- NHS Isle of Wight CCG
- NHS Islington CCG
- NHS Kingston CCG
- NHS Leeds CCG
- NHS Morecambe Bay CCG
- NHS North Cumbria CCG
- NHS North Tyneside CCG
- NHS Northumberland CCG
- NHS Portsmouth CCG
- NHS South Kent Coast CCG
- NHS Thanet CCG
- NHS West Lancashire CCG
What is a virtual clinic and how does it work?
The virtual clinic (VC) will be take place as a conversation between the specialist clinical pharmacist or anticoagulation nurse and the GP, either face-to-face, or remotely via telephone or skype. They will use the VC to discuss the optimal treatment they should recommend to the patient.
Routine data will be collected by the specialist anticoagulation pharmacists and anticoagulation nurses in a spreadsheet. Following the virtual clinic discussion with the GP, the pharmacists will then provide information on the discussion at the virtual clinic, the recommendation arising from the virtual clinic, and action taken by the practice following the virtual clinic.
Data will be collated from all practices on a quarterly basis by the CCG, then anonymised and sent for analysis and interpretation.
What support will be offered to CCGs in delivering this?
A range of national organisations are involved in the steering group of this project such as Public Health England, NHS RightCare and the British Heart Foundation. Project support will be coordinated by local AHSN leads, who will act as the day to day contact for CCGs involved in this programme. The AHSN will also provide further training and education support on the virtual clinic model to the seconded specialist.
How does this programme link to wider work on CVD prevention?
The Plan sets the ambition for the NHS to help prevent over 150,000 heart attacks, strokes and dementia cases over the next 10 years and includes a focus on secondary prevention, i.e. those who have already been diagnosed with CVD but are not receiving optimal treatment.
We will gather data from the demonstrator sites on a quarterly basis, until March 2020. Towards the end of the programme, we will carry out a qualitative evaluation, to understand the successes and challenges of the programme, and lessons learnt. We will look at the available evidence, and decide whether to implement the programme more widely, across a larger number of CCGs, in future.