There is a need to meet the demand, led by primary care, for the appropriate assessment and management of patients with heart failure. Standard 11 (heart failure) of the National Service Framework (NSF) for Coronary Heart Disease (CHD)1 has been paid much less attention within primary care than other NSF standards with a much greater emphasis on and investment in services for secondary prevention of CHD. The current changes in primary care, particularly those relating to practice-based commissioning, will inevitably lead to a review of all services, including those for heart failure, with cost-effectiveness being one important consideration.
The evaluation of an urban heart failure service by Patel et al. (see pages 35–9)2 in this issue supports the use of open access echocardiography/heart failure services for patients with suspected heart failure. One might argue that, from a number of different perspectives, such services may be better delivered from a primary care base. Given the less than favourable financial circumstances of many primary care organisations at the present time, however, ongoing and additional investment in primary care-based heart failure services may be under threat unless we can provide more robust3 data in areas such as quality of service and cost-effectiveness.
Setting an example
The primary care-based heart failure service in Gloucestershire is now four years old and has promising data from its 2006 audit. The audit comprises data from all patients (n=524) with left ventricular systolic dysfunction managed by the service throughout 2006. Results showed all-cause mortality in this high-risk group of only 8.2%, with half of these patients dying at home. In the group of patients who had died during 2006, almost one third had previously discussed and indicated the place they wished to be cared for during the final phase of their illness, with the vast majority opting for home. In over 70% of these cases, patients died in the place they had chosen. Sixteen per cent of patients had one or more admission (all causes) to hospital during the year. Only 3% of patients were admitted to hospital with decompensated heart failure, resulting in important cost savings as a consequence of preventing admissions. We are hoping, at least locally, that our results will persuade commissioners to ‘keep faith’ with existing services, although we are also aware that we will have to compete with the independent sector in future.
Requirements for a good service
Primary care-based heart failure services need to be well organised and to function using appropriately experienced and educated clinical staff with appropriate systems in place, not only to provide ongoing educational opportunities, but also to assess the ongoing quality of service and to meet clinical governance requirements. Finally, and perhaps most importantly, any primary care service must have seamless links with local secondary care services where ‘primary care-based’ refers to the initial point of referral, assessment and treatment, but where pathways have been developed to facilitate prompt assessment and treatment when required in secondary care.
Conflict of interest
- Department of Health. National Service Framework for Coronary Heart Disease. London: Department of Health, 2000.
- Patel KR, Prince J, Mirza S et al. Evaluation of an open-access heart failure service spanning primary and secondary care. Br J Cardiol 2008; 15:35–9.
- Health Care Commission. Pushing the boundaries: improving services for people with heart failure. London: Health Service Commision, 2007