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

Service components

The key components of a heart failure service are:

• ensuring access to timely and accurate diagnosis of people with heart chronic failure
• ensuring access to a high-quality heart failure service, including effective pharmacological management.

Ensuring access to timely and accurate diagnosis of people with chronic heart failure

Ensuring that people with chronic heart failure are identified, accurately diagnosed and receive optimal treatment is important both in terms of improving the quality of life and the prognosis. The diagnosis and general management of chronic heart failure are described in detail in NICE clinical guideline CG5 on chronic heart failure. Commissioners should be aware that the diagnostic tests required can be provided in either primary or secondary care, however service models will be influenced by care pathways and local needs. Commissioners will need to review local provision to determine the most effective local model.

The NICE clinical guideline recommends that only patients whose diagnosis is confirmed should be managed in accordance with the clinical guideline. To make a diagnosis of heart failure, healthcare professionals should have access to the following investigations:

• 12-lead ECG
• and/or natriuretic peptides (BNP or NTproBNP) - where available
• transthoracic Doppler 2D echocardiography.

To evaluate possible aggravating factors and/or alternative diagnoses, the following tests may also be required:

• chest x-ray
• blood tests
• urinalysis
• peak flow or spirometry.

The diagnosis of heart failure can be complex, and where the diagnosis is unclear the patient should be referred for more specialist assessment. Access to timely diagnosis and clinical confidence in effectively managing heart failure are important factors in improving the management of people with chronic heart failure^[1],^[2]. Greater access to diagnostic tests in primary could reduce unnecessary referrals - at present approximately 60% of people referred for specialist assessment are not subsequently diagnosed with heart failure. See also the assumptions used in estimating a population benchmark within this guide.

Strategies providing GPs with direct access to diagnostics are increasingly being put in place. Commissioners may wish to consider the use of BNP or NTproBNP, which can be used to help discriminate between breathlessness due to heart failure and breathlessness due to other pathology. The availability of trained cardiac physiologists is an issue in some areas, and BNP or NTproBNP can be used to triage access to echocardiography and support the management of patient waiting times. Commissioners may wish to ensure that there is sufficient capacity for diagnostics and be aware that the Heart Improvement Programme suggests a maximum wait time of 2 weeks for echocardiography in order to meet the 18 week referral to treatment target.

Developing a high-quality heart failure service

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.
• Management of heart failure should be seen as a shared responsibility between patient and healthcare professional.
• Treatment includes aspects of lifestyle and pharmacological therapy.
• Patients with heart failure should be encouraged to adopt regular aerobic and/or resistive exercise. This may be more effective when part of an exercise programme or a programme of rehabilitation. See also the commissioning guide on cardiac rehabilitation service.
• Patients with heart failure and their carers should have access to professionals with palliative care skills within the heart failure team.
• The education needs of non-NHS agency carers should be considered.

Optimising pharmacological therapy for patients with chronic heart failure is particularly important. A recent Healthcare Commission report indicated that there is still variation in prescribing of drugs recommended in the NICE clinical guideline CG5 on chronic heart failure - at individual practice level of ACE inhibitors, and of beta-blockers following admission to hospital^[3].

Commissioners may need to consider:

• how to improve access to specialist heart failure services and support through good discharge planning
• how service models and referral pathways facilitate optimal pharmacological management, including dose titration and clinical monitoring, underpinned by the appropriate skills and competencies
• how to ensure sufficient capacity
• how to improve access to assessment of psychological status, exercise programme or rehabilitation and palliative care
• how to meet the information needs and improve communication with patients and their carers.

In some places, specialist nurse management programmes for people with heart failure have been shown to improve the uptake of pharmacological therapy^[4], reduce recurrent hospital stay by 30-50% and appear to be most effective in ‘high risk' patients^[5]. Specialist nurses can also support dose titration of pharmacological therapy, which needs to be undertaken at short intervals (for example, every 2 weeks) particularly where GPs do not have the capacity to provide this level of support. To make the specialist nurse model most effective, discharge planning and good communication with the primary care team is important, and patients and carers should know how to access advice in the high risk period immediately following discharge.

Commissioners may wish to consider delivering a heart failure service in a number of different ways, and mixed models of provision may be appropriate across a local health economy. The ‘National service framework for coronary heart disease' identified three service delivery models: outreach follow-up by specialist nurses of patients with heart failure following discharge from hospital, multidisciplinary support in the community for those with established heart failure, and heart failure clinics for investigation and/or follow-up based in either primary or secondary care. The national service framework also identified that models of care should use a systematic approach to the identification, investigation and treatment of people with heart failure.

Examples of service models are given in the report ‘Managing chronic heart failure: learning from best practice'. General examples include: heart failure specialist nurse service and community based nurse led clinics, rapid access and one stop diagnostic clinics, practitioner with a speciaI interest in cardiology, and shared care with cardiologists and the specialist nursing team. The Heart Improvement Programme is exploring different models of providing heart failure services as part of the 'Making best use of inpatient beds' project. The examples are offered to share local practice, but NICE makes no judgement on the compliance of these services with its guidance.

Local stakeholders, including service users and carers, should be involved in determining what is needed from a heart failure service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for people with chronic heart failure.

The Healthcare Commission identified that the recorded prevalence of heart failure in most primary care trusts (PCTs) is well below the expected level; in a few PCTs prevalence is well in excess of what might be expected. Therefore commissioners may wish to audit current provision, local prevalence rates, GP referral rates, emergency admissions and readmission rates, and mortality rates to benchmark local variation. This will provide the opportunity to review current practice and to develop an integrated care pathway, thereby seeking to overcome some of the barriers to effective diagnosis and treatment and discharge planning. As management shifts to community based models of care, the impact of more complex needs of patients being managed by specialist services may need to be considered.

The service specification needs to consider:

• The required competencies of, and training for, staff responsible for providing the echocardiography and the specialist service. See also the Ensuring corporate and quality assurance´ section within this guide.
• The expected number of patients (this should take into account how quickly any changes in service provision are likely to take place, including current and expected rates of prevalence).
• Ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally. The specification and location of echocardiography equipment, including economies of scale and the impact on other clinical users - for example, pre-operative assessment - needs to be considered.
• Care and appropriate referral pathways for timely and accurate diagnosis of heart failure and referral to more specialist assessment, psychological assessment, exercise rehabilitation and good quality palliative care.
• Information and audit requirements, including IT support and infrastructure. The Healthcare Commission recommends that providers establish systematic and comprehensive audit requirements.
• Planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks.
• Service monitoring criteria.

Useful sources of information may include:

• The ‘Heart Improvement Programme' provides resources and practical service improvement knowledge and expertise via cardiac networks to support the improvement of local cardiac services.
• ‘Delivering the 18 week patient pathway: 18 week commissioning pathways' and the breathlessness (heart failure) pathway. Further information on meeting the 18 week referral to treatment target and improving access to echocardiograph can be found in ‘Transforming cardiac diagnostic services to deliver 18 weeks - a good practice guide'
• The ‘NHS networks: learning from practice' database offers examples of innovative commissioning across the NHS and its partners.
• The ‘Map of medicine' provides an information resource that visually organises the latest evidence and best practice guidelines.
• The NICE ‘shared learning´ database offers examples of how organisations have implemented NICE guidance locally, including a community based heart failure service providing diagnosis with BNP testing, titration of medication, patient support and input from a cardiologist and palliative care team.
• Considering the impact of patient choice. The ‘Generic choice model for long term conditions' provides good practice examples to commission services for people with long term conditions, which aim to offer choice of treatment and improve care.

References

1. Fuat A, Hungin AP, Murphy JJ (2003) Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. British Medical Journal 326: 196-201.

2. Gani S, Gray J, Khunti K et al. (2004) Managing heart failure in primary care: first steps in implementing the National Service Framework. Journal of Public Health 26: 42-7.

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

4. 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.

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