1. Improving Detection & Management of Atrial Fibrillation Brendan Young Lynda Dando

2. NHS South Worcestershire CCG 21 PMS* 10 GMS 1 APMS 14 Dispensing 1 Local Authority 1 Acute 1 Community Practitioner 1 April 2015: Delegated commissioning 1 Jan 2014: 1 GP Federation 32 Member Practices 215 gps 4 Localities £48.8m Primary Care allocation £2.6m PMS premium £2.4m Enhanced Services £890k Anticoag 298,000 patients £384m budget

3. Why we want to co-commission Deliver the best outcomes for our population Support sustainable, high quality primary care – working at scale Implement Place based commissioning – ending the fragmented commissioning of primary care services Better, More, Integrated out of hospital care Promote innovation-locality solutions Alignment of Contracts and Incentives

4. Co-Production – How it all began

5. Primary Care Co-commissioning Intentions and Governance Structure Primary Care Commissioning Committee Primary Care Clinical Advisory Group Excellent integrated personalised care for long term conditions Proactive, Co- ordinated Care for the Frail Elderly Accessible, Responsive, Patient-centred care Place-based / Prevention / Reducing Health Inequalities Effective use of resources (Prescribing, planned care) Patient Co-production Co-commissioning Group ‘the COCO Group’

6. Case for Change First of all we’re doing really well! Continuous Improvement Comparison with our ONS Group Variation amongst practices Evidence base: – Public Health & NHS England Commissioning for Value pathways – West Midlands Cardiovascular Strategic Clinical Network & NHS England atrial fibrillation QIPP report 2013-14 – Hammersmith & Fulham CCGs with Imperial College London – Tower Hamlets Clinical Networks – RCGP & British Geriatric Society Fit for Frailty Focus on what matters & makes a difference for patients & clinicians DM007 The percentage of patients with diabetes. on the register. in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months DM008 The percentage of patients with diabetes. on the register. in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 12 months DM009 The percentage of patients with diabetes. on the register. in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months

7. Promoting Clinical Excellence Contract Standards 1.Proactive care for older people living with frailty 2.Excellence in LTC – Blood Pressure Measurement 3.Excellence in LTC – Hypertension Management 4.Excellence in LTC – Atrial Fibrillation Management 5.Best Care - COPD and Asthma 6.Best Care – End of Life 7.IQSP 8.Audits and Study Days 9.E-Referrals 10.Coding

8. Atrial Fibrillation 17 practices under-detecting AF Currently 65.95% of those with AF receiving OAC National Aspiration 85%-100% Current Exception rate 18.60% National Recommendation - 15% or less

9. Potential Health Gain through Incentivisation of Improved AF Detection & Management If South Worcestershire CCG practices were detecting AF at 1.89% prevalence rate with 85% of those assessed to be high-risk being treated with anticoagulants = extra 33 strokes being prevented per year Total costs associated with stroke £12,228- £40,000 Savings = £403,524 minimum – Source: West Midlands Cardiovascular Strategic Clinical Network & NHS England Atrial Fibrilation QIPP Report

10. Atrial Fibrillation

11. Hypertension Management

12. Blood Pressure Measurement

13. Improving Quality Supporting Practices Clinical lead Primary care lead All GP’s to attend 2 meetings x 2.5 hours

14. 12

15. Prescribing for Patients with Atrial Fibrillation NICE CG180 (June 2014) - Importance of anti-coagulation - Lack of evidence for aspirin Spring Gardens data – (EMIS search and report) Number on AF register = 279 Of these, number on warfarin = 157 number on NOAC = 30 number on aspirin = 58 13

16. NOACS Fewer opportunities for healthcare professionals to provide information, monitor adherence and check for side effects. Currently NO national standardised patient alert card as there is for Warfarin. Proprietary cards are in tablet packs Flow chart and FAQ for patients for AF on APC website Example practice protocols/ leaflets in pack NMS consultations from community pharmacy: – will ensure that initial essential information provided – monitoring during the first month.

17. NOACs & CKD 17 patients in 13 practices who are taking current courses of NOACs at doses not in line with their eGFRs Majority are patients on Rivaroxaban 20mg or Dagibatran 150mg with eGFRs <50 Search is on EMIS search & report

18. Guidance, top tips, best practice

20. Detection Target prevalence rate – 1.89% Current - 2%

21. What Next? Promoting Clinical Excellence 2016\17-more of the same IQSP – on-going AF focus Anticoagulation Enhanced Services : – Simple KPIs Indication\Diagnosis Target time in range % time in range – Approach to managing patients with high results 21