Berkshire East: Nithya Nanda, GP Clinical Lead/Sangeeta Saran, Associate Director Planned Care and Slough Operations, NHS East Berkshire CCG
Oxfordshire: Kiren Collinson, Clinical Chair, Oxfordshire CCG
Berkshire West: Heike Veldtman, Chair for LTC, Berkshire West CCG/Sarah Bow, Transformation Lead, Long Term Conditions
Buckinghamshire: Raj Thakkar, Clinical Lead for Thames Valley LTC/CVD programme, Clinical director for planned care in Buckinghamshire/Stuart Logan, Clinical Director for Long Term Conditions/Steve Goldsmith, Head of Long Term Conditions, Ill Health Prevention and Supported Self Care
Significant variation in the quality and safety of anticoagulant prescribing across was noted within Oxfordshire. NHSE/PHE estimated a savings opportunity of £2.7m for Oxfordshire over 3 years if anticoagulation is optimised. As a result, a successful 18 month pilot has been completed; pilot interventions are associated with estimated avoided stroke tariff cost of over £150k within year.
Funded by Pfizer, collaboration between Oxford AHSN, Oxford University NHS Foundation Trust and Oxfordshire CCG has led to:
• 1 WTE specialist anticoagulation pharmacist employed who is aimed at optimising anticoagulation control.
• GPs are offered a range of support to review patients with poor therapeutic time in range (TTR) through education sessions, structured list review, email and telephone advice.
• Grant offered to GPs to fund backfill for educational activities.
• 55 practices (78%) have engaged with the project to date, and those with higher levels of poor TTR are specifically targeted.
Use of GRASP AF tool in Berkshire West has helped identify high risk patients who have not been prescribed anticoagulant treatment as a part of the Prescribing Quality Scheme. Early information indicated % of high risk patients not on anticoagulation has decreased.
Chiltern CCG has developed a scheme to improve take up of GRASP AF where patients should be anticoagulated. This scheme is running in conjunction with a public awareness campaign Feel Your Pulse.
Healthcare professionals receive education and support from pharmacists to make improvements to detect people with undiagnosed AF, coding accuracy and anticoagulation. This has ensured sustainability in monitoring AF.
There is an ongoing evaluation of the scheme, and the quality improvement methodology provides a sense of system ownership in healthcare professionals.
The model adopted by Chiltern CCG creates a sense of urgency to promote early diagnosis, provides performance feedback and a continuous campaign to raise awareness of the value of robust monitoring systems.
Nine Berkshire West practices have signed up to a new pharmacist-led model, funded by Pfizer, which aims to:
• Increase the number of high risk patients with AF receiving oral anticoagulation therapy.
• Improve the quality of prescribing of oral anticoagulants.
• Reduce the number of patients poorly controlled on warfarin.
• Improve GP access to high quality advice about anticoagulation.
Buckinghamshire CCGs have recommissioned warfarin monitoring services under an AQP scheme to improve access to warfarin, ensure consistency and equity of service and ensure high quality assurance in the anticoagulation of patients with warfarin. The service specifications are comprehensive and detailed performance information is produced by providers each quarter.
Buckinghamshire Healthcare NHS Trust has introduced an award-winning, pharmacist-led clinic that offers patients appropriate anticoagulation treatment in line with clinical need and patient preference.
All patients with AF who may be suitable for a NOAC are referred to this clinic. A team of specialist pharmacists, led by a consultant pharmacist, offer patients a thorough 30 minute consultation to discuss the risks and benefits of anticoagulation.
Two weeks after the first prescription, patients have a follow-up telephone conversation to discuss any side effects or concerns. Feedback from patients and GPs has proven extremely positive.
Buckinghamshire CCGs have encouraged practices to integrate opportunistic pulse checking into every patient contact (over 65) through education programmes, a ‘Feel the Pulse’ campaign and a quality improvement scheme. This led to an increase in AF prevalence from 2% to 2.15% between February 2015 and July 2016.
The Oxford Academic Health Science Network, together with funding from Bayer, has engaged 34 Buckinghamshire practices to complete 20 week QI cycles. The first six re-audits have shown an additional 100 patients were anticoagulated, potentially saving five strokes with an aim to anticoagulate an additional 600 patients.
Since June 2011 there have been daily TIA clinics in Buckinghamshire for people at high risk of stroke and the majority (92% in August 2012) are now seen and treated within 24 hours.
The Cardiology and Stroke Unit at Buckinghamshire Healthcare NHS Foundation Trust have introduced a supportive feedback scheme to advise GPs when AF has not been adequately managed, or a stroke has occurred in a patient with known AF who did not receive anticoagulants.