East Midlands Cardiac Network

1. East Midlands Cardiac Network Regional Atrial Fibrillation Programme Planned Approach

2. Contents • Background and Context • Understanding the problem – The National and Local picture • Understanding what works • Identifying the Critical Success Factors • Proposal for the East Midlands Network • References • Appendixes

3. Background and Context • Atrial Fibrillation is a significant burden to patients and the wider health economy across the East Midlands, affecting around 66,000 people and accounting for between 15% and 20% of all stroke admissions to local acute services and around 450 deaths. • Nationally the detection and treatment of AF is recognised as suboptimal despite significant evidence that optimal treatment and management could reduce stroke incidence by 10%. As such, systematic identification and treatment of AF in primary and secondary care has been identified nationally as a high impact QIPP opportunity. • There is no defined data set or detailed understanding of current prevalence , practice, service quality or costs across the East Midlands although some top line work is underway to address this via EMPHO and a commissioners survey developed by the network. • As far as we understand, none of the NHS organisations in the East Midlands (Commissioner or Provider) has identified AF as a focus within its QIPP programme for 2011/12 • The East Midlands Cardiac Network wishes to develop a programme of activity which will address this and which focuses on 2 key aims: • Improvement of the identification and treatment of patients with AF across the East Midlands to reduce the incidence of death and disability resulting from stroke • Enable the provision of equitable, affordable and value for money services which will ensure that outcomes for patients with AF in the East Midlands are comparable with the top quartile of services nationally.

4. Background and Context • A considerable amount of work has been done in other areas throughout the UK all of which aimed to improve detection and treatment of AF. These programmes have used a number of different models and approaches and achieved varied outcomes. Successfully increasing the numbers of patients being effectively initiated onto and managed with warfarin has been a particular challenge with some disappointingly low “conversion” rates. • The East Midland network wishes to learn from these projects, to understand what has worked well and what hasn’t and use that learning to explore alternative approaches which may facilitate a more successful outcome. • The network wishes to work in a consultative and inclusive way with all relevant stakeholders across the health economy including the third sector and is also open to the idea of working with the pharmaceutical and healthcare sector through appropriate Joint Working arrangements as long as this is robustly governed. • Given the current reorganisation of the NHS and constituent organisations and bodies, the future of the cardiac network is unclear, with funding guaranteed only until April 2012. • This proposal therefore aims to outline the scope of a future project which will take the learnings from previous work and suggest a model of activity and implementation which aims to overcome many of the barriers and challenges experienced by other networks. • In recognition of the uncertain future ( or funding of) the East Midlands Cardiac Network post March 2012, the proposal will focus on a plan of activity which aims to engage CCGs and PCTs at the earliest opportunity to underpin a longer term implementation strategy • Based on the success of work being undertaken across Nottinghamshire in other disease areas in partnership with the pharmaceutical industry this proposal will include opportunities for joint working with commercial stakeholders including the pharmaceutical and healthcare industries.

5. Process of Development 4 Stages Identifying Critical Success Factors The core “must do” elements Understanding the problem. Mapping of AF picture nationally and in East Midlands Proposal for the East Midlands Understanding what works Mapping of work being done elsewhere

6. Understanding the ProblemThe National and Regional Picture Step 1

7. AF The National Picture • Prevalence of AF in England and Wales is approximately 1.3% and equates to around 600,000 patients₁ • Significant risk factor for stroke accounting for around 14% or 12,500 of all strokes recorded. • Cost to the NHS of around £148 million plus additional £4.2 billion in social care and lost productivity₂ • Estimates suggest that the cost of treating 1 stroke in the first year are around £11,900 ₂ • Strokes associated with AF tend to be more serious and have higher mortality but the risk of stroke can be significantly reduced by the treatment of AF with anticoagulation and specifically Warfarin which has been shown to reduce annual rates of stroke by up to 64% compared to Aspirin at 22%₃ • The annual cost of treating 1 patient with warfarin ( including monitoring is estimated at £383 per year with a NNT of 37 to prevent 1 primary stroke, suggesting that the cost of preventing 1 stroke would be between £10 - £14 k₂ • QOF data suggests that current use of anticoagulant therapies is suboptimal with significant variance in the use of Warfarin vs Aspirin and the NICE Clinical Guidelines for AF ₄suggest that only 46% of pts who are eligible for warfarin are getting it and this is backed up by other studies₅ • NICE concluded that if all patients who were eligible for treatment received warfarin that around 6000 strokes per year would be saved. • There are also significant issues regarding the time in therapeutic range (TTR) for patients taking Warfarin with most benefit of therapy being lost below 65% and some INR clinics are thought to run TTR targets as low as 60% making it unlikely that any significant benefit of treatment is being gained.

8. AF in the East Midlands • Of 8531 stroke admissions in 2009/10 , 1844 were recorded as AF related accounting for 22% of all stroke admissions. This is higher than the national average of 15%₆ • QOF registers for the East Midlands SHA show that 65937 are registered on AF registers giving an observed prevalence of 1.45% ( vs 1.2% nationally)₆ • However there is significant variation between East Midlands PCTs and their constituent practices on observed prevalence with the highest prevalence of 1.71% ( Bassetlaw) and lowest of 0.9% ( Leicester City).

9. AF in the East Midlands • The variance appears to affect those areas with a majority inner city population which could also reflect the fact these areas tend to have higher levels of deprivation, younger populations and resultant lower utilisation of primary care services as well as a higher proportion of single handed GP practices who may have less capacity and resource to for proactive case finding and register management. • The QOF data does however suggest that for those patients who are on GP registers that the majority ( 93.8%) are receiving some form of treatment. However the QOF indicator as it currently stands ( AF 3) does not allow differentiation between antiplatelet or antithrombotic treatment. Taking national data therefore it would be reasonable to suggest that only around 46% of these patients will be receiving warfarin and the rest will be on aspirin or possibly clopidogrel, leaving them at higher risk of having a stroke. • The data also identifies a further 3692 patients who are on AF registers in the East Midlands but are not recorded as receiving any treatment at all. • APHO and Imperial College London modelling also suggests that there could be a further 9000 patients in the East Midlands who have an undiagnosed stroke of which 15% will be related to Atrial Fibrillation

10. QOF Performance East Midlands – AF1,3 and 4 (EMPHO) - There are 50,534 patients across the East Midlands who appear on AF registers but have not had a confirmed diagnosis by ECG or specialist. Of patients eligible for anti-coagulation or anti-platelet therapy there are 3957 patients who do not appear to be receiving any therapy.

11. The commissioning focus is varied across the region A survey of commissioning organisations throughout the East Midlands undertaken by the East Midlands Cardiac Network (June 2011) identified that there is significant variance throughout the region with regard to commissioning intentions and priority of AF including: • Service provision and model for INR testing • Implementation of GRASP AF – only Derby City actively implementing (Northants and Derbyshire have plans to do so) • Identification of AF within PCT QIPP priorities • Systematic incorporation of opportunistic pulse checks into service specifications and / or current heart check programmes. • Clinical governance processes to monitor and regulate implementation of existing guidelines and anticoagulation services AF is just not on commissioners radars!

12. Why Not? • General and historic lack of understanding of the impact of AF amongst commissioners and particular impact on stroke and stroke prevention. Issue of non – clinical commissioners? • AF generally seen as a “prevention” issue and thus tends to sit within public health agenda rather than primary care or “front line” commissioning? • Issues around INR testing and service provision are complicated and commissioners may focus on the service rather than the reason ( and outcomes needed) for it? • Current national focus on AF is perhaps being diluted at local level due to on-going reorganisation of PCTs, transition to CCGs and loss of key staff?

13. Summary and Conclusion • Variance across the region with regard to identification and management of patients with AF. • Although QOF performance suggests that patients on AF registers are receiving some form of therapy it is likely that many are not receiving appropriate therapy and there is no way of measuring TTR for these patients . • It is likely that there are a significant number of additional patients who have not yet been diagnosed. • There are areas within the region where observed prevalence is significantly below regional and national average and so immediately present themselves as obvious “targets” for project activity . • The lack of priority being placed on AF by PCTs and CCGs within the commissioning agenda is a significant barrier, however as emerging and developing CCGs begin to develop their local commissioning plans, and local GPs and clinicians begin to have more input, there is a window of opportunity to influence those plans. • CCGs will have the opportunity to develop local QOF plus incentives which could be a lever by which proactive case finding and systematic review could be implemented. • CCGs ( Gps and Commissioners) need to understand the potential impact of AF and stroke and the impact that effective treatment has on stroke reduction. This information needs to be presented to them in a format that relates to their own local population with cost impact analysis data to help recognise the value.

14. Step 1 Step 2 Understanding What Works

15. What are other areas doing? • Preliminary research has identified some 27 referenced AF projects which have either been borne out of the first wave of NHS Improvement priority projects which reported in 2009, have developed from those, or are the second wave of national priority projects. • The projects generally have the same overarching aim to reduce the number of AF related strokes and cite one or more of the following methods to achieve that: • Raising awareness • Increasing the detection of AF by means of opportunistic screening • Driving the roll-out of the GRASP-AF tool to improve the management for those diagnosed with AF • Sharing good practice, ideas and innovations to improve detection, diagnosis and management • Improving the quality of care for patients requiring anti-coagulation • Addressing the need for education and training

16. They have generally incorporated one or more of the following elements • Opportunistic pulse screening in flu clinics/chronic disease clinics/ambulance services • Implementation of GRASP AF tool • Pathway development • Primary care education • Fast Track AF clinics in secondary care. • Near patient testing • Telehealth ( heart monitoring) • Some degree of incentivisation • External nurse support via BHF or pharmaceutical industry • Patient education But nowhere did them all and all used very different approaches to implementing them A detailed summary of each project is attached to this proposal but we have highlighted 3 very different approaches taken across the country to illustrate examples.

17. Focus on 3 Colchester Practice Based Commissioning Group (Essex Cardiac Network) • PBC initiated programme • Opportunistic pulse screening at flu clinics – inviting patients over 65 to have a pulse check. • 37 out of 43 practices in PBC Group incentivised to use approach • 34,201 patients screened in 6 weeks. • 189 patients found with AF (0.55%) • Estimated strokes prevented in following year = 5 ( Lead Gps own assumption) • Project funding: LES - £2 per patient screened • Pulse: How to run low cost high impact AF screening at flu clinics, Nov 08. • Easy to set up and implement within current practice activity • Required little additional manpower, time or resource over and above LES payment • No systematic plan for patient follow up however – left to individual practices to devise and monitor • No information available on conversion rates.

18. Focus on 3 York Health Group PBC GRASP-AF pilot group – West Yorkshire Cardiac Network • 24 practices ( 100% within PBC) used GRASP-AF • Incentivised via LES • £50 to run baseline to identify pts with CHADS2 score of 2 or more NOT taking warfarin • £10 / pt reviewed • £50 to re run GRASP tool • Supported by significant education programme and patient education materials via AFA • 3613 patients (out of a population of 228,651) were identified with AF.( 1.58% prevalence) • 53% of patients had a CHADS score of > 2 and of those, 899 (47%) with a CHADS score > 2 were not on warfarin ( pre study expectation was 25%) • Conversion rate 8-10% • Reasons for none initiation of warfarin in AF pts identified • Pt Declined 14% • Absolute contraindication – 7.2% • Other ( pt died, pre surgery, infection) – 2.7% • GP Decision( i.e not medical exception) 32% • New improved AF template developed and in use • New practice codes – Warfarin discussed and CHADS2 Score • AF registers to be reviewed yearly • Significantly upskilled practice teams

19. York Learnings • GP knowledge and confidence in use of warfarin is a major barrier to effective conversion • PCT concerns about costs of increased anticoagulation • Need robust impact modelling to show cost benefits and education re role of AF in stroke • Local clinical leadership and champion vital GP and consultant • Education EducationEducation • Dynamic and organised project manager to keep things moving. • Project focus on a small and defined geography and within one overarching NHS organisation enabled systematic communication, both within the PBC and to practices and meant that the project became part of the PBC core activity for the duration of the project. Reduces the issues of cross organisational decision making and competing priorities.

20. Focus on 3 Avon, Gloucestershire, Wiltshire and Somerset Cardiac Network (AGWS) – Strike at Stroke Project • AGWS Network has the highest level of GRASP-AF downloads across the country. (Ref: NHS Improvement) • 2010/11 wave- practices incentivised to use GRASP-AF: increase of 3% in patients prescribed coagulation or 220 patients. £2000 training funds made available to each participating PCT but left to individual PCTs as to how they implemented that. • 2011/12 wave–Incentives available for first 200 practices to apply for second wave and trigger point for incentive is 3% rising to 15% ( of patients initiated onto warfarin). Focus on outcomes rather than just inputs • Average available per practice will be £750.00 • Launched with large GP education event in May. • Compulsory use of GRASP-AF tool and upload to CHART.Practices supported by partnership with BoehringerIngelheimnurse team to run GRASP and review patients as well as provide education to practice staff • At time of writing 30 practices have signed up.

21. Learnings from Avon • Incentives for use of GRASP AF encourage GP and practice uptake • Strong clinical leadership and GP engagement vital • Someone to drive the programme and keep it all going • Provision of additional manpower – in this case dedicated externally sourced AF nurses, is welcomed by practices , encourages engagement and helps to make programme sustainable via education of practice staff.. • Education on use of warfarin and impact of AF needs to be embedded into programme

22. Common challenges across all of the reviewed projects • GP and practice engagement • Reluctance to commit time for what is perceived to be a time consuming task • Capacity of practices to review patients • Low awareness of potential impact of AF and scale of problem • Reluctance by GPs to prescribe warfarin resulting in low conversion rates • Lack of confidence based on low knowledge and misconception particularly around risks in the elderly – low awareness of BAFTA study for instance • Misconceptions about benefits of aspirin • Common misconceptions amongst general public regarding warfarin (Rat Poison) • Low awareness of impact of AF on stroke amongst commissioners resulting in low priority and associated funding support. • Pulse checks on their own are not necessarily worthwhile without a programme of action to ensure follow up and reporting of outcome. • Availability of funding and resources to support implementation • Cross organisational communication and co-operation – lots of silo working • Varying quality and access to anticoagulation services and monitoring. • Competing priorities workloads for individuals within organisations which are magnified when working across organisational boundaries. • Engaging with the public – low awareness amongst patients of AF.

23. Step 1 Step 2 Step 3 Identifying the Critical Success Factors

24. Based on the learnings from the national pilot programmes the following have been identified as Critical Success Factors for an effective programme: • Strong clinical leadership at a local (PTC / CCG ) level • GP and Secondary Care Consultant – a named champion who can lead from the front • Buy in and support from local commissioners regarding the impact of AF and the benefits of proactive management • A clearly defined care pathway for anticoagulation backed up by effectively commissioned and robust anticoagulation services working to service specifications which have clear KPIs around TTR for all patients. • Locally developed and supported clinical guidelines for management of AF that are communicated effectively to stakeholders and implementation monitored. • Systematic education of GPs, Practice Staff and Patients • Use of GRASP AF tool by practices and upload to CHART for reporting purposes. • Supported by incentives – Local LES • Dedicated nurse support to increase capacity in practices and provide on site education • BHF or pharmaceutical industry sources. • Public awareness • Robust and dedicated project management • Implementation at local level within a defined geography and organisational framework has a higher success rate than trying to develop a regional “ one size fits all” approach

25. Step 1 Step 2 Step 3 Proposal for the East Midlands Step 4

26. East Midlands AF Project This proposal is based on the recommendation that The East Midlands Cardiac Network engages in a Joint Working programme with the pharmaceutical and healthcare industries, the voluntary sector and NHS organisations across the region to: • Increase the appropriate detection, diagnosis, treatment and risk management of patients with AF in primary care. • Reduce the numbers of emergency admissions into secondary care and costs associated with the on going provision of stroke services • Improve shared knowledge amongst health professionals across the health economy and within localities building relationships between primary and secondary care, and between cardiac and stroke clinicians. • Improve the commissioning of AF services to incentivise good clinical practice and support on going delivery of value for money services. • Improve the patient pathway and speed up access to specialist services as well as providing equity for patients with AF.

27. Overview Based on the learnings from other work and the critical success factors identified, the project should include the following key elements: • Focused commissioner programme to raise awareness and understanding of the impact of AF on stroke, how that relates to their local population and the potential QIPP benefits that can be gained by a coherent and supported strategy for primary care risk identification and appropriate management. • Systematic roll out of GRASP AF programme within primary care, underpinned by specialist AF nurse teams working in practices to provide support for baseline audit, patient review and focused education. Ideally supported by local incentives via QOF plus or LES. • Systematic education programme for primary care HCPs, utilising a range of formats including group education as part of PLT, on line accredited learning modules, one to one in practice facilitated learning • Public awareness campaign ( towards back end of implementation phase) to raise awareness of AF and encourage patients to check pulse and visit GP. • Development of clear and simple AF guidelines and pathways • All backed up by robust and coherent communications plan and strong leadership from the project team.

28. What will success look like? • Commissioners across the region will have an understanding of the impact of AF on stroke rates within their own health economy , the evidence base for effective management of AF and the potential cost and quality benefits that can be achieved as part of the QIPP agenda and prioritise AF management within their commissioning programmes • Anti-coagulant clinics adhere to existing NPSA guidelines on audit and clinical governance, with particular emphasis on time in therapeutic range and that the audit data generated is actively reviewed by commissioners • Reduced Stroke rates and associated admissions and costs • Gps understand the impact and burden of AF within their own practices and actively identify and manage patients with appropriate therapies • Warfarin therapy will become the widely accepted first line treatment for newly diagnosed AF and a minimum of 20% of all eligible patients currently taking an antiplatelet will be switched to warfarin during the project. • Patients are more aware of the symptoms of AF and proactively attend their GP practice to ask for a pulse check. • Once diagnosed patients are aware that warfarin is the best treatment for them , are educated in its use and are happy to take it and manage their condition in partnership with their healthcare professional.

29. Potential for Stroke Reduction and Associated Cost Savings Across the RegionAssumptions Used ( with thanks to Matt Fey and Greg Fell in Bradford for input)

30. Example Metrics These will be formally agreed and developed by the project steering committee in line with the project plan but are intended to demonstrate examples of what could be measured.

31. Is it possible? • This is an ambitious approach and is based on the principle of • An intensive but highly focused and systematic programme of activity over a relatively short period of time ( up to 6 months) • Robust project plan and project management • Limited budget availability from within the network • Resources , skills and manpower from potential partners • The approach aims to produce a working model which demonstrates successful outcomes and which provides a business case and practical implementation plan which can then be easily replicated in other areas • It may be appropriate to consider a “pilot” project and work in one defined PCT / CCG to begin with to develop the approach, test , refine and evaluate it in order to provide an “evidence base” and toolkit for other PCT’s/ CCGs to follow. • This will also provide the partner organisations ( pharmaceutical, healthcare, voluntary) with an evidence base to justify their continued involvement and contribution of resource.

32. Why the pharmaceutical industry? • Because the evidence from other programmes is that success requires a multi faceted approach and to do that we need all the help we can get • We have shared goals: • For the NHS to prioritise detection and effective treatment of AF • Increase in the numbers of patients identified with AF and more patients treated in line with NICE guidelines • A reduction in the number of patients suffering a stroke . • Engaging GPs and CCGs is vital and the companies are working with them already – they have the relationships every day. • They are talking to GPs, Practices and CCGs anyway so there is an opportunity harness that and create a shared communications approach to reinforce the messages and communication of the project objectives .

33. The companies have access to and may contribute significant resources over and above that which the network can alone • Manpower to increase capacity to deliver the project – coal face implementation support. • Sophisticated cost / impact modelling tools for AF prevalence and cost impact of stroke / treatment variances to help commissioners understand their population and the burden of AF and stroke. • Provision of AF nurse specialist teams to • Support primary care implement GRASP AF and review patients • Provide 1:1 training in practices and across the Health Economy • Accredited clinical education programmes and the people to deliver them • Change management expertise to facilitate pathway redesign • Engagement with commissioners at PCT and CCG level • Marketing and communications expertise and change management support. • Access to national opinion leader network and sharing of best practice • On line resource tools for education , clinical development and management support.

34. What is Joint Working? “Situations where for the benefit of patients, organisations pool skills, experience and/ or resources for the joint development of patient centred projects and share a commitment to successful delivery” * • Joint working is distinctly different from sponsorship arrangements whereby companies merely providefor a specific event or work programme. • In joint working, goals are agreed jointly by the NHS organisation and company, in the interest of patients, and shared throughout the project. • A joint working agreement is drawn up and management arrangements conducted with participation from both parties in an open and transparent manner. • For many organisations, joint working will represent a new way of workingand requires a different mindset from sponsorship and a collaborative approach. • Successful experiences have shown that it can be of major benefit to patients, the NHS and pharmaceutical companies. *http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119052.pdf

35. Case Studies • There are many examples of successful Joint Working programmes underway throughout the UK that have bought measurable benefits to patients across a range of disease areas.₇ • The DH supports the approach and together with the ABPI has issued guidance to the NHS on appropriate governance arrangements₈,₉ • The National QIPP programme has a work stream focusing on how successful local JW projects can be up scaled and replicated to benefit organisations and patients across the UK • NHS Nottingham City has engaged in Joint Working on 4 large scale programmes all aimed at reducing avoidable hospital admissions and improving outcomes for patients • Each project has been developed with multi stakeholder involvement from the PCT, Primary Care, Secondary Care, Community Services, Patient Groups and the pharmaceutical industry. • All underpinned by robust governance arrangements and written partnership agreements signed by all parties • Dedicated project management funded by the partnership. 7.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119052.pdf 8.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_082569.pdf 9.http://www.abpi.org.uk/media-centre/newsreleases/2009/Documents/ABPI_Code_Guidance_Notes.pdf

37. Joint Working in Nottingham City Press Releases Newsletters Primary Care Info Patient Information

38. Pharmaceutical and Healthcare Companies Companies who have so far confirmed their interest in working on a programme in the East Midlands and support the approach being suggested: • BoehringerIngelheim • Bayer • Pfizer • Roche Diagnostics

39. Voluntary Sector There are a number of national patient groups/charities with an interest in AF and who run their own campaigns aimed at raising awareness amongst patients, clinicians and policy makers • Stroke Association - Ask First Campaign • In conjunction with NHS Improvement. Raising awareness of link between AF and Stroke. Supported by targeted radio campaign encouraging the public to check their pulse. • Have already expressed an interest in running the campaign in the East Midlands. • Atrial Fibrillation Association (AFA) • Various educational programmes and patient materials , training for HCPS, Toolkits • Supporting the All Party Parliamentary Group for AF • Have expressed strong interest in working on a programme in the East Midlands • Arrhythmia Alliance • Know your pulse campaign screened in general practice waiting rooms in various parts of the country with free pulse check guide and smartphone app. • British Heart Foundation • Large team of nurse specialist funded posts across the country • NHF traditionally have not engaged with the pharmaceutical industry. Working closely with these groups enables the project to: • Engage directly with patients and understand what they want and need. • Access national awareness raising campaigns and support tailored for local need.

40. How would it work? Project Steering Committee Written Joint Working Agreement signed by all parties and Terms of Reference Pharmaceutical Companies EMCSN Voluntary Groups • To include senior lead from • primary care • Secondary care • Commissioning • Medicines Management 1 representative from each ( 4-5) National and local representation PCT (Pilot) PCT PCT PCT PCT PCT Implementation team Lead local GP, Commissioner, Medicines management, project manager, pharmaceutical company lead

41. Who Would the Partners Be?( Organisational Level) • East Midlands Cardiac Network with representation from • Acute Trusts • Clinical • Provider / Service • CCGs / PCTs • Clinical lead primary care • Commissioning • Medicines Management • Community Provider ? • The Pharmaceutical and Healthcare partner companies • Patient Groups / Charities

42. Governance • The involvement of the pharmaceutical companies would be underpinned by a written Joint Working agreement signed by all parties. This agreement aims to ensure that all activities are conducted in an open and transparent way. • The agreement will also document funding / resource contributions from each partner ( including the NHS organisations) , expected outcomes and procedures regarding confidentiality, Intellectual property, data protection and other legal necessities. An example of an agreement can be supplied in confidence if required. • The template for this has been trialled and approved by both the DH and the ABPI • The pharmaceutical companies have to work within the ABPI code of practice and the agreement underpins this. • The representatives of the companies working on the project must not have a promotional role outside of the project. • The project steering committee will have clear terms of reference • Development of the Governance framework can be informed by the agreements and contracts in place for the 3 NHS Nottingham City Joint Working programmes.

43. Project Components Overseen by Steering Committee Commissioners Pharma EMPHO Impact Modelling GRASP AF Nurse Support Education Programme Primary Care Pharma Voluntary Sector Clinical Guidelines Development Anticoagulation Services Pathway / Guidelines and Service development Secondary Care EMCSN Public Awareness Programme and Education Patients Pharma Voluntary Sector

44. Budget • A full financial assessment will need to be developed as part of the project plan and will be dictated by the scope of that plan however, if the approach is agreed then many of direct project costs will be met by the pharmaceutical company partners through use of their services • The main cost to the network would be project management, communications and any running costs of the steering committee (Meetings, Clinician backfill etc) • Additional costs to be factored in at local level will be: • Incentive payments for GPs at local level if agreed( PCT / CCG) • Additional prescribing ( PCT / CCG) • Additional diagnostic tests ( ECHO / referrals to secondary care • However it would be hoped that development of the cost impact modelling tool for commissioners will help to demonstrate the cost benefit of this investment at local level and it is hoped that we can work with the pharmaceutical company partners to develop that.

45. Initial Risk Assessment A detailed Risk Assessment will be undertaken as part of the project plan

46. Regional Activity Key Milestones Pilot Area Agreement to proceed Monthly Steering Committee Meetings Agree Partners Joint Working Agreement Project Plan Financials and confirm resources Agree pilot area Communications programme and sign up of stakeholders Project Initiation and set up Nurses from pharma companies to support installation, baseline audit and patient review Develop and test commissioner impact tool Launch Event Pharma led with input from EMPHO Test in pilot PCT before roll out GRASP AF and nurse support implementation in pilot area Evaluation Milestones Pilot HCP Education Programme Local Communications Programme Regional Commissioner Programme Utilisation of pharma companies to talk to commissioners using impact tool underpinned by regional communications programme Regional Communications Programme Regional Roll Out Public Awareness Campaign

47. Key Stakeholders • East Midlands Stroke and Cardiac Network • Management Team • Clinical Leads • Pharmaceutical Companies • GPs and Primary Care HCPS • Commissioners • Medicines Management • Public Health • Cardiologists • Anticoagulation Service providers • PCT / CCG Communications • NHS Improvement • East Midlands SHA and its successor organisation • Patients • Voluntary Sector and National Charities

48. References 1.NHS Information Centre for health and social care, Quality and Outcomes Framework Achievement Data 2008/9, NHS, Editor. 2009, NHS. 2.Marian Kerr, Standards and Quality Analytical Team. Atrial Fibrillation Cost benefit Analysis DH 3. Hart R, Pearce L, Aguilar M. Meta analysis: antithrombotic therapy to prevent stroke in patients who have non-valvular atrial fibrillation. Ann Intern Med 2007; 146: 857-867. 4. The Management of atrial fibrillation CG 36 June 2006 5. Commissioning for Stroke Prevention in Primary Care – The role of Atrial Fibrillation NHS Improvement 2009 6. Atrial Fibrillation and Stroke Prevention - East Midlands Public Health Observatory June 2011. 7. Moving Beyond Sponsorship – Joint Working between the NHS and the Pharmaceutical Industry – Toolkit DH 2011 8.Best practice guidance for joint working between the NHS and the pharmaceutical industry – DH 2008 9.ABPI guidance notes on joint working between pharmaceutical companies and the NHS and others for the benefit of patients ABPI March 2009