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SCHEDULE 2 – THE SERVICES

A. Service Specifications

Service Specification No: Version 20

Service Atrial Fibrillation: Detect and Protect Locally Commissioned Service

Commissioner Lead Keith Hoare, Bruce Allan

Provider Lead

Period 01/10/2021 – 30/09/2024

Date of Review 01/10/2023

1. Population Needs

1.1 National/local context and evidence base The NHS Long Term Plan identifies stroke as a new national priority for the next 10 years1. Public Health England (PHE) has set an objective to reduce the incidence of avoidable AF- related strokes by 5,000 nationally over the next 5 years, and the following areas have been identified to help reduce the incidence of avoidable AF-related strokes2:

a) Improving the detection of AF b) Regular systematic audit in all practices to identify those at risk who are either not, or are sub-optimally, anticoagulated c) Strengthening clinical leadership on AF

AF is the most common type of irregular heart rhythm with over 1 million people in the UK living with the condition. The prevalence increases with age. People with AF have a five-fold increased risk of stroke and account for between 20% and 30% of the 110,000 new strokes each year in the UK. AF-related strokes have trebled in people aged 80 years or older in the past 25 years and will continue to increase as more people live longer with the condition. The consequences of not identifying and treating patients with known AF at risk of stroke with protective anticoagulant therapy can be devastating. In England in 2019/2020 there were 5,755 people who experienced a stroke with known AF prior to hospital admission, who were not prescribed anticoagulant therapy at the time of their stroke. Stroke is a significant cause of disability. In England, two thirds of stroke survivors leave hospital with a disability. The strategy for the NHS is focused around case finding and early treatment of CVD risk factors including hypertension, hypercholesterolemia and Atrial Fibrillation. It recognises the under detection and sup-optimal treatment of these risk factors. If these are managed

1 NHS Long Term Plan, 2019 https://www.longtermplan.nhs.uk/ 2 AHSN Business Case: Improving AF Identification and Optimising Management to Prevent AF-Related Stroke http://www.londonscn.nhs.uk/

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correctly, with both lifestyle changes and pharmacological interventions, a significant reduction in morbidity and mortality can be achieved. Personalised care and access to specialist care in a timely manner will play an integral role in achieving the ambitious target over the next 10 years (NHS 2019). This Locally Commissioned Service (LCS) builds on the QOF requirements and is designed to help Sussex meet the national targets for the detection and treatment of AF. The QOF target for anticoagulation in AF is 70% and allows for exception reporting. The national targets for AF are as follows:

• Detection: 85% of the expected number of people with AF to be diagnosed by 2029 • Treatment: 90% of the total number of people diagnosed with AF, and who are at

high risk of stroke, to be treated to target (as per NICE guidelines) by 2029. According to Quality and Outcomes Framework (QOF) data 2019-20 for Sussex CCGs (See Appendix 1):

• 47,753 people are on practice AF registers in Sussex. Based on estimated prevalence figures from Public Health England there could be over 6000 people with undiagnosed AF in Sussex.

• 85.4% of patients with known AF and at high risk of stroke, in Sussex, are anticoagulated.

All practices are expected to provide essential and those additional services they are contracted to provide to all their registered patients. This LCS specification for Atrial Fibrillation: Detect and Protect outlines the more specialised services to be provided. No part of this specification by commission, omission or implication defines or redefines essential or additional services. This service must be provided in a way that ensures it is equitable for patients in respect of race, creed, culture, diversity, disability, sex and age. 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely X Domain 2 Enhancing quality of life for people with long-term

conditions X

Domain 3 Helping people to recover from episodes of ill-health or following injury

X

Domain 4 Ensuring people have a positive experience of care

X

Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm

X

2.2 Local defined outcomes The aspiration of this LCS for Sussex NHS Commissioners is to go beyond the national targets, where possible and clinically appropriate, as follows:

• 90% of the expected number of people with AF will be diagnosed by 2025 (currently 87.6%)

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• 90% of patients with AF at high risk of stroke will be adequately anticoagulated by 2023 (currently 85.4%)

(These aspirations apply to the whole of Sussex rather than individual practice populations, as estimated prevalence figures cannot be applied accurately to small populations) The records of all patients with AF who are at high risk of stroke and who are not currently prescribed anticoagulation will be reviewed annually as to the suitability or otherwise of anticoagulant therapy. Where anticoagulation is not suitable, a clear record will be made as to the reasons.

The DOAC and Warfarin LCS will ensure that all patients with AF who are currently prescribed anticoagulation are reviewed at least annually to ensure optimisation of current treatment. 3. Scope 3.1 Aims and objectives of service The aims of this service are threefold. Aim 1: to improve detection of undiagnosed AF by embedding opportunistic case finding (‘pulse checks’) of registered patients aged 65 years or over (not on the AF register) in routine appointments Objective:

• For 2020/21 (6 month part year effect): to provide pulse checks to 20% of registered patients aged 65 years who are not already on the AF register

• From April 2022 onwards: to provide pulse checks to 50% of registered patients aged 65 years who are not already on the AF register, each year

Aim 2: To ensure all patients on the AF register who are not currently prescribed anticoagulants have their stroke and bleeding risk assessed and, where at high risk of stroke and appropriate, are prescribed anticoagulant therapy in line with national guidance Objectives:

• For 2021/22 (6 month part year effect): to undertake an annual review of 50% of patients on the AF register who are not currently anticoagulated to ensure they have had an up to date stroke risk assessment using CHA2DS2VASc, and an assessment of bleeding risk, using either ORBIT (NICE NG196 guidance preferred tool) or HAS-BLED scores

• From April 2022 onwards: to ensure all patients on the AF register who are not currently anticoagulated have had an up to date stroke risk assessment using CHA2DS2VASc, and an assessment of bleeding risk, using either ORBIT (NICE NG196 guidance preferred tool) or HAS-BLED scores

• To ensure all patients considered at high risk of a stroke (CHA2DS2VASc score two or more in women or one or more in men) are assessed and offered anticoagulant therapy where appropriate

• To identify and document the reason on all patients at higher risk who are not currently on anticoagulation

• To increase the number of patients at high risk of stroke prescribed anticoagulation for stroke prevention in AF

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Aim 3: To educate practice staff on the use of stroke risk assessment tools, bleeding risk assessment tools and the role of anticoagulation in stroke prevention in AF Objectives:

• Practice representative to attend Sussex NHS Commissioner led educational session(s)

• Practices to hold an educational session regarding AF each year, informed by practice performance data regarding relative prevalence and treatment rates

3.2 Population covered and Health Inequalities All patients registered with a Sussex GP practice are eligible. This service must be provided in a way that ensures it is equitable for patients in respect of race, creed, culture, diversity, disability, sex and age. 3.3 Service description/care pathway Practices should familiarise themselves with the AF toolkit https://aftoolkit.co.uk/. The AF Toolkit model of care consists of three components:

1. Detect - targeted case finding to identify previously undiagnosed AF 2. Protect - prescribing anticoagulation therapy unless contraindicated 3. Perfect - optimisation of anticoagulant therapy (This part is addressed by the

separate DOAC and Warfarin LCS specifications) Practices signing up to this LCS are not obliged to participate in all parts. The ‘detect’ (pulse checking) section should be considered to be optional, whereas the ‘protect’ and ‘education’ parts are obligatory. 3.3.1 DETECT A manual pulse check is the simplest, most cost effective method of identifying undetected AF. Opportunistic case finding of patients those aged 65 years and above has been proven to be the most cost-effective strategy. Further information can be found at https://aftoolkit.co.uk/detect-find-more/ Practices are asked to implement pulse checks into routine clinical practice. For the second two quarters of 2021/22 practices are asked to aspire to provide pulse checks to 20% or more of patients aged 65 years (excluding those already on the AF register). From April 2022, practices are asked to aspire to provide pulse checks to 50% or more of patients aged 65 years (excluding those already on the AF register) each year. An average practice with 10,000 patients can expect to have circa 2,000 patients aged 65 years or over and should therefore aim to provide 1,000 pulse checks over a full year if possible. Additional payments are available for meeting the aspiration targets set (see section 6).

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Implementation of manual pulse checks in clinical settings is a matter for individual practices but the following settings should be considered:

• Influenza and other vaccination clinics • Chronic disease clinics and NHS health checks • GP/ANP face to face appointments • Phlebotomy appointments

Note that practices might expect 70% or more of patients aged 65y or over to attend for influenza vaccination each year. Implementing pulse checks as part of influenza vaccination can be an effective strategy. Practices should use the code-set in section 5 to indicate that a pulse check has occurred. Clinical record systems provide the ability to write clinical alerts to remind clinicians to perform pulse checking on an annual basis and practices should consider this. Practices may wish to consider the use of digital devices to detect AF. The use of digital devices in clinical practice to detect AF has been increasing rapidly over the past few years, as have the number of different devices available on the market. Although the value of a manual pulse check should not be overlooked, many of these devices are proven to be more sensitive and specific than a manual check alone. Further information can be found at https://aftoolkit.co.uk/detect-find-more/detection-devices/ Staff performing pulse checks must have appropriate training. Practices must have clear processes in place for staff performing pulse checks to report any abnormal findings to an appropriate clinician.

• If pulse irregular or unsure, a single lead ECG can be helpful to confirm the underlying rhythm

• In all cases a 12 lead ECG should be performed • Clinician should then review for diagnosis and treatment

3.3.2 PROTECT Practices should identify all patients with AF (as defined by QOF register AF001) who are not currently prescribed anticoagulation by:

• Running their own searches and reports • Using searches and reports provided by Sussex NHS Commissioners • Using search tools such as CDRC, PRIMIS, UCL CVD Proactive Care Frameworks

o https://uclpartners.com/proactive-care/ o https://uclpartners.com/proactive-care/search-and-risk-stratification-tools/

All patients with AF should have an up to date CHA2DS2-VASc score. All patients with AF (regardless of any QOF exception reporting) with the following should have their medical record thoroughly reviewed and a clinical decision made as to whether anticoagulation may be appropriate:

• CHA2DS2-VASc score of 2 or more in women or 1 or more in men;

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• not currently prescribed anticoagulation. NICE guidance NG196 states as follows:

1.6.3 Offer anticoagulation with a direct-acting oral anticoagulant to people with atrial fibrillation and a CHA2DS2-VASc score of 2 or above, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance

1.6.4 Consider anticoagulation with a direct-acting oral anticoagulant for men with atrial fibrillation and a CHA2DS2-VASc score of 1, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban and rivaroxaban are all recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance

Each patient to be considered for anticoagulation should have their bleeding risk assessed using either ORBIT (NICE NG196 guidance preferred tool) or HAS-BLED scores. Practices may continue to use HAS-BLED until ORBIT is embedded in clinical pathways and practice electronic systems. To organise this work, practices may wish to consider the AF Virtual Clinic Model https://aftoolkit.co.uk/protect-treat-more/af-virtual-clinics/ Practices may find it helpful to download the following information into a single report or spreadsheet:

• Patient name, age, identifier • Last CHA2DS2-VASc score and date • Last ORBIT or HAS-BLED score and date • Anticoagulation codes date and text (declined, not tolerated, not indicated,

contraindicated) • Adverse reaction codes date and text (apixaban, rivaroxaban, edoxaban, dabigatran,

warfarin) Actions required

1. Patients suitable for anticoagulation should be contacted, assessed and offered appropriate medication.

2. Where patients have declined anticoagulation in the past, it is appropriate to contact them to offer a review in order to confirm informed dissent and that their decision is still valid.

3. Where anticoagulation is not appropriate, this must be recorded in the patient record

using one of the following codes with associated explanatory text (whether or not the patient has been exception reported from the AF domain for QOF) • Anticoagulation not indicated • Anticoagulation contraindicated • Anticoagulation declined • Anticoagulation not tolerated

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4. Patients whose records have been reviewed according to this specification should

have the following code added to the record: • Atrial fibrillation annual review

In this way every patient with AF should be accounted for each year as being in one of the following groups:

• Currently prescribed an anticoagulant • CHA2DS2-Vac score one or zero not on anticoagulant • CHA2DS2-Vac score two or more

• Recorded as to a) the reason why not anticoagulated and b) that a review has been done

Evidence that the work has been satisfactorily completed must be submitted for full payment annually (see sections 5 and 6). 3.3.3 EDUCATION It is a requirement of this LCS that relevant practice clinicians attend the following:

• Sussex NHS Commissioner led education session(s) on AF and anticoagulation • An in-house or PCN based education session on AF / anticoagulation.

In support of the latest NICE Guidance NG196 practices are recommended to refer to the NICE AF algorithm – see link below: NG196 Algorithms for atrial fibrillation: diagnosis and management (nice.org.uk) Practices may find the following an interesting basis for discussion: https://aftoolkit.co.uk/anticoagulation-myth-busters/ Practices may also find the following useful:

• Home - CHSS eLearning - free e-learning platform with Stroke, AF and other CVD modules for healthcare professionals.

• Proactive care frameworks | UCLPartners - UCL partners proactive care frameworks launched 2020

• https://www.stroke.org.uk/professionals/stroke-prevention - professionals network Practice data on prevalence and treatment rates should be discussed at practice based or PCN meetings. Sussex NHS Commissioners intend to provide practice based comparative data as a basis for discussion at in-house meetings.

There should be at least one session annually at which most clinicians attend. Practices do not have to provide evidence of such a meeting unless requested to do so but it may be required as part of post payment verification.

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3.4 Any acceptance and exclusion criteria and thresholds This LCS covers patients who meet these criteria:

• Detect – all patients registered with a practice in Sussex aged 65 years and above • Protect - all patients registered with a practice in Sussex who are on the practice AF

register (as defined by QOF AF001). 3.5 Interdependence with other services/providers The ‘Perfect’ part of the ‘Detect, Protect, Perfect’ Model is addressed in the DOAC and Warfarin LCS specifications. The diagnosis of AF should be confirmed by 12 lead ECG which is commissioned from general practice via the ECG LCS. 4. Applicable Service Standards The Provider is responsible for ensuring that:

• premises used are registered with the Care Quality Commission (CQC) and the service is provided in a suitable setting

• equipment meets all criteria set out in national and local guidance and is maintained in line with manufacturer’s guidance

Summary of requirements

• Implement pulse checking for AF in the practice (optional)

• Training for all staff performing pulse checks • Aspire to provide pulse checks to 20% of those 65y

and over (not on the AF register) in 2021/22 and 50% each year thereafter (optional)

• Account for the anticoagulation status of all AF patients each year (in 2021/22 undertake annual reviews on 50% of those on AF register and at high risk of stroke but not anti-coagulated)

• Make appropriate records to support any decision not to anti-coagulate

• Clinicians to attend an education session on AF annually

• Annual self-declaration that quality standards have been met

• Agreement to automatic extraction of practice data related to this specification

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• training meets all relevant criteria set out in national and local guidance • any serious incidents within this service are reported to the CCG • infection control guidance is adhered to

4.1 Applicable national standards (eg NICE)

NICE guideline NG196: Atrial fibrillation diagnosis and management - https://www.nice.org.uk/guidance/ng196

4.2 Applicable standards set out in Guidance and/or issued by a competent body

(eg Royal Colleges)

All providers must meet CQC standards. It is also recommended that providers give due regard to the UCL Partners CVD Proactive Care AF Framework - https://uclpartners.com/work/increasing-detection-and-treatment-for-atrial-fibrillation/

4.3 Applicable local standards Quality Requirements

• The provider is required to have a Serious Incident policy and procedure in place and to follow the serious incident procedure in the event of a notifiable incident related to this Service. Serious incidents related to this service should be reported to the CCG quality team

• Important, potentially recurrent, problems involving other providers should be submitted to PQIT (Provider Quality Improvement Tool) https://www.sussexccgs.nhs.uk/clinical/quality-improvement/

• Clinical Governance arrangements for this service are as set out in Schedule 5 of the NHS Standard Contract. In addition, the provider is required to evidence an effective system of clinical governance, and put in place appropriate and effective arrangements for quality assurance, continuous quality improvement and risk management.

• All data kept for this LCS must adhere to appropriate Information Governance and data security policies.

• Providers will be required to comply with all National Quality Requirements set out in the NHS Standard Contract which can be found at www.england.nhs.uk/nhs-standard-contract.

4.4 Training requirements

• Practices should comply with the education requirements for clinicians in section 3.3.3

• Staff performing pulse checks should have appropriate training, at the discretion of the practice

• Practices will be expected to make a self-declaration annually that they have met the quality requirements of this service

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5. Coding, Records and Data Quality Providers must use NHS Sussex Commissioners approved codes in order to support automated data extraction, as follows:

• O/E pulse rhythm • O/E pulse rhythm regular • Pulse regular • O/E irregular pulse • O/E pulse regularly irregular • On examination – pulse irregularly irregular • Pulse irregular • Exception reporting – AF quality indicators • Excepted from AF quality indicators – informed dissent • Excepted from AF quality indicators – patient unsuitable • Anticoagulation not indicated • Anticoagulation contraindicated • Anticoagulation declined • Anticoagulation not tolerated • Atrial fibrillation annual review

Codes used to trigger payment must be ‘reserved’ for that purpose and practices must have systems in place to avoid ‘coding creep’ or ‘up-coding’.

Adequate records must be maintained to provide an audit trail for post payment verification purposes.

Anonymised data will be automatically extracted from practice systems on 1st April each year, as described in the table below. Practice Number of patients 65y or over on 31st March Of the above, Number who are recorded as having had a pulse check in the preceding 12 months

Number of patients on practice AF register AF001 Of the above, Number NOT currently prescribed anticoagulation Of the above, in the last 12 months Number with CHA2DS2-VASc score of >1 (female) or >0 (male)

Of the above, number last recorded (in the last 12m), Number recorded ‘anticoagulation not indicated’ Number recorded ‘anticoagulation contra-indicated’ Number recorded ‘anticoagulation declined’ Number recorded ‘anticoagulation not tolerated’ Number recorded with ‘AF annual review’ Number exception reported from AF – informed dissent Number exception reported from AF – unsuitable

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This data will only be used for verification purposes in support of the payment system, as well as to provide practice level comparative data.

6. Payment/Claiming Detect (Pulse checks/optional):

• Practices participating in this part should submit claims quarterly via the LCS multi-claim form

• Bonus payments are payable for achievement after 31st March each year Protect:

• Practices signing up to this LCS will receive an aspiration payment of 75% of the year end protect payment, paid monthly, in order to support the work required.

• The full payment will be made for achievement after 31st March each year (deducting any previously paid aspiration payments)

Training and set-up costs Payable as a single non-recurrent

fee on sign-up £229.38

Pulse checks (optional) Payment per pulse check (one per patient allowable)

£1.60 per patient

Pulse checks bonus payment (2021/22 6 month part year effect)

Payable if >20% of eligible patients 65y or over have received a pulse check in the period 1.10.21-31.3.22

50% bonus payable after 31.3.22

Pulse checks bonus payment Payable if, on the 31st March each year, >50% of eligible patients 65y or over have received a pulse check in the preceding 12 months

25% bonus payable, after 31st March each year

AF ‘protect’ work completed

Payment per patient reviewed £50.90

Note that

• The AF ‘protect’ work will be deemed to have been completed satisfactorily if the [number of AF patients with CHA2DS2-VASc score two or more who are not anticoagulated but are coded with AF annual review in the last 12 month] is >/= 95% of the current AF register (AF001). If the proportion is <95%, practices will be asked to complete the work and submit further data should they wish to receive full payment.

Practices whose claims are at variance with expectations may be asked to submit additional evidence to support past or future claims.

The Sussex NHS Commissioners reserve the right to check practice held information at any time to support post-payment verification.

Prices will be uplifted annually in agreement with the LMC. The default uplift will be in line with the GMS global sum uplift. Practices will be notified of any price changes.

Inaccurate/Late claims

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Where a practice is aware of any delay or inaccuracy in claims, it should notify the primary care team without undue delay. Verifiable claims delayed by less than 6 months or within the same financial year (April-March), will be honoured. Delayed claims falling outside this timeframe will be managed on a discretionary basis. Past overpayments to practices will be recovered over a reasonable timeframe in agreement with the practice. 7. Termination Unless otherwise notified, this Locally Commissioned Service terminates on 30 September 2024.

The service may be terminated by either the Sussex NHS Commissioners or the Contractor through the service of three months’ notice.

The CCG may require the contractor to suspend the provision of the service immediately if it has reasonable grounds for believing that patient health or safety is at risk as a result of continuing provision of this service.

The LCS may be subject to review by the Sussex NHS Commissioners at any time during the term of the service.

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Appendices

Appendix 1 QOF Requirements https://www.england.nhs.uk/publication/update-on-quality-outcomes-framework-changes-for-2021-22/ Atrial fibrillation (AF) Indicator Points Achievement

thresholds Records AF001. The contractor establishes and maintains a register of patients with atrial fibrillation

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Ongoing management AF006. The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHA2DS2-VASc score risk stratification scoring system in the preceding 12 months (excluding those patients with a previous CHADS2 or CHA2DS2-VASc score of 2 or more) (NICE 2014 menu ID: NM81)

12 40-90%

AF007. In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated with anti-coagulation drug therapy (NICE 2014 menu ID: NM82)

12 40-70%

EXTENDED Equality and Health Inequalities Impact Assessment (EHIA)

An EHIA is a tool to explore the potential for a policy, strategy, service, project or procedure to have an impact on a particular group, groups or community. This includes the impact on one or more of these groups: • Protected characteristic groups (as outlined in the Equality

Act 2010) • Disadvantaged or marginalised groups or communities

• Deprivation and socio-economic disadvantage within local communities

• Local health inequalities for groups and communities Please complete this Equality and Health Inequalities Impact Assessment when the proposed change has a potential negative impact on staff, patients, public or local communities. Please note: To comply with our agreed Equality Policy and Procedure and meet our requirements under legislation, all new policies and new and proposed services or strategies must be impact assessed before being introduced. Within this document, you will need to provide evidence to demonstrate:

• Consideration of the impact of your initiative for each protected characteristic and other disadvantaged groups and communities • Assessment of the impact you have identified and a clear action plan to mitigate the issues and concerns which arise from this.

For further support or advice please contact:

• Associate Director of Public Involvement

• Head of Equality, Diversity and Inclusion

Extended EHIA v.2 – 02.11.2020

1. Introduction and overview

Title of EHIA Locally Commissioned Service for the detection and treatment of Atrial Fibrillation ID No. #220

Team / Department Primary Care Directorate Assessor Completing the EHIA

Assistant Manager Community Services & Assistant Head of Community Commissioning

Date EHIA Started 30/06/21 Date EHIA Completed

What is the focus of this EHIA?

Workforce Policies

Organisational strategy

Clinical services YES

Clinical policies

YES

Other: Please state

What is the status of this policy / function / practice or provision?

New YES

Revised YES

Monitoring End Who will be affected?

Staff Carers Patients / service users

YES

Communities Other

Extended EHIA v.2 – 02.11.2020

Brief description of the aims of the service, policy, strategy, function that this EHIA relates to.

Atrial Fibrillation (AF) is the most common type of irregular heart rhythm. About 1.4 million people (2.5% of the total population) in England are estimated to have the condition1&2. People with AF have a 5-fold increased risk of stroke, which can result in long term morbidity and disability and/or death. AF is also a major contributor to the development of heart failure. Through the improved detection and management of AF, strokes are preventable. This is a new service, elements of which are already being delivered, but not consistently, via various differing LCS across the three Sussex CCG’s. The new LCS specification will replace any related existing LCS with a single, consistent specification for the county. This LCS will guard against patients not being screened for AF and being anticoagulated for AF because it will equalise service coverage across Sussex. There is therefore no risk in the decommissioning of existing, non-universal LCSs. The new LCS will target resources at the patient groups with the greatest risk of AF and stroke, as recognised through newly emerging national guidance. These can be summarised as:

• Any patient over 65, as this group is at significantly higher risk of AF; • Those who have been identified as having AF and at high risk of Stroke but who are not currently

receiving anticoagulation treatment.

In summary, the AF LCS will deliver:

• Improved detection rates of undiagnosed AF by embedding opportunist case finding (pulse checks) of patients aged 65 years or over, who are not on the AF register, during routine appointments

• Improved anticoagulant treatment rates for patients not currently prescribed anticoagulants and where they are at high risk of stroke

• Improved education of practice staff on the use of stroke and bleeding risk assessment tools and the role of anticoagulation in stroke prevention for AF patients seen under the Locally Commissioned Service (LCS) for the for the detection and treatment of Atrial Fibrillation (AF) across Sussex.

Extended EHIA v.2 – 02.11.2020

Outline the links to national and local policy and strategy.

1-https://www.nice.org.uk/guidance/ng196 2 - https://www.nhs.uk/conditions/atrial-fibrillation/ 3 - https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222147 4 - https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222147 5 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719055/ 6 - https://doi.org/10.1080/14779072.2019.1606713 7 - https://www.nhs.uk/conditions/atrial-fibrillation/ 8 - https://www.stroke.org.uk/sites/default/files/af-data_2018_england_eng_2.pdf 9 - https://www.bhf.org.uk/informationsupport/risk-factors/ethnicity 10 Diabetes and atrial fibrillation 11- https://www.longtermplan.nhs.uk/online-version/chapter-3-further-progress-on-care-quality-and-outcomes/better-care-for-major-health-conditions/cardiovascular-disease/ (Section 3.67) 12-https://bjgp.org/content/69/679/58 13-https://www.bhf.org.uk/for-professionals/healthcare-professionals/blog/2019/atrial-fibrillation-finding-the-missing-300000 The NHS Long Term Plan identifies stroke as a new national priority for the next 10 years1. The plan includes the ambition to prevent 150,000 strokes and heart attacks over the next ten years by improving the treatment of the high-risk conditions – hypertension, high cholesterol and AF. Public Health England has set an objective to reduce the incidence of avoidable AF-related strokes by 5,000 nationally over the next 5 years, and the following areas have been identified to help reduce the incidence of avoidable AF-related strokes:

a) Improving the detection of AF b) Regular systematic audit in all practices to identify those at risk who are either not, or are sub-optimally, anticoagulated c) Strengthening clinical leadership on AF

This LCS builds on Quality and Outcomes Framework (QOF) requirements for General Practice and is designed to help Sussex meet the national targets for the detection and treatment of AF. The QOF target for anticoagulation in AF is 70% and allows for exception reporting. The national targets for AF are as follows:

• Detection: 85% of the expected number of people with AF to be diagnosed by 2029

Extended EHIA v.2 – 02.11.2020

• Treatment: 90% of the total number of people diagnosed with AF, and who are at high risk of stroke, to be treated to target (as per NICE guideline requirements) by 2029.

The aspiration for Sussex NHS Commissioners is to go beyond the national targets, where possible and clinically appropriate, as follows:

• 90% of the expected number of people with AF will be diagnosed by 2025 • 90% of patients with AF at high risk of stroke will be adequately anticoagulated by 2023

Substantial evidence has now accrued to robustly support systematic case finding using pulse regularity checks in general practice to detect AF in people aged ≥65 years. Fay et al have summarised this evidence to make the case to detect an additional 10–15 cases of AF per 1000 people screened. Cole et al have shown that such ascertainment in people aged ≥65 years by GPs is feasible in entire local CCG populations, with increases in AF register size of 5–10% (February 2019). NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely X Domain 2 Enhancing quality of life for people with long-term conditions X Domain 3 Helping people to recover from episodes of ill-health or following

injury X

Domain 4 Ensuring people have a positive experience of care X Domain 5 Treating and caring for people in safe environment and protecting

them from avoidable harm X

1 NHS Long Term Plan, 2019 https://www.longtermplan.nhs.uk/

Extended EHIA v.2 – 02.11.2020

What patient and public engagement has already taken place in relation to this proposal?

There has not been any patient engagement in relation to this proposal. This is firstly because the tests involved in checking for AF and treating AF are unchanged from current clinical recommendations. For example, pulse wrist checks already exist as an established clinical examination and method of detecting irregular heart rhythm, during physical examination in primary care. The other element of the LCS involves case finding using QOF registers and a remote assessment of risk of stroke. Those who are found to be at high risk will be asked to attend a consultation which may result in other common and established clinical tests such as an ECG. The only change that this LCS will introduce is to extend the reach of current clinical practice via a consistent Sussex wide LCS, with the aim of screening as many people as possible known to be at higher risk of AF (over 65s) and case-finding those with AF at high risk of stroke register who are not currently being treated with anticoagulants. This proposal will create one LCS to cover the whole of West Sussex, Brighton and Hove and East Sussex CCG’s. It will replace the unequal coverage of differing LCS specifications currently in place and create a level playing field, using criteria that are NICE recommended.

2. Update on previous EHIA (where one exists) and outcomes of previous actions or if this is new, then record N/A. What actions did you plan last time? (List them from the previous EIA)

How has this action progressed?

What further actions do you need to take? (add these to the Action plan below)

General practices in partnership with their PPGs to share information through their normal communication channels so that patients are aware of the fact that they will receive opportunistic pulse checks as part of their appointments if over 65 years old..

The Service has not yet started so there is no current update.

See section 8.

There is now a contractual requirement for general practices to record ethnicity opportunistically.

This is an arrangement which is part of the nationally agreed general GP contract.

Extended EHIA v.2 – 02.11.2020

3. Health inequalities YES NO

DON’T KNOW

Provide evidence to support your assessment

Will this initiative help to reduce health inequalities for any specific groups and communities? e.g. access to services, improved health outcomes

Y

This LCS will enhance all other pathways by providing extra opportunities for

case finding. It should help to ensure that there will be a positive health impact

for all patients. AF affects the whole population regardless of protected

characteristic although it is most prominent in the older population.

All those aged over 65 years of age will receive a consistent, practice led LCS

which will offer opportunistic pulse checks to screen for AF. There is no primary

care service in place at present for the pulse checking of over 65 year old

patients to detect AF. The universal offer of pulse checks will therefore help to

reduce health inequalities.

Patients of any age who are on the QOF AF register will also be equally

assessed for their risk of stroke and offered treatment accordingly. This proactive

case finding will further help to reduce health inequalities.

This service will be uniformly applied across the three Sussex CCG’s and will

help to reduce health inequalities across the county by identifying and then

treating patients with AF at risk of stroke.

The screening processes employed use the most efficient denominators to

capture and treat the highest number of patients possible, prevent the greatest

number of strokes and save the most lives. Other protected characteristic

groups will benefit as a result of this universal offer.

Extended EHIA v.2 – 02.11.2020

4. Impact assessment Please consider each protected characteristic and consider whether the policy / function / practice or provision has the potential to impact on each protected characteristic group and / or community. Po

sitiv

e

Neu

tral

Neg

ativ

e

No

Impa

ct

Data to support your assessment This can be census data, research, complaints, surveys, reports etc.

Engagement / feedback information to support

your assessment

This could be focus groups, face-to-face meetings, surveys, speak out events, etc.

ons to take forward with a focus on

• advance equality of

opportunity, • eliminate discrimination

foster good relations

Race Y

(2011 census) There were estimated to be

22,064 BAME people in the population across

East and West Sussex, Brighton and Hove.

Approximately 18% of these would be over 65

(3,971). One in 83 checks in this group would be

positive. Meaning a total of 261 cases would be

found across the three regions.

Although the prevalence of AF is lower in the

BAME population, the incidence of stroke and

mortality in BAME individuals is higher as other

conditions may be prevalent such as high blood

pressure and diabetes. The British Heart

Foundation says that South Asians are more

likely to develop coronary heart disease than

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

patients on the AF

register who are not

currently receiving

medication, so that

they may receive

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people with

protected

characteristics to

access the care

and treatment

they need.

Extended EHIA v.2 – 02.11.2020

white Europeans. African or African Caribbean

people are at higher risk of developing high blood

pressure and having a stroke than other ethnic

groups. Africans, African Caribbeans and South

Asians are more likely to develop Type 2

diabetes than the rest of the population.

Diabetes may be linked to the development of

atrial fibrillation 10..

Where BAME patients are identified and treated

through this LCS, although the numbers may be

small, the service interventions would have a

positive, impactful benefit for this group.

treatment. It

provides intervention

over and above the

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

Sex Y

AF is the most common heart rhythm disorder,

and its prevalence is increasing. Previous studies

have shown that it is twice as common in men as

in women, but the risk of adverse outcomes such

as stroke is higher in women.

https://www.bmj.com/content/359/bmj.j4802

This LCS will benefit patients of all sexes. There

are various reports and research on incidence A

BMJ report published in 2017 showed that more

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people with

protected

characteristics to

Extended EHIA v.2 – 02.11.2020

men than women may not be aware that they

have AF: 10% men with AF did not experience

symptoms, compared with 5% of women. Male

study participants reported less severe

symptoms and a lower frequency of symptoms.

It reported a higher risk of stroke and other

arterial thromboembolic events in women despite

a high proportion of adequate anticoagulation

treatment. Underuse of anticoagulation in women

despite relevant stroke risk, was suggested as

another explanation for gender disparities. The

study suggests a stronger association between

AF and heart attack in women. Heart failure is a

complication in individuals with AF, with male and

female differences in physiological cause.

The Stroke Association: A recent research study

in England found that the risk of ischaemic stroke

(caused by a blockage) is more likely to be

inherited by women than by men.

People with a family history of stroke who had

experienced a stroke, were two to three times

more likely to be female than male, according to

patients on the AF

register who are not

currently receiving

medication, so that

they may receive

treatment. It

provides intervention

over and above the

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

access the care

and treatment

they need.

Extended EHIA v.2 – 02.11.2020

the study, although the reasons for this remain

unclear.

Hormone replacement therapy increases the

levels of atrial fibrillation and stroke in women.

However, women on HRT are managed and

monitored by their GP separately from this LCS.

This LCS will enhance all other pathways by

providing extra opportunities for case finding.

It should help to ensure that there will be a

positive health impact for all patients including

male, female and those who identify as non-

binary.

The latest NICE guidance identifies that men with

a stroke risk score of 1 should be considered for

anticoagulation, while men and women with a

score of 2 should be offered treatment. This LCS

is designed to reflect this NICDE guidance.

As previously stated, the LCS is targeting by age

(over 65) and those on the QOF register with AF

who are not receiving treatment. Although there

Extended EHIA v.2 – 02.11.2020

are differences in cause of AF between the

sexes, this LCS will benefit all but it will target

men with a lower stroke risk score than women

based on the latest national clinical guidance.

Gender

reassignment Y

Hormone replacement therapy increases the

levels of atrial fibrillation and stroke in Trans

people. However, there is a separate Trans LCS

in development which will include blood pressure

and pulse checks.

This LCS will however enhance all other

pathways by providing extra opportunities for

case finding as part of routine health checks for

Trans people over 65 years of age and those on

the QOF AF register.

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

patients on the AF

register who are not

currently receiving

medication, so that

they may receive

treatment. It

provides intervention

over and above the

current service

provision, as

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people with

protected

characteristics to

access the care

and treatment

they need.

Extended EHIA v.2 – 02.11.2020

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

Age Y

The incidence of AF increases over age,

especially those patients aged 65 years or over.

These patients will benefit because all over 65’s

will receive a pulse check during routine

appointments. Also, those on the QOF AF

register, who tend to be older, will also be

contacted and be offered anticoagulant treatment

as appropriate to avoid a high risk of stroke.

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

patients on the AF

register who are not

currently receiving

medication, so that

they may receive

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people with

protected

characteristics to

access the care

and treatment

they need.

Extended EHIA v.2 – 02.11.2020

treatment. It

provides intervention

over and above the

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

Religion and belief Y

It is unlikely that the AF LCS would specifically

impact on people who have religious beliefs or no

belief.

It is recognised that there are some patients

whose beliefs may prevent them from accessing

this service or accepting the suggested

interventions.

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people with

protected

characteristics to

Extended EHIA v.2 – 02.11.2020

The pulse check is done using the patient’s wrist,

so is not likely to cause any difficulties related to

modesty.

As in all GP consultations interpretation services

are available to enable a full informed discussion

that allows for shared decision making.

Information may also be translated into various

languages to enhance understanding of the

service on offer.

Patients are also able to discuss any concerns

they have with suitably qualified Healthcare

Professionals.

patients on the AF

register who are not

currently receiving

medication, so that

they may receive

treatment. It

provides intervention

over and above the

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

access the care

and treatment

they need.

Disability Y

This LCS is not specifically targeted at those with

disability, but these patients will also benefit from

the additional opportunities to case find and

This is about

providing an

additional,

opportunistic pulse

The opportunistic

pulse checking of

all over 65s will

advance the

Extended EHIA v.2 – 02.11.2020

through the opportunistic pulse checks for the

over 65’s.

Patients living with long term health conditions

such as diabetes, will also benefit from this

service through opportunistic pulse checks for AF

when visiting the practice.

Some learning disabilities (such as Down

Syndrome) are genetically linked to atrial

fibrillation. The over 65’s in this group will

receive this service where appropriate, as there

are also separate annual health checks (which

are in place for those with learning disability from

age 14 and over, separately from this LCS).

People with physical disabilities will be provided

with this service from the familiar and accessible

general practice setting. If physical examinations

are required, general practice buildings are

required to be wheelchair friendly environments.

General practice is also separately required to be

dementia and disability friendly, encouraging the

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

patients on the AF

register who are not

currently receiving

medication, so that

they may receive

treatment. It

provides intervention

over and above the

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

equality of

opportunity for all

people with

protected

characteristics to

access the care

and treatment

they need.

Extended EHIA v.2 – 02.11.2020

involvement of carers in the care and treatment

of patients such as those with learning disability.

As with all GP consultations, those who have

sensory disabilities such as hearing difficulties

will have access to tools such as hearing loops or

interpreters to help them access the service.

engagement is

planned.

Sexual orientation Y

Delivery of this service will be via general

practice and all practices must undertake training

in equality and diversity. The provision of this

service is targeted by age and practice AF

registers. The sexual orientation of individuals is

not a factor in case finding those at higher risk of

AF. It is however important that the CCG and

service providers ensure all patients are treated

with dignity and have equality of opportunity of

access to the service, regardless of their sexual

orientation. Practices are not required to gather

detailed information about most protected

characteristics (including sexual orientation) of

their patients and this information is not therefor

available for monitoring, even if it were identified

as a useful measure.

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

patients on the AF

register who are not

currently receiving

medication, so that

they may receive

treatment. It

provides intervention

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people with

protected

characteristics to

access the care

and treatment

they need.

Extended EHIA v.2 – 02.11.2020

The delivery of this AF LCS is likely to have a

positive health impact on all individuals equally,

including those who identify as LGBT.

over and above the

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

Marriage or civil

partnership Y

The delivery of this LCS will have a positive

impact to this group by helping to prevent stroke

and resulting disability. This is of major benefit to

couples whether married, in civil partnership or

unmarried. Partners of those who suffer stroke

can be impacted in many ways. This includes

economic, mental, and physical health and

general wellbeing.

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

patients on the AF

register who are not

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people with

protected

characteristics to

access the care

Extended EHIA v.2 – 02.11.2020

currently receiving

medication, so that

they may receive

treatment. It

provides intervention

over and above the

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

and treatment

they need.

Pregnancy and

maternity Y

This area is not in scope of the LCS. Separate

specialist separate services are targetted to this

younger age group.

This area is not in

scope of the LCS.

Separate specialist

separate services

are targeted to this

younger age group.

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

Extended EHIA v.2 – 02.11.2020

people with

protected

characteristics to

access the care

and treatment

they need.

Other

Disadvantaged or

inclusion groups

Y

This service is likely to be beneficial to

disadvantaged groups as part of the general

population. It is not targeted differently in areas

of higher deprivation. Those in disadvantaged

groups are more likely to be picked up

opportunistically at the practice and will be

offered interventions at an accessible and

familiar setting without the need to travel to other

service providers

Accessing the service will also benefit those with

caring responsibilities i.e. carers due to its ease

of access. General practice would also actively

encourage the involvement of carers in the care

and treatment of patients such as those with

learning disability.

Those who are homeless, or travellers may find

accessing the service easier in a general practice

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

patients on the AF

register who are not

currently receiving

medication, so that

they may receive

treatment. It

provides intervention

over and above the

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people to access

the care and

treatment they

need.

Extended EHIA v.2 – 02.11.2020

setting although it is recognised that these

groups often do not attend GP services. The

means of consultation can be adapted dependent

on patient needs, and annual reviews will ensure

that patients are monitored on an on-going basis.

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

Deprivation and

socio-economic

disadvantage

Y

The provision of a dedicated AF detection and

treatment service is socio-economically

protective because experiencing stroke can have

a huge impact on people’s ability to work and

may result in some degree of long-term disability.

It will not be specifically targeted to areas with

poverty related issues, but rather to all.

Being checked at their own practice is likely to

have a positive impact on deprived and socio-

economically disadvantaged people because

they may not be able to afford the time or cost

involved to travel to another service.

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

practice. It is also

about identifying

patients on the AF

register who are not

currently receiving

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people to access

the care and

treatment they

need.

Extended EHIA v.2 – 02.11.2020

Whilst accessing healthcare can be problematic

for refugees, asylum seekers and travellers,

having opportunistic screening for atrial fibrillation

based in general practice may make access

easier.

medication, so that

they may receive

treatment. It

provides intervention

over and above the

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

Community

Cohesion Y No impact is foreseen.

This is about

providing an

additional,

opportunistic pulse

check during routine

appointments for

over 65’s in their GP

The opportunistic

pulse checking of

all over 65s will

advance the

equality of

opportunity for all

people to access

Extended EHIA v.2 – 02.11.2020

practice. It is also

about identifying

patients on the AF

register who are not

currently receiving

medication, so that

they may receive

treatment. It

provides intervention

over and above the

current service

provision, as

opposed to changes

to an existing service

received, and is

therefore likely to be

welcomed by

patients and for this

reason no patient

engagement is

planned.

the care and

treatment they

need.

Extended EHIA v.2 – 02.11.2020

5. Cumulative Impact What factors could increase the impact of this proposed change for some groups of people?

Which groups of people or communities are affected?

Are there any additional actions to include in this EIA?

There could be communications via PPG’s to inform patients that the over 65’s will be receiving pulse checks during appointments to identify those at risk of stroke.

All patients over 65 years of age. Inform PPG’s.

6. Equalities or health inequalities data gaps YES NO DON’T

KNOW Provide evidence to support your assessment and include this as an Action below.

As a result of undertaking this EHIA, are there any gaps in equalities or health inequalities data or information?

General practice is not commissioned to record much information about the protected characteristics of patients. For now this only includes age, sex and ethnicity. This situation and the clarity of reporting arrangements may improve over time. It is a national rather than local issue.

7. Overall summary of impact. Please tick an overall equality impact grade for this initiative.

❏ ❏ ❏ ❏ Please explain your decision: Through this new LCS, tens of thousands of patients aged over 65 will receive a pulse check during their routine appointment to identify if they have AF, are therefore at greater risk of stroke and may therefore benefit from anticoagulation treatment or be referred for specialist

Negative Impact Neutral Impact Positive Impact No Impact

Extended EHIA v.2 – 02.11.2020

care. In addition, the detection element of the LCS will enable those who have AF (as indicated on QOF register) have improved access to treatment. 8. Summary of Actions Record all your EHIA assessment potential concerns (impact) and actions below:

Please try and prioritise your actions

Potential Impact Actions to mitigate impact

These actions could prevent, reduce or control

the negative impact on specific groups or the

wider initiative.

Staff or Patient Engagement Outline any proposed

engagement to achieve these

actions

Lead Person Deadline

1 GP sign-up to LCS -

any gaps in coverage

across the county

Pre-implementation review with practice Managers (complete)leads Education and Awareness webinars for practices Incentive payments for pulse checking A payment framework that rewards both past and future review activity Targeted pre and post implementation engagement with and support for practices with low detection and treatment rates

The actions describe the

staff engagement required

Programme

Manager

Clinical Leads

PCN

Managers &

Quality Team

March

2022

Extended EHIA v.2 – 02.11.2020

Please try and prioritise your actions

Potential Impact Actions to mitigate impact

These actions could prevent, reduce or control

the negative impact on specific groups or the

wider initiative.

Staff or Patient Engagement Outline any proposed

engagement to achieve these

actions

Lead Person Deadline

2 (not an

action

but a

major

issue)

Lack of equality data

impacts service design

GP practices are not commissioned to

record equality data on all protected

characteristics. There is now a

contractual requirement to record

ethnicity where provided (in addition to

age and sex). Other characteristics are

not currently included. For practices to

record this data there would need to be a

change to the national GP contract.

N/A N/A N/A

EHIA written by:

Assistant Manager Primary Care &

Community Services East Sussex

Brighton & Hove

Date: 7th July 2021

EHIA reviewed by: Equality, Diversity and Inclusion

Manager

Date: 17/08/2021

EHIA authorised by:

(manager)

Assistant Head of Community

Commissioning

Date: 3rd August 2021

Extended EHIA v.2 – 02.11.2020

EHIA

approved:(governance) YES NO

Date:

Further comments Date:

EHIA published on the

SES website

Date

Person to review EHIA

post implementation

Date

Project Title: Reviewed & updated on -

25-Feb-21

Quality Impact Assessment

By - Primary Care Clinical Quality ManagerClinical Prog Lead - New Models of CareClinical LeadAssistant Head of Community Commissioning

Key Line of Enquiry Impact Consequence Score Score Summary Supporting Evidence Guidance3

SAFETY

3 Moderate Positive This Locally Commissioned Service (LCS) provides a service to detect and effectively manage Atrial Fibrillation (AF) in a general practice setting. AF related LCS are in place in most of the legacy CCGs across Sussex (the exception being in Coastal West Sussex) but this LCS goes further than these existing LCS while ensuring consistency of offer across Sussex. There will be a need to either re-commission or de-commission existing LCS following the introduction of this new LCS.If the service was not available in general practice it would need to be provided by secondary care or another provider in order to meet NHS targets for the detection and treatment of patients with AF in line with the national CVD strategy, so by commissioning the service in general practice there is less pressure on other providers. There are approxiamtrly 48,000 patients on AF registers in Sussex, but this only equates to just over 87% of those projected to have AF in the county. There is no direct impact on the duty to protect children, young people and adults at risk, though the risk of developing more complex heart conditions and / or stroke may be reduced if symptoms are detected earlier through early detection of AF. Although this LCS will primarily benefit older adults, given the increasing prevalence of the conditon as people age, the opportunistic case finding of patients will delviery longer term benefits for younger adults. The service will have a positive impact on patient safety in that early detection of Atrial Fibrillation will reduce the likelyhood of stroke and heart attack, but there should be no impact on the level of incident reporting.The reliability of safety systems will not be impacted by this service. It is also unlikely to increase the risk of health care acquired infections, since this is a non-invasive procedure and all the usual clinical precautions will be in place in line with all primary care provision. One of the core aims of the LCS is to ensure patient safety. As a core element of the LCS annual reviews will ensure the safe prescribing and monitoring of medications for patients. As such there will be minimal risk of adverse outcomes as a

• What is the impact on partner organisations and any aspect of shared risk? • Will this impact on the organisations duty to protect children, youngpeople and adults at risk? • Impact on patient safety and preventable harm, e.g. level of incident reporting? • Will it affect the reliability of safety systems?• How will it impact on systems and a process for ensuring that the risk of healthcare acquired infections to patients is reduced?

3

EFFECTIVENESS 3 Moderate Positive

The LCS will be delivered in line with NICE clinical guidance 180 - Artial Fibrillation: Management.The NHS Long Term Plan identifies stroke as a new national priority for the next 10 years, and Public Health England (PHE) has an objective to reduce the incidence of avoidable AF-related strokes by 5000 nationally over the next 5 years. The Sussex HCP Strategic Plan commits the ICS to reducing unwarranted variation with regard to CVD and it recognises that variability in the identification and management of Atrial Fibrillation and stroke prevention is a local challenge. conditions. In response to this the plan commits to reduce the number of people to have suffered from stroke through the delivery of proactive diagnosis and optimisation of anticoagulation treatment of Atrial Fibrillation. If this LCS achieves the targets set over 1900 additional people with AF will be diagnosed and similarly a further 1900 will receive treatment. There is therefore a growing understanding of the importance of early AF detection and effective managment. There will be a positive impact on self-care for people with long term conditions since they will be able to access the service more easily in a local health care setting and gain advice and interventions at an early stage.Providing this service in a local general practice setting means it is more cost effective for both the NHS and patients who can access the service nearer their home rather than having to travel. The introduction of this LCS should reduce demand for secondary care services in the longer term as a result of a reduction in the number of strokes. The service is above and beyond any current commissioned services such as the Boots CPAMS in Brighton & Hove i.e. opportunistic case finding, more comprehensive medication reviews and active reviews. CPAMS may see an increase in referral activity following introduction of the LCS as more patients are diagnosed with AF who require warfarin monitoring, but these numbers will be minimal given the sift towards the prescribing of DOACs as an alternative therapy. There is a positive impact on the patient care pathway, again because of the fact that this service can be accessed locally, and in many cases can be managed in primary care. There is a mixed impact on workforce capability and capacity. Practices will experience some additional pressure on their workforce and premises since to provide this service and meet the targets set they are required to provide the staff to deliver the service and the clinical room in which the procedure will be carried out This impact will be marginal though as

https://www.nice.org.uk/guidance/CG180

• How does it impact on implementation of evidence based practice?• Is there an impact on self-care for people with long term conditions?• Does it ensure that care is delivered in the most clinically and cost effective setting?• is there effective use of all resources including budget, staff and estates (if relevant) • Does it lead to improvements in patient care pathways?• Is there an impact on workforce capability and capacity?

3

EXPERIENCE 3 Moderate Positive

As a Locally Commissioned Service this is an enhanced service provided in a local general practice setting. No specific patient engagement has been undertaken regarding this service development but given the ease of patient access to the service at their local general practice their experience will be improved. Patients are able to express their views in person at the practice, in writing or via the practices website. Patients are also invited to give their views through regular patient surveys or through the practices Patient Participation Group (PPG) where these exist. Patient views may also be provided through 'Friends and Family'. Practices engage regularly with their PPGs and along with their review of patient feedback from other sources this informs their delivery of services. The LCS aims to ensure care is patient centred and involves Shared Decision Making regarding the risks related to treatment. The LCS will enhance patient reassurance with regard to the management of their condition given access to a proactive review to optimise their care and then ongoing Annual Reviews. Active reviews of harder to reach groups e.g. BAME will ensure more equity of access and improved equality of health outcomes. The LCS will incentivise the proactive identification, treatment and review of BAME communities, supported by the recoding of ethnicity data. The LCS will be delivered by Multi-Disciplinary Teams overseen by GPs, ensuring that patients receive care from the most appropriate healthcare professional .

• How does the proposed service support both patients and staff to express their views and be actively involved in decisions about care and treatment? • How are patients privacy and dignity respected and promoted?• Evidence of effective systems for capturing patient and staff feedback about the service, e.g. via complaints, Friends and Family Test etc. • Evidence that feedback from patients/ carers impacts on service improvement developments

TOTAL SCORE 9

-5 Catastrophic -4 Major Negative -3 Moderate Negative -2 Minor Negative -1 Negligible Negative0 Neutral 1 Negligible Positive2 Minor Positive 3 Moderate Positive 4 Major Positive 5 Excellence

Blue- No risk (score =>0)Green- low risk (score between -1 and -4)Yellow- Medium risk (score between -5 and -7)

Pink- High Risk (score between -8 and -11)Red- Very High Risk (score =<12)

Locally commissioned Service for Atrial Fibrillation