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Joint Working Project between Eastern Academic Health & Science Network (AHSN), Lea Valley Health GP federation and Pfizer

Optimising the Atrial Fibrillation Pathway in Lower Lea Valley, a Joint Working Partnership between Pfizer, Eastern AHSN & Lea Valley Health GP federation.



Atrial Fibrillation (AF) is a heart condition that causes an irregular and often abnormally fast heart rate. It is the most common heart rhythm disorder. Common symptoms include dizziness, shortness of breath and fatigue. The worst clinical outcome of AF is a stroke. Sometimes AF can be completely asymptomatic. About 1.4 million people in England have AF; around 2.5% of the population.  Across England about 425,000 people are living with undiagnosed and untreated AF. There are several treatment options recommended in NICE Clinical Guidance, including anticoagulant medicines that alleviate symptoms and reduce the risk of a stroke.1

In NHS East & North Herts CCG, Public Health England estimates there are more than 3,800 people with undiagnosed AF. This results in a considerably higher risk of AF-related strokes for those not undergoing treatment. We also know that over 1,500 patients with identified AF in NHS East & North Herts CCG and at a high risk of stroke are not on the anticoagulation treatment recommended in NICE Guideline CG180.2

Lea Valley Health is a federation of 8 NHS affiliated GP Practices in Lower Lea Valley, Hertfordshire serving a growing population of over 75,000 patients. (These practices also form one of the 6 localities of NHS East & North Herts CCG). The aim of the federation is to maintain, improve and innovate healthcare services and ensure that appropriate care is delivered to the patients in the right place, at the right time.3

Eastern Academic Health and Science Network (AHSN) is working to reduce the incidence of AF-related stroke and improve health outcomes for the population in the Eastern region.

Pfizer will collaborate formally through joint working with both Eastern AHSN and Lea Valley Health GP Federation to support the implementation of the patient pathway for atrial fibrillation for its population in Lower Lea Valley and build on existing services for the screening, diagnosis and treatment of atrial fibrillation patients closer to their home.



This joint working partnership will successfully implement an efficient AF screening, diagnosis and treatment pathway within primary care.

There are 3 separate elements of the project;

  • Detect – Using the Eastern AHSN chosen medical devices in optimal settings to increase AF detection and reduce the prevalence gap.  
  • Protect – Reviewing existing AF patients on practice registers who are not anticoagulated and ensuring that they are appropriately anticoagulated
  • Perfect – Review existing AF patients receiving anticoagulation medication to ensure that mechanisms are in place to monitor and support the patients through optimisation of treatment.


Joint Working

  • Pfizer will provide £10,040 funding for clinical pharmacist time and training events, 5 days project delivery support from the Pfizer UK Strategic Accounts Team for development of the initial project plan, 5 days Health Economic consultancy from the Pfizer Payer Evidence team and 2 days of facilitation from the Pfizer Local Account Manager.
  • Lea Valley Health will provide £4,045 funding for detection hardware, 15 days of Clinical oversight and support and operational insights from their Executive team and 5 days of IT support to help with data collection.
  • Eastern AHSN will provide £1,800 funding for AF detection devices, educational resources, 10 days of programme management expertise from a Senior Programme Manager and 5 days of Events coordinator time to support delivery of training events.



After 6 months the project aims to achieve the following:

  • 90% of patients at risk of an AF-related stroke are appropriately anticoagulated in all practices in the Lower Lea Valley locality.
  • 100% of relevant Health Care Professionals are trained in the use of chosen AF detection device and embedding their usage in the primary care AF referral pathway.
  • An increase in diagnosed prevalence of AF.
  • Reduction in admissions to hospital with an AF related stroke and patients not on anticoagulation.
  • Reduction in the variation in AF management across GP practices in Lower Lea Valley.



Benefits for Patients with Atrial Fibrillation
  • Provide the patient with a timely and convenient opportunity to be diagnosed and reviewed according to agreed local protocols and pathway.
  • Increase the numbers of patients with AF who are managed in accordance with NICE guidance
  • Improved patient safety and reduction in risk of AF related stroke through appropriate anticoagulation
  • Reduce AF related and or anticoagulation related assessments and admissions to emergency department.
  • Provision of care closer to home


Benefits for the NHS
  • Meeting NICE quality standards for the management of atrial fibrillation and adherence to national guidelines for patients requiring anticoagulation.
  • Increase the proportion of patients receiving appropriate anticoagulant therapy through clear guidelines on initiation and discontinuation of therapies as clinically appropriate thereby improving avoidable stroke prevention.
  • Prevention of unnecessary hospital admissions and referrals in line with the NHS 10 -year plan.
  • Delivering an innovative, standardised and high-quality service in primary care can minimise unwarranted variation between GP practices.
  • Best practice sharing across NHS as the outputs from this project can then be used to work with other GP Federations across England to enable commissioning of further primary care led screening, diagnosis and treatment services.


Benefits for Pfizer:
  • Improved reputation as a result of working in partnership with NHS to benefit patient outcomes and experience.
  • Increasing the number of patients suitable for anticoagulation in line with NICE guidance.
  • Gain valuable insights and develop further understanding of the NHS within primary care settings.





PP-GIP-GBR-4352 / May 2019