Commissioning a heart failure service for the management of chronic heart failure

Heart failure is a clinical syndrome in which the heart's ability to pump blood around the body is reduced. Patients with chronic heart failure often experience a poor quality of life, with over one third having severe and prolonged depressive illness. Survival rates are worse than for breast and prostate cancer, with mortality ranging between 10% and 50% per year depending on severity. The NICE clinical guideline CG5 on chronic heart failure recommends that heart failure care should be delivered by a multidisciplinary team with an integrated approach across the healthcare community and the management of heart failure should be seen as a shared responsibility between patient and healthcare professional.

Effective multidisciplinary specialist services for people with chronic heart failure can have a positive effect on patients' life expectancy and quality of life^[1] and help to reduce recurrent hospital stays by 30-50%^[2]. Some research indicates that a specialist heart failure nurse can be effective in assessing individual needs and optimising care by improving the uptake of pharmacological treatments^[2],^[3].

‘Pushing the boundaries: improving services for people with heart failure' published by the Healthcare Commission indicated that further improvements are still required in the care of heart failure patients, and recommended that the NICE guideline was more effectively implemented.

The national recorded prevalence (1.8%) of heart failure is lower than expected (2.3%)^[1], with 140,000 fewer people than estimated reported as having heart failure^[4], indicating that improvements in diagnosis are required. The Healthcare Commission has identified considerable variation in the prevalence of heart failure by primary care trust (0.19% to more than 5%) and that patients are not receiving optimal levels of care. Commissioners will need to develop strategies to manage this unmet need and the expected rise in the number of people with heart failure over the next 20 years^[1].

Benefits

The potential benefits of robustly commissioning an effective heart failure service and providing better care for the treatment of people with chronic heart failure include:

• Reduce recurrent hospital stay for some people with chronic heart failure by providing coordinated specialist care, including support for high risk patients, by optimising their management plan and communicating effectively with the primary care team, patient and carers.
• Improving clinical outcomes by slowing down the rate of disease progression.
• Prolonging life and improving the quality of life and management of depression, for people with chronic heart failure and their carers, by ensuring accurate and timely diagnosis and optimisation of treatment.
• Reducing inequalities by improving access to diagnostics and angiotensin converting enzyme (ACE) inhibitors for women, who are less likely to receive them than men^[1], and exercise or programmes of rehabilitation and palliative care^[5]. Also improving knowledge of heart failure among patients from ethnic minority groups where there is evidence of deficiencies in the information being given^[6]. Commissioners may need to consider the provision of patient information and targeting high risk groups.
• Increasing patient choice and improving partnership working, patient experience and engagement. Commissioners will need to take account of treatment options for people with chronic heart failure as the policy on choice is extended to long term conditions.
• Better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways. There is evidence that effective diagnosis and coordinated specialist care can reduce recurrent hospital stay and associated cost. In addition, the use of B-type natriuretic peptides (BNP or NTproBNP) in triaging access to echocardiography might enable more efficient use of resources, reduce patient waiting times and support timely diagnosis and treatment.

Key clinical issues

Key clinical issues in providing an effective heart failure service for the management of chronic heart failure are:

• Accurately diagnosing all people with chronic heart failure, and where the diagnosis is unclear, referring for more specialist advice and treatment.
• Ensuring that appropriate referral pathways are in place and that the multidisciplinary specialist heart failure service is integrated with other services including primary, secondary and social care. Engaging clinicians is important in agreeing pathways of care and referral criteria to ensure timely and accurate diagnosis, continuity of care and access to specialist advice and treatment and palliative care. Timely referral for patients with lesions that are potentially correctible should be considered. The presence of co-morbidities and the need for a range of diagnostics can fragment patient pathways and delay diagnosis.
• Providing effective and efficient clinical care by optimising treatment in line with NICE clinical guideline CG5 on chronic heart failure.
• Providing a quality assured service.

By addressing the key clinical issues, commissioners will ensure that services provide the best possible outcomes for individual people/patients, their carers and local communities.

National priorities

National priorities and initiatives relevant to commissioning a heart failure service for the treatment of people with chronic heart failure include:

• 'World class commissioning'.
• 'The NHS in England: The operating framework for 2009/10´.
• ‘National service framework for coronary heart disease' defines standards of care for patients with heart failure and proposes a model of a ‘one stop' diagnostic clinic.
• ‘Delivering the 18 week patient treatment pathway'.
• The ‘Care closer to home' initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• ‘Commissioning framework for health and well-being'.
• Considering the impact of patient choice.
• The ‘Expert patients programme'.
• ‘A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services'.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with ‘Standards for better health'.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. Healthcare Commission (2007) Pushing the boundaries: improving services for people with heart failure. London: Commission for Healthcare Audit and Inspection.

2. Stewart S, Horowitz JD (2003) Specialist nurse management programmes: economic benefits in the management of heart failure. Pharmacoeconomics 21: 225-40.

3. Cowie MR, McIntyre H, Panahloo Z (2002) Delivering evidence-based care to patients with heart failure: results of a structured programme. British Journal of Cardiology 9: 171-81.

4. Healthcare Commission (2007) State of Healthcare: improvements and challenges for services in England and Wales. London: Commission for Healthcare Audit and Inspection.

5. Nicol ED, Fittall B, Roughton M et al. (2008) NHS heart failure survey: a survey of acute heart failure admissions in England, Wales and Northern Ireland. Heart 94: 172-7.

6. Lip GYH, Khan H, Bhatnagar A, et al. (2004) Ethnic differences in patient perceptions of heart failure and treatment: the West Birmingham heart failure project. Heart 90: 10