The latest Quality and Outcomes Framework (QOF) results reveal that a programme rolled out across the NHS to reduce strokes related to atrial fibrillation (AF) prevented 3,165 strokes and 791 lives last year (2018/19).
The NHS initiative focused on improving the detection and treatment of AF, a common type of irregular heart rhythm that increases risk of stroke by a factor of 5. In the UK, one million people are known to be affected by AF and an additional 422,600 people are undiagnosed. AF is responsible for approximately 20% of all strokes, and AF strokes are much more likely to cause death or severe disability. The average expenditure on health and social care following a stroke amounts to £45,000 over 5 years, and nationally the NHS over £2.2 billion each year on stroke treatment.
But AF strokes are very preventable – taking anticoagulant medication can reduce the risk of stroke in AF by up to two thirds. Despite this, almost half of all people with known AF who have a stroke have not been treated with anticoagulants before their stroke. One reason for this is that this common condition is often silent with no symptoms, and getting the diagnosis and treatment right can be difficult in time-pressured GP consultations where multiple priorities are the norm.
To address this, Academic Health Science Networks (AHSN) decided to do things differently. Their approach has been to promote more routine pulse taking during consultations with nurses and pharmacists, supported by mobile one lead ECG devices, to identify the patients with undiagnosed or untreated AF who are ‘hidden in plain sight’, and to draw on the expertise of clinical pharmacists with virtual clinics to support clinical decision-making and treatment optimisation.
As a result, across England last year over 61,000 people were diagnosed with AF for the first time and almost 80,000, including some who were previously diagnosed, were given appropriate medication.
So, what can we learn from this approach and how can it be applied to prevent cardiovascular disease (CVD) for others at high risk? It’s clear from the results we’ve seen with AF that targeting specific populations and drawing on the expertise of a variety of professionals working in primary care can benefit patients. Using this learning, UCLPartners, one of 15 Academic Health Science Networks in England, is now extending the same principle to two other high-risk conditions for heart attacks and strokes – high blood pressure and high cholesterol. Under diagnosis and suboptimal treatment is widespread in these conditions although treatment is highly effective at preventing CVD.
Working with STPs across North London and parts of Essex, Hertfordshire and Bedfordshire, UCLPartners will systematically focus on building capacity to ‘do things differently’ in emerging primary care networks (PCNs), using CVD prevention as a clinical framework for change, building assets and skills in the primary care workforce. This will include:
- Embedding local clinical leadership for quality improvement and population health
- Mobilising resources to translate audit data into actionable insights
- Developing new local pathways for diagnosis and treatment, extending the roles of clinical pharmacists, nurses and patients
- Community mobilisation – increasing awareness and access to testing and support to take action when high risk conditions are detected
This work will be underpinned by the primary care transformation that sits at the heart of the Long Term Plan and is supported by the new GP and community pharmacy contracts. This includes the substantial increase in clinical pharmacists who will work across PCNs to support GPs and their teams; CVDprevent, the new national primary care audit that will deliver regular, timely practice level data for professionally led quality improvement; the PCN level contract for CVD prevention (due April 2021 and focused on AF, blood pressure and cholesterol optimisation); and a potential QOF Quality Improvement module on CVD prevention.
Transforming our ways of working in primary care in this way has the potential to deliver huge population health impact while releasing GP time for other clinical activity. Indeed, across the UCLPartners geography of 6 million people, if we achieve the national ambitions for optimisation in AF, blood pressure and cholesterol, we can expect to prevent up to 12,000 heart attacks and strokes over ten years, with significant reductions emerging within 2-3 years.
Find out more about our work here.