Transforming health and social care in Kent and Medway is a partnership of all the NHS

organisations in Kent and Medway, Kent County Council and Medway Council. We are working

together to develop and deliver the Sustainability and Transformation Plan for our area.

Joint Committee of CCGs for the

review of urgent stroke review

services in Kent and Medway Thursday 10th October 2019

1

1

Prevention Business Case

Welcome, Introductions, review of minutes from last

meeting

AOB

Agenda

Mike Gill

Saloni Zaveri

ALL

2

2

Prevention Business Case

Welcome, Introductions, review of minutes from last

meeting

AOB

Agenda

Mike Gill

Saloni Zaveri

ALL

3

Please see separate document titled:

The case for stroke prevention in Kent and Medway

Prevention Business Case

1

Programme Board

Title of Report: The case for stroke prevention in Kent and Medway

Date: 10th October 2019

Workstream: Stroke

Sponsor: SRO of the work stream

Author: Dr Saloni Zaveri, Consultant in Public Health Medicine (Public Health England South East)

Presenter: Dr Saloni Zaveri, Consultant in Public Health Medicine (Public Health England South East)

1. Purpose of the paper

This paper seeks to summarise the case for the implementation of focused stroke

prevention strategies throughout the stroke clinical pathway in Kent and Medway.

2. Recommendation

The Committee is asked to consider the evidence provided in this paper and endorse the

following recommendations:

2.1. There should be a sustained emphasis on achieving a clear understanding of, and

systematically using, intelligence relating to local need/inequities to inform targeted

allocation of resources and interventions for those at highest risk of CVD. Targeted

approaches should, in particular, be considered for groups with a higher incidence of CVD.

2.2. Action to address behavioural risk factors should be embedded in stroke service

specifications to ensure that it is integrated throughout the entire stroke pathway.

2.3. Health equity audits and CVDPrevent could inform the development and targeting of

interventions and resources with the aim of identifying unmet needs and reducing

inequalities in health outcomes.

2.4. Those with a raised QRISK score who are not on statin treatment should be

systematically identified, behavioural risks modified and statin treatment offered if

indicated.

2.5. Continued support for and investment in optimising the detection and management of

AF, hypertension and hypercholesterolaemia is crucially important to stroke prevention.

2.6. It is recommended that an STP-wide commitment is made to commence efforts to

adopt the 140/90 hypertension treatment threshold.

2.7. Following TIA or first stroke the modification of behavioural risk factors and

optimisation of the management of high risk conditions are critical to the prevention of

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further strokes. Tertiary prevention should be embedded into pathways of stroke care.

3. Background

3.1. A review of urgent stroke services has been in progress over a five-year period across

Kent and Medway which aims to improve the quality of stroke care and subsequent

outcomes for the population through the creation of hyperacute (HASU) and acute

stroke units (ASU). An option of three co-located HASUs and ASUs in Kent and

Medway has now been agreed. Recent system-wide discussions have highlighted the

need to improve stroke prevention in order to decrease the incidence of first and

subsequent strokes.

3.2. Cardiovascular Disease (CVD) is largely preventable but is the second largest cause

of mortality in England, causing almost a quarter of premature deaths with 33,800

deaths in under 75s per year in England. Healthcare costs relating to CVD are

estimated at £9bn per year, with the cost to the UK economy (including premature

death, disability and informal costs) estimated to be £19bn.1

3.3. CVD is also a major driver of health inequalities, accounting for a quarter of the life

expectancy gap between rich and poor. CVD is more common where a person is

male, older, has a severe mental illness or ethnicity is South Asian or African

Caribbean. CVD is the largest cause of premature mortality in deprived areas, with

mortality from CVD several higher in the most deprived decile compared to the least

deprived decile.3

3.4. Stroke is the largest single cause of complex disability. Without further action, due to

changing demographics, the number of people having a stroke will increase by almost

half nationally, and the number of stroke survivors living with disability will increase by

a third by 2035.2 Stroke therefore places a significant and growing burden on health

and care services in the UK.

3.5. Approximately three quarters of strokes are first events, and it has been shown that

up to 90% of strokes in the UK are preventable- the stroke risk in these cases can be

explained by ten modifiable risk factors.7 The CDC also estimate that up to 80% of

strokes in the US could be prevented through healthy lifestyle changes and control of

high-risk conditions for stroke. These figures highlight the importance of prevention

strategies- primary prevention and throughout the stroke pathway- and targeted

elimination of modifiable risk factors for stroke as the most effective approach for

reducing the incidence of stroke, addressing related health inequalities and reducing

the long-term burden on health and care services.4

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3.6. Policy context and drivers for change

3.6.1. The Long Term Plan for the NHS2 (NHS LTP) includes a new national focus

on CVD, including stroke. The plan includes the ambition to prevent 150,000

strokes and heart attacks over the next ten years by improving the treatment

of the high-risk conditions – hypertension, high cholesterol and Atrial

Fibrillation (AF). These common conditions are known to cause CVD.

Although treatment of these conditions is very effective at preventing

cardiovascular events, late diagnosis and under treatment is common. The

National Stroke Programme has been developed jointly by NHS England and

the Stroke Association in consultation with clinical experts and people

affected by stroke. Building on the work of the National Stroke Strategy

(2007), the programme supports the health and care system to deliver better

prevention, treatment and care for the 80,000 people who have a stroke in

England each year, and meet the ambitions set out in the NHS LTP.

3.6.2. Next Steps on the Five Year Forward View5, published in 2017, includes a

clear commitment to tackle CVD, with a focus on the delivery of at scale

improvement in the secondary prevention of CVD by Sustainability and

Transformation Partnerships (STPs) working with partners. PHE subsequently

approved a programme of activities and resourcing in November 2017,

leading to the collaborative year-long national FYFV CVD Prevention Project.

The aims of this project, which launched in March 2018, were to increase the

detection & optimal management of atrial fibrillation, high blood pressure &

cholesterol, the three identified high-risk conditions, leading to a reduction in

heart attacks, strokes & vascular dementia.

3.6.3. The National Cardiovascular Disease Prevention System Leadership Forum

was convened by Public Health England (PHE) and brings together a range of

national partners who have expertise and influence within the CVD prevention

agenda. The Forum enables system leadership, system-wide collaboration

and alignment of CVD prevention priorities, with a focus on the early detection

and management of the three major high-risk conditions for CVD: AF, high

blood pressure and high cholesterol. By effectively diagnosing and managing

these conditions we can prevent a large number of CVD events, effect a

reduction in morbidity and mortality, as well as seeing a return on investment

in a relatively short time frame. The Forum agreed the following ten-year CVD

ambitions for England in 2019:

4

Figure 1: 10 year CVD ambitions for England

3.6.4. Kent and Medway (K&M) STP Prevention Workstream have provided their

support to the development of the Five Year Forward View CVD prevention

project.

3.6.5. The National Clinical Stroke Guidelines6 highlight that the identification of

risk factors for stroke and TIA should be part of the assessment during the

acute phase. The importance of regular review of risk factors and secondary

prevention in primary care is also highlighted.

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4. Overview of stroke in Kent and Medway

The following profile, created using PHE’s Fingertips tool, gives an overview of the

prevalence of stroke/ high-risk conditions and stroke-related morbidity and mortality across

Kent and Medway CCGs; and gives an indication of the level of variation in these factors

between CCGs (figure 2).

Figure 2: Fingertips stroke profile, Kent and Medway STP

Further, significant variation will be evident at a smaller area level within CCGs and will

indicate where targeted strategies may be needed to reduce stroke (and broader CVD)

risk.

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4. Key Issues

Up to 90% of strokes are preventable and associated with a number of potentially

modifiable risk factors.7 Suboptimal systolic blood pressure, uncontrolled atrial fibrillation

(AF), high cholesterol, excess salt intake, low fruit and vegetable consumption, high

alcohol consumption, cigarette smoking, being overweight and physical inactivity have

been identified as major modifiable contributory factors leading to an increase in stroke

risk.4 Strategies to reduce these factors include:

Supporting people to modify behavioural risk factors

Optimising the management of people with high-risk conditions

Prevention of further stroke following TIA or first stroke

4.1. Supporting people to modify behavioural risk factors

Research suggests that stroke risk decreases as the number of healthy behaviours

adopted increases.9 Action to address behavioural risk factors throughout CVD pathways-

from primary through to tertiary prevention- is essential to the NHS LTP aspiration to

improve ‘upstream prevention of avoidable illness and its exacerbations’, and to address

health inequalities relating to CVD.

Diet: A considerable body of evidence suggests that healthy dietary patterns – including at

least five portions of a variety of fruit and vegetables a day, fibre and oily fish; and

choosing lower salt, saturated fat and sugar options– have a positive impact on key stroke

risk factors (for example, high blood pressure, high serum cholesterol and

hyperglycaemia) and are therefore an important tool for stroke prevention.4

Obesity: Overweight and obesity increase the risk of high blood pressure, high serum

cholesterol, diabetes and ischaemic stroke, independently of other CVD risk factors.10

Physical Activity: A sedentary lifestyle is associated with a number of adverse health

impacts, including an increased risk of stroke.8 Even moderate physical activity- 30

minutes of moderate activity on five days each week- can reduce the risk of stroke by up

to 27% (Stroke Association, 2019).

Smoking: Stroke risk in tobacco smokers is approximately two to four times that of non-

smokers. It is estimated that 10% of strokes are attributable to current smoking: active

smoking in particular has been shown to be associated with ischaemic stroke.11,12,13

Stopping smoking rapidly reduces stroke risk: Within two years of stopping smoking, a

former smoker’s risk of stroke is reduced to that of a non-smoker14

regardless of age at

which smoking started and number of cigarettes smoked/day (Stroke Association, 2019).

The ASH ready reckoner tool (2019) calculates that the total annual cost of smoking to the

NHS across Kent is about £70.5 million. £25.7 M is due to approximately 12,170 hospital

admissions for smoking related conditions and £44.8M is due to treating smoking related

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illness, via primary and ambulatory care services. For Medway the total annual cost to the

NHS is £12.8M, of which £5.1M is due to 2,100 hospital admissions for smoking related

conditions and £7.7M is due to treating smoking related illness, via primary and

ambulatory care services.

Alcohol: There is a strong relationship between alcohol consumption and stroke: research

has shown that drinkers of over 35 units/week had double the risk of mortality compared

with non-drinkers. A major contributor to this relationship is the negative impact of alcohol

on a number of known stroke risk factors: high blood pressure, diabetes, being overweight,

atrial fibrillation and liver damage.15

4.2. Optimising the management of people with high-risk conditions

Hypertension

Hypertension is the main risk factor for stroke: people with hypertension are three times

more likely to have a stroke than those with normal blood pressure.16 Figure 3 shows that

the greatest risk associated with CVD burden in the South East of England is high blood

pressure.

Figure 3: Risks associated with CVD burden, South East England, 2017

Source: GBD Compare

Five million people in England have undiagnosed hypertension and of those diagnosed,

40% have poorly controlled blood pressure (Stroke Association, 2019). It is known that

there is a gap in the prevalence of recorded and modelled hypertension across Kent and

Medway, as for the South East and other parts of the country. The diagnosis gap for Kent

and Medway is shown in figure 4. It should be noted that the estimated numbers of people

with hypertension (diagnosed and undiagnosed) has been calculated using the PHE

hypertension prevalence model. It has not been possible to update the data for this paper

since the underlying model is currently being updated.

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Figure 4: Hypertension diagnosis gap. England, Kent & Medway STP and CCGs,

2016/17

Figure 5 shows the hypertension treatment gap for those with known hypertension for

England, the STP and Kent & Medway CCGs. It should be noted that NICE guidance,

QOF standards and national ambitions are now aligned to measuring and treating

hypertension to 140/90 mmHg. From an analysis of INLIQ data across the STP, 53% of

patients are treated to a target of 140/90 mmHg. The model for estimated prevalence is

expected to be updated in the near future when it will be possible to estimate the gap to

this level of achievement.

Figure 5: Estimated number of people with diagnosed hypertension who need to

achieve a blood pressure of 150/90, to reach the 80% treatment level, England, STP

and CCG level, 2017/18

Source: QOF 2017/18 treatment figures. Numbers rounded to the nearest 10

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Figure 6 shows the proportion and number of people with hypertension in England, Kent

and Medway STP and CCGs using the 140/90 threshold. Cost savings and clinical benefit

would be considerably greater for treatment to this threshold due to the resulting larger

numbers of people with better hypertension control.

Figure 6: Proportion and number of people diagnosed with hypertension, CCG, STP

and England, 2009/10 to 2017/18

Source: QOF diagnosed hypertension figures

NB:

Numbers are rounded to the nearest 10 and not displayed in STPs where there are 8 or more CCGs due to space issues.

It is estimated in 2017 that over 12 million people may have hypertension (diagnosed and undiagnosed) in England, around 22% of the population

Estimated cost savings and clinical impact that could be derived from potential heart

attacks and strokes averted through optimal treatment of hypertension are described in

Table 1. They replicate the “Size of the Prize” methodology and are based on numbers

needed to treat. The reported “savings” do not include any intervention/drug costs. It

should be noted that the rates of disease identification and optimal treatment will not be

equitable across the population.

Table 1: Clinical and financial impact over three years if the STP/CCG addresses the

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treatment gap for hypertension

Notes:

Savings are rounded to nearest £1,000.

STP values may not match the sum of CCG values due to rounding.

Canterbury and Coastal CCG not shown as gap < 100, Swale CCG not shown as already met treatment ambition

Atrial Fibrillation

Atrial Fibrillation (AF) accounts for 20% of all strokes. People with AF are five times more

likely to suffer a stroke, and people who experience an AF-related stroke are more likely to

die or suffer severe disability than any other type of stroke.17

Of critical importance to stroke prevention is the optimal detection and treatment of AF.

Anticoagulation for patients with AF reduces stroke risk by two thirds; however, recent

national audit data have shown that even in those in whom AF has been diagnosed prior

to stroke, only 59% were known to be on oral anticoagulants prior to admission in England

in 2017/18.18 According to NHS Digital (QOF 2017/18) there are more than 147,000

people in England with AF and at risk of stroke who are not receiving anticoagulation.

The figures reported in table 2 are estimates of the number of strokes potentially averted

per annum if the STP/CCG addressed the diagnosis and treatment gaps. The Imperial

College AF Budget Impact Model has been used to generate estimates.

Table 2: Clinical impact (number of strokes averted) of addressing the AF diagnosis

STP/CCG Heart

attacks

averted

Heart

attacks

savings

Strokes

averted

Strokes

savings

Kent and Medway STP 38 £283,000 57 £793,000

Ashford CCG 6 £45,000 9 £125,000

Dartford, Gravesham and Swanley CCG 5 £37,000 7 £97,000

Medway CCG 9 £67,000 14 £195,000

South Kent Coast CCG 8 £60,000 11 £153,000

Thanet CCG 5 £37,000 7 £97,000

West Kent CCG 7 £52,000 10 £139,000

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and treatment gaps, Kent & Medway STP and CCGs.

NB: *Assume all newly diagnosed patients have same risk profile as for QOF 17/18 diagnosed

patients and that all of those at high risk of stroke are adequately anticoagulated. STP values may

not match the sum of CCG values due to rounding. These figures are based on the three year

period covered by the model.

The cost savings that could be derived from strokes prevented through optimal detection

and management of AF are described in Table 3. With more strokes prevented, the most

substantial savings are associated with optimal anticoagulation of the existing diagnosed

and anticoagulated patient population. Cost savings have been derived from strokes

prevented through addressing detect, protect and perfect gaps. Calculation are taken from

the Imperial College AF Budget Impact Model and use published data regarding primary

care performance against QOF targets, together with estimated prevalence data to

compare current management of AF with optimal goals.

Table 3: Estimated associated savings (including savings for social care) over three years if the STP/CCG addressed the diagnosis and treatment gaps

*Assume all newly diagnosed patients have same risk profile as for QOF 17/18 diagnosed patients

and that all of those at high risk of stroke are adequately anticoagulated. Savings are rounded to

nearest £1,000. STP values may not match the sum of CCG values due to rounding. These figures

STP/CCG Detection

ambition met*

Treatment

ambition met

Both ambitions

met

Kent and Medway STP 64 87 151

Ashford CCG Ambition already met 9 9

Canterbury and Coastal CCG Ambition already met 12 12

Dartford, Gravesham and Swanley CCG 33 5 38

Medway CCG 25 8 33

South Kent Coast CCG 0 21 21

Swale CCG 9 4 13

Thanet CCG 4 10 14

West Kent CCG 10 17 27

STP/CCG Detection

ambition met*

Treatment

ambition met

Both ambitions

met

Kent and Medway STP £1,703,000 £3,535,000 £5,238,000

Ashford CCG Ambition already met £378,000 £378,000

Canterbury and Coastal CCG Ambition already met £512,000 £512,000

Dartford, Gravesham and Swanley CCG £950,000 £208,000 £1,158,000

Medway CCG £790,000 £317,000 £1,107,000

South Kent Coast CCG £4,000 £879,000 £883,000

Swale CCG £280,000 £154,000 £434,000

Thanet CCG £111,000 £409,000 £520,000

West Kent CCG £270,000 £687,000 £957,000

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are based on the three year period covered by the model. Reported savings are not necessarily

cashable ones

Hypercholesterolaemia

The global burden of disease (GBD) study shows that nationally raised cholesterol is a

significant contributor to CVD risk second only to hypertension or ranked third if all dietary

risks are combined. This picture is similar for South East England as shown in figure 3.

A meta-analysis19 of the efficacy and safety of reducing cholesterol included 14 studies

and 90,056 participants. The study showed a substantial reduction in cardiovascular

outcomes including a reduction in CVD and all-cause mortality without an increase in

adverse events. The figures in table 4 show the clinical benefit in terms of CVD mortality

avoided and strokes prevented for a 1mmol/L reduction in total cholesterol:

Table 4: Effects on cardiovascular outcomes per mmol/L reduction in cholesterol

CVD outcome Improvement per mmol/L reduction in

cholesterol

All cause mortality 12% CHD mortality 19%

Major coronary events 23%

Ischaemic stroke 19%

All strokes 17%

Source: Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data

from 90 056 participants in 14 randomised trials of statins; Lancet 2005

It has been estimated that there are 47,358 people aged 35-74 years in Kent and Medway

with a QRISK score of >=20% and 184,217 people 35-74 years with a QRISK score

>=10% who are not on treatment with statins. NICE guidance suggests that lifestyle

interventions would be appropriate for those with a QRISK score >=10% and treatment

with statins for those with a QRISK score >=20%.

4.3. Prevention of stroke following TIA

The risk of a second TIA or stroke is significantly increased after a first event, particularly

within the first 48 hours after the TIA. Treatment of high risk conditions can significantly

reduce risk in the long term. Medical treatments with clear evidence of benefit include:20

o Lowering blood pressure after all types of stroke or TIA.

o Lowering blood cholesterol with a statin after ischaemic stroke or TIA.

In addition, lifestyle changes can reduce the risk of future strokes:

13

Stopping smoking. Continued smoking following a stroke has been shown to have

an adverse effect on prognosis compared with past smokers and never-smokers,

notably on functional outcomes at discharge, one-year mortality and length of

hospital stay in hospital.21,22

Reducing the amount of salt in the diet

Cutting down on excess alcohol consumption

Undertaking at least 150 minutes of moderate intensity physical activity each week,

in bouts of 10 minutes or more, or 75 minutes of vigorous activity across a week or

a mixture of moderate and vigorous activity

5. Stroke prevention: what does good look like?

5.1. The NHS Health Check programme

The programme offers a check for adults aged 40-74 in England every five years and aims

to help prevent and detect early signs of heart disease, kidney disease, Type 2 diabetes

and dementia.

Kent & Medway are amongst the highest performers in the South East, meeting the

mandatory requirements to offer checks to all those eligible once every 5 years and

therefore reliably acting as an at-scale enabler of identification of cardiovascular disease

and disease risk. Both local authorities work closely with local stakeholders to ensure the

design and delivery of the universal programme is tailored to local population need and

system priorities. In Kent, a health equity audit (HEA) was undertaken in 2017 which has

since been used to inform targeted allocation of resources to ensure equity of access for

under-represented groups. Building on this work, Phase Two of the HEA is currently in

progress, focusing on exploring equity of outcomes. Recommendations from this work are

anticipated to inform further tailoring to maximise health impact and address health

inequalities. In Medway, implementation has been aligned to the CCGs work on reducing

unwarranted clinical variation. Through partnership with the CCG, an outreach service

was developed, based in the Smokefree Advice Centre in Chatham High Street. This

enables practices in more deprived areas where there are limited resources to refer

people for checks. Further work has led to the outreach service hosting in clinics

throughout Medway where a need has been identified and patients have been unable to

attend the centre. This has proved an effective approach between the CCG, GP Practices

and the local authority to reaching the intended demographic. Medway’s Public Health

Team will continue to fund this service to ensure checks are available to those in need.

5.2. National 10-year CVD ambitions for England

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As described in section 3.6.3., in 2019 the National Cardiovascular Disease Prevention

System Leadership Forum agreed the ten-year CVD ambitions for England, underpinned

by the overarching ambition to reduce health inequalities by significantly reducing the gap

in amenable CVD deaths between the most and least deprived areas by 2029.

5.3. NHS RightCare: high value interventions

RightCare’s CVD Prevention Pathway identifies a number of key high impact interventions

which are common to all the high-risk conditions for CVD:

Undertake systematic audit across practices to identify undiagnosed and under

treated patients.

Work with practices and local authorities to maximise NHS Health Check uptake

and follow up in general practice.

Work with Local Authorities and community leaders to embed CVD prevention

within health and wellbeing initiatives.

Build local primary care leadership to challenge unwarranted variation and drive

quality improvement in detection and management of the high-risk conditions – for

example through the local communities of practice model being supported by the

British Heart Foundation.

Ensure interventions and referral pathways embrace ethnic and cultural diversity

and specifically target communities with historically poorer outcomes.

Commission new models of diagnosis and management, for example, by

expanding the role of community pharmacists, support for self-measurement and

new technologies.

5.4. NICE guidance

NICE recommends a range of population-level and individual level interventions that can

be delivered as part of a system-wide approach to addressing CVD. NICE guidance

covers support for behaviour change, promotion of positive behaviours, early identification

of CVD risk (e.g., through the NHS Health Check Programme) and the optimisation of

clinical treatment for high risk conditions.

5.5. “What good Cardiovascular Disease prevention looks like” (see Appendix 2)

This document, produced by Public Health England and the Association of Directors of

Public Health on behalf of the WGLL Thematic Group on CVD prevention, identifies the

following principles which will enable successful action to prevent CVD:

Leadership to develop a compelling local narrative and take a whole system

approach.

Plans informed by population health intelligence to identify need and priorities and

address variation within and between populations.

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Systematic population-based approach to prevention using evidence-based

interventions at scale.

Use of behavioural science and local insights to engage professionals and the

population in CVD prevention.

New models and pathways in primary care and the community to improve

detection and management of the high-risk conditions.

Embedding of quality improvement within the programme, underpinned by routine

collection and use of data.

A health and wellbeing strategy which provides an environment which supports

healthy lifestyle choices and health; and care services which embed Making Every

Contact Count

Health in all policies approaches to ensure community assets and services support

healthy lifestyles

6. Existing programmes of work:

6.1. Kent and Medway STP have prioritised CVD prevention, with clear recognition of the

importance of secondary CVD prevention. Programmes to improve the detection of AF, for

example, have been in place since 2018 across the STP, and the Prevention Board have

recently considered and given broad approval to the STP-wide implementation of the

Virtual AF Clinic model which aims to optimise the management of AF. Details of the

model are included in Appendix 2.

6.2. NHS RightCare is prioritising, during 2019/20, the implementation of the CVD

prevention pathway. This is one of a series of evidence-based Optimal Value Pathways

which aim to provide local systems with a case for change, a best practice pathway and

examples of best practice for aspects of the pathways which indicate what and how to

effect change. The size of the prize shows the scale of opportunity at STP level to avoid

cardiovascular events and save money through CVD prevention interventions.23

6.3. The KSS AHSN Alliance for AF was formed in 2016 and aims to reduce the number of

people dying from or being disabled by AF-related stroke by optimising the use of

anticoagulants in line with NICE CG180 guidelines. The project’s key areas of focus are:

• Detect: increase prevalence of AF – using Lead 1 ECG devices

• Review: increase anticoagulation – perform timely reviews

• Protect: increase optimal anticoagulation – ensure patients receive appropriate

care

Further details of this project are given in within Appendix 1.

6.3. NHS England has established a demonstrator programme to target patients who have

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been diagnosed with AF but are not receiving optimal treatment. This national programme

involves 23 CCGs nationally, chosen on the basis of their deprivation levels and QOF

attainment rates (indicator AF001), and builds on the success of a model implemented

previously in Lambeth and Southwark CCGs. In the KSS region, Thanet CCG and South

Kent Coast CCG are participating in this pilot programme. Further details of this

programme, including costs, are given within the paper in Appendix 2.

6.5. CVDPrevent is a national cardiovascular disease prevention audit for primary care

which has been commissioned by NHS England. The audit programme will automatically

extract routinely recorded data from GP systems and will provide real time intelligence and

reporting, thus driving quality improvement relating to the identification and management

of the key high-risk conditions for CVD. Data extraction is anticipated to commence in April

2020.

7. Conclusions and recommendations

7.1. Behavioural risk factors are more prevalent amongst certain population groups, and

rates of diagnosis and optimal treatment of high risk conditions is not equitable across the

population. An emphasis on achieving a clear understanding of, and systematically using,

intelligence relating to local need/inequities to inform targeted allocation of resources

targeted interventions for those at highest risk will contribute to reducing health inequalities

relating to CVD.

7.2. Targeted approaches should, in particular, be considered for groups with a higher

incidence of CVD including those with severe mental illness and those of South Asian and

African Caribbean ethnicity. Early diagnosis of CVD and risk factors is key: the NHSHC

programme and annual health checks for people with severe mental illness and learning

disabilities are effective in identifying risk factors and making earlier diagnoses of CVD.

7.3. Action to address behavioural risk factors should be embedded in stroke service

specifications to ensure that it is integrated throughout the entire stroke pathway.

7.4. Health equity audits and CVDPrevent (when available) could be used to inform the

development and targeting of interventions and resources within universal programmes

such as the NHS Health Check Programme, with the aim of identifying unmet needs and

reducing inequalities in health outcomes.

7.5. As previously described, there are many people in Kent and Medway estimated to

have a raised QRISK score who are not on treatment with statins. There should be an

emphasis on effective identification of these people, modification of their behavioural risks

17

and optimal treatment with statins when indicated by QRISK score as per NICE guidance.

7.6. The case for the at-scale rollout of the AF Virtual Clinic model has been made

(appendix 2) and has received broad support from the Kent and Medway STP Prevention

Board. Continued support for investment in the improved diagnosis and optimal

management of AF, hypertension and hypercholesterolaemia is crucially important to

stroke prevention.

7.7. NICE guidance, QOF standards and national ambitions are now aligned to measuring

and treating hypertension to 140/90 mmHg. It is recommended that an STP-wide

commitment is now made to commence efforts to adopt this threshold.

7.8. Following TIA or first stroke the modification of behavioural risk factors and

optimisation of the management of high risk conditions are critical to the prevention of

further strokes. Tertiary prevention should be embedded into pathways of stroke care.

References:

1. European Heart Network. European Cardiovascular Disease Statistics 2017.

Accessed via: http://www.ehnheart.org/cvd-statistics/cvd-statistics-2017.html

18

2. The NHS Long Term Plan. NHS England, 2019.

3. Socioeconomic inequalities in avoidable mortality, England and Wales: 2001 to

2016. Office for National Statistics.

4. Iacoviello, L et al. Diet and primary prevention of stroke: Systematic review and

dietary recommendations by the ad hoc Working Group of the Italian Society of

Human Nutrition. Nutrition, Metabolism and Cardiovascular Diseases. Volume 28,

Issue 4, April 2018, Pages 309-334

5. Next Steps on the NHS Five Year Forward View. NHS England, March 2017.

6. National Clinical Guideline for Stroke. Royal College of Physicians, 2016.

7. The Stroke Association, 2019. Accessed via: https://www.stroke.org.uk/get-

involved/campaigning/nhs-long-term-plan.

8. Meschia JF et al (2014). Guidelines for the primary prevention of stroke: a

statement for healthcare professionals from the American Heart

Association/American Stroke Association. Stroke; 45: 12, 3754-3832.

9. Larsson SC et al (2015). Primary prevention of stroke by a healthy lifestyle in a

high-risk group. Neurology; 84: 22, 2224-2228.

10. Strazzullo, P. et al (2010). Excess Body Weight and Incidence of Stroke Meta-

Analysis of Prospective Studies With 2 Million Participants. Stroke 41(5):e418-26

11. The Stroke Association. Smoking and the Risk of Stroke. April 2012

12. Health Committee second report 2000: The Tobacco Industry and the health risks

of smoking. The Stationery Office Ltd.

13. Global and regional effects of potentially modifiable risk factors associated with

acute stroke in 32 countries (INTERSTROKE): a case-control study O’Donnell, M.

J et al. The Lancet 2016; 388: (10046) 731-840)

14. Aldoori M, Rahman SH. (Editorial) Smoking and stroke: a causative role. BMJ

1998; 317: 962

15. Hart, C.L. et al. Alcohol consumption and mortality from all causes, coronary heart

disease, and stroke: results from a prospective cohort study of Scottish men with

21 years of follow up. BMJ, 1999 Jun 26; 318(7200): 1725–1729.

16. The Annual Report of the Chief Medical Officer of the Department of Health 2001

17. National Institute for Health and Care Excellence. Atrial fibrillation: management

(article, 2014). Accessed via:

https://www.nice.org.uk/guidance/cg180/documents/thousands-of-strokes-in-

people-with-common-heart-rhythm-disorder-are-avoidable-says-nice

18. SSNAP Annual Portfolio for April 2017-March 2018 admissions and discharges,

available from https://www.strokeaudit.org/Home.aspx

19. Cholesterol Treatment Trialists’ (CTT) Collaborators, 2005

20. Sudlow, C. Preventing further vascular events after a stroke or transient ischaemic

attack: an update on medical management. Pract Neurol. 2008 Jun8(3):141-57.):

19

21. Edjoc RK, Reid RD, Sharma M, Fang J. Registry of the Canadian Stroke Network.

The prognostic effect of cigarette smoking on stroke severity, disability, length of

stay in hospital, and mortality in a cohort with cerebrovascular disease. J Stroke

Cerebovasc Disease 2013; doi:10.1016/j. jstrokecerebrovasdis.2013.05.001

22. Kim J, Gall SL, Dewey HM, et al. Baseline smoking status and the long-term risk of

death or nonfatal vascular event in people with stroke: a 10-year survival analysis.

Stroke 2012; 43: 3173-8.

23. Size of the prize in CVD Prevention.

https://www.healthcheck.nhs.uk/commissioners-and-providers/data/size-of-the-

prize-and-nhs-health-check-factsheet/

Appendices:

Appendix 1: “Atrial fibrillation: opportunities to prevent strokes by optimised

management of patient anticoagulation, Kent and Medway Sustainability and

Transformation Partnership” (January 2019).

Appendix 2: Public Health England and The Association of Directors of Public

Health, 2019. “What good Cardiovascular Disease prevention looks like”.

1

Atrial fibrillation: opportunities to prevent strokes by optimised

management of patient anticoagulation, Kent and Medway

Sustainability and Transformation Partnership

Authors

Jen Bayly, Cardiovascular Lead, KSS AHSN

Jodi Brown, CVD Prevention Programme Manager, Public Health England (South East)

Dr David J Roberts, Specialty Registrar in Public Health, Health Care Public Health, Public Health

England (South East)

Dr Saloni Zaveri, Consultant in Health Care Public Health, Public Health England (South East)

Dr Mohit Sharma, Consultant in Health Care Public Health, Public Health England (South East)

Audience

Members of Kent & Medway Sustainability and Transformation Partnership (STP) Prevention

Workstream.

Purpose

The Kent and Medway STP Prevention Workstream Group is asked to review the options for

optimising treatment of those diagnosed with AF and recommend the preferred option.

2

1. Background

The Long Term Plan for the NHS1, published in January 2019, includes a new national focus on

cardiovascular disease, including stroke. Both have been recognised as clinical priorities, and distinct

themes in the development of the plan. The plan includes a major ambition to prevent 150,000

strokes and heart attacks over the next ten years by improving the treatment of the high-risk

conditions – hypertension (high blood pressure), high cholesterol and Atrial Fibrillation (AF).

Kent and Medway (K&M) STP Prevention Workstream have provided their support to the

development of the Five Year Forward View Cardiovascular Disease (CVD) prevention project. The

initial focus was on reducing the Atrial Fibrillation (AF) detection gap through a collaborative project

between Kent Community Health NHS Foundation Trust, Kent, Surrey and Sussex (KSS) Academic

Health Science Network (AHSN), Kent County Council, Medway Council, Kent and Medway Clinical

Commissioning Groups (CCGs) and Public Health England. At the November meeting of the STP

Prevention Workstream, a paper was presented which demonstrated the potential for improvement

(in terms of strokes prevented and cost savings) by addressing all four key areas of AF detection and

management through:

• better diagnosis of AF

• better identification of those at high risk of stroke

• initiation of anticoagulant therapy in line with national guidelines

• maintenance of adequate anticoagulation / medicines optimisation

A whole-STP approach to the improved management of AF received broad support and the STP

Prevention Workstream requested that a more detailed paper prepared, outlining a proposed model

for intervention with associated costings.

2. Purpose of this paper

It is proposed that with the approval of K&M STP Prevention Workstream, this paper should be

submitted to the Clinical and Professional Board and Stroke Programme Board in order to gain

transformation funding to enable STP-wide implementation of the chosen proposal.

The Board is asked to review the options and recommend the preferred option.

3

3. The national and local picture

CVD accounts for more than a quarter of deaths in England and is the largest cause of premature

mortality in deprived areas, with mortality from CVD several higher in the most deprived decile

compared to the least deprived decile.2

Healthcare costs relating to CVD are estimated at £9bn per year, with the cost to the UK economy

(including premature death, disability and informal costs) estimated to be £19bn.3

The costs of treatment and rehabilitation are particularly high. For example, the cost to the NHS for a

patient in the first year following a stroke is around £12,228.4 When including the costs of social care,

this rises to £22,439 in the first year, and £46,039 over five years.5 In contrast, the cost of treating a

patient with Atrial Fibrillation with anticoagulants is on average under £500 per patient per year.6

Atrial Fibrillation accounts for 20% of all strokes. People with AF are five times more likely to suffer a

stroke, and people who experience an AF-related stroke are more likely to die or suffer severe

disability than any other type of stroke.7 One key way to prevent strokes is to provide the best

diagnosis and treatment for patients with AF. Anticoagulation for patients with AF reduces stroke risk

by two thirds; however, recent national audit data have shown that even in those in whom AF

has been diagnosed prior to stroke, only 59% were known to be on OAC prior to admission

in England in 2017/18.8 According to NHS Digital (QOF 2017/18) there are more than 147,000

people in England with AF and at risk of stroke who are not receiving anticoagulation.

The cost savings that could be derived from strokes prevented through optimal detection and

management of AF are described in Table 1. With more strokes prevented, the most substantial

savings are associated with optimal anticoagulation of the existing diagnosed and anticoagulated

patient population.

4

Table 1: Cost savings1 for K&M STP

AF detection

and treatment

for K&M STP

Cost savings if

detection

ambitions met*

Cost savings if

anticoagulation

ambition met

Cost savings

if both

ambitions met

Cost savings if 80% of

patients currently

inadequately

anticoagulated are

addressed

1 year cost

savings £1,448,712 £140,847 £1,589,559 £3,601,659

5 year cost

savings £2,983,104 £290,024 £3,273,128 £7,416,328

1Cost savings have been derived from strokes prevented through addressing detect, protect and perfect gaps.

Calculation are taken from the Imperial College AF Budget Impact Model and use published data regarding

primary care performance against QOF targets, together with estimated prevalence data to compare current

management of AF with optimal goals.

Nationally, AF initiatives are generally aimed at the triad of detection, protection and perfection gaps,

aiming to:

• Detect AF through the use of manual pulse checks or mobile electrocardiogram (ECG)

devices, thus reducing the detection gap between estimated and recorded prevalence.

• Protect those with AF who are most at risk (those with a CHA2DS2-VASc ≥ 2) by

ensuring that all eligible patients have access to treatment with an anticoagulant.

• Perfect treatment approaches, to ensure optimal treatment for everyone with AF who is

receiving an anticoagulant.

This paper focuses on models for the protection and perfection (optimal treatment) of those with AF.

Whilst this paper does not focus on the detection of AF, we should note that KSS AHSN will continue

to monitor the usage and impact of the 560 Lead 1 ECG devices as part of the NHSE project

(Devices are NHSE funded; Project delivery is AHSN funded).

5

4. NHS England national investment in AF

Review and Protect: roll-out of virtual anticoagulation clinics

NHS England is supporting a demonstrator programme to target patients who have been diagnosed

with AF but are not receiving optimal treatment. This national programme will involve 21 CCGs

nationally, building on a successful model implemented in Lambeth and Southwark CCGs. In the

KSS region, Thanet CCG and South Kent Coast CCG are participating in this pilot programme.

Over the next 18 months, NHS England will invest £9m to fund this project nationally to provide

clinical pharmacist capacity for case finding and treatment of up to 20,000 high-risk untreated

patients with known AF from GP records. This work could prevent up to 700 strokes within this period

and approximately 200 deaths from stroke.

Funding will be allocated to CCGs to:

• Cover the cost of clinicians engaged to provide the service;

• Provide virtual clinics with GPs to discuss patient treatment options, and

• Provide a contribution towards the additional drug costs.

This programme will focus on areas with both high levels of untreated AF patients and high health

inequalities, in order to have the greatest impact. Evidence will be collected to demonstrate

effectiveness as the programme progresses, to make the case for supporting wider implementation.

A range of national organisations are involved in the steering group of this project nationally,

including Public Health England (PHE), NHS RightCare and the British Heart Foundation. Locally,

AHSN leads will act as the day-to-day contact for participating CCGs and will coordinate project

support. The AHSN will also provide further training and education support to the seconded

specialist.

6

5. Models for the optimisation of AF management

We provide an overview of three case studies, as options of models for the improved management of

people with AF. Further details for the models are available in appendices two and three. The three

models presented are:

5.1. Merseyside Primary Care AF (PCAF) Service

5.2. The Virtual Clinic Model

5.3. Oberoi case-finding and audit service

5.1. Merseyside Primary Care AF (PCAF) Service

The PCAF service was a novel cooperative pathway providing specialist resources within general

practitioner (GP) practices. It utilised a four-phase protocol (see figure 1) to identify high-risk patients

with AF (CHA2DS2-VASc ≥1) and cases who were sub-optimally anticoagulated, and delivered

Consultant-led anticoagulation assessment within the local GP practice.

Figure 1: The Merseyside Primary Care AF (PCAF) service four-step pathway

AFCQF - PRIMIS+ AF Query Case Finder; GRASP-AF refers to the name of a tool and is not an acronym

7

Inspira Health, and external provider, were commissioned to undertake clinical audit of all patients

with a coded diagnosis of AF as per the GRASP-AF tool. Patients with AF who were considered at

high-risk of stroke, but either not currently anticoagulated, or not optimally anticoagulated, were

identified and invited to attend their local GP practice for a one-to-one specialist consultation with a

local Consultant Cardiologist. Further detail on the PCAF service and its outcomes can be viewed

here: Das et al., (2015)

The consultant-led and ‘call and recall’ components (to offer face to face clinical review) of the PCAF

model is expected to be relatively costly, although the availability of information relating to the costs

of implementing the PCAF model is limited. Additionally, the success of finding high-risk/sub-

optimally anticoagulated patients is dependent on availability of high-quality data. Once found, a

proportion will not be eligible for a change in treatment (e.g. there were short term reasons for

fluctuant INR such as antibiotic prescription). For example, only 29% of patients reviewed in the

Merseyside PCAF project as having sub-optimal anticoagulation progressed to NOAC prescription.

Therefore, local audit may help to inform the likely impact of PCAF type reviews on a wider scale.

5.ii. Virtual Clinic Model

Lambeth and Southwark CCGs and Kings College Hospital, London, worked in partnership for 12

months from 2016-17 to implement a project which aimed to optimise anticoagulation for AF in

Primary Care. The project provided support from a specialist anticoagulation pharmacist to all GP

practices in Lambeth and Southwark to review their AF patients who were not receiving

anticoagulation treatment. Specialist anticoagulant pharmacists were commissioned to deliver virtual

clinics in primary care, to support the GPs with evidence based decision making regarding

anticoagulation for patients with AF. This resulted in a significant increase in the number of patients’

receiving anticoagulation treatment, and up to 45 strokes prevented per annum. Further information

on this project can be found in Appendix three.

A broad overview of the resource requirements and costs of implementing the Virtual Clinic Review

Model (supplied by Southwark CCG, November 2018) is as follows:

• Approx. 0.1wte pharmacist per 100,000 population

• Case study had 0.6wte for 12 months to cover 91 practices and 600,000 population = £36k

8

• The GP incentive was paid through the existing CCG monies within the Prescribing

Improvement Scheme (PIS) and amounted to about £30k across the two CCGs = approx.

£300 per practice. This was embedded within the wider prescribing improvement scheme

which is worth quite lot of money to the practices (the AF element was mandatory); i.e. if they

did not do this they would not get any PIS payment at all across the wider scheme, hence

100% GP engagement.

• Case study scheme costs per CCG were £18k +£15k =£33k

Thanet CCG and South Kent Coast CCG will be participating in the NHS England demonstrator

programme to improve the management of people who have been diagnosed with Atrial Fibrillation

(AF) using an approach which is based on the Lambeth/Southwark Virtual Clinic Model. The Atrial

Fibrillation patient optimisation demonstrator programme is co-ordinated by NHS England, in

partnership with Academic Health Science Networks (AHSNs), NHS RightCare, Public Health

England and the British Heart Foundation and will be introduced across a total of 21 CCGs nationally.

The aim of the programme is to support primary care to increase rates of anticoagulation in people

with AF to reduce their risk of stroke. The selected CCGs will be provided with additional funding to

support delivery of this programme.

KSS AHSN will be the delivery partner to Thanet and South Kent Coast CCGs for the NHSE virtual

clinic pilot programme. The implementation lessons from this programme will provide valuable insight

and experience to guide an STP-wide initiative, based on a similar model to the NHSE virtual clinic

programme.

National agreement between the AHSN AF National Team and NHS England has been reached on

the estimation of resources required to deliver the programme, and related costs. These are as

follows, per 100,000 population:

• Pharmacist resource: 0.1 WTE

• Cost of Pharmacist resource: £10,000

• Cost of GP incentives: £6,667

9

Table 2 shows a breakdown of the NHSE virtual clinic funding allocation for both of the CCGs:

Table 2: NHS England virtual clinic funding allocation for South Kent Coast and Thanet CCGs

CCG

WT

E a

lloc

atio

n o

f

ph

arm

acis

t fun

din

g

Cash

allo

catio

n o

f

ph

arm

acis

t fun

din

g

2018-1

9

Cash

allo

catio

n fo

r

virtu

al c

linic

s 2

018

-19

Cash

allo

catio

n fo

r

dru

g c

os

ts 2

018-1

9

To

tal C

CG

fun

din

g fo

r

2018/1

9

Ind

icativ

e c

ash

allo

catio

n o

f

ph

arm

acis

t fun

din

g

2019-2

0

Ind

icativ

e C

ash

allo

catio

n fo

r virtu

al

clin

ics 2

019

-20

Ind

icativ

e c

ash

allo

catio

n fo

r dru

g

co

sts

2019-2

0

Ind

icativ

e to

tal C

CG

fun

din

g fo

r 2019

-20

NHS

South

Kent

Coast

CCG

0.5 17,500.00 3,383.33 67,995.79 88,879.12 35,000.00 6,766.67 308,596.26 350,362.93

NHS

Thanet

CCG

0.3 10,500.00 1,633.33 38,414.54 50,547.87 21,000.00 3,266.67 174,342.90 198,609.57

Source: NHS England

South Kent Coast CCG and Thanet CCG both plan to utilise a team of in-house Medicines

Optimisation Pharmacists to deliver this project, with anticipated additional support from

anticoagulation pharmacists in the acute setting.

Table 3 considers the costs of implementing the Virtual Clinic Model across Kent & Medway

(excluding Thanet and South Kent Coast CCGs).

10

Table 3: AF Virtual Clinic Model: estimated annual costs for Kent & Medway CCGs1

CCG

Total

population

(all persons)2

Pharmacist costs

(based on 0.1 WTE &

£10,000 per 100,000

population

Scheme costs (based

on estimated cost of

£6,667 per 100,000

population)

Total estimated

cost for 12 months

Ashford CCG 127,527 £12,800 £8,533.76 £21,333.76

Canterbury &

Coastal CCG 212,468 £21,200 £14,121.32 £35,321.32

Dartford,

Gravesham &

Swanley CCG

261,974 £26,200 £17,467.54 £43,667.54

Medway CCG 277, 616 £27,800 £18,534.26 £46,334.26

Swale CCG 116,255 £11,600 £7,733.72 £19,333.72

West Kent CCG 485,774 £48,600 £32,401.62 £81,001,62

Total costs for six

CCGs £148,200 £98,792.22 £246,992.22

1The figures in this table have been calculated using the resource requirements and cost assumptions agreed

by the AHSN and NHS England.

2Population estimates: ONS, Mid-2017 population estimates for CCGs in England

11

5.iii. Oberoi case-finding and audit service

To support Thanet and South Kent Coast CCGs to deliver and evaluate the impact of the virtual clinic

project, KSS AHSN will co-ordinate the implementation of the Oberoi Stroke Prevention in AF (SPAF)

Case Finding and Audit Service across 15 GP practices until March 2020. The Oberoi service will

provide practices with patient level data on detection of new cases of AF, dosing and monitoring of

anticoagulants.

KSS AHSN will provide £15,000 funding to implement the Oberoi AF Case Finding and Audit Service

in 15 GP practices across Thanet and South Kent Coast CCGs that are using the Lead 1 devices as

part of the Detect project. The Oberoi service will provide monthly data reports at practice level on

impact and outcomes and a detailed breakdown of AF prevalence and anticoagulation rates.

Practices, CCGs, the STP and AHSN will also have super-user access to the Oberoi reports that will

demonstrate benchmarking across practices for each CCG. Further information on the Oberoi service

can be found here:

https://www.oberoi-consulting.com/oberoi-spaf-and-case-finding/

Table 4 displays total costs for implementation and delivery of the Oberoi SPAF Audit and Case

Finding Service up until end of March 2020 across K&M STP. Thereafter, it will be optional for the GP

practice / CCG / STP to continue with the service at an annual cost of 10p per patient on the total list

size.

12

Table 4: Costs of implementing Oberoi SPAF service at scale across K&M STP

CCG List size Cost @10p per patient (£)

Ashford 136,530 13,653.00

Canterbury and Coastal 240,730 24,073.00

Dartford, Gravesham and Swanley 269,178 26,917.80

Medway 310,669 31,066.90

*SKC - KSS AHSN

Funding for implementation in 5 practices 42,144 4,214.40 (funded by KSS AHSN)

South Kent Coast 168,165

16,816.50 (Cost for remaining practices

@10p)

Swale 114,685 11,468.50

*Thanet KSS AHSN

Funding for implementation in 10 practices 108,210 10,821.00 40 (funded by KSS AHSN)

Thanet 41,107

4,110.70 (Cost for remaining practices

@10p)

West Kent 502,248 50,224.80

Total for CCGs/practice level implementation

@10p per patient on total list size 1,933,666 193,366.60 (total cost @10p)

*Total for Kent and Medway STP (excluding

KSS AHSN Funding for 15 practices) @ 10p

per patient 1,783,312

178,331.20 (total cost @10p less

£15,035.40 funded by KSS AHSN)

Total for Kent and Medway STP (implemented

at scale, whole-STP) @9p per patent on total

list size 1,933,666 174,029.94 (total cost @9p)

Source: Kent, Surrey & Sussex AHSN

13

6. Conclusions and recommendations

The AF Virtual Clinic Model is an evidence based model which, as an example of best practice, has

formed the basis of NHS England’s demonstrator programme for optimisation of AF management.

Costs and resource requirements of implementing this model are known, and the model has been

shown to be cost effective. Thanet and South Kent Coast CCGs will be implementing this model as

part of the NHSE demonstrator programme.

It is therefore recommended that the Virtual Clinic Model, delivered in accordance with NHS

England’s model, should be the favoured option for optimising AF management across K&M STP. It

is recommended that the STP consider scaling the virtual clinic model to all K&M CCGs. This may be

achieved by using seconded specialist pharmacists or nurses in anticoagulation, or using existing

CCG pharmacist resource (thus ensuring sustainability).

Further consideration could be given to:

• Deploying pharmacists who are also Independent Prescribers to deliver the project (additional

cost)

• implementing the Oberoi SPAF model at scale across K&M STP- this could either be funded

by Bayer via a joint working agreement with KSS AHSN until March 2020 (as is the case for

15 selected practices within Thanet and South Kent Coast CCGs), or by the CCG which

would incur additional costs as described in section 5.iii.

14

References

1. The NHS Long Term Plan. NHS England, 2019.

2. Socioeconomic inequalities in avoidable mortality, England and Wales: 2001 to 2016. Office

for National Statistics.

3. European Heart Network. European Cardiovascular Disease Statistics 2017. Accessed via:

http://www.ehnheart.org/cvd-statistics/cvd-statistics-2017.html

4. Youman P, Wilson K, Harraf F, Kalra L. The economic burden of stroke in the United

Kingdom. Pharmacoeconomics. 2003;21 Suppl 1:43-50

5. The economic burden of stroke care in England, Wales and Northern Ireland: Using a national

stroke register to estimate and report patient-level health economic outcomes in stroke.

Accessed via: Error! Hyperlink reference not valid.

6. Xiang-Ming Xu et al. The economic burden of stroke care in England, Wales and Northern

Ireland: Using a national stroke register to estimate and report patient-level health economic

outcomes in stroke. European Stroke Journal 2018, Vol. 3(1) 82–91

7. National Institute for Health and Care Excellence. Atrial fibrillation: management (article,

2014). Accessed via: https://www.nice.org.uk/guidance/cg180/documents/thousands-of-

strokes-in-people-with-common-heart-rhythm-disorder-are-avoidable-says-nice

8. SSNAP Annual Portfolio for April 2017-March 2018 admissions and discharges, available

from https://www.strokeaudit.org/Home.aspx

15

Appendix 1

Box A1. CHA2DS2-VASc risk score

Risk factor

Score

Congestive heart failure/LV dysfunction 1

Hypertension 1

Age ≥75 years 2

Diabetes mellitus 1

Previous stroke/TIA/TE 2

Previous vascular disease 1

Age 65-74 years 1

Sex (female) 1

Data sources and modelling

Data sources

The count of patients with diagnosed AF, with high risk AF1, and treated with an anticoagulant was

extracted from the Quality and Outcomes Framework (QOF) register of SES STP GP practices for

financial year 2016/17. CCG-level data were produced by aggregating practice-level data, therefore

only GP practices which have estimated prevalence data and relevant QOF data are included.

Modelling

Expected AF prevalence is taken from the National Cardiovascular Intelligence Network2 (NCVIN)

prevalence model3. The estimates were developed using data from the NHS Digital using population

estimates (taken from a Swedish population survey, the most accurate method to detect an often

asymptomatic condition such as AF) and diagnosed prevalence of AF in England in 2015/16. The

estimates have been calculated using age-sex specific prevalence rates from a reference population

which have then been applied to each local population. These estimates are an update to the ones

published by NCVIN in 2015.

1 Patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more 2 See https://www.gov.uk/government/news/new-national-cardiovascular-intelligence-network 3 Atrial fibrillation prevalence estimates in England, Public Health England 2017

16

Appendix 2

Case study example of virtual clinic model - taken from lead organisation and joint partners

Lambeth and Southwark CCGs and King’s College Hospital – supported by Health Innovation

Network (HIN) AHSN. A full description of the case study can be read in the embedded PDF below:

Aims of the virtual clinic review model:

• To ensure all patients on the AF register have had an assessment of stroke risk using

CHA2DS2VASc in line with the new QOF indicators from 2017/18.

• To ensure all patients considered at risk are offered appropriate anticoagulant therapy,

including reviewing any patients currently treated with aspirin for stroke prevention in AF.

• To identify reasons why patients at risk are not currently offered anticoagulation.

• To educate practice staff on the use of stroke risk assessment tools, bleeding risk

assessment tools and the role of anticoagulation in stroke prevention in AF.

Project plan

• To utilise local pharmacists with expertise in stroke prevention in AF to undertake in-practice

reviews of patients on the AF register who are not currently prescribed anticoagulants.

• To assess stroke and bleeding risk and, where appropriate, ensure patients are prescribed

anticoagulant therapy in line with national guidance.

• In-practice virtual clinics to be funded for 12 months (October 2018 – December 2019),

whereby two specialist anticoagulation pharmacists to be commissioned to deliver one virtual

clinic per practice, to review all patients identified as being on the AF register and not

currently anticoagulated.

• An EMIS Web Enterprise search to be set up by the medicines optimisation team so that

practices can easily identify appropriate patients for review.

• The review to be included as an essential part of the GP delivery scheme or prescribing

incentive scheme within CCGs to encourage GP engagement.

Tips for success using a virtual review clinic model

• Support GP practices with funding to allow time for review of the untreated AF patients.

• Provide support to GP practices in the form of anticoagulant specialists to ensure evidence

based decision-making.

• Ensure local referral pathways for anticoagulation are streamlined to maximise patient uptake.

PDF 19 NHS

Lambeth virtual clinics.pdf

17

Appendix 3

Case study – KSS AHSN Alliance for AF – Detect – Review – Protect.

The KSS AHSN Alliance for AF aims to reduce the number of people dying from or being disabled by

AF-related stroke by optimising the use of anticoagulants in line with NICE CG180 guidelines.

Formed in 2016, it has now completed phase one of the project, looking at the known AF population

in the region and identifying patients eligible for anticoagulation therapy.

Figure 1. Infographic from KSS AHSN on AF detection and management across Kent and

Medway STP

18

The primary target to benefit from this project is the patient and the Alliance aims to educate and

upskill primary care practitioners around stroke prevention, to sustain the learning and close the AF

prevalence gap described by Public Health England across KSS.

The project has three main areas of focus, namely:

• Detect: increase prevalence of AF – using Lead 1 ECG devices

• Review: increase anticoagulation – perform timely reviews

• Protect: increase optimal anticoagulation – ensure patients receive appropriate care

KSS AHSN collaborated with three independent review organisations to work in 29 GP Practices

across KSS, looking at the known AF population and identifying patients eligible for anticoagulation

therapy.

Phase one of the project ran from December 2016 to May 2018, and throughout, anonymised data

dashboard reports were shared which could be broken down at STP, CCG and GP Practice level for

participating organisations.

Impact of the KSS AHSN AF detect-review-protect project

The project worked across 29 GP Practices, reviewing 6,000 AF individual records through a

combination of register, case note and face to face reviews. All patients were identified as being

eligible for anticoagulation, had confirmed AF and were at a high risk of having an AF-related stroke.

From the 6,000 records, the project identified 1,390 individuals who were eligible for anticoagulation

and would benefit from a change of treatment to reduce their risk of AF-related stroke.

By the end of May 2018, 503 individuals had had their medicines optimised by their GP Practice,

thereby avoiding 14 AF-related strokes. As well as avoiding the debilitating effects on individuals and

their families, this will also represent a cost reduction of more than £380,000 for the NHS.

The impact would be far greater if all the remaining 887 eligible individuals were optimised on

anticoagulation therapy. A further 24 AF-related strokes could be avoided, with an additional Health &

Social Care cost saving of over £620,000.

The full case study of the KSS AHSN AF phase one project can be read in the embedded file below:

Jen AFA_Healthcare

Pioneers Report_2019 edits.pdf

19

Potential impact of the KSS AHSN AF detect-review- protect project

The project has shown that the KSS AHSN approach can make a significant impact on patient health

and if data is extrapolated, the potential impact of this work can be seen.

Identifying and treating a third of eligible patients from the KSS population (4,739,731 individuals)

could potentially prevent 202 strokes in one year, with a potential cost saving of £5,691,911 over five

years.

If all the eligible patients were treated, 559 strokes could be prevented in one year, with a

potential cost saving of £15,729,139 over five years.

Key findings and learnings from the KSS AHSN project:

• The impact of this work would be far greater if all of the eligible patients were treated.

• Reviews need to be carried out by a prescriber.

• It is imperative to plan to implement anticoagulation review models at scale, delivered by Clinical

Pharmacists / nurses who are prescribers, commissioned by the STP / CCG.

• TTR data needs to be held by the GP Practice (even if the INR service is out-sourced)

• Patients unstable on Vitamin K….(On VKA, TTR less than 65% or 1 or more INR over 8, 2 or

more INR less than 1.5 and 2 or more INR over 5) need to be reviewed by the GP Practice.

• As prescribers, GP Practices need to check that all patients taking DOAC are on the right dose

and monitored.

Next steps for the KSS AHSN detect-review-protect project

Building on the learning and experience of the past two years, this project is ready to scale. KSS

AHSN has set out a robust delivery plan through collaborative working to provide primary care with a

variety of interventions and education, to demonstrate how the services they deliver improve quality,

reduce variation, place patients at the centre of change and deliver value for money.

The KSS Alliance for AF project plan (if scaled) across K&M STP:

• Detect: increase prevalence of AF – distribute 250 Lead 1 ECG devices across K&M to multiple

organisations and widespread professional groups.

• Review: increase anticoagulation – implement virtual anticoagulation clinic reviews as per Lambeth

Case Study model. Added suggestion for K&M to ensure virtual clinics are delivered by prescribers.

• Protect: increase optimal anticoagulation – ensure patients are safe and receiving appropriate care

Data: Measure the impact in the three key focus areas via implementation of the Oberoi SPAF Audit

and Case Finding Service in GP Practices.

20

A new project plan, based on learnings so far, is now set to be rolled out. The work is still focussed

on the three key areas of Detect, Review and Protect. However, the approach is supported by an

innovative SPAF Audit & Case finding service that will demonstrate how the services GP Practices

deliver improved quality, reduce variation, place patients at the centre of change and deliver value for

money.

This link provides an example of the Oberoi SPAF Audit and Case Finding Service reports that the

GP practices, CCGs and AHSN will be able to access monthly: https://www.oberoi-

consulting.com/oberoi-spaf-and-case-finding/

An example practice baseline report from Oberoi is embedded below:

A81035_-_2018-11-0

7__01-51pm_-_Baseline_Report.pdf

What good Cardiovascular Disease prevention looks like

The What Good Looks Like (WGLL) programme aims to facilitate the collective efforts of local organisations and wider society (the system) towards improvements in their population health outcomes. This publication represents the practical translation of the core guiding principles and features of what a good quality tobacco control programme looks like in any defined place. It was developed collaboratively through the synthesis of existing evidence, examples of best practice, practitioners’ experiences and consensus expert opinions. It is intended to serve as a guide and will be iterative with regular reviews and updates when new evidence and insights emerge. Produced by: Alison Barnett (PHE), Andrew Scott-Clark (ADPH) and Jamie Waterall (PHE) on behalf of the WGLL Thematic Group on CVD prevention

Introduction

Over recent decades great strides have been taken in reducing premature deaths due to CVD in England. However, CVD remains a significant cause of disability, death and health inequalities through conditions such as heart disease, strokes, kidney disease and dementia. • CVD is the leading cause of years of life lost1 and causes almost a quarter of premature deaths

with 33,800 deaths in under 75s per year in England • CVD is a key driver of health inequalities, accounting for a quarter of the life expectancy gap

between rich and poor. Global Burden of Disease (GBD) data show that people living in the north of England have more years of life lost to CVD on average than in the south – an effect driven largely, but not wholly, by socioeconomic differences1

• Healthcare costs in England relating to CVD are estimated at £7.4 billion each year, with CVD costing the wider economy £15.8 billion annually2

• The rate of CVD increases with age3 and as the population ages many people will live with multiple long-term conditions

• High blood pressure, cholesterol and fasting plasma glucose are amongst the top 10 risk factors for years of life lost in England.1 Treatment of these risk factors and atrial fibrillation reduces the risk of cardiovascular events. Late diagnosis of these high risk conditions and under treatment are common and there is wide variation in performance across England.

There is a wealth of evidence on effective interventions to reduce the risk of CVD through behavioural changes and treatment of risk factors. This document focuses on the NHS Health Check programme; management of hypertension, cholesterol and atrial fibrillation; NHS Diabetes Prevention Programme and cardiac rehabilitation as the interventions with greatest impact. Other chapters in this publication will focus on important behavioural changes including smoking and healthy weight.

Vision

1 Changes in health in the countries of the UK and 150 English Local Authority areas 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016, Steel et al, The Lancet, 2018 https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2932207-4 2 British Heart Foundation (2018) CVD Statistics: BHF England Factsheet. (Last reviewed and updated February 2018). Available from: https://www.bhf.org.uk/statistics 3 British Heart Foundation (2017) The CVD challenge in England. Available from: https://www.bhf.org.uk/informationsupport/publications/healthcare-and-innovations/cvd-challenge-in-england

We will build healthier communities with reduced inequalities by taking a system wide and systematic approach to reducing CVD risk factors and implementing evidence based clinical interventions to reduce the incidence and progression of CVD. This will contribute to the NHS Long Term Plan milestone for the NHS to help prevent up to 150,000 heart attacks, strokes and dementia cases over the next 10 years.4 We will work towards achieving the 10 year CVD ambitions for England agreed by the CVD Prevention System Leadership Forum:

Cardiac Rehabilitation

By 2028 the proportion of patients accessing cardiac rehabilitation will be amongst the best in Europe, with up to 85% of those eligible accessing care (NHS LTP)

Local system leadership

Tackling CVD requires local system leadership by STPs and ICSs, including local authorities, to engage partners in delivering a system wide approach to the use of population health intelligence to plan and deliver services effectively, engage communities and maximise the use of community assets. This includes actions by local government and the NHS to address the wider determinants of health, behavioural risk factors and early detection of risk conditions for CVD. Many of these actions will also contribute to the prevention of other non-communicable diseases.

Health inequalities

4 The NHS Long Term Plan 2019 https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan-june-2019.pdf

Any approach to prevent CVD must also address the fact that 40% of amenable CVD deaths occur in the three most deprived deciles. Health equity audits can be used to develop universal programmes, such as NHS Health Check, to tackle inequalities and to identify needs for targeted services.5 Targeted approaches are needed for groups with a higher incidence of CVD including those with severe mental illness and those of South Asian and African Caribbean ethnicity. Annual health checks for people with severe mental illness or learning disabilities are effective in identifying risk factors and making earlier diagnosis of CVD. There are many opportunities to reduce inequalities by taking action on risk factors throughout the life course from the antenatal period onwards – these are covered in other chapters of this publication e.g. tobacco and healthy weight. Given the greater incidence, and at an earlier age, of CVD in deprived populations and some ethnic groups there are opportunities to target these groups earlier in the life course.

Principles

The following are principles which will enable successful action to prevent CVD

• Leadership to develop a compelling local narrative and take a whole system approach with partners and the local community to tackle primary, secondary and tertiary prevention of CVD and address inequalities. This will support development of joint plans and alignment of actions and pathways between services as well as engage the population in knowing their numbers and taking action. Integrated Care Systems will provide opportunities for joint commissioning for CVD prevention by local government and the NHS. Leadership is needed at all levels within a local system to ensure effective action is taken. CVD networks can support leadership and sharing of good practice across systems

• Plans informed by population health intelligence to identify need and priorities. This can be across an ICS to identify strategic priorities and at Primary Care Network and practice level to target action. It will also inform actions to address variation within and between populations

• Systematic population-based approach to prevention using evidence-based interventions at scale will allow identification of all those eligible for testing or treatment, offer of appropriate interventions and reduction of inequalities.

• Behavioural science and local insights are used to engage professionals and the population in CVD prevention

• Improving detection and management of the high risk conditions will require new models and pathways in primary care and the community – eg systematic case finding of the under treated, pharmacist or nurse led treatment optimisation, community mobilisation with wider access to BP testing making it easier for people to know, understand and act on their numbers.

• Quality improvement embedded within the programme and underpinned by routine collection and use of data to support development of the programme to improve delivery and outcomes, achieve the CVD prevention ambitions and reduce variations

5 NHS Health Check and HEA guidance https://healthcheck.nhs.uk/commissioners-and-providers/national-guidance/

• A health and wellbeing strategy which provides an environment which supports healthy choices on smoking, diet, healthy weight, physical activity and alcohol; and health and care services which embed Making Every Contact Count6

• Supported by health in all policies approaches to ensure community assets and services support healthy lifestyles

Application of evidence

NICE has identified a range of interventions that can be delivered at a population and individual level as part of a system wide approach to addressing CVD.

• Make a healthy diet the easy choice:7 work to continue to reduce the salt and saturated fat content of food consumed inside and outside the home.

• Improve air quality8,9: by taking action to reduce emissions. • Make physical activity the easy choice5: by developing an environment which encourages

active travel and physical activity in public spaces. • Identify and assess people for their risk of CVD4 ,10:: the NHS Health Check programme

provides a crucial mechanism for identifying people 40-74 years at risk of CVD, helping people to reduce their risk of developing CVD and the early detection of disease. Effective strategies for assessing the risk of developing type 2 diabetes allow referral to the NHS Diabetes Prevention Programme

• Support individuals at risk of CVD to make behaviour changes10: becoming more active, maintaining a healthy weight, safe levels of drinking and stopping smoking will help individuals to reduce their risk.

• Optimise clinical treatment11,12: health outcomes can be improved if people at risk of CVD and those diagnosed with disease receive optimal clinical treatment.

All Our Health has a CVD Prevention e-learning module providing bite sized sessions for all health and care professionals.13 NHS RightCare has produced an optimal value pathway for CVD prevention and will be prioritising its implementation in 2019/2014 The size of the prize15 shows potential cardiovascular events avoided and money saved through CVD prevention interventions at STP level.

Measuring our achievements

6 Making Every Contact Count. Health Education England https://www.makingeverycontactcount.co.uk/ 7 NICE (2010) cardiovascular disease prevention (system level) https://www.nice.org.uk/guidance/ph25 8 NICE (2017) Air pollution: outdoor air quality and health https://www.nice.org.uk/guidance/ng70 9 NICE (2019) Air pollution quality standard https://www.nice.org.uk/guidance/qs181 10 NICE cardiovascular disease prevention pathway overview (individual level) https://pathways.nice.org.uk/pathways/cardiovascular-disease-prevention 11 NICE (2016) Hypertension in adults: diagnosis and management https://www.nice.org.uk/guidance/cg127 12 NICE (2016) Atrial Fibrillation: management https://www.nice.org.uk/guidance/cg180 13 All Our Health CVD prevention https://portal.e-lfh.org.uk 14 Optimal value pathway https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2018/02/cvd-pathway.pdf 15 Size of the prize in CVD Prevention https://www.healthcheck.nhs.uk/commissioners-and-providers/data/size-of-the-prize-and-nhs-health-check-factsheet/

Measurement is key to the ‘Plan-Do-Study-Act’16 improvement cycle – allowing systems to understand where work may be needed and review the success of any changes. There is a multitude of national indicators and other sources available at the local level that can be used to monitor local progress in CVD prevention17, many of which are available via PHE’s ‘Fingertips’ Public Health Profiles tool18. NHS RightCare Where to Look Packs identify variations in detection and management of CVD risk factors. Where national indicators do not exist, local audit against quality standards can provide additional insight19. The national CVD prevention audit for primary care will provide real time data, including cholesterol data which is not currently available, to track progress and inform local action to improve detection and treatment of high risk conditions for CVD.

Mapping the local system can help to identify useful measurements, and baseline assessment tools may highlight particular areas for attention20. Areas may wish to consider measurements within a structure, process and outcome model. An example of how indicators, quality standards, and other datasets from a range of sources could align with this model is shown below.

Regardless of which measures are chosen locally, where possible it is useful to consider:

• How are they changing over time? Could a statistical process control (SPC) chart be drawn?21 • How do they compare to other areas? Consider using ‘nearest neighbours’.22 • Do they reveal any inequalities? Of particular relevance to CVD prevention are inequalities

by deprivation, gender, ethnicity, or the presence/absence of serious mental illness.

16 Plan Do Study Act cycles. NHS Improvement https://improvement.nhs.uk/resources/pdsa-cycles/ 17 CVD data https://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionals 18 QOF, PHOF, CCG OIS and NHS Health Checks are available via https://fingertips.phe.org.uk/ 19 Such as NICE quality standard 100 https://www.nice.org.uk/guidance/qs100 20 NICE produces a range of implementation resources https://www.nice.org.uk/guidance/CG181/resources 21 For more information, please see https://improvement.nhs.uk/resources/making-data-count/ 22 These can be automatically compared for indicators shown in PHE’s ‘Fingertips’ public health profiles

Stru

ctur

e Local arrangements are in place to ensure that the QRISK2 tool is used to formally risk assess adults under 85 years when an estimated increased risk of CVD is identified[NICE QS100-1: audit

Referrals to cardiac rehabilitation within 5 days of admission for coronary heart disease[CCG OIS 1.24]

Proc

ess Cumulative % of the

eligible population who received an NHS Health Check[NHS Health Check]

Proportion of adults with a 10-year risk of CVD of 10% or more who receive advice on lifestyle changes before any offer of statin therapy[NICE QS100-3: audit]

AF patients treated with anti-coagulant therapy if CHA2DS2-VASc >= 2[QOF AF007]

Out

com

e Coronary heart disease prevalence[QOF CHD001]

Under 75 mortality rate from cardiovascular diseases considered preventable[PHOF 4.04ii]

Description of GP practice experience, according to long-term condition e.g. hypertension[GP patient survey Q31]

4

4

Prevention Business Case

Welcome, Introductions, review of minutes from last

meeting

AOB

Agenda

Mike Gill

Saloni Zaveri

ALL