Care City logo


We've been announced as one of the AF Association Healthcare Pioneers Report 2019 – Showcasing Best Practice in AF winners for our project “A collaborative approach to AF screening and rapid resolution” at the All Party Parliamentary Group on Atrial Fibrillation meeting held on 21 November 2018 in the Palace of Westminster, London.

Trudie Lobban MBE, Founder and CEO of AF Association congratulated the 2019 winners stating “The AF Association Healthcare Pioneers Report 2019 demonstrates truly innovative best practice covering identification, diagnosis, management, treatment and care of patients with atrial fibrillation (AF), which we summarise as Detect, Protect, Correct and Perfect. Each year we share the Report with Commissioners and healthcare professionals across the NHS plus policy makers and MPs urging them to use these case studies as a benchmark to drive improvement in processes and patient pathways for the diagnosis, treatment, and care of AF patients.”

“This years’ entries were once again of a very high standard demonstrating the ongoing innovative work aimed at improving the lives of AF patients. I would like to thank everyone who entered, and especially commend those chosen as this year’s AF Association Healthcare Pioneers Report 2019 winners.”

The Report was released during the AF Association Global AF Aware Week which aims to raise awareness worldwide of atrial fibrillation.  This year the focus is on promoting ‘Know Your Pulse to Know Your Heart Rhythm.’  Knowing your pulse can save your life, it is the easiest way to detect an arrhythmia (irregular heart rhythm). If your resting heart rate is irregular, too fast, or too slow, it is possible that you have an undiagnosed arrhythmia.

Our innovative One Stop Atrial Fibrillation (AF) Pathway finds people with undiagnosed AF, reduces the number of appointments needed to confirm diagnosis and waiting times for treatment. It utilises the accessibility of community pharmacists to identify people with undiagnosed AF, directly refer for specialist review, and if required, invite for an appointment at a one-stop AF clinic, substantially reducing the number of appointments and time needed to confirm diagnosis to receiving treatment, from 3 months to 2 weeks. It also demonstrates how public access to screening services and subsequent patient experience can be improved by delivering these interventions using digital innovation.

John Craig, Chief Executive commented “We are delighted to have our hard work recognised by the AFA Association. Working together with AliveCor, North East London Pharmaceutical Committee, First Care Connection, Barts Health NHS Trust, Waltham Forest CCG and Sonar Informatics, we have developed a pathway that benefits not just patients, but GP’s and community pharmacists, relieving pressure on workloads and expanding skills. The BHR Provider Alliance has also now committed to rolling this pathway out across Barking, Havering and Redbridge over 2019.”

For more information on AF Association visit:

Media resources

Notes to editors

  • AF Association provides support, information and guidance to anyone affected by atrial fibrillation. It works in partnership with patients and clinical experts to advance the education of both the medical profession and the general public on the risks, detection and treatment of AF.
  • The AF Association Healthcare Pioneers Report identifies best practice in the diagnosis, treatment and care of patients with atrial fibrillation (AF) and is used as a benchmark across the world to improve on how services are delivered.
  • Care City is a Healthy Ageing Innovation Centre that has been created by local health and social care partners to deliver measurable improvements in health for the population we serve and to act as a catalyst for regenerating one of London’s most deprived regions. Central to our work is a commitment to work in partnership with the local community to ensure that the research, innovation and education we deliver is driven by their needs.
  • AliveCor is marketed as the first mobile heart monitor which can allow individuals to detect, monitor and manage heart arrhythmias with automatic analysis. This device can capture electrocardiogram recordings of the heart anytime, anywhere producing instant feedback. It has the potential to transform diagnostic pathways particularly for sufferers of undiagnosed palpitations. It allows patients to share their readings with clinicians, which in turn could support a local move of diagnostic services out of secondary care (hospitals) and into the community.
  • North East London Pharmaceutical Committee is formed under the NHS regulations to represent local pharmacy owners and pharmacists. The committee represents all pharmacies in the London Boroughs of Barking and Dagenham, Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest
  • Barts Health NHS Trust is a group of hospitals providing a range of clinical services to people in east London and beyond. It operates from four major hospital sites (The Royal London, St Bartholomew’s, Whipps Cross and Newham) and a number of community locations, including Mile End hospital. Around 2.5 million people living in east London look to their services to provide them with the healthcare they need.
  • Waltham Forest CCG leading the way to ensure the people of WalthamForest get reliable high quality healthcare services.
  • Sonar Informatics aims to be the first contact for all Healthcare Providers to access information(Clinical Records), Support and Training.

With funding from NHS England Healthy New Towns programme, Care City delivered an Escape Pain programme in Thames Ward, Barking, between August–October 2018.

Osteoarthritis affects approximately 8 million people in the UK, and is becoming more common as we live longer. ESCAPE-pain is a rehabilitation programme for people with chronic joint pain, that integrates educational self-management and coping strategies with an exercise regimen individualised for each participant. It helps people understand their condition, teaches them simple things they can help themselves with, and takes them through a progressive exercise programme so they learn how to cope with pain better. 

The Escape Pain programme was delivered at the Sue Bramley Children’s Centre, a community centre in the heart of Thames Ward to residents who were either self-referred or referred via the local GP Practice at Thamesview. All participants were screened by a Physiotherapist for suitability for the programme. 

Over the next seven days we will share with you the feedback that we received from the participants of the programme including what has changed for the participant as a result of Escape Pain, what they can do now that they couldn’t do before and what key things they have taken away from the group sessions.

Day 7 – Sustainability

As part of support to participants to sustain behavioural change, Care City worked closely with the local authority to provide up to date information and signposting about the local health and wellbeing offer. Community Solutions presented to the group and explained how they could access gym passes through the Exercise on Prescription pathway. Doing this as a group provided peer support to utilise this resource. While the gym was previously an intimidating location for many of the participants, gaining confidence in exercise through Escape Pain meant many of them now felt confident and prepared to join the gym and attend exercise programmes within the leisure centre. As an additional session a taster yoga session was provided to the participants as an example of another local offer which they could engage with. This was met really well. Transitioning participants into other services and peer led groups is challenging in Thames Ward due to limited resources and opportunities. Care City will continue to work with the local authority and local residents to develop the pathway for graduates of Escape Pain to support sustained behavioural change.

In addition, two exercise practitioners from LBBD will be training in delivery of Escape Pain to increase the offer across Barking and Dagenham.

“We’re definitely going to continue to meet up as a group; we’ve got the whatsapp group. We will carry on helping each other to exercise” 

“I’d never thought to try yoga before; it’s harder than it looks! This has made me confident to try other things too, and it was good to do it with my friends here in the group”


Day 6 – Impact 

Participants were particularly enthusiastic about the impact of the programme, both on their physical symptoms, but also their mental health and wellbeing. This was translated into increased confidence in managing their pain, feeling less anxious about their condition and seeing marked improvement in their physical symptoms, such as improved range of movement and reduced pain. This manifested in practical changes such as being able to walk further, take the stairs, taking up an additional exercise and feeling generally more active. Participants actively highlighted where they had seen such improvements in their peers, and the general group progress was another marker of success for them. 

“I can move more than before, I couldn’t believe it. I feel so happy with myself and really proud. I’ve walked from my house – the long way not the short one, for the first time in six months and I felt confident about it” 

“Now I come to Escape Pain, I feel confident to walk without my stick. I didn’t do that before” 

“This group [Escape Pain] has challenged me to think differently about my pain and I’m less scared to exercise. I’m not making it more damaged” 

“Well, thanks to you, I’ve just seen my surgeon and because of all my work here at group [Escape Pain] he’s said that we can hold off surgery on my knee for now. I don’t need it for at least another 6 months when we’ll review again. And even if I do need it eventually, I’m stronger and will be better ready for it and the recovery” 

“Confidence is the big thing. All I done before was walking. I’d walk here and there, but I didn’t do exercise. Coming here [to Escape Pain] has given me confidence to try other exercises and take them from here to a gym or whatever.” 

“I go to yoga now, it’s another way I can carry on the things I’ve learnt here”


Day 5 – Peer Support

Peer support was crucial to the success of this programme. Not only did this happen within the group, but participants had begun to support and encourage each other outside of the session. Many of the participants reported feeling lonely and isolated, but were positive about the relationships they built within the group and the value of peer support and mutual understanding.

‘I think the others will agree, we find it hard to talk about our condition and living with pain like we do, can make you invisible. Others don’t see it so they don’t understand. Coming here, I just felt relaxed and knew I was with people like me, who understood about what I’ve been through and could encourage me to feel better’ 

“There’s a shared understanding here. People aren’t bored of me talking about my pain, but they’re supportive” 

“Long-term illness and injury makes you feel so isolated. I’ve really appreciated the common bond I’ve found here at the group” 

“We’ve made new friends and can support each other”


Day 4 – Group Structure 

Some participants felt that the age range from 45+ was quite broad and could have both a positive and negative effect on group dynamics. For example, a younger person in a group of much older participants could find this intimidating, and vice versa. They felt that in order to get the tone and content right, it would be helpful to have participants from a similar age band. However, others felt that it could be inspiring for both older and younger participants and that there could be some effective inter-generational support and encouragement.

“I think it would be good to get a better, smaller age range. Because I’m only 45 and turning up to work with a 90 year old, I’m just not there yet.” 

“I think it can be really encouraging for people of a wide age range to support each other and it’s really inspiring to see someone older than you working hard at exercise. I think its inspiring having a broad age range”


Day 3 - Content 

The participants were positive about the balance between exercise and education/discussion sessions. Initially the sessions kicked-off with an education component, followed by the exercise circuit. However, on participant suggestion, this was reversed, so that they commenced exercise as soon as they arrived and finished with an education discussion and debrief. This also meant that they stayed longer than the hour to speak to other participants and bond as a group and allowed for participants to have some ‘cool down’ time whilst taking part in the discussion.

“We really learnt so much from Hannah, but also from each other. We could share things that helped us and see how other people were improving. It was amazing to see other people making improvement, from being afraid of exercise to adding dancing into the mix!” 

“Escape Pain really is just a ‘come as you are’ group, doesn’t matter if you don’t have the right clothes or whatever, it’s just a supportive place” 

“My advice for anyone else taking this course is to give it your best, support each other and be ok to laugh about things. That makes a really safe environment to try new things and be able to manage the pain”


Day 2 – Timing 

The programme was delivered on Monday mornings (9.30am-10.30am) and Wednesday afternoons (3.30pm-4.30pm). Participants must attend the two sessions delivered each week. Timing was extremely important to the group, and they provided invaluable feedback as to how timings could be improved i.e. they should not clash with school run times when roads are busy.

The intensity of two sessions a week was also debated, some felt this was problematic because if they missed a week (for holiday or sickness) they had then missed two sessions which could be significant. Others felt that the frequency had helped with motivation and encouraged them to continue to be active throughout the week. Some also felt that having two sessions a week close together had enabled the group to bond quickly and created a supportive and motivating environment.

“At first I was worried about the commitment with work and everything, but I’ve actually found it really motivational coming here twice a week, and the two sessions really keeps up the energy” 

“I loved having Monday and Wednesday, even though I find it hard to get out of bed, when I turned up it really kicked off my week. But, I did find the gap between Weds and Monday a bit big, and would have liked another session or to have another day between”


Day 1 - Location

We worked closely with local residents to identify the best location for delivery of the ESCAPE-Pain programme. Considerations included, access, location and type of venue which were all found to be of importance to local residents. Finding a venue which was central to Thames Ward, easily accessible and familiar to the local community was crucial to ensuring uptake and engagement with the programme.

In addition, some residents highlighted their discomfort at entering a leisure centre or gym as was intimidating and off-putting and they would have found it difficult to go to a class in that setting, but indicated that they would feel happy using a community hall. As a result, the Sue Bramley Centre, a community centre adjacent to the Doctor’s practice was identified as the most ideal venue. The centre hosts a number of community groups, is easily accessible and is at the heart of the Thames View community. 

“Sports centres can be intimidating. Escape Pain helps break down some of the barriers” 

“For some of us, like we don’t even own a pair of trainers. So going into a gym isn’t going to happen. They can be, like, intimidating, you know? I’m there with my broken bits and not looking fit, you feel like you stand out. Whereas now after coming to this [community centre based Escape Pain] and making friends I feel like I could go with them to the sports centre and make the most of the gym pass. But you need a first step to help break that fear”

Developing new care pathways for cardiac rehabilitation delivered by hospital administrators

Care City is one of seven Test Beds selected for Wave 2 of the innovative health and care programme, focussed on tackling the challenges laid out in the NHS Five Year Forward View.

Long term conditions and lack of staff are the NHS’s biggest priority right now and Care City will respond to three East London STP challenges1, which are also present nationally. Care City’s ambitious programme will work to transform how we identify, treat and manage long-term conditions; increase skills and work force productivity; remodel areas of the workforce and service pathways across East London; and to scale these models nationally.

John Craig, Chief Executive, Care City, is delighted to lead another successful Test Bed opportunity:

“Our aim for this Test Bed is to use innovation to enhance the work and productivity of junior health and care roles. Domiciliary carers, healthcare assistants and hospital administrators represent around one million people across our health and care system. Enhancing their productivity is urgent for them and their careers, for patients and for the system as a whole. For Care City, it is a perfect focus, combining our twin aims of enabling healthy aging and helping to regenerate East London.”

The Test Beds programme run by NHS England and the Office for Life Sciences tests combinations of digital technologies with pathway redesign in a clinical setting with real patients. It harnesses the potential of innovations to help transform the way in which healthcare is delivered; empowering staff to deliver care that improves the quality of life for patients and carers.

Care City will work in partnership with eight innovations2 comprising of diagnostics, smartphone applications and management tools which are already making dramatic contributions to people with long-term conditions. Currently, there are barriers to their wider use caused by varying types of digital exclusion faced by patients, staff, organisations and systems. Care City will look at the power of junior members of the workforce to overcome those barriers, in partnership with patients.

Jane Milligan, Executive lead, East London Health and Care Partnership, is excited about the potential for the Care City Test Bed:

“We are delighted to support this Test Bed. We are excited about the chance both to improve outcomes for people with long-term conditions and to enhance the roles of vitally important junior members of our workforce, who too often remain hidden. We will learn with Care City and its partners, and are keen to rapidly grow successful solutions across East London.”

One way Care City will achieve this is by supporting Administrators to use digital tools TickerFit and DrDoctor to support patients to change their lives. These latest digital innovations will make pathway management in heart failure more personalised and efficient, which will save transactional time for administrators, and use the time saved to support them to encourage and support patients, capture data and shape the pathway around their needs. Testing will be in partnership with Barts Health’s heart failure service.

Avril Copeland, Managing Director, Innerstrength Health, believes the Test bed partnerships will drive positive change for patients and the workforce:

“We believe collaboration is key in developing sustainable pathways that will truly make a difference in patient care, so we’re delighted to join forces with Care City on the Test Bed Programme. Our goal is that TickerFit will be provided to all patients living with cardiovascular disease and we believe being part of the NHS Test Bed programme can help us realise this vision.”

Care City will be supported on its Test Bed Programme by Nuffield Trust, Innovation Unit, Good Things Foundation and UCLPartners.


1Care City’s Test Bed will respond to three East London STP challenges, which are also present nationally

  1. Primary Care - 26% of primary care services in NEL are rated 'inadequate' or 'requires improvement' by the CQC versus 13% nationally
  2. Right care – Low reported vs expected prevalence rates for long-term conditions with high rates of hospital admission
  3. Workforce - There are 1,769 patients/GP in East London compared to the London average of 1,660. These are challenges locally for East London, where there is a 14% turnover rate and 11% vacancy rate in adult nursing.

2The Eight Test Bed Innovations are:


Cardiac Rehabilitation (CR) is offered to patients who have suffered a cardiac event or undergone heart surgery, and is proven to reduce five-year mortality by 27% and hospital readmissions by 40%. However, only 51% of eligible patients receive this life saving treatment in the UK. Innerstrength Health’s first product, TickerFit, enables healthcare providers to deliver cardiac rehabilitation programmes to patients remotely, allowing them to scale their programmes to many more patients. TickerFit is personalised for patients, supporting behaviour change and focusing support on those likely to benefit from it.


DrDoctor transforms the way hospitals and patients communicate, automating processes and reducing costs. The platform improves appointment scheduling, reducing no-shows and filling vacant appointments. Currently deployed across 22 major hospitals around the UK including Guy's and St Thomas' & Great Ormond Street, DrDoctor has already saved the NHS millions of pounds and 3000 years' worth of missed appointments. DrDoctor’s pathway management product shifts their focus from transactions to transformation, collecting outcome measures and using this data intelligently – in partnership with clinicians – to personalise pathways around patients’ needs.

Whzan Digital Health

Whzan Digital Health provide digital equipment to record vital signs and photos, and deliver assessments and questionnaires, reporting to a cloud triage system.  The tools are used by community nurses, care home staff, and some chronically ill and post-operative patients.  Whzan enables staff to assess temperature, blood pressure and pulse, and other devices can be added.  Case studies from the ~10,000 patients being monitored show NHS resource savings of up to 71% alongside significant improvements in patient lives. is the first company to be CE accredited for using the smart phone camera as a clinical grade diagnostic device. Their first product is digital urine testing, which has multiple uses.  The most significant for Care City is ACR (albumin to creatinine ratio) screening in people with hypertension and diabetes to identify chronic kidney disease (CKD). People with diabetes and hypertension should have their urine tested for protein (albumin) annually. Nationally, adherence is poor (66% for type-2 diabetes) and we believe that locally perhaps 10% of over-65s with diabetes have undiagnosed CKD, which can help to identify quickly and inexpensively.


Echo is a simple, free digital service that delivers medicine to patients’ doors. Many Echo users are young, but they are focusing on a new segment – older patients with more complex needs for whom getting to a pharmacy is more difficult and comprehensive support important. Echo recently introduced a service for patients’ representatives, which can be used by paid carers and which is being used by 250 patients today. Almost half of all adults take a repeat prescription, but 40% of medication isn’t taken as directed, costing the NHS billions. Echo removes the barriers to adherence, providing nudges through their app to take and re-order medication. Echo’s data suggests that its users’ adherence is much higher than the average.

Metric: Improvement in medicinal adherence and reduction and medicine wastage

Our Mobile Health  

Our Mobile Health helps healthcare organisations to navigate health apps, assessing and curating apps according to the NHS standards, enabling providers to recommend and prescribe them to patients. Appropriate apps suggested for a patient will be displayed alongside medications, encouraging the GP to suggest an app-based therapy for appropriate conditions in place or alongside medicinal therapy.


Sleepio is a self-guided, six-week digital CBT package for insomnia developed by Big Health. The application includes sleep hygiene, a sleep diary, sleep scheduling, and a variety of cognitive behavioural sleep interventions.  Sleepio has been evaluated in seven randomised controlled trials, and endorsed by NICE in a Health Application Briefing. Evidence suggests that Sleepio not only improves sleep but can help to relieve depression, anxiety and risk factors for psychosis.  Sleepio is currently free of charge to Londoners via a partnership with Good Thinking, a pan-London digital mental wellbeing service, aimed at population-wide prevention of poor mental health.


LIVA Healthcare’s platform facilitates ongoing personalised lifestyle support through an intuitive app, building on a strong bond between coach, patient and healthcare professionals. Its focus is to improve outcomes for those with or at risk of chronic illnesses by driving lifestyle behaviour change.  Liva is proven to be effective across all socio-economic backgrounds, with over 9,000 registered users to date, and is capable of engaging older patients. It is based upon nine to 18 months of continuous patient engagement to make new habits and behaviours stick.