Atrial Fibrillation in Primary Care Project - National Priority Projects 07/08 Summary Document

NHSNHS Improvement

HEART

STROKE

CANCER

DIAGNOSTICS

Heart Improvement

Atrial Fibrillationin Primary CareNational Priority Project

Atrial Fibrillation in Primary Care is a national priority project of the Heart ImprovementProgramme focusing on improving the identification and management of patients withatrial fibrillation (AF) in primary care.

The time scale for the projects varies, with many projects still in the initial stages ofcollecting data and working more closely with primary care in March 08.

Key learning from the project is available in the following formats:

1. Project summaryThis document includes a description of the national project, supporting informationgained so far and key learning up until March 2008.

Project summaries include issues to be addressed, baseline position, actions taken andplanned, key learning and results to date from the 18 projects participating in this work.Contact details are included to provide additional information with regular updatesavailable on the website.

2. Presentations at National Conference 8 May 2008Copies of presentations from the speakers at the conference are available on the website:www.improvement.nhs.uk/heart

3. Web based resourcesProject team members found this a very useful opportunity to share learning across thedifferent project areas. These are now available to share on the improvement website at:www.heart.nhs.uk/priority_projects

These are categorised into three chapters:1. Identifying, reviewing and managing AF patients2. Education and training3. Developing AF pathways and clinics

Content includes:• Guidelines• Presentations• Proformas• Algorithms• Job descriptions• Educational information.

Additional information will be included as it becomes available and existing materialsregularly updated.

Further information and updates email: [email protected]

Introduction

Project Summaries

Atrial Fibrillation in Primary Care - Suffolk

North Somerset PCT Atrial Fibrillaton in Primary Care Project

Management of Atrial Fibrillation in Primary Care - Bristol

Atrial Fibrillation Screening Pilot Project - Bedford

Atrial Fibrillation in Primary Care - Dudley Health Economy

Atrial Fibrillation in Primary Care - Walsall Health Economy

Develop, Agree and Commission Atrial FibrillationPathway - Coventry and Warwick

Screening for Unidentified Patients - Essex

Atrial Fibrillation in Primary Care National Project - Oldham and Bolton

Primary Care Arrhythmia Service - Medway PCT

Managing Atrial Fibrillation in Primary Care - Lancaster and Morecambe

Managing Atrial Fibrillation in Primary Care - Northamptonshire

Whitby Group Practice Near Patient INR Testing Project

Atrial Fibrillation in Primary Care - Rotherham

Identification and Management of Atrial Fibrillationin Primary Care - Sheffield

A Sector Wide Approach to Optimising Therapy for AtrialFibrillation Patients in Primary Care - South West London

Atrial Fibrillation in Primary Care Project - West Surrey

Optimising Atrial Fibrillation Management and Atrial FibrillationRelated Stroke Prevention in Leeds

Project Team Leads and Participating Sites

3Atrial Fibrillation in Primary Care

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www.improvement.nhs.uk/heart

4 Atrial Fibrillation in Primary Care


Introduction

Chapter Eight of the National Framework forCoronary Heart Disease; Arrhythmias and SuddenCardiac Death, published in March 2005, set outthe quality requirements for the prevention andtreatment of patients with cardiac arrhythmias. Thispriority project was established to progress theimproved identification and management ofpatients with atrial fibrillation (AF) within primarycare.

BackgroundAtrial fibrillation (AF) is both under recognisedand under treated and evidence demonstratesthat systematic screening increases the detectionof new cases by approximately 60%. It is knownthat:

• AF is an important risk factor for stroke and isassociated with about 15% of all strokes

• It has been estimated that optimal treatmentof AF in the population would reduce overallstroke risk by 10%

• Anticoagulation is highly effective in reducingstroke risk in patients with AF byapproximately 70%

• In a primary care population of about half amillion, there will be about 1000 new cases ofstroke per annum.

Since March 2006, data on AF has beencollected by individual practices as part of theQuality Outcomes Framework (QOF). In June2006 NICE published guidelines on themanagement of atrial fibrillation.

ProcessSixteen cardiac networks are currently workingwith primary care trusts (PCTs) and targetcohorts of practices to address the identificationand management of AF in primary care in termsof:

• Identification of new cases of AF• Ensuring appropriate treatment of AFpatients

• Provision of arrhythmia clinics, pathways andservice.


There are a variety of approaches, with localprojects being encouraged to:

• Use age corrected prevalence data and/orindividual practice data to highlight practiceswith potentially low rates of AF

• Support practices in screening of appropriatepatients using targeted opportunisticscreening

• Support practices in reviewing their protocolsfor dealing with AF patients to ensure thatapproaches are evidence-based and consistentwith current best practice

• Support practices’ efforts to developappropriate treatment services such aspractice-based anticoagulation

• Examine local links for services for AF patientsto ensure that these patients start promptly onan effective treatment pathway, includingadequate systems for onward referral andspecialist treatment.

OutcomesEach project was asked to establish a baselineagainst which progress and improvement in theidentification and management of patients withAF could be measured. This will demonstratethe positive impact of changes that are made inrespect of:

• Numbers of new patients with AFidentified and their subsequent treatment

• Numbers of existing AF patients reviewedand, where necessary, subject to optimaltherapy

• Establishment of a clear and agreedpatient pathway for AF patients (Chapter8: Quality Requirements and Markers ofgood practice).



Key LearningThere has been a longer lead in time for theseprojects due to the multifaceted approaches thathave been needed to agree active engagementin primary care.

Projects have needed to retain flexibility in theirapproaches to account for wide variation anddifferences in levels of expertise and access toresources in primary care.

Key areas for the focus of improvement workare around additional education, resources ornew service models in the following areas:

• Interpretation of ECGs in primary care• Warfarin prescribing in those over 75 yearsof age

• Access to anticoagulation services• QOF points• Using practice data from primary careinformation systems

• Opportunistic screening through pulsepalpation.

Progress and Next StepsFollowing the long lead in time, these projectshave now established themselves over the lastsix months and are now gaining momentum,actively working with 22 primary care trusts andmore than 139 general practices across England.

Early progress in some projects has resulted in:• 1540 patients in a target population subject toopportunistic screening

• 25 new cases of AF identified andsubsequently treated.

New service models are being established,for example:• INR near patient testing• Consortia based anticoagulation services• Community diagnostic services.

During the next 18 months NHS Improvementwill continue to provide a national lead to drivethis improvement forward in primary care. Theprognosis of patients who suffer a stroke as aresult of AF is particularly poor, with only onethird surviving one year1. The work to improvethe identification, management and optimaltreatment of patients with AF will also benefitfrom future alignment with the Department ofHealth’s ‘National Stroke Strategy’, publishedDecember 07, Quality Marker 2: Managing Risk2.

In addition, the emerging work following thepublication of the Department of Health ‘Puttingprevention first. Vascular Checks: risk assessmentand management’ in March 2008, will providefurther focus and support to those cardiac andstroke networks who are hosting these projectsin partnership with primary care.

SummariesThe following summaries give an overview ofthe work of some of the 18 individual priorityprojects. More detailed information andsupporting documents are available from theweb-based resource at:www.heart.nhs.uk/priority_projects/atrial_fibrillation_in_primary_care_/fibrillation.html


1Lin H-J, Stroke Severity in Atrial Fibrillation: The Framingham Study. Stroke 1996: 27: 1760-17642Risk factors include hypertension, obesity, high cholesterol, atrial fibrillation (irregular heart beats) and diabetes aremanaged according to clinical guidelines, and appropriate action is taken to reduce overall vascular risk.


Project Summaries



Issues to be addressed• Potential for screening programme• Engaging GP practices• Management pathway for AF across primaryand secondary care

• Educational programme for ECGinterpretation and risk stratification.

Project commenced: December 2007

Baseline position• No screening programme available at present• Variable level of GP interest and engagement• NICE guidelines in place but level of adoptionunclear

• Variable level of knowledge, skills andconfidence in primary care.

Actions taken and planned• Review of unplanned admissions for AF usingthe PCT’s information system

• Audit of primary care for emergencyadmissions and ECG usage

• Audit of outpatient referrals in secondary care• Assessment of education and training needsof GPs

• Review of literature in preparation for pathwaydevelopment

• Scoping the potential of a screeningprogramme.

Key learning from the work• Variable level of interest and understanding inprimary care

• Issues around confidence levels regarding ECGinterpretation and usage and risk stratificationfor thromboprophylaxis.

Results to date• Still at very early stages of development• Have reviewed the amount of unplannedadmissions to secondary care for AF betweenNov 06 – Dec 07 in order to select the patientsfor audit within primary care

• In process of carrying out audit in primary andsecondary care.

Contact informationMelissa ReeveEmail: [email protected]

Atrial Fibrillation in Primary CareIpswich Hospital NHS Trust, Suffolk PCT, 17 GP Practicesand Primary Care, Suffolk Cardiac NetworkAnglia Cardiac Network



Issues to be addressedThe AF project in North Somerset is focusing onareas of the national project: a) diagnosis and;b) appropriate treatment, to reduce the risksassociated with AF:

• By increasing the rate of diagnosis of AF byopportunistically screening to identify newcases of AF

• By ensuring the appropriate management ofnew and existing patients with AF by:• Promoting the recent Avon, GloucestershireWiltshire and Somerset (AGWS) Cardiac andStroke Network Arrhythmia Guidelines andundertaking a post project audit of referralsto secondary care

• Reviewing the management of patientsusing the CHADS2 risk tool (Congestiveheart failure, history of hypertension, age >75, diabetes, stroke/TIA).

The AGWS Cardiac and Stroke Network is keenfor this project to be a supportive bridgebetween effective cardiac care and prevention ofstroke. Reduction of strokes will be the key longterm outcome - better identification andmanagement of atrial fibrillation is the key nearterm goal. The network is offering an incentiveof £2000 per practice for participation in thisproject linked to the identification of new AFpatients and review of existing patients.

Project commenced: January 2008

Baseline positionBaseline data was collected before screeningcommenced. This included the number ofpatients on AF registers and the percentage ofpatients >65 years old with known AF. A total of1516 patients were recorded with AF across theten practices. The range was 7.2 to 14.4 % withand average of 9.0%.

Data on the number of existing AF/AF flutterpatients who were prescribed or recorded ascontraindicated for Warfarin, aspirin, clopidogreland dipyridamole was also collected. Over theten practices the following patient prescribingpatterns were found:

On Contraindicated

Aspirin 23.4% 10.9%

Warfain 30.7% 14.4%

Clopidogrel 2.7% 8.6%

Dipyridamole 1.9% 7.4%

Actions taken and plannedPatients in the >65 age group are beingopportunistically screened between 1 Januaryand 31 December 2008 using the agreedpathway. Progress will be reviewed at threemonths. Practices will complete a ‘new patientproforma’ for each new patient identified.Doctors and nurses were asked to take pulsesopportunistically and code in the records. Amacro was created for speed and ease ofentering pulse. One practice has put a poster upin the waiting room explaining the project topatients, encouraging them to ask to have theirpulse taken.

All existing patients with diagnosis of AF/AFflutter will be reviewed by 31 December 2008using CHADS2 tool with 25% reviewed by 31March 2008. Practices will complete a ‘Proformafor Audit of Known AF Patients’.

Progress will be reported three monthly andfollowing each project meeting and as furtherrequired.

The project manager and co-ordinator, MaggieRobins, will ensure the systematic recording ofdata in a central spreadsheet and provide ananalysis ahead of project meetings.Improvements will be measured againstbaseline data including:

• Number and percentage of patients > 65 yearsof age newly identified with AF

• Number of patients on or contraindicated toaspirin, Warfarin, clopidogrel, dipyridamole

• Number and percentage of patients referred tosecondary care

• Audit of management in accordance with theAGWS Cardiac and Stroke NetworkArrhythmia Guidelines.

North Somerset PCT Atrial Fibrillaton in Primary Care ProjectNorth Somerset PCT and a cohort of ten GP practicesAvon, Gloucestershire, Wiltshire and Somerset Cardiac and Stroke Network


Key learning from the workCollection of data from practices is challengingand difficult for practices. A high level of detailis needed on how exactly practices need to sendin information as different practices havedifferent clinical systems, different ways ofentering data; many practices did need clinicalsupport especially for the medication searches.

With any project in primary care the difficulty isremembering to continue to engage becausethere are so many other things going on. Timelyreminders do help. Reviewing patients whoalready have a diagnosis is quite time consumingand it may be more appropriate for more moneyto be allocated for this part of the project andwill therefore be subject to review.

Funding each individual completed form for newAF cases does ensure they are completed andreturned.

Even with relatively high levels of known AFpatients it is possible to identify cases ofpreviously unknown AF using opportunisticscreening.

Results to date• Total new AF cases found: 13• Total pulses taken by five of thepractices = 897

• Number of practices who have reviewed someof their known AF patients = 5

• Number of known AF patients reviewed usingCHADS2 = 279

• From four practices with analysed data, tenpatients in total have been identified that werenot on medication, however four of thesedeclined Warfarin when recommended.

Contact informationElsa BrownEmail: [email protected]




Issues to be addressed• Audit to assess if appropriate patientsreceiving Warfarin

• Consortium review audit and considerimplication of findings

• Practices implement care pathway.

Project commenced: April 2008

Baseline position• PBC plan approved by consortia andProfessional Executive Committee (PEC) on the20 March 2008

• Bristol wide analysis being compiled tohighlight practices to work with (see below).

Actions taken• Compiling analysis across Bristol:• increased screening levels• improved management of AF patients

• Then target ten practices to work with toachieve the above aims

• Agree a monitoring and reporting system forthe PBC audit work.

Key learning from the work• Need to be persistent• Work with people you know who areresponsive and influential

• Need to• identify the incentives• present the problem• approach the issue as an opportunity.

Results to date• AF work included in PBC plan.

Contact informationRachel HolmesEmail: [email protected]

Management of Atrial Fibrillation in Primary CareInner City and East (Bristol) Practice Based Commissioning Consortia (PBC)currently supported by Bristol PCTTen further practices to be identified to work with across BristolAvon, Gloucestershire, Wiltshire and Somerset Cardiac and Stroke Network



Issues to be addressedAs nurses no longer routinely palpate pulses,asymptomatic AF may go undiagnosed.In order to find the unmet need it is necessary tofind a simple way of routinely screening the over65 population by palpating their pulses.

Project commenced: October 2007

Baseline position• 80% of over 65 population attend annualflu clinics

• National prevalence of AF from QOF is 1.30%,but this is thought to be too low

• Pemberley has 9433 patients and 174 knownAF patients giving a prevalence of 1.84%,already higher than the national average

• Pemberley felt that they already screenedopportunistically and did not believe that wewould find many new cases.

Actions taken and planned• Organised for two extra nurses to attend thetwo days of flu clinics and take the pulse ofevery attendee over 65 who was not alreadyon the AF register

• Organised and agreed to pay the practice forperforming a screening ECG on all patientsfound to have an irregular pulse

• Designed information leaflets for patients.

Key learning from the work• If practices above the national average for AFprevalence could increase their prevalence bysystematic screening to find their unmet need,practices below the national average couldfind even greater numbers

• Even practices that feel they are good atscreening could improve.

Atrial Fibrillation Screening Pilot ProjectPemberley Surgery, BedfordBedfordshire and Hertfordshire Heart and Stroke Network

Results to date• 345 patients were screened• 21 irregular pulses were detected• 14 agreed to attend for follow-up ECG• 7 new cases of AF were identified• New AF prevalence 1.9%

Contact informationDelyth WilliamsEmail: [email protected]



Issues to address• Improving access to diagnostics – ECG• Streamlining pathways and guidance forpatients with AF

• Improving access to anticoagulation services.

Project commenced: July 2007

Baseline position• Full review and audit carried out at WorcesterStreet Commissioning Cluster against NICEguidance July – September 07

• Investigation of QOF data – July 07• Baseline assessment of hospital admissions atRussells Hall Hospital.

Actions taken and planned• Baseline investigation at Worcester StreetPractice against NICE guidance

• Formation of project group as sub-group ofthe Coronary Heart Disease LocalImplementation Team (CHDLIT)

• Action planning at pilot practice followingbaseline assessment

• Searches at Worcester Street Practice toidentify further potential patients

• Review of patients identified by searches forpotential AF

• Development of draft AF guideline• Development of outreach anticoagulationclinic at Worcester Street Practice

• ECG provision training at Worcester StreetPractice for Health Care Assistants (HCA)

• Pulse checking for irregular rhythms added toall templates at pilot practice

• Finalisation of AF guidelines prior to pilot.

Action PlanAF patient journeyActively develop and agree a local pathway andguidance for the assessment, management andreferral of patients with AF:

• Comprehensive patient journey to cover bothprimary and secondary care interfaces

• Journey to be piloted at Worcester StreetSurgery

• Format both paper and electronic with links toexisting Long Term Conditions pathwayscurrently available in this format on DudleyPCT intranet

Atrial Fibrillation in Primary Care – Dudley Health EconomyDudley PCT, Dudley Group of HospitalsWorcester Street Commissioning Cluster (Pilot Site)Black Country Cardiac Network

• Launch of completed and ratified patientjourney to include educational sessions andongoing practice support

• Professional development – offer developmentopportunities to clinicians and practice supportstaff with clinicians to improve the earlydetection of AF by increasing awareness ofhigh risk groups and the importance of regularmonitoring

• Work in partnership with Black CountryCardiac Network and WolverhamptonUniversity in developing the CVD Skills Moduleforming part of the cardiovascular rollingprogramme

• Development of a rapid assessment arrhythmiaservice at Russells Hall Hospital.

QOF AF IndicatorsTo support practices in attaining higherthresholds for AF indicators in respect ofmanagement of people with AF:

• Through baseline review of borough wide AFprevalence from QOF registers, identificationof individual practice prevalence compared toaccepted UK prevalence

• To support practices to develop validated AFregisters in primary care, based on acceptedQOF prevalence rates.

Access to ECGTo improve the current access to both highquality recoding and reporting within theprimary care setting:

• Baseline audit of practices with access to andthe usage of ECG equipment within thepractice

• Development of ECG provision options paperto include cost provision, training needs,impact and expected outcomes

• To develop ECG competencies as a componentof a locally enhanced service.



Reducing Secondary RiskTo improve outcomes for patients with AF byreducing risk of cardiovascular complicationswith emphasis on the secondary development ofstroke and TIA:

• Expansion of hospital based anticoagulationservices to provide community outreach clinicsand domiciliary provision

• Baseline audit of practice based prescribing ofanticoagulation versus antiplatelet therapy tobe included in the annual audit programme ofPCT Medicines Management Team

• To explore the development of software inconjunction with MSD to risk stratify patientswho are not currently receivinganticoagulation

• Development with practices to riskstratify and review patients as a component ofa locally enhanced service.

Key learning from the workCommunication processes and joint workingbetween primary and secondary care.

Results to dateThere were originally 219 registered cases withAF at Worcester Street for a practice size of20,820, giving an actual prevalence rate of 1%.We identified a further 184 potential casesthrough the searches of which the majority werefound to have confirmed AF but had beenmiscoded to ‘History of AF’ giving us an actualprevalence of 1.9 %.

Patients now receive their anticoagulationinitiation and monitoring within the practicesetting and therefore closer to home.

Contact informationJoanne GutteridgeEmail: [email protected]



Atrial Fibrillation in Primary Care – Walsall Health EconomyWalsall tPCTWalsall Hospitals NHS TrustBlack Country Cardiac Network

Issues to be addressed• Develop Arrhythmia Care Pathway• Improve access to anticoagulation services inprimary care

• Improve access to ECGs.


Baseline position• Identified the proportion of AF patientscurrently prescribed anticoagulant/antiplatelettherapy during the Impact Campaign

• Baseline assessment of hospital admissions andlength of stay at Walsall Manor Hospital.

Actions taken and planned• Facilitated workshop held• Formation of project group as sub-group ofthe CHD Local Implementation Team and LongTerm Conditions Executive Sub Group

• Impact Campaign delivered to all GP practicesacross PCT

• Manual pulse checking added to templates atall GP practices

• Baseline investigation of AF patients currentlyprescribed anticoagulant/antiplatelet therapy

• Appointment of arrhythmia nurse to post anddevelopment of referral pathway fromprimary care

• Identified issues around the use of andinterpretation of ECGs and training andeducational opportunities for practices

• Searches at Lichfield Street Practice to identifyfurther potential patients

• Review of patients identified by searches forpotential AF

• Baseline audit of practices with access to andthe usage of ECG equipment within thepractice

• Develop draft AF guidelines• Continue to develop local pathway toarrhythmia clinic by spreading pilot sites forreferral of patients with AF

• Professional development – offer developmentopportunities to clinicians and practice supportstaff with clinicians to improve the earlydetection of AF by increasing awareness ofhigh risk groups and the importance of regularmonitoring

• Work in partnership with Black CountryCardiac Network and WolverhamptonUniversity in developing the CVD Skills Moduleforming part of the cardiovascular rollingprogramme

• To support practices in attaining higherthresholds for AF indicators in respect ofmanagement of people with AF. Throughbaseline review of borough wide AFprevalence from QOF registers, identificationof individual practice prevalence compared toaccepted UK prevalence

• To support practices to develop validated AFregisters in primary care, based on acceptedQOF prevalence rates

• To develop ECG competencies as a componentof a locally enhanced service.

Key learning from the workWell received within primary care following onfrom Impact Campaign.

Results to dateA total of 3233 patients were identified ashaving a diagnosis of AF (prevalence of 1.3%)Warfarin was prescribed in approximately 50%of all AF patients, aspirin alone in 32% ofpatients and clopidogrel in 4% of patients.However, 9% of patients did not appear to bereceiving any form of anticoagulant orantiplatelet therapy. These patients werereviewed to determine possible explanations,e.g. diagnosis, poor treatment, compliance. Ifappropriate, AF patients will be considered forWarfarin or aspirin in order to reduce their riskof ischaemic stroke.

Contact informationAngela NelsonEmail: [email protected]



Issues to be addressed• High referral rate to secondary care for AF• No direct referral for echo available• Opportunistic pulse check to pick upundiagnosed cases

• Quality of ECG interpretation• Recording of heart rate• Initiating Warfarin in primary care• INR monitoring – who to do and where isbest for everyone

• Warfarin to be considered as first linetreatment regardless of age andcontraindications clearly recorded if notsuitable and alternative treatments consideredand discussed with patients

• Cardioversion – more patients need to beconsidered for cardioversion and referred assoon as possible

• After referral all patients to have INR checksdone by lab to ensure consistent results,reducing risks of last minute cancellation forcardioversion as a result of INR not withinrequired levels

• Patient and clinician education.


Baseline position• Very few nurses and GPs, approximately 30%only, doing opportunistic pulse check

• >20% of cardiology referral due to AF,palpitation and flutter

• All practices achieving 90% in QOF fortreatment of AF patients but detailed auditresults revealed that only around 48% ofpatients are on Warfarin

• Prevalence already very good with a mean of1.46% on whole population

• A small number of practices initiate Warfarin,but this is extra work and cost with noadditional reimbursement currently. Othersstated that they do not want to do this

• A number of practices are doing near patientstesting for INR but there are potentialproblems about consistency of readings whenpatients are referred for cardioversion.

Actions taken and planned• Community based echocardiography service inSouth Warwickshire to include referral of AF.This is to be audited at the end of May toreview impact on referrals and possible rollout of service

• Met with consultants, GPs and nurses todiscuss proposed pathway

• Education day later this year to ensureimproved understanding of using CHADS2scoring system and importance of patienteducation and support.

Key learning from the work• Difficult to engage primary care• CHADS2 score not used by primary care andmany may not even be aware of this

• General reluctance to risk prescribing Warfarinto the elderly due to concerns about potentialbleeds

• Poor and no education of patients withdiagnosis of AF and no community support

• Patients following cardioversion who are atrisk of recurrence should be managed on longterm (life long) anticoagulation

• Difficulty getting financial support from PCTfor increased provision of rehabilitationservices.

Results to date• Practices where detailed audit was carriedout, started to:• use template to record heart rate• review patients with diagnosis of AF toensure correct diagnosis

• considered alternative, i.e. amiodarone, ifpatients refused Warfarin

• clearly note both clinical and socialcontraindication to Warfarin

• Community based echocardiogram servicestarted in February with good uptake to date

• Secondary care agreeing that most patientswith AF can be managed in the community.

Contact informationJuelene WhiteEmail: [email protected]

Develop, Agree and Commission Atrial Fibrillation PathwayWarwickshire PCT, Coventry PCT, George Eliot Hospital, South WarwickshireHospital and University Hospital Coventry and WarwickshireCoventry and Warwickshire Cardiovascular Network



Issues to be addressed• Data analysis• Practice engagement and commitment to findadditional workload.

Project commenced: Summer 2007

Baseline positionAll practices in Essex have had prevalence dataanalysed by calculating estimated numbers of AFpatients by age band and comparing this to thenumber of AF patients on QMAS.

Twenty practices have been identified withpossible patients missing from their AF register.

Actions taken and plannedOne pilot practice was contacted who agreed topulse palpate everyone over the age of 65 yearsduring normal routine consultation.

Number of patients seen during themonth who fit criteria 298

Number of patients with irregularpulse and sent for ECG 20

Number of new AF diagnosesfrom the ECGs 2

Total new AF diagnoses, including twoby practice nurses and possibleone hospital discharge 5

Number of new AF diagnoses in thesame period last year 5

Although pulse palpating everyone did notincrease the number of patients identified, it isstill thought to be a worthwhile exercise.

Additional practices are being contacted as partof the roll out. Practice data will be analysed incloser detail to see if there is a specific agegroup of patients missing who could betargeted.

Key learning from the workOne consideration for the difference betweenthe estimated and actual numbers of AF patientsis that many patients may have paroxysmal AFand have not reported palpitations to their GP orpractice nurse. Pulse palpation and ECG areonly diagnostic if patient is in AF wheninvestigated.

We will now design and supply the practiceswith a poster for the waiting room, encouragingpatients to report any palpitations.

Results to dateToo early for proper significant analysis.

Contact informationAlison SpringettEmail: [email protected]

Screening for Unidentified PatientsEssex Cardiac and Stroke Network and a cohort of GP Practices



Issues to be addressed• Target practices with low knownprevalence of AF

• Promote the concept of manual pulsepalpation for opportunistic screening ofpatients at high risk of AF

• Addition of pulse rhythm prompt (READ code2431) to chronic disease templates

• Review anticoagulation rates of patients withknown AF

• Review rate/rhythm management of patientswith known AF

• Develop primary care based rapid access clinicsfor patients with AF

• Support the identification and management ofpatients with arrhythmias across primary,secondary and tertiary care.

Project commenced: October 2007

Baseline position• 0.9% prevalence of AF in both Oldham andBolton PCTs, ranging from 0.1% to 1.7% and0.08% to 1.8%% respectively

• Acute trust provides access to diagnostics andmanagement of patients with AF throughsecondary care cardiology clinics

• Very little primary care provision for patientswith actual or suspected AF.

Actions taken and planned• Development of guidelines for themanagement of patients with AF

• Identification of practices with low knownprevalence of AF

• Use of statistical process control (SPC) toprioritise practices for education and trainingwith opportunistic screening, anticoagulationmanagement and rate/rhythm control ofpatients with AF

• Establishing contact with GP practices anddelivering update sessions for managementof AF

• Updating chronic disease managementtemplates to prompt for manual pulsepalpation

• Reviewing practice registers forimplementation of NICE guidelines for themanagement of AF

• Working with PCTs to determine most suitablemodel of rapid access clinic for patients withundiagnosed arrhythmia/AF.

Key learning from the work• Need for ongoing awareness sessions for allclinic staff including medical and nursingpersonnel to promote the implementation ofNICE guidelines for AF and recommendationsfrom Chapter 8 of NSF for CHD

• Need for IT support to assist with the updatingof chronic disease templates on some primarycare clinical management systems

• Pathways for access to diagnostics will need tobe developed between PCTs and acute truststo support the development of primary carebased clinical services

• Many GPs are content with secondary careinput for ongoing management of patientswith AF

• Support with ECG interpretation andarrhythmia diagnosis required across the PCTs.

Results to date• Initial work completed in eight practices acrossOldham and Bolton including update session(s)for practice staff, development of chronicdisease templates and register reviews.Prioritised roll out of programme to otherpractices in both PCTs to continue

• Recommendations for clinical managementmade to GP practice where appropriate

• Supported ECG acquisition in one practice• Further ECG and arrhythmia training sessionsbooked to take place in April-May 2008.

Contact informationJohn CampbellEmail: [email protected]

Atrial Fibrillation in Primary Care National ProjectOldham PCT, Pennine NHS Trust, Bolton PCT, Bolton NHS TrustGreater Manchester and Cheshire Cardiac and Stroke Network



Issues to be addressed• Under identification of AF patients• Low percentage of eligible patients with AFbeing anticoagulated

• The high number of marginal arrhythmiareferrals to secondary care outpatients

• Reduce the incidence of strokes• Increase the knowledge base of primary carethrough an Arrhythmia Education Plan

• Equitable standard of care and access inMedway.

Project commenced: September 2007

Baseline positionQOF data for Medway PCT suggests an underidentification of approximately 1300 AF patients.

Actions taken and plannedDeveloping a service model which will:• Provide nurse led primary care arrhythmiaclinics

• Undertake and co-ordinate the patient’sdiagnostic investigations

• Where necessary refer patients to secondarycare clinic for further management

• Manage appropriate patients within thearrhythmia service, or

• Refer patients back to the GP formanagement within primary care

• Help GP practices identify and search for AFand other arrhythmia patients.

Business case prepared and submitted.

Key learning from the workECGs are fundamental to ensuring an accuratediagnosis. Studies have shown that manyprimary care professionals cannot accuratelydetect AF on an ECG. Diagnosis of AF in thecommunity needs to have ECGs read byappropriately trained people. A communitydiagnostic service will be part of the primarycare arrhythmia service and has been built intothe business case.

Results to dateCurrently awaiting the outcome of a businesscase submission.

Contact informationTim WaiteEmail: [email protected]

Primary Care Arrhythmia Service – Medway PCTMedway PCT, The Medway NHS Trust (Medway Maritime Hospital)Kent Cardiac Network



Issues to be addressed• Ensure that AF prevalence in the practicesmatches what is expected nationally

• Ensure that all diagnosis has been confirmedas per NICE guidelines

• Ensure that all patients are receivingantiplatelet/anticoagulation therapy asappropriate

• Review prescribing trends for AF patientsagainst NICE/local guidelines

• Audit acute admissions and cardiology referralsfor AF patients

• Address training needs in particular aroundECG recording and interpretation

• Review local anticoagulant service and addressservice improvements.

Project commenced: December 2007

Baseline position• According to QMAS data AF prevalence in allbut one of the six pilot practices is abovenationally expected levels (King Street is auniversity practice). However, in some practicesregisters require validating in view of highelderly population

• Baseline data suggests that confirmation ofdiagnosis is good

• Prescribing data is still being collated, but earlyindications are that Warfarin prescribingparticularly in the >75s is lower thanrecommended

• Training needs assessed in relation to ECGrecording and interpretation

• Admission data for AF into RLI has beencollated and practices have submitted cardiologyreferral data from April 2007 to date.

Actions taken and planned• Developed a project guide to informstakeholders of background detail

• Visited each practice team individually tooutline project aims, request baseline data anddisseminate and discuss ‘Management of AFin Primary care’ guidelines

• Collating and analysing baseline data (workingwith network data analyst)

• Organising the delivery of ECG training withnetwork cardiac physiologist trainer

• Developed a communication plan to ensurethat stakeholders are kept informed ofdevelopments

• Set up a project steering group, withrepresentation from all stakeholders, in orderto agree aims and objectives and provideguidance and support to the project

• Liaising with colleagues in secondary care inrelation to the local anticoagulation service.

Key learning from the workIdentified recurring themes in relation to theidentification and management of patients withAF e.g.

• Prevalence in all age groups is generally higherthan expected nationally

• Practices need to ensure that pulse checksare inserted into all appropriate chronicdisease templates

• Alternative methods of opportunistic screeninghave been discussed and shared by allparticipating practices, focusing in particularthose at higher risk

• All practitioners have concerns about Warfarinprescribing in >75s

• Many GPs are accessing the localanticoagulant service differently and are notconfident that this aspect of their AFmanagement is being delivered effectively

• Offer of ECG training and updates receivedpositively from all practices.

Results to date• Practices have reported that as a result ofvalidation work, they have increased numberson their AF register

• As a result of discussions it was revealed thatfewer pulse checks are being performed sincethe arrival of digital BP machines and that thisneeded to be raised as an important issue withregards to opportunistic screening for AF

• Discussions have begun with colleagues insecondary care in relation to some redesignaround the anticoagulation service

• More guidance is being sought to supportWarfarin prescribing, particularly in >75s

• A number of developments have beenidentified for discussion by the PBC Consortia.

Contact informationLauren ButlerEmail: [email protected]

Managing Atrial Fibrillation in Primary CareSix GP practices in Lancaster and Morecambe, Royal Lancaster Infirmary (RLI),North Lancs Primary Care Trust, Lancaster/Morecambe Practice BasedCommissioning ConsortiaLancashire and South Cumbria Cardiac Network



Issues to be addressed• Spread of project• Warfarin/anticoagulation - service andmanagement

• ECG skills - taking and reading.


Baseline position• No standard referral or pathway informationavailable

• ECG reading and taking skills differ across thePCT

• Validation of registers not routinely carried out• Referral for Warfarin management notstandardised across PCT.

Actions taken and planned• Developed an information folder for GPs thatincludes pathways, referral process, treatment,QOF points, READ codes, validation of AFregisters and information regarding the NICEand clinical indicators for patients presentingwith AF

• Survey of practices across PCT assessing ECGskills and training needs. From this a basic‘taking an ECG’ training programme has beendelivered with reading ECGs skills trainingprogramme being developed

• Review of anticoagulation and Warfarinmanagement is being undertaken as part ofthe cardioversion service redesign

• Working with PCT data quality facilitators tosupport validation of AF registers.

All outcomes are currently being reviewed by GPpanel prior to spread which will be done bynetwork GP clinical lead using GP PLT.

Key learning from the work• Anticoagulation guidelines and service to bereviewed as part of the local redesign of thecardioversion service and the 18 weekpathway

• Compare QOF indicators one year on to see ifthe number of AF patients with an ECG hasrisen

• Further work on developing the ECG trainingin conjunction with the PCT.

Results to date• Folder for GP practices containing:• How to create and validate an AF register ingeneral practice

• QOF triggers along the AF pathway withBMA guidance

• A postcard for practices showing CHADS2score chart/example ECGs

• ‘Guidance on treatment of patientspresenting with AF symptoms showingreferral process’ (two sided with NICEreferences)

• Protocol for managing AF in GeneralPractice, Dr Shribman – Bugbrooke MedicalPractice

• Patient pathway showing diagnostics,information and referral process

• Delivered three sessions on ‘How to take anECG for practice staff’.

Contact informationBen KnightEmail: [email protected]

Managing Atrial Fibrillation in Primary CareNorthants PCT, Bugbrooke Medical PracticeLeicestershire, Northamptonshire and Rutland Cardiac Network



A practice of 15,133 patients in a rural/coastalarea, with a satellite clinic at Robin Hoods Bay

Issues to be addressed• 267 patients are on the AF register – 229 ofwhom are on anticoagulants. The existing INRtesting system for stable AF patients requiredblood specimens to be sent to ScarboroughHospital approximately 20 miles away

• The narrow parameters of the software usedresulted in patients being recalled and retestedmore regularly than was thought necessary

• Phoning for results and informing patients ofdosages required approximately 21 hours ofnursing time per week, with particular timedelays over bank holidays

• Non face-to-face changes of doses could resultin dosing errors

• Because of the restrictions of the transportservice, patients could only be offered morningappointments which could be problematicbecause of the rurality of the area and averageage of the patients

• Funding was not available via the PCT to pilotthe benefits of a near patient testing systemso the NEYNL Cardiac Network agreed topump prime this work.

The project aims to:• Reduce the number of INR tests required tomaintain good control

• Improve patient convenience• Improve efficiency in the use of GP/nurse time• Reduce the potential for dosing errors.

Project commenced: August 2007

Baseline position• Nursing time measured for phone calls for thecurrent service was a minimum 21 hours perweek

• AF registers showed 229 patients on Warfarinfrom a possible 267. A case note review wasperformed to ensure patients were notinappropriately untreated

• A satisfaction survey was performed on staffand patients. Whilst staff were dissatisfiedwith the service, patients found the currentservice efficient and were generally satisfied

• Overall costs of current service were difficult tocalculate. Costs of the new service are beingmonitored although comparison may proveunreliable.

Actions taken and planned• Equipment purchased by practice managerincluding three Coagucheck XS plusmonitoring machines, testing strips and INRstar software

• Staff were trained in the use of equipment andthe use of the software – initially practicenurses, but there are plans to roll this out todistrict nurses who will undertake hometesting

• Appointment slots being redesigned• Mechanism of calibrating equipment andvalidating tests set up with lab

• System set up within the practice with GP whowill check and advise on results if required

• Training delays have meant that there havebeen delays transferring to the new systemwhich finally went live week commencing10 March 2008.

Key learning from the work• This project is still ongoing, so learningcontinues. Initial experience shows that settingup new services often takes longer thanexpected and does not always run as smoothlyas hoped

• Cardiac network pump priming can act as acatalyst to service improvement – particularlyto projects which enthusiastic individualswould like to progress but cannot moveforward without a small amount ofinvestment

• Beware of patient satisfaction surveys – theydo not always provide the results staff expect

• Measuring current activity can reallydemonstrate waste in the system e.g. 21hours of nursing time spent on the phone.

Results to date• It is too early to have robust results yet butsome should be available by early May

• The practice based commissioning group arenow discussing rolling out near patient testingto other practices.

Contact informationCarol HargreavesEmail: [email protected]

Whitby Group Practice Near Patient INR Testing ProjectWhitby Group PracticeNorth and East Yorkshire and Northern Lincolnshire (NEYNL) Cardiac Network



Issues to be addressed• Assess current care of patients with AF or atrisk of developing it

• Develop an AF pathway• Review of ECGs within general practice• Training and development for primary carestaff. Identify those practices notparticipating

• Anticoagulation services• Stroke services


Baseline positionTo review what services are currently availablewithin primary and secondary care in Rotherhamfor patients with atrial fibrillation or for those atrisk of developing atrial fibrillation.

Actions taken and planned• Undertook a scoping exercise to identify whatis happening in other areas in relation to ECGmonitoring and reporting/telemetry/24 hourmonitoring and reported the findings back tothe Practice Based Commissioning group. AGP has put in a bid to deliver these services ona local level

• Undertook a scoping exercise to identify whattraining and competencies are available tosupport near patient testing for INR. This wasthen fed back to the Anticoagulation Group

• A programme of training and development forprimary care staff including:• Hypertension update• ECG basic interpretation and recording• Coronary heart disease (CHD) update• Diploma in CHD

• A review of all admissions with a primarydiagnosis of atrial fibrillation during 2007

• ECG provision and interpretation withinprimary care has been assessed. This reviewedwhether patients were being seen in the GPpractice or referred to the open access ECGdepartment, training needs, who wasinterpreting the reports and whether or notreports were being sent to the cardiologist andif so why. This report is being fed back to thecare pathway group

• A review of heart failure patients with three ormore admissions identified that a number alsohad atrial fibrillation

• There is an established anticoagulation groupand they have been reviewing the possible useof near patient testing for INR in primary care.The funding has been identified and thisservice is to be developed – training andguidelines are to be developed

• The CHD Local Implementation Team (LIT) hasnow encompassed stroke and is now thecardiovascular disease (CVD) LIT and the leadphysician from secondary care has joined thegroup

• A meeting about stroke was held forstakeholders within the network to identifycurrent care and how services can bedeveloped further. Key people from bothprimary and secondary care attended

• A stroke project group has been developedand this will feed into the CVD LIT. Itencompasses members from both secondaryand primary care

• Work is being undertaken to target patientsfrom within the South Asian population whohave or are at risk of developing cardiovasculardisease. A meeting is being held withmembers of the South Asian HealthFoundation to assess how this group of peoplecan be engaged. This also links in with workaround BME and equity

• The pharmacy advisors are to reviewprescribing for atrial fibrillation patients withinprimary care to identify if there are any issuesand whether there is a training need

• Hypertension guidelines have been developedfor use in primary care.

Atrial Fibrillation in Primary CareRotherham PCT, Rotherham Hospital NHS Foundation TrustNorth Trent Network of Cardiac Care



Key learning from the work• May need a time limited project group to drivethe work forward

• Training needs to be ongoing• There is very little training or competenciesavailable to support near patient testing inprimary care and this needs to be assessed

• The work around AF may need to belinked to the work for stroke

• Need to map current AF services within thehealth community

• To continue the project• To link in with the AF pathway which has beendeveloped by the North Trent Network ofCardiac Care

• That patients who are diagnosed with atrialfibrillation need to get on the appropriatepathway of care, with the appropriatetreatment

• Although the majority of practices have sentstaff to training updates, some have not andthese are to be identified and targeted.

Results to date• Funding has been identified and a near patienttesting service for INR is to be developedwithin primary care

• A GP has put in a bid for a PBC service toundertake and review ECGs/24hourmonitoring etc

• The CHD LIT has now become the CVD LIT,and the stroke lead physician from the acutetrust has joined the group as has the PCT leadperson for stroke

• A stroke project group has been establishedcovering secondary and primary care

• To identify work and services relating to atrialfibrillation and put this into a report formatwhich will then be presented and an actionplan developed at the next care pathwaymeeting in May 2008.

Contact informationAnn BainesEmail: [email protected]



Issues to be addressed• Engaging practices• Agreeing data set• Monitoring anticoagulation for thehousebound and care homes

• Agreeing referral criteria/process for rapidaccess AF clinic

• Managing the interface between primary andsecondary care.

Project commenced: September 2007

Baseline positionIdentification and management of atrialfibrillation (AF) is variable across the city.National reported prevalence is 1.29%compared with 1.5% PCT prevalence. Inaddition there is considerable under diagnosis,demonstrated by the wide variation 0.20% -3.29% in QMAS (QOF) reporting for 2006/7.The percentage of patients with AF who arecurrently treated with anticoagulation or anantiplatelet therapy is also variable across thecity, suggesting that patients may be missing outon treatments to reduce their risk of stroke.There appears to be some inequity in access toanticoagulation services for the housebound andthe elderly.

Actions taken and planned• Key stakeholders identified and a projectgroup established

• Ten practices linked to the enhanced publichealth programme were identified and invitedto participate in the project

• Query set under discussion• Meetings with the first wave (five) practicesarranged to discuss the project and issuesspecific to practices

• Working with the acute trust on thedevelopment of rapid access AF clinic

• Discussing anticoagulation service provision forthe housebound and care home patients.

Key learning from the work• Test out data query set prior to commencingsearches in practices

• Perceived issues by project group not alwaysissues for practices

• Initially engage with those practices whoexpress an interest in participating

• Gaining support from the PEC has been key toengaging with practices

• Establish what practices require beforedeveloping guidelines, protocols etc.

Results to date• Data query set tested and is now underrevision

• First wave (five) of practices invited toparticipate

• Appointments made with four of the fivepractices

• First practice agreed to participate• Secondary care pilot of rapid access AF clinicdue to commence in April.

Contact informationColette LongfordEmail: [email protected]

Identification and Management of Atrial Fibrillation in Primary CareSheffield Primary Care Trust, Sheffield Teaching Hospital NHS Foundation TrustNorth Trent Network of Cardiac Care



Issues to be addressedTo improve the ongoing management ofpatients with AF in primary care.

Project commenced: November 2007

Baseline positionA preliminary audit from one practice suggestedat least 30% of patients on the AF register couldbenefit from having their therapy optimised.

Actions taken and plannedAn audit was carried out of AF treatmentagainst NICE guidelines in two practices, in twoseparate PCTs. Key findings were:

• Although 90% of AF patients were prescribedantithrombotic therapy, 65-70% of those onaspirin or clopidogrel should have been onWarfarin

• A substantial number of patients wereprescribed either digoxin only for rate controlor no rate control at all

• That AF patients were not regularly reviewedand their stroke risk was not re-evaluated.

These results were fed back to the practicesconcerned, highlighting specific patients forreview. It is planned to re-audit these patients inthree to six months to assess the full impact ofthe audit.

Following these initial audits, we are in theprocess of rolling the audit out sector wide.Because of different levels of expertise andresource in primary care, this is being addressedin a number of ways:

• Development of an audit template for useacross the sector

• Targeting of practices that have lower thanaverage QOF returns for AF to offer support tocarry out the audit

• Offering audit template to PCTs and PBCgroups for local implementation

• Development of simple care pathway for AFpatients in primary care

• Inclusion of review and maintenancerecommendations in discharge letters fromoutpatients clinics in secondary and tertiarycare

• Education event.

Key learning from the workIn primary care, AF patients are not reviewedregularly, and their treatment is sometimessuboptimal. These patients can be identified byaudit to allow optimisation of their treatment.

Results to date• Initial audit carried out and fed back to sectorwide steering group

• Plan for sector wide approach agreed• Dissemination agreed.

Contact informationLaura GillamEmail: [email protected]

A Sector Wide Approach to Optimising Therapy forAtrial Fibrillation Patients in Primary CareFive PCTs and four acute trusts in South West LondonSouth West London Cardiac and Stroke Network



Issues to be addressed• Awareness and knowledge of atrial fibrillationamongst clinicians in primary care

• Appropriate treatment of atrial fibrillation andwhen to refer for a specialist opinion

• Improving the detection of atrial fibrillationamongst older people

• Highlighting patients who require a review ofanticoagulation medication.


Baseline positionThirteen practices are taking part in the pilot,with a combined population of 107,304. Ofthese patients, 1,346 were already registered byMarch 2007 as having AF giving a prevalence of1.25%.

Actions taken and plannedCurrently, all 13 practices have started theopportunistic screening phase of the project.They have been encouraged to carry out pulsepalpation of all patients over the age of 75 yearsthat attend the practice. This may be expandedto all patients over the age of 65 yearsdepending upon the initial outcomes.

Three GP education updates have been held thatattracted 35 GPs and several practice nurses.These were led by the consultant cardiologistwho is involved with the project and were auseful launch pad for the project itself.

Practices will be also trialling the usefulness of ahand-held ECG device in detecting AF amongstthe subset of patients who are not symptomaticwhen they attend surgery but report symptomsof AF at other times.

After this, it is intended to run a MIQUEST queryon current AF patients to highlight those in needof a review. This query is currently beingdeveloped by another network that is workingon making it compatible across all GP systems.

Key learning from the work• GPs have welcomed the local educationalupdates and reported that they would changecertain aspects of their practice as a result ofattending e.g. earlier warfarinisation

• The hand-held device (OMRON HeartScan) isseen as a useful adjunct to usual practice butthere have been problems with the softwareand compatibility with GP systems that havedelayed its use in several practices.

Results to dateNo results so far, aside from good participationamongst practices without the need to providefinancial incentives so far. They have allwelcomed the educational aspect of the projectand have been keen to try out the new devices.

However, no firm results as of yet with respectto detection rates or improvements inmanagement of current AF patients.

Contact informationLiz PatroeEmail: [email protected]

Atrial Fibrillation in Primary Care Project – West SurreyGeneral practices in Woking and West Byfleet,Surrey PCT and St. Peter’s Hospital, ChertseaSurrey Heart and Stroke Network



Issues to be addressedEarly stages of project:

• Commitment from organisations• Difficulties following commissioning a patientled NHS (CPLNHS) to identify portfolio lead forcardiac and stroke for this project.

Possible future issue to ensure work is spreadand continues across rest of city by fitting inwith PCT structures.


Baseline positionThe only baseline data available at the beginningof the project was QOF data related to thenumber of patients on AF registers. This wouldnot get us a true and accurate figure of actualnumbers of patients whose condition wasmanaged in line with NICE guidance. A moreaccurate figure would follow once the projectbegan exploring further with individual practices.

Actions taken and planned• Pulled together a project group to begin toagree project aims and outcomes

• Identified time for arrhythmia specialist nursesto commit to project

• Identified practices to support project basedon geographical location and social status toensure as fair representation as possible acrossthe city

• Developed a CD tool to interrogate GPsystems in order to risk stratify AF patients onthe register using CHADS2. This tool has beendeveloped to interrogate systems other thanSystem1 and have been trialled during theproject.

Ongoing:• Continuing work on the tool to ensure it isuser friendly and also working on making itcompatible with System1

• Contacting practices involved in project toensure results of the project are collected andproduced for national team

• Working closely with practices in the project toact on results once tool has been adoptedusing a menu of options, either one to onesupport, opportunistic or utilising thearrhythmia clinic at LTHT, all supported byarrhythmia nurses

• Linking into PCT to ensure the project isspread across the rest of the city

• Ensuring the project spreads across the rest ofWest Yorkshire via WYCN.

Key learning from the workAlthough not a surprise, the actual time takento get the project off the ground and allinvolved signed up was longer than anticipateddue to time constraints of project members;again as always a key learning point. Also,actual visiting of practices to enrol in project waschallenging both in gaining access and timerelated to fitting into practice time.

Results to date• CD tool developed and results from it positivein terms of time taken to perform and visually,how information is presented

• Discussions commenced with expert help tomake it user friendly and compatible withSystem1

• Results from project will be collated andshared.

Contact informationAdele Graham and Keith TyndallEmail: [email protected]: [email protected]

Optimising Atrial Fibrillation Management and Atrial FibrillationRelated Stroke Prevention in LeedsLeeds PCT, Leeds Teaching Hospitals NHS Trusts (LTHT)West Yorkshire Cardiac Network (WYCN)


Project Team Leadsand Participating Sites





Project Team Leads and Participating Sites

Anglia Cardiac NetworkMelissa Reeve, Julie Collier, HannahDrinkwater, Genevieve DaltonIpswich Hospital NHS Trust, Suffolk PCT, GPs andPrimary Care, Suffolk Cardiac Network.

Avon, Gloucestershire, Wiltshire andSomerset Cardiac and Stroke NetworkElsa Brown, Rachel HolmesNorth Somerset PCT and the following GPpractices: Clevedon Riverside, Nailsea FamilyPractice, The Green Practice, Sunnyside, LongAshton, Nailsea and Backwell, Riverbank,Winscombe, Wrington and Churchill, Yatton andCongresbury, Inner City and East (Bristol) PracticeBased Commissioning Consortia (PBC) currentlysupported by Bristol PCT. Ten further practicesto be identified to work with across Bristol.

Bedfordshire and HertfordshireHeart and Stroke NetworkCandy Jeffries, Delyth WilliamsPemberley Surgery, Bedford

Black Country Cardiac NetworkJoanne Gutteridge, Angela NelsonDudley PCT, Dudley Group of Hospitals,Worcester Street Commissioning Cluster,Walsall tPCT, Walsall Hospitals NHS Trust

Coventry and WarwickshireCardiovascular NetworkJuelene WhiteWarwickshire PCT, Coventry PCT, George EliotHospital, South Warwickshire Hospital andUniversity Hospital Coventry and Warwickshire

Essex Cardiac and Stroke NetworkAlison SpringettEssex Cardiac and Stroke Network anda cohort of GP practices

Greater Manchester and CheshireCardiac and Stroke NetworkJohn CampbellOldham PCT, Pennine Acute NHS Trust, BoltonPCT, Bolton Acute NHS Trust

Kent Cardiac NetworkTim WaiteMedway PCT, The Medway NHS Trust(Medway Maritime Hospital)

Lancashire and South CumbriaCardiac NetworkLauren Butler, Jeannie HayhurstSix GP practices in Lancaster and Morecambe,Royal Lancaster Infirmary (RLI), North LancsPrimary Care Trust, Lancaster/MorecambePractice Based Commissioning Consortia

Leicestershire, Northamptonshire andRutland Cardiac NetworkBen KnightNorthants PCT, Bugbrooke Medical Practice

North and East Yorkshire and NorthernLincolnshire Cardiac NetworkCarol Hargreaves, Melanie DunwellWhitby group practice

North Trent Network of Cardiac CareAnn Baines, Colette LongfordRotherham PCT and Rotherham Hospital NHSFoundation Trust, Sheffield Primary Care Trust,Sheffield Teaching Hospital Foundation Trust

South West London Cardiac NetworkLaura Gillam, Michelle BullFive PCTs and four acute trusts in South WestLondon

Surrey Heart and Stroke NetworkLiz Patroe, Vanessa LodgeGeneral practices in Woking and West Byfleet,Surrey PCT and St. Peter’s Hospital, Chertsey

West Yorkshire Cardiac NetworkAdele Graham, Keith TyndallLeeds PCT, Leeds Teaching Hospitals NHS Trust

National Team Members

Dr Campbell CowanNational Clinical Lead, Consultant Cardiologist

Dr Strat LiddiardNational Clinical Lead, General Practitioner

Ian GoltonDirector, NHS Improvement

Sue HallNational Improvement Lead, NHS Improvement

Anne ColemanPersonal Assistant, NHS Improvement

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Atrial Fibrillation in Primary Care Project - National Priority Projects 07/08 Summary Document