Totally Health, the UK’s leading provider of clinical health coaching via the NHS, has developed a pioneering new programme to help patients with atrial fibrillation (AF) manage their condition and reduce the risk of stroke via an upskilled primary care team combined with intensive clinical health coaching.  The landmark service will be delivered in Stowhealth GP practice by Totally Health.

There is an estimated 1.4 million people living with Atrial Fibrillation (AF) in England, however over a third of these people are undiagnosed1. Statistics suggest that 1 in 10 of the over 65s are affected by the condition, making it one of the most common forms of abnormal heart rhythm. The associated risks and harmful complications are significant, with AF patients having a five-fold higher risk of stroke.  In addition, AF related strokes are often more severe with higher mortality and greater disability, requiring a longer period of rehabilitation and putting significant pressure on social and health care services to provide intervention and support.

Treatment with an anticoagulant (e.g. a blood thinner such as Warfarin) significantly reduces the risk of stroke in people with AF. It is widely recognised in the medical community that anticoagulation and rate control are key priorities in managing AF – both of which require compliance with medication for most patients.  With medication adherence hugely influenced by patient understanding and confidence, as well as good communication with health care practitioners, this project aims to address this issue via an intensive clinical health coaching programme.

This innovative service will combine providing education and upskilling to the practice GPs and nurses in effective AF detection, diagnosis and treatment with clinical health coaching to increase the knowledge and confidence of the patients in the management of their disease.  Totally Health’s Chief Medical Officer will deliver the training to the GPs to detect AF and as a result, newly diagnosed patients, patients without anticoagulation treatment and those patients that have poorly controlled INR will be referred into a 3-month intensive clinical health coaching programme, at which point patients will be discharged into the care of the GP.  Totally Health will deliver this innovative programme into Stowhealth practice in a total 15-month programme and helping up to 200 patients overall.

Clinical health coaching delivered by nurses is a proven means of delivering improved outcomes for long term conditions, in terms of reduced unscheduled care episodes and primary care contacts.  Key to this innovative approach is the focus on educating patients about why it is so important to take medication for AF, giving lifestyle and nutritional guidance to help individuals improve the self-management of their condition. The project has a clear set of objectives including increasing atrial fibrillation prevalence, increasing effective anticoagulation, managing AF in a primary care setting via an upskilled team and improving patient outcomes via 3 months of clinical health coaching.

Emma-Jane Roberts, Chief Operating Officer of Totally Health comments, “The impact of AF on a patient is life changing and significantly increases their risk of a stroke. So, we’re incredibly proud to have developed such an innovative stroke prevention intervention to reduce the burden of this disease and are excited to be working in partnership with the patients and team at Stowhealth.” 

Dr Neil Macey, Lead LTC GP at Stowhealth comments, “We’re absolutely delighted to be working alongside Totally Health on such a unique concept in the management of AF.  Totally Health will be providing upskilling to GPs and nurses in the detection and management of AF. In addition to our usual care, we will be able to refer our patients into an intensive clinical coaching service that will educate and increase THEIR confidence in managing their AF condition alongside any other long term conditions.   We anticipate significant benefits for our patients in self-managing their condition, which supports us in our clinical role to optimally manage their risk of stroke.”

The project will be delivered with advice from the AF Association (


For further information please contact Katie Coombs or Caroline Beswick at Trinity PR on 020 7112 4905 or email Visit for further information on clinical health coaching.


  1. AF Association

Notes to Editors:

  • Stowhealth GP Practice is a large innovative GP practice, rated Outstanding by CQC with a registered population of 19,136.  It provides its registered population with personal health care of a high quality and to seek continuous improvement on the health status of the practice population overall. They aim to achieve this by developing and maintaining a happy, sound practice which is responsive to patient needs and expectations and which reflects whenever possible the latest advances in Primary Health Care.
  • Totally Health Ltd is a specialist provider of Clinical Health Coaching services. They help individuals make positive changes in their lives, to address health conditions including Long Term Conditions and wider wellness issues (e.g. quitting smoking and losing weight).
  • Tailored one-on-one coaching enables patients to gain the knowledge, skills and confidence to become active participants in their own healthcare, reducing their reliance on emergency health services. The model is proven to complement existing health services. It delivers lasting changes for patients, resulting in more effective management and better compliance with treatment, as well as an improved usage of available health services.
  • The Totally Health management team, combined, has over 100 years’ experience of working in the NHS.  The management team is comprised of experienced health care professionals: clinical leaders, GPs and specialist nurses. They are based in London and the company is a subsidiary of AIM listed Totally Plc (ticker “TLY”).
  • Totally Plc is addressing some of the biggest challenges our country faces in terms of healthcare and the growing demands facing our NHS. It is their aim to become the leading provider of out of hospital care and Clinical Health Coaching Services in the UK. These are services that support people to manage their own health better to avoid reliance on urgent GP and hospital services and to support the NHS to meet its targets by providing the highest quality out of hospital care.
  • My Clinical Coach, is Totally Health’s new direct-to-consumer offering – providing the same valuable health coaching services to patients not within existing NHS programmes, where a patient can access the same service privately through a self-subscription portal at MyClinicalCoach transforms care for these patients, giving people direct access to tailored care delivered by a personal Health Coach – an NHS trained nurse – to transform their health from as little as £1 per day

Awards for Totally Health services

  • WINNERS; November 2016; Clinical Team of the Year (Diabetes); The General Practice Awards
  • FINALISTS; November 2016; Clinical Team of the Year (Long Term Conditions); The General Practice Awards
  • SPECIAL COMMENDATION; October 2016; Pathway Innovation of the Year; National Association of Primary Care
  • FINALISTS; November 2015; Technology Enabled Care Services; Innovation in Healthcare Awards; East Midlands Academic Health Science Network
  • WINNERS; November 2014; Clinical Team of the Year (Respiratory); The General Practice Awards
  • FINALISTS; November 2014; Innovators of the Year; The General Practice Awards
  • WINNERS; November 2014; Excellence in Healthcare Collaborations and Partnerships; PMEA