2Contents Background and Context Understanding the problem – The National and Local pictureUnderstanding what worksIdentifying the Critical Success FactorsProposal for the East Midlands NetworkReferencesAppendixes
3Background and Context Atrial Fibrillation is a significant burden to patients and the wider health economy across the East Midlands, affecting around 66,000 people and accounting for between 15% and 20% of all stroke admissions to local acute services and around 450 deaths.Nationally the detection and treatment of AF is recognised as suboptimal despite significant evidence that optimal treatment and management could reduce stroke incidence by 10%. As such, systematic identification and treatment of AF in primary and secondary care has been identified nationally as a high impact QIPP opportunity.There is no defined data set or detailed understanding of current prevalence , practice, service quality or costs across the East Midlands although some top line work is underway to address this via EMPHO and a commissioners survey developed by the network.As far as we understand, none of the NHS organisations in the East Midlands (Commissioner or Provider) has identified AF as a focus within its QIPP programme for 2011/12The East Midlands Cardiac Network wishes to develop a programme of activity which will address this and which focuses on 2 key aims:Improvement of the identification and treatment of patients with AF across the East Midlands to reduce the incidence of death and disability resulting from strokeEnable the provision of equitable, affordable and value for money services which will ensure that outcomes for patients with AF in the East Midlands are comparable with the top quartile of services nationally.
4Background and Context A considerable amount of work has been done in other areas throughout the UK all of which aimed to improve detection and treatment of AF. These programmes have used a number of different models and approaches and achieved varied outcomes. Successfully increasing the numbers of patients being effectively initiated onto and managed with warfarin has been a particular challenge with some disappointingly low “conversion” rates.The East Midland network wishes to learn from these projects, to understand what has worked well and what hasn’t and use that learning to explore alternative approaches which may facilitate a more successful outcome.The network wishes to work in a consultative and inclusive way with all relevant stakeholders across the health economy including the third sector and is also open to the idea of working with the pharmaceutical and healthcare sector through appropriate Joint Working arrangements as long as this is robustly governed.Given the current reorganisation of the NHS and constituent organisations and bodies, the future of the cardiac network is unclear, with funding guaranteed only until April 2012.This proposal therefore aims to outline the scope of a future project which will take the learnings from previous work and suggest a model of activity and implementation which aims to overcome many of the barriers and challenges experienced by other networks.In recognition of the uncertain future ( or funding of) the East Midlands Cardiac Network post March 2012, the proposal will focus on a plan of activity which aims to engage CCGs and PCTs at the earliest opportunity to underpin a longer term implementation strategyBased on the success of work being undertaken across Nottinghamshire in other disease areas in partnership with the pharmaceutical industry this proposal will include opportunities for joint working with commercial stakeholders including the pharmaceutical and healthcare industries.
5Process of Development 4 StagesUnderstanding the problem.Mapping of AF picture nationally and in East MidlandsUnderstanding what worksMapping of work being done elsewhereIdentifying Critical Success FactorsThe core “must do” elementsProposal for the East Midlands
6Understanding the Problem The National and Regional Picture Step 1Understanding the Problem The National and Regional Picture
7AF The National Picture Prevalence of AF in England and Wales is approximately 1.3% and equates to around 600,000 patients₁Significant risk factor for stroke accounting for around 14% or 12,500 of all strokes recorded.Cost to the NHS of around £148 million plus additional £4.2 billion in social care and lost productivity₂Estimates suggest that the cost of treating 1 stroke in the first year are around £11,900 ₂Strokes associated with AF tend to be more serious and have higher mortality but the risk of stroke can be significantly reduced by the treatment of AF with anticoagulation and specifically Warfarin which has been shown to reduce annual rates of stroke by up to 64% compared to Aspirin at 22%₃The annual cost of treating 1 patient with warfarin ( including monitoring is estimated at £383 per year with a NNT of 37 to prevent 1 primary stroke, suggesting that the cost of preventing 1 stroke would be between £10 - £14 k₂QOF data suggests that current use of anticoagulant therapies is suboptimal with significant variance in the use of Warfarin vs Aspirin and the NICE Clinical Guidelines for AF ₄suggest that only 46% of pts who are eligible for warfarin are getting it and this is backed up by other studies₅NICE concluded that if all patients who were eligible for treatment received warfarin that around 6000 strokes per year would be saved.There are also significant issues regarding the time in therapeutic range (TTR) for patients taking Warfarin with most benefit of therapy being lost below 65% and some INR clinics are thought to run TTR targets as low as 60% making it unlikely that any significant benefit of treatment is being gained.
8AF in the East MidlandsOf 8531 stroke admissions in 2009/10 , 1844 were recorded as AF related accounting for 22% of all stroke admissions. This is higher than the national average of 15%₆QOF registers for the East Midlands SHA show that are registered on AF registers giving an observed prevalence of 1.45% ( vs 1.2% nationally)₆However there is significant variation between East Midlands PCTs and their constituent practices on observed prevalence with the highest prevalence of 1.71% ( Bassetlaw) and lowest of 0.9% ( Leicester City).
9AF in the East MidlandsThe variance appears to affect those areas with a majority inner city population which could also reflect the fact these areas tend to have higher levels of deprivation, younger populations and resultant lower utilisation of primary care services as well as a higher proportion of single handed GP practices who may have less capacity and resource to for proactive case finding and register management.The QOF data does however suggest that for those patients who are on GP registers that the majority ( 93.8%) are receiving some form of treatment. However the QOF indicator as it currently stands ( AF 3) does not allow differentiation between antiplatelet or antithrombotic treatment. Taking national data therefore it would be reasonable to suggest that only around 46% of these patients will be receiving warfarin and the rest will be on aspirin or possibly clopidogrel, leaving them at higher risk of having a stroke.The data also identifies a further 3692 patients who are on AF registers in the East Midlands but are not recorded as receiving any treatment at all.APHO and Imperial College London modelling also suggests that there could be a further 9000 patients in the East Midlands who have an undiagnosed stroke of which 15% will be related to Atrial Fibrillation
10QOF Performance East Midlands – AF1,3 and 4 (EMPHO) There are 50,534 patients across the East Midlands who appear on AF registers but have not had a confirmed diagnosis by ECG or specialist.Of patients eligible for anti-coagulation or anti-platelet therapy there are 3957 patients who do not appear to be receiving any therapy.-Total Number of patients on AF registersTreated with anti-coagulation or anti-platelet therapyEligible for therapyNo. of eligible patients not treated with anti-coagulation or anti-platelet therapyConfirmed by specialist (QOF – post 2008)Diagnosis not confirmed by a specialist or ECG for eligible patients.659376020064157 (2.7% not eligible)395713623(21% of eligible pts)50534
11The commissioning focus is varied across the region A survey of commissioning organisations throughout the East Midlands undertaken by the East Midlands Cardiac Network (June 2011) identified that there is significant variance throughout the region with regard to commissioning intentions and priority of AF including:Service provision and model for INR testingImplementation of GRASP AF – only Derby City actively implementing (Northants and Derbyshire have plans to do so)Identification of AF within PCT QIPP prioritiesSystematic incorporation of opportunistic pulse checks into service specifications and / or current heart check programmes.Clinical governance processes to monitor and regulate implementation of existing guidelines and anticoagulation servicesAF is just not on commissioners radars!
12Why Not?General and historic lack of understanding of the impact of AF amongst commissioners and particular impact on stroke and stroke prevention. Issue of non – clinical commissioners?AF generally seen as a “prevention” issue and thus tends to sit within public health agenda rather than primary care or “front line” commissioning?Issues around INR testing and service provision are complicated and commissioners may focus on the service rather than the reason ( and outcomes needed) for it?Current national focus on AF is perhaps being diluted at local level due to on-going reorganisation of PCTs, transition to CCGs and loss of key staff?
13Summary and Conclusion Variance across the region with regard to identification and management of patients with AF.Although QOF performance suggests that patients on AF registers are receiving some form of therapy it is likely that many are not receiving appropriate therapy and there is no way of measuring TTR for these patients .It is likely that there are a significant number of additional patients who have not yet been diagnosed.There are areas within the region where observed prevalence is significantly below regional and national average and so immediately present themselves as obvious “targets” for project activity .The lack of priority being placed on AF by PCTs and CCGs within the commissioning agenda is a significant barrier, however as emerging and developing CCGs begin to develop their local commissioning plans, and local GPs and clinicians begin to have more input, there is a window of opportunity to influence those plans.CCGs will have the opportunity to develop local QOF plus incentives which could be a lever by which proactive case finding and systematic review could be implemented.CCGs ( Gps and Commissioners) need to understand the potential impact of AF and stroke and the impact that effective treatment has on stroke reduction. This information needs to be presented to them in a format that relates to their own local population with cost impact analysis data to help recognise the value.
14Understanding What Works Step 1Step 2Understanding What Works
15What are other areas doing? Preliminary research has identified some 27 referenced AF projects which have either been borne out of the first wave of NHS Improvement priority projects which reported in 2009, have developed from those, or are the second wave of national priority projects.The projects generally have the same overarching aim to reduce the number of AF related strokes and cite one or more of the following methods to achieve that:Raising awarenessIncreasing the detection of AF by means of opportunistic screeningDriving the roll-out of the GRASP-AF tool to improve the management for those diagnosed with AFSharing good practice, ideas and innovations to improve detection, diagnosis and managementImproving the quality of care for patients requiring anti-coagulationAddressing the need for education and training
16They have generally incorporated one or more of the following elements Opportunistic pulse screening in flu clinics/chronic disease clinics/ambulance servicesImplementation of GRASP AF toolPathway developmentPrimary care educationFast Track AF clinics in secondary care.Near patient testingTelehealth ( heart monitoring)Some degree of incentivisationExternal nurse support via BHF or pharmaceutical industryPatient educationBut nowhere did them all and all used very different approaches to implementing themA detailed summary of each project is attached to this proposal but we have highlighted 3 very different approaches taken across the country to illustrate examples.
17Focus on 3Colchester Practice Based Commissioning Group (Essex Cardiac Network)PBC initiated programmeOpportunistic pulse screening at flu clinics – inviting patients over 65 to have a pulse check.37 out of 43 practices in PBC Group incentivised to use approach34,201 patients screened in 6 weeks.189 patients found with AF (0.55%)Estimated strokes prevented in following year = 5 ( Lead Gps own assumption)Project funding: LES - £2 per patient screenedPulse: How to run low cost high impact AF screening at flu clinics, Nov 08.Easy to set up and implement within current practice activityRequired little additional manpower, time or resource over and above LES paymentNo systematic plan for patient follow up however – left to individual practices to devise and monitorNo information available on conversion rates.
18Focus on 3 York Health Group PBC GRASP-AF pilot group – West Yorkshire Cardiac Network24 practices ( 100% within PBC) used GRASP-AFIncentivised via LES£50 to run baseline to identify pts with CHADS2 score of 2 or more NOT taking warfarin£10 / pt reviewed£50 to re run GRASP toolSupported by significant education programme and patient education materials via AFA3613 patients (out of a population of 228,651) were identified with AF.( 1.58% prevalence)53% of patients had a CHADS score of > 2 and of those, 899 (47%) with a CHADS score > 2 were not on warfarin ( pre study expectation was 25%)Conversion rate 8-10%Reasons for none initiation of warfarin in AF pts identifiedPt Declined 14%Absolute contraindication – 7.2%Other ( pt died, pre surgery, infection) – 2.7%GP Decision( i.e not medical exception) 32%New improved AF template developed and in useNew practice codes – Warfarin discussed and CHADS2 ScoreAF registers to be reviewed yearlySignificantly upskilled practice teams
19York LearningsGP knowledge and confidence in use of warfarin is a major barrier to effective conversionPCT concerns about costs of increased anticoagulationNeed robust impact modelling to show cost benefits and education re role of AF in strokeLocal clinical leadership and champion vital GP and consultantEducation Education EducationDynamic and organised project manager to keep things moving.Project focus on a small and defined geography and within one overarching NHS organisation enabled systematic communication, both within the PBC and to practices and meant that the project became part of the PBC core activity for the duration of the project. Reduces the issues of cross organisational decision making and competing priorities.
20Focus on 3Avon, Gloucestershire, Wiltshire and Somerset Cardiac Network (AGWS) – Strike at Stroke ProjectAGWS Network has the highest level of GRASP-AF downloads across the country. (Ref: NHS Improvement)2010/11 wave- practices incentivised to use GRASP-AF: increase of 3% in patients prescribed coagulation or 220 patients. £2000 training funds made available to each participating PCT but left to individual PCTs as to how they implemented that.2011/12 wave –Incentives available for first 200 practices to apply for second wave and trigger point for incentive is 3% rising to 15% ( of patients initiated onto warfarin). Focus on outcomes rather than just inputsAverage available per practice will be £750.00Launched with large GP education event in May.Compulsory use of GRASP-AF tool and upload to CHART. Practices supported by partnership with Boehringer Ingelheim nurse team to run GRASP and review patients as well as provide education to practice staffAt time of writing 30 practices have signed up.
21Learnings from AvonIncentives for use of GRASP AF encourage GP and practice uptakeStrong clinical leadership and GP engagement vitalSomeone to drive the programme and keep it all goingProvision of additional manpower – in this case dedicated externally sourced AF nurses, is welcomed by practices , encourages engagement and helps to make programme sustainable via education of practice staff..Education on use of warfarin and impact of AF needs to be embedded into programme
22Common challenges across all of the reviewed projects GP and practice engagementReluctance to commit time for what is perceived to be a time consuming taskCapacity of practices to review patientsLow awareness of potential impact of AF and scale of problemReluctance by GPs to prescribe warfarin resulting in low conversion ratesLack of confidence based on low knowledge and misconception particularly around risks in the elderly – low awareness of BAFTA study for instanceMisconceptions about benefits of aspirinCommon misconceptions amongst general public regarding warfarin (Rat Poison)Low awareness of impact of AF on stroke amongst commissioners resulting in low priority and associated funding support.Pulse checks on their own are not necessarily worthwhile without a programme of action to ensure follow up and reporting of outcome.Availability of funding and resources to support implementationCross organisational communication and co-operation – lots of silo workingVarying quality and access to anticoagulation services and monitoring.Competing priorities workloads for individuals within organisations which are magnified when working across organisational boundaries.Engaging with the public – low awareness amongst patients of AF.
23Identifying the Critical Success Factors Step 1Step 2Step 3Identifying the Critical Success Factors
24Based on the learnings from the national pilot programmes the following have been identified as Critical Success Factors for an effective programme:Strong clinical leadership at a local (PTC / CCG ) levelGP and Secondary Care Consultant – a named champion who can lead from the frontBuy in and support from local commissioners regarding the impact of AF and the benefits of proactive managementA clearly defined care pathway for anticoagulation backed up by effectively commissioned and robust anticoagulation services working to service specifications which have clear KPIs around TTR for all patients.Locally developed and supported clinical guidelines for management of AF that are communicated effectively to stakeholders and implementation monitored.Systematic education of GPs, Practice Staff and PatientsUse of GRASP AF tool by practices and upload to CHART for reporting purposes.Supported by incentives – Local LESDedicated nurse support to increase capacity in practices and provide on site educationBHF or pharmaceutical industry sources.Public awarenessRobust and dedicated project managementImplementation at local level within a defined geography and organisational framework has a higher success rate than trying to develop a regional “ one size fits all” approach
25Proposal for the East Midlands Step 1Step 2Step 3Step 4Proposal for the East Midlands
26East Midlands AF Project This proposal is based on the recommendation that The East Midlands Cardiac Network engages in a Joint Working programme with the pharmaceutical and healthcare industries, the voluntary sector and NHS organisations across the region to:Increase the appropriate detection, diagnosis, treatment and risk management of patients with AF in primary care.Reduce the numbers of emergency admissions into secondary care and costs associated with the on going provision of stroke servicesImprove shared knowledge amongst health professionals across the health economy and within localities building relationships between primary and secondary care, and between cardiac and stroke clinicians.Improve the commissioning of AF services to incentivise good clinical practice and support on going delivery of value for money services.Improve the patient pathway and speed up access to specialist services as well as providing equity for patients with AF.
27OverviewBased on the learnings from other work and the critical success factors identified, the project should include the following key elements:Focused commissioner programme to raise awareness and understanding of the impact of AF on stroke, how that relates to their local population and the potential QIPP benefits that can be gained by a coherent and supported strategy for primary care risk identification and appropriate management.Systematic roll out of GRASP AF programme within primary care, underpinned by specialist AF nurse teams working in practices to provide support for baseline audit, patient review and focused education. Ideally supported by local incentives via QOF plus or LES.Systematic education programme for primary care HCPs, utilising a range of formats including group education as part of PLT, on line accredited learning modules, one to one in practice facilitated learningPublic awareness campaign ( towards back end of implementation phase) to raise awareness of AF and encourage patients to check pulse and visit GP.Development of clear and simple AF guidelines and pathwaysAll backed up by robust and coherent communications plan and strong leadership from the project team.
28What will success look like? Commissioners across the region will have an understanding of the impact of AF on stroke rates within their own health economy , the evidence base for effective management of AF and the potential cost and quality benefits that can be achieved as part of the QIPP agenda and prioritise AF management within their commissioning programmesAnti-coagulant clinics adhere to existing NPSA guidelines on audit and clinical governance, with particular emphasis on time in therapeutic range and that the audit data generated is actively reviewed by commissionersReduced Stroke rates and associated admissions and costsGps understand the impact and burden of AF within their own practices and actively identify and manage patients with appropriate therapiesWarfarin therapy will become the widely accepted first line treatment for newly diagnosed AF and a minimum of 20% of all eligible patients currently taking an antiplatelet will be switched to warfarin during the project.Patients are more aware of the symptoms of AF and proactively attend their GP practice to ask for a pulse check.Once diagnosed patients are aware that warfarin is the best treatment for them , are educated in its use and are happy to take it and manage their condition in partnership with their healthcare professional.
29Potential for Stroke Reduction and Associated Cost Savings Across the Region Assumptions Used ( with thanks to Matt Fey and Greg Fell in Bradford for input)Pts on East Midlands AF Registers65,937QOFPts assumed on warfarin27,692based on NICE assumption of 46%Pts assumed on Aspirin32508The balancePts Untreated3957Total potential eligible for warfarin36465If all were treated with warfarin potential number of strokes saved1459assume NNT 25 for CHADS score of 2However likely only 75% would achieve good Tx control so potential strokes saved more likely to be nearer1094Potential cost avoided£12,471,000Based on cost in first year of £11,400Cost of treating all of these patients£14,586,000Based on pts at av cost per patient of £400 per year ( Warfarin and INR)Net Cost£2,115,000
30Example MetricsNumber of CCGs/PCTs who have AF identified within their QIPP or commissioning intentions.Number of LES or local QOF incentives linked to AFNo of CCGs with agreed local guidelines for anticoagulation% of patients with TTR > 60%Number of practices using GRASP AF and uploading via CHARTNumber of practices utilising specialist nurse support via project% increase of diagnosed AF on register% Increase in use of warfarinConversion rates for existing patients being switched from anti platelet to warfarinNumber of newly diagnosed patients prescribed warfarinNumber of AF related stroke admissionsPatient satisfaction surveys - % patients feeling confident in the management of their condition and their warfarin control.These will be formally agreed and developed by the project steering committee in line with the project plan but are intended to demonstrate examples of what could be measured.
31Is it possible?This is an ambitious approach and is based on the principle ofAn intensive but highly focused and systematic programme of activity over a relatively short period of time ( up to 6 months)Robust project plan and project managementLimited budget availability from within the networkResources , skills and manpower from potential partnersThe approach aims to produce a working model which demonstrates successful outcomes and which provides a business case and practical implementation plan which can then be easily replicated in other areasIt may be appropriate to consider a “pilot” project and work in one defined PCT / CCG to begin with to develop the approach, test , refine and evaluate it in order to provide an “evidence base” and toolkit for other PCT’s/ CCGs to follow.This will also provide the partner organisations ( pharmaceutical, healthcare, voluntary) with an evidence base to justify their continued involvement and contribution of resource.
32Why the pharmaceutical industry? Because the evidence from other programmes is that success requires a multi faceted approach and to do that we need all the help we can getWe have shared goals:For the NHS to prioritise detection and effective treatment of AFIncrease in the numbers of patients identified with AF and more patients treated in line with NICE guidelinesA reduction in the number of patients suffering a stroke .Engaging GPs and CCGs is vital and the companies are working with them already – they have the relationships every day.They are talking to GPs, Practices and CCGs anyway so there is an opportunity harness that and create a shared communications approach to reinforce the messages and communication of the project objectives .
33The companies have access to and may contribute significant resources over and above that which the network can aloneManpower to increase capacity to deliver the project – coal face implementation support.Sophisticated cost / impact modelling tools for AF prevalence and cost impact of stroke / treatment variances to help commissioners understand their population and the burden of AF and stroke.Provision of AF nurse specialist teams toSupport primary care implement GRASP AF and review patientsProvide 1:1 training in practices and across the Health EconomyAccredited clinical education programmes and the people to deliver themChange management expertise to facilitate pathway redesignEngagement with commissioners at PCT and CCG levelMarketing and communications expertise and change management support.Access to national opinion leader network and sharing of best practiceOn line resource tools for education , clinical development and management support.
34What is Joint Working?“Situations where for the benefit of patients, organisations pool skills, experience and/ or resources for the joint development of patient centred projects and share a commitment to successful delivery” *Joint working is distinctly different from sponsorship arrangements whereby companies merely provide for a specific event or work programme.In joint working, goals are agreed jointly by the NHS organisation and company, in the interest of patients, and shared throughout the project.A joint working agreement is drawn up and management arrangements conducted with participation from both parties in an open and transparent manner.For many organisations, joint working will represent a new way of working and requires a different mindset from sponsorship and a collaborative approach.Successful experiences have shown that it can be of major benefit to patients, the NHS and pharmaceutical companies.
35Case StudiesThere are many examples of successful Joint Working programmes underway throughout the UK that have bought measurable benefits to patients across a range of disease areas.₇The DH supports the approach and together with the ABPI has issued guidance to the NHS on appropriate governance arrangements₈,₉The National QIPP programme has a work stream focusing on how successful local JW projects can be up scaled and replicated to benefit organisations and patients across the UKNHS Nottingham City has engaged in Joint Working on 4 large scale programmes all aimed at reducing avoidable hospital admissions and improving outcomes for patientsEach project has been developed with multi stakeholder involvement from the PCT, Primary Care, Secondary Care, Community Services, Patient Groups and the pharmaceutical industry.All underpinned by robust governance arrangements and written partnership agreements signed by all partiesDedicated project management funded by the partnership.9.http://www.abpi.org.uk/media-centre/newsreleases/2009/Documents/ABPI_Code_Guidance_Notes.pdf
37Joint Working in Nottingham City Press ReleasesNewslettersPrimary Care InfoPatient Information
38Pharmaceutical and Healthcare Companies Companies who have so far confirmed their interest in working on a programme in the East Midlands and support the approach being suggested:Boehringer IngelheimBayerPfizerRoche Diagnostics
39Voluntary SectorThere are a number of national patient groups/charities with an interest in AF and who run their own campaigns aimed at raising awareness amongst patients, clinicians and policy makersStroke Association - Ask First CampaignIn conjunction with NHS Improvement. Raising awareness of link between AF and Stroke. Supported by targeted radio campaign encouraging the public to check their pulse.Have already expressed an interest in running the campaign in the East Midlands.Atrial Fibrillation Association (AFA)Various educational programmes and patient materials , training for HCPS, ToolkitsSupporting the All Party Parliamentary Group for AFHave expressed strong interest in working on a programme in the East MidlandsArrhythmia AllianceKnow your pulse campaign screened in general practice waiting rooms in various parts of the country with free pulse check guide and smartphone app.British Heart FoundationLarge team of nurse specialist funded posts across the countryNHF traditionally have not engaged with the pharmaceutical industry.Working closely with these groups enables the project to:Engage directly with patients and understand what they want and need.Access national awareness raising campaigns and support tailored for local need.
40Project Steering Committee Pharmaceutical Companies How would it work?Project Steering CommitteeWritten Joint Working Agreement signed by all partiesand Terms of ReferenceEMCSNPharmaceutical CompaniesVoluntary GroupsTo include senior lead fromprimary careSecondary careCommissioningMedicines Management1 representative from each( 4-5)National and local representationPCT(Pilot)PCTPCTPCTPCTPCTImplementation teamLead local GP, Commissioner, Medicines management, project manager, pharmaceutical company lead
41Who Would the Partners Be? ( Organisational Level) East Midlands Cardiac Network with representation fromAcute TrustsClinicalProvider / ServiceCCGs / PCTsClinical lead primary careCommissioningMedicines ManagementCommunity Provider ?The Pharmaceutical and Healthcare partner companiesPatient Groups / Charities
42GovernanceThe involvement of the pharmaceutical companies would be underpinned by a written Joint Working agreement signed by all parties. This agreement aims to ensure that all activities are conducted in an open and transparent way.The agreement will also document funding / resource contributions from each partner ( including the NHS organisations) , expected outcomes and procedures regarding confidentiality, Intellectual property, data protection and other legal necessities. An example of an agreement can be supplied in confidence if required.The template for this has been trialled and approved by both the DH and the ABPIThe pharmaceutical companies have to work within the ABPI code of practice and the agreement underpins this.The representatives of the companies working on the project must not have a promotional role outside of the project.The project steering committee will have clear terms of referenceDevelopment of the Governance framework can be informed by the agreements and contracts in place for the 3 NHS Nottingham City Joint Working programmes.
43Overseen by Steering Committee Project ComponentsOverseen by Steering CommitteeCommissionersPharmaEMPHOImpactModellingGRASP AFNurse SupportEducation ProgrammePrimary CarePharmaVoluntary SectorClinical Guidelines DevelopmentAnticoagulation ServicesPathway / Guidelines and Service developmentSecondary CareEMCSNPatientsPublic Awareness Programme andEducationPharmaVoluntary Sector
44BudgetA full financial assessment will need to be developed as part of the project plan and will be dictated by the scope of that plan however, if the approach is agreed then many of direct project costs will be met by the pharmaceutical company partners through use of their servicesThe main cost to the network would be project management, communications and any running costs of the steering committee (Meetings, Clinician backfill etc)Additional costs to be factored in at local level will be:Incentive payments for GPs at local level if agreed( PCT / CCG)Additional prescribing ( PCT / CCG)Additional diagnostic tests ( ECHO / referrals to secondary careHowever it would be hoped that development of the cost impact modelling tool for commissioners will help to demonstrate the cost benefit of this investment at local level and it is hoped that we can work with the pharmaceutical company partners to develop that.
45Initial Risk Assessment A detailed Risk Assessment will be undertaken as part of the project plan
46Key Milestones Milestones Agreement to proceed Month 1 Month 2 Month 3 Regional ActivityPilot AreaAgreement to proceedMonthly Steering Committee MeetingsMonth1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Agree PartnersJoint Working AgreementProject PlanFinancials and confirm resourcesAgree pilot areaCommunications programme and sign up of stakeholdersProject Initiation and set upNurses from pharma companies to support installation, baseline audit and patient reviewDevelop and test commissioner impact toolLaunch EventPharma led with input from EMPHO Test in pilot PCT before roll outGRASP AF and nurse support implementation in pilot areaEvaluationMilestonesPilot HCP Education ProgrammeLocal Communications ProgrammeRegional Commissioner ProgrammeUtilisation of pharma companies to talk to commissioners using impact tool underpinned by regional communications programmeRegional Communications ProgrammeRegional Roll OutPublic Awareness Campaign
47Key Stakeholders East Midlands Stroke and Cardiac Network Management TeamClinical LeadsPharmaceutical CompaniesGPs and Primary Care HCPSCommissionersMedicines ManagementPublic HealthCardiologistsAnticoagulation Service providersPCT / CCG CommunicationsNHS ImprovementEast Midlands SHA and its successor organisationPatientsVoluntary Sector and National Charities
48References1.NHS Information Centre for health and social care, Quality and Outcomes Framework Achievement Data 2008/9, NHS, Editor. 2009, NHS. 2.Marian Kerr, Standards and Quality Analytical Team. Atrial Fibrillation Cost benefit Analysis DH 3. Hart R, Pearce L, Aguilar M. Meta analysis: antithrombotic therapy to prevent stroke in patients who have non-valvular atrial fibrillation. Ann Intern Med 2007; 146: The Management of atrial fibrillation CG 36 June Commissioning for Stroke Prevention in Primary Care – The role of Atrial Fibrillation NHS Improvement Atrial Fibrillation and Stroke Prevention - East Midlands Public Health Observatory June Moving Beyond Sponsorship – Joint Working between the NHS and the Pharmaceutical Industry – Toolkit DH Best practice guidance for joint working between the NHS and the pharmaceutical industry – DH ABPI guidance notes on joint working between pharmaceutical companies and the NHS and others for the benefit of patients ABPI March 2009