Phase 1 begins with a focus on the 6 CVD domains within QOF. A personalised QOF Disease prevalence platform will be provided, casting a lens of all patients across the population to identify those meeting the QOF criteria while not being recorded on disease registers. A clinical Pharmacist will support by training PCN teams on the platform and begin actioning the review and addition of patients onto practice registers through a coding review. As part of the ongoing QI cycle, outcomes will be measured through Revalidation reports. Remote consultation support is also available for ongoing assistance and clinical outcomes.
Supplementing each of the 4 phases, the programme is underwritten by a chosen Attend2 platform in a chosen long term condition. Attend2 platforms enable national guidelines and best practice to be reinforced within general practice. Where gaps in care are identified, the Attend2 platforms allow action plans to be generated, clinical work to be implemented and improvements measured.