Developing a population health model and community-based AF clinics in west Norfolk to reduce stroke

The Norfolk and Waveney sustainability and transformation partnership (STP) in the east of England has one of highest estimated prevalence for atrial fibrillation (AF) in the country. The STP covers a population of around 1 million people and includes five clinical commissioning groups (CCGs). The estimated AF prevalence varies between 1.49% to 4.24% across the CCGs. West Norfolk CCG, with a population of 174,000 people, has the second-highest estimated prevalence (3.08 %) of AF of the CCGs. In 2017, there was an estimated 5,953 people with undiagnosed AF in west Norfolk. In terms of equality and health inequalities West Norfolk has high levels of inequality when compared to 10 similar CCGs in England for unplanned hospitalisations for chronic ambulatory conditions including AF. This project aims to address this area to identify and manage patients reducing the risk of hospital admissions. Between September 2018 to March 2019, we developed and piloted the new West Norfolk Atrial Fibrillation Service to bridge the gap between primary and secondary care AF service delivery. This service aims to optimise treatment for patients with known AF not on anticoagulation, to reduce the gap in undetected AF and to improve patient care and prevent AF-related stroke. This successful initial pilot service included only two of the 21 GP practices in the West Norfolk CCG. We would now like to expand this service and adopt a population health model (PHM) across four emerging primary care networks (PCNs) to identify AF and provide efficient and timely access to community-based AF clinics to improve AF detection and management. The project will establish fortnightly AF clinics within a PCN initially before being rolled out across the other three PCNs phased over 12 months. The PHM supporting the identification of patients is defined as bringing together health related data to identify a specific population to prioritise services to be developed to improve patient outcomes across a region. West Norfolk CCG is fully committed to delivering a service that identify patients with AF and then effectively manage them. The CCG is in a position to provide comprehensive project management throughout the project, clinical pharmacy guidance including medicines optimisation and full evaluation to provide quality data to apprise the delivery and ensure outcomes are achieved.