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Case studies > 2019 annual report > Improving the identification of patients in atrial fibrillation at Lambeth and Southwark CCGs

Improving the identification of patients in atrial fibrillation at Lambeth and Southwark CCGs

Lambeth and Southwark CCGs

Clinical challenge
To reduce the incidence of AF-related stroke in Lambeth and Southwark CCGs through improved rates of anticoagulation for AF in general practice.

  • To utilise local pharmacists to undertake in-practice reviews of patients on the AF register who are not currently prescribed anticoagulants.
  • To assess stroke and bleeding risk and, where appropriate ensure patients are prescribed anticoagulant therapy.
  • 2 specialist anticoagulation pharmacists were commissioned to deliver 1 virtual clinic per practice alongside a GP, to review all patients identified as being on the AF register and not currently anticoagulated.
  • Any patients identified at the virtual clinic were contacted by the GP practice and referred into local services for assessment and initiation of anticoagulation.
Across 91 GP practices, 1574 patients with AF not receiving anticoagulation were reviewed in virtual clinics across Lambeth and Southwark over a 12-month period.
  • 1291 additional patients anticoagulated
Using SSNAP data to look at the number of strokes in people with known AF across Lambeth and Southwark CCGs, it was possible to see a 22.5% reduction between 2013/14 – 2017/18, compared to 11.2% nationally over the same period.

  • An updated and educated primary care workforce – myths and misconceptions addressed.
  • Strengthened relationships between specialist anticoagulation services and primary care.
  • Redesign of anticoagulant referral form across all three tertiary centres to ensure all necessary info on referral.
  • Supported DOAC (direct oral anticoagulants) initiation in primary care for housebound and nursing home patients.
  • In-depth data on untreated population to guide further service developments.
  • The challenge is to sustain these changes.

Find us

Sentinel Stroke National Audit Programme
Kings College London
Addison House
Guy's Campus


0116 464 9901