The programme

Yorkshire and Humber AHSN is leading, nationally and regionally, the transformation of how the prevention of Atrial Fibrillation (AF) related stroke is achieved. By scaling up and spreading AF related stroke prevention strategies across the region and the country we will see care improved at pace and scale.


Many strokes associated with AF can be avoided. Each AF related stroke causes life changing morbidity and suffering. We have estimated that there are 46,180 people in Yorkshire and Humber who have AF but are not on their GP’s AF register. Of the 101,788 people known to have AF, around 37,000 are at high risk of stroke and are not being adequately protected. The consequences of this are 2,415 avoidable strokes per annum. Eliminating these deficits in identifying and treating AF would save the NHS at least £17m over the next three years.
In addition to the obvious benefits for patients, the effective management of AF could result in a £124m per year saving across England as a result of avoided strokes. Reducing the NHS deficit, avoiding unplanned care and mortality are key components of the Five Year Forward View.

How are we helping?

Nationally we have established the AHSN network AF community of practice. We are supporting the community to enable each AHSN to go further and faster in their endeavours to reduce the number of avoidable AF related stroke. We will achieve this by identifying the synergies between AHSN AF projects and exploiting these to achieve spread and adoption of improvements in care.

Across Yorkshire and Humber we are capitalising on exemplars of effectiveness such as the West Yorkshire Healthy Futures Stroke Programme, West of England AHSN’s “Don’t wait to anticoagulate” programme and the locally produced Community Pharmacy AF consultation resource to bring about the improvements in care. We have built a programme that has the flexibility to build in the innovations in AF developed by AHSNs across the country. Examples of which can be found here.

Wessex AHSN, on behalf of the AHSN Network, has created a new video to meet this need for patients, their family and carers after anticoagulants have been prescribed. Starting Anticoagulation with Jack explains about clotting and why abnormal clots can form as people age. The different types of medicines are shown, and Jack and his son discuss common concerns, side effects and sources of support.

We know that many people taking anticoagulants don’t fully understand what side effects to look out for, or when to seek help. Starting Anticoagulation with Jack has been created to prevent people becoming unwell while on anticoagulant medicines, and avoid unnecessary admissions to hospital.
As we build this programme of work we are sharing and facilitating stroke prevention strategies in other AHSNs through:

  • Highlighting unwarranted variation and care and using data and infographics to share best practice
  • Developing collaboration as a platform for clinicians to communicate
  • Implementing Quality Improvement methodologies
  • Identifying and using innovative diagnostic devices and reviewing pathways

The Expected Impact

  • Managing AF improves the quality of life of patients, preventing debilitating strokes and vascular dementia
  • The AF programme will reduce demand on urgent care and stroke services, shifting capacity to planned care and primary care; this reduces the NHS deficit
  • The quality improvement and behaviour change methodologies in the AF programme will embed capability and capacity in primary care to ensure the sustainability of general practice.
  • A minimum of 37 strokes avoided every 18 months post intervention.
  • Potential funding and efficiency improvements of £467,680 to the system (based on 37 strokes being avoided)

Next Steps

  • We are recruiting CCGs from across Yorkshire & Humber to take part in our innovative programme of stroke prevention. More details can be found in this presentation.
  • Implement Quality Improvement activity in AF in 50 per cent of CCGs in Yorkshire and Humber.
  • Improve the patient experience.