Increasing the Heart Failure Nursing Workforce

British Journal of CardiacBritish Journal Nursing 2019https://doi.org/10.12968/bjca.2019.0109 [email protected] Email: Jayne Masters Correspondence to: Wrexham, UK 3 City, UK Trust,NHS WelwynGarden Hertfordshire Community 2 Wessex Doctoral Fellow CLARHC of theBSHHFNForum; Southampton, UK;Chair Foundation Trust, Southampton NHS 1 Failure Jayne Masters, Failure Heart Lead Nurse Society for Failure Heart Nurse Forum workforce: recommendations by the British failure nursing Increasing the heart Nightingale House Hospice, Cardiology ClinicalLead, University Hospitals

2 , Lynda Blue, Deceased Email:

worse aspopulationsincrease.Inastudydesignedtoassesstrendsintheincidence (Aaronson and Cowger, 2012). Cowie (2017) describes an epidemic that will get et al, 2018). It is the final common pathway for almost every cardiovascular disease numbers oftheUKpopulationandincreasesinprevalence associetyages(Conrad Heart failure remainsacommon,progressive, disablingconditionthataffects large INTRODUCTION Cardiac Nursing.2019:14(11)1–12. https://doi.org/10.12968/bjca.2019.0109 workforce: recommendationsbytheBritishSocietyforHeartFailure NurseForum. BritishJournalof How tocitethisarticle:MastersJ,BartonC,BlueL, Welstand J.Increasing theheartfailure nursing cancer combined(CancerResearch UK,2012). failure in the UK is increasing and is now similar to the four most common types of presentation ofheartfailure alsoincreased. This meansthattheburden ofheart (750 numbers ofprevalent heartfailure casesintheUKincreasedbyeven more:23% largely becauseofanincreaseinpopulationsizeandage. The estimatedabsolute diagnosed heartfailure intheUKincreasedby12%during2002–2014. This was (2018) demonstratedthattheestimatedabsolutenumber ofindividuals with newly and prevalence of heart failure in a large general UK population cohort, Conrad et al Submitted: 9October2019;acceptedfollowingdoubleblindpeerreview: 20October2019 Key words: help ensure sustainabilityofheart failure servicesoverthelongerterm. inequalities ofcare, reduce costsassociatedwithheartfailure hospitalisationsand able tobeseenbyaheartfailure specialistnurseinatimelymanner, helpreduce It makesanumberofrecommendations thatwouldensure heartfailure patients are in theUK,andoutlinechallengescurrently facingheartfailure specialistnurses. same. Thisarticlewilldescribethedevelopmentofcommunityheartfailure nursing recommended numberof heartfailure specialistnursesper100 recommendations from theNationalInstituteforHealthandCare Excellence, the Yet, despiteincreased prevalence, considerableadvancesintherapies,andnew improve patientoutcomesandreduce thecostsassociated withhospitalisation. budget. Studieshavedemonstratedthatcommunityheartfailure specialistnurses associated withthosehospitalisationsaccountforasignificantproportion oftheNHS this numbercontinuestorise.Itisacommoncauseofhospitalisationandcosts There are almost1millionpeoplediagnosedwithheart failure intheUK,and Abstract 127–920 † , Dr Jenny Welstand, Hospice Failure Heart Nurse Specialist ■ 616). Over thestudyperiod, patientageandmultimorbidityatfirst Heart failure 1 , Carys Barton, Clinical Lead Nurse Specialist Heart ■ Heart failure specialistnurses Downloaded from magonlinelibrary.com by002.218.211.012 onNovember 9, 2019. 1 ■ Clinic 000 hasstayedthe Models ofcare al Review al 3

Heart failure is now the world’s leading cause of hospitalisation according to Ferreira et al (2019). Hospitalisations account for the high cost of treating heart failure, which comprises almost 2% of the NHS budget (National Confidential Enquiry into Patient Outcome and Death [NCEPOD], 2018); 60–70% of those costs are because of hospital admissions. The NHS budget for the whole of the UK in 2017/2018 was £144 864 billion; if 2% was spent on heart failure, this equates to £2897.28 million, meaning between £1738.368 million and £2028.096 million is likely to have been spent on heart failure admissions (House of Commons Library, 2019). Economic evaluations carried out by Stewart et al (2002) and the British Heart Foundation (BHF) (2015) demonstrate that community heart failure specialist nurse models can reduce costs by reducing unscheduled admissions. Over the past 3 decades treatment and management of heart failure has improved significantly and includes new pharmacological and device therapies, and novel biochemical monitoring systems. Pharmacological therapies such as angiotensin converting enzyme inhibitors, beta blockers, mineralocorticoid receptor antagonists and newer drugs such as ivabradine and sacubitril valsartan are now mainstay treatments (National Institute for Health and Care Excellence [NICE], 2016, 2018). Pharmacological treatments in conjunction with sophisticated implantable devices, e.g. biventricular pacemakers, implantable cardioverter defibrillators and implantable pulmonary artery monitoring systems, have changed the treatment and monitoring available for patients with heart failure, particularly those with reduced ejection fraction. New models of care such as specialist multidisciplinary teams, rapid access heart failure clinics and community heart failure nursing services have ensured patients have better access to specialist services (NICE, 2010; BHF, 2015; Masters et al, 2017; Morton et al, 2018). The European Society of Cardiology Guidelines (Ponikowski et al, 2016) use the following terminologies to describe heart failure. The term heart failure comprises a wide range of patients from those with a normal ejection fraction (typically considered >50%) and often referred to as heart failure with preserved ejection fraction, to heart failure with reduced ejection fraction, typically with an ejection fraction <40%. Patients with heart failure based on an ejection fraction from 40–49% represent a grey area that Ponikowski et al (2016) now define as mid-range Table( 1). Differentiation of patients with heart failure based on left ventricular ejection fraction is important because of different underlying aetiologies, demographics, comorbidities and response to therapies (Paulus and Tschope, 2013). Historically heart failure nurses in the UK were referred only patients with heart failure with reduced ejection fraction (Blue et al, 2001; BHF, 2008). It is useful to understand the different terminologies for heart failure and the impact that normal left ventricular ejection fraction/heart failure with preserved ejection fraction has had on referral numbers since 2015.

Table 1. Terminology used in heart failure

Type of HF HFrEF HFmREF (mid-range) HFpEF

Criteria Symptoms of HF Symptoms of HF Symptoms of HF

Left ventricular EF (LVEF) <40% LVEF 40–49% LVEF >50%

Elevated levels of natriuretic Elevated levels of natriuretic peptides and at least one additional peptides and at least one criteriona.Relevant structural heart other additional criteriona. disease eg left ventricular hypertrophy Relevant structural heart (LVH) or left atrial enlargement (LAE)b. criterion disease eg LVH Diastolic dysfunction or LAE

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This article discusses the role of the community heart failure specialist nurse, outlining the changes and developments that have occurred since the role was conceptualised in the late nineties. The discussion will illustrate how these developments in conjunction with an aging society make it imperative that the number of heart failure specialist nurses practising today is increased.

EVOLUTION OF THE HEART FAILURE SPECIALIST NURSE ROLE

A seminal Scottish study of patients managed by a trained heart failure specialist nurse after discharge, found patients with heart failure with reduced ejection fraction were less likely to be readmitted post discharge, than those receiving normal care (Blue et al, 2001). The patients also reported improvements related to quality of life. These were highly relevant findings for a group of patients where hospital admissions were high (McMurray and Stewart, 2000), and quality of life was documented as poor (Stewart et al, 2001). From 2004 to 2007, the BHF (2008), in conjunction with the Big Lottery Fund, guaranteed 3 years of funding for 76 heart failure specialist nurses in 26 primary care organisations across England. The programme demonstrated a 35% reduction in all-cause admissions (BHF, 2015). The intervention in the BHF project and the earlier study by Blue et al (2001), was a heart failure specialist nurse, who provided post-discharge care for patients with heart failure with reduced ejection fraction through a combination of home visits and outpatient clinics. The care and management delivered by the heart failure specialist nurse included: cardiovascular review, respiratory and fluid status assessments, with appropriate adjustment of pharmacological treatment, titration of evidence-based therapies, monitoring of renal function and other biochemical and haematological tests; as well as patient and carer education and support. The economic evaluation carried out by Stewart et al (2002) demonstrated substantial cost benefits associated with the heart failure specialist nurse model. It was calculated that if a specialist heart failure nursing service was implemented at 60 sites in the UK, based on the reductions seen in the earlier intervention by Blue et al (2001), there could be a net benefit to the NHS of £20 000 000. Following the evaluation, Stewart et al (2002) recommended that a community heart failure nursing service employing one community heart failure nurse per 100 000 was established across the UK. This was based on the prevalence of heart failure with reduced ejection fraction in the population at the time and a caseload of 60 patients per heart failure specialist nurse. The BHF project quoted similar cost savings and made similar recommendations. Based on a caseload of 60 patients with heart failure with reduced ejection fraction, 1 whole-time equivalent heart failure specialist nurse demonstrated a cost saving of £42 000 per annum or £169 000 per 1000 patients (BHF, 2015).

EVOLUTION OF THE HEART FAILURE MULTIDISCIPLINARY TEAM

In 2006, a Health Care Commission audit (Nichol et al, 2008) of heart failure admissions to acute trusts in England, Wales and Northern Ireland reported poor patient outcomes, with notably high incidences of readmission and death. It was recognised that those who received management or input from a cardiologist fared better than those who were managed by non-specialists (Nichol et al, 2008).

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failure multidisciplinary teams led by a cardiologist, and also a national audit of all primary heart failure admissions in England and Wales. The National Heart Failure Audit was established in 2006 with the first report published in 2007 (NHS Digital, 2012), and annually thereafter. The information provided by the audits highlight inequalities in care. In 2016, English Trusts were subsequently incentivised to provide multidisciplinary teams and take part in the National Heart Failure Audit through the development of the enhanced heart failure tariff (NHS Improvement, 2016). The tariff is achieved if 70% of patients coded with a primary diagnosis of heart failure (Hospital Episode Statistics [HES] data) are entered into the National Audit, and 60% of these admissions are seen by a member of the specialist multidisciplinary team (National Institute for Cardiovascular Outcomes Research [NICOR], 2018). Although there are still significant improvements to be made, more patients admitted with heart failure are identified and seen during their admission by heart failure specialists. This increases their likelihood of being discharged alive, and also with a recommendation for community heart failure follow-up; if compared with earlier audit data from the National Audit (NHS Digital, 2012; NICOR, 2017). However, no provision has been made for additional community heart failure specialist nurses. In 2015, the NICE Acute Heart Failure Quality Standards (NICE, 2015) recommended that all patients admitted with a primary diagnosis of heart failure in England and Wales should be seen by a member of the specialist heart failure multidisciplinary team during their index admission, and then followed up by the team within 2 weeks of discharge. Standard 5 stated that this could be a community heart failure specialist nurse. This recommendation changed the character of patients requiring follow-up by heart failure specialist nurses, for example, the recommendation included patients with heart failure with preserved ejection fraction; a cohort of patients who are usually older, have more comorbidities and fewer treatment options (Paulus and Tschope, 2013). In the report of the National Heart Failure Audit of 2016/2017 (NICOR, 2017), 33% of the records submitted, reported non-elective admissions for patients with heart failure with preserved ejection fraction. According to international registry data, approximately 50% of patients diagnosed with heart failure have heart failure with preserved ejection fraction (Paulus et al, 2007; Arora, 2017).Consequently, after NICE (2014) published acute heart failure recommendations in 2014, followed by Quality Standards in 2015 (NICE, 2015), the number of patients potentially eligible for community heart failure services in England and Wales doubled. However, again, no provision was made to increase the number of community heart failure specialist nurses.

ADVANCES IN TREATMENT AND MANAGEMENT

Heart failure treatment and management are consistently evolving. New therapies, such as biventricular pacemakers and implantable cardioverter defibrillators, give increasing hope to patients in terms of both quality of life and prognosis. These devices collect haemodynamic data and can alert clinicians to potential decompensation and risk of events before they take place (Virani et al, 2016). Implantable pulmonary artery monitors (CardioMems) monitor fluid status, allowing clinicians to alter diuretic therapy in high-risk patients, often preventing an unscheduled admission (Abraham et al, 2011). These monitors are currently undergoing evaluation, but early data are promising. These devices could help prevent further hospitalisations and thus create potential savings for the healthcare economy; however, action is still required on behalf of the clinician, but at a

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Table 2. Comparison of heart failure treatments 2001 and 2019

Treatments 2001 Number of drug titrations Treatments 2019 Number of drug titrations

ACE-inhibitors 4 ACE-inhibitors 4

Diuretics Various Beta blockers 4–5

Digoxin 1 MRAs 2–3

Ivabradine 2

Sacubitril valsartan 2–3

Dapagliflozin 1

Diuretics Various

Source: Blue et al, 2001

The PARADIGM trial (McMurray et al, 2014) demonstrated the benefit of a new class of drug: angiotensin receptor blocker with a neprilysin inhibitor. This new treatment demonstrated significant reduction in mortality and rehospitalisation for patients with heart failure with reduced ejection fraction of less than 35% (McMurray et al, 2014). Sacubitril valsartan is now approved for use across the UK (NICE, 2016). Firstly, patients are established on standard treatment (ie angiotensin-converting- enzyme inhibitors or angiotensin receptor blockers with no adverse effects). Once safety has been established, patients are switched over to sacubitril valsartan and the titration process begins again. This means that heart failure specialist nurses are now being asked to see patients who had been optimised previously and subsequently discharged; as well as new and existing patients. Unfortunately, many UK services are unable to provide any additional resource to deliver this treatment. Most recently, the Dapagliflozin And Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial (McMurray et al, 2019) reported that dapagliflozin (an SGLT2 inhibitor) met the primary composite endpoint with a statistically significant and clinically meaningful reduction of cardiovascular death or the worsening of heart failure (defined as hospitalisation or an urgent heart failure visit), compared to placebo. The trial was conducted in patients with heart failure with reduced ejection fraction on standard heart failure treatment, including those with and without type-2 diabetes. This treatment will improve outcomes for patients but, inevitably, like sacubitril valsartan, will provide additional work for already stretched heart failure services. Table 2 shows a comparison of the treatments available to treat heart failure with reduced ejection fraction in 2001 and 2019.

COMMUNITY HEART FAILURE NURSING 2019

Most English Clinical Commissioning Groups and Scottish and Welsh Health Boards now commission community heart failure specialist nurses. Many require that they provide follow-up for all primary heart failure admissions within 2 weeks of discharge as recommended by NICE (NICE, 2015), and see patients who are at risk of hospital admission more urgently (eg within 48 hours). Establishment and up-titration of evidence-based therapies remains an important part of the role. As outlined earlier, patients with heart failure have frequent admissions for other illnesses, at which time heart failure medications are highly likely to be stopped. These medications then need to be restarted after discharge and so re-referral to heart failure specialist nurses is common. Additionally, the care of patients with heart failure who are approaching the end of

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such as cancer (Gadoud et al, 2014). Care and management are fragmented and uncoordinated, which ensures many patients do not access specialist palliative care services. It is recognised that coordinated care provided by palliative care teams in conjunction with cardiology, community heart failure specialist nurses and primary care improves outcomes (Hospice UK, 2017). Therefore, the heart failure specialist nurses also need to have the resources to develop end-of-life services for this group of patients with their palliative and primary care colleagues. The NCEPOD (2018) found that in 29.5% of the hospital admissions examined, the final admission could have been avoided if an end-of-life plan had been in place (NCEPOD, 2018)— something that commonly aligns with patients’ preferred place of care (Department of Health, 2008).

BSH HEART FAILURE NURSE FORUM

In 2017, the British Society for Heart Failure established a Heart Failure Nurse Forum to bring together heart failure specialist nurses across the UK to help develop and support the heart failure nurse role. It became apparent after the first year that heart failure specialist nurses across the UK were reporting difficulties managing the volume of referrals received and caseloads were increasing dramatically. To develop an understanding of the picture of heart failure care and management in the UK, a survey was sent out to the clinical or heart failure nursing leads of 16 acute trusts and four health boards to establish: ■■ If services were managing to see patients with heart failure within 2 weeks of discharge; if not, what percentage were meeting this objective ■■ Whether they see all patients with heart failure or heart failure with reduced ejection fraction only ■■ If they covered a rural or urban population ■■ The number of nurses commissioned per 100 000 population. The Scottish Heart Failure Nurse Forum (2018) was undertaking a Scotland-wide review, and Scotland was therefore not included in the survey. There were 18 initial responses. Most of the clinical leads found it difficult to answer the survey questions, because the heart failure services were provided by community trusts and they did not have access to this data. In the replies, seven clinical leads said they knew the community heart failure specialist nurses were struggling, and had ‘unmanageable caseloads’; they put the Forum in contact with the heart failure specialist nurses who provided services in their areas. In a British Society for Heart Failure Nurse Forum update, the lead author also asked heart failure specialist nurse members of the British Society for Heart Failure to contact the Forum if they would be willing to take part in the survey. A further 18 surveys were received. A total of 36 surveys were then sent out and 25 replies received. Of the 25 services that replied: ■■ All but four employed one heart failure specialist nurse per 100 000 ■■ 8/25 managed to see >65% of patients within 2 weeks ■■ 6/25 could see 10–50% of patients within 2 weeks ■■ 5/25 had waiting lists >6 weeks ■■ 6 services did not collect data on referral times ■■ 15/25 services saw all patients with heart failure. Typically, services that covered populations in urban areas were better able to meet or come close to meeting the 2-week standard than services covering rural populations. Interestingly, of the services that could see less than 20% of patients in 2 weeks, each one covered an area known to be a popular retirement area with a

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There is strong evidence demonstrating heart failure is more common as people age (Conrad et al, 2018). Additionally, in areas associated with higher levels of deprivation, as demonstrated in Glasgow and Greater Clyde, the overall burden of cardiovascular disease is greater (ISD Scotland, 2019), which means the overall burden of heart failure is also greater. The Scottish Heart Failure Nurse Forum (2018) reported that across Scotland, heart failure services are also struggling to manage the additional demands of an ageing population. Most Scottish heart failure nurses have historically been referred patients with heart failure with reduced ejection fraction only, but the report recommends that this is reviewed and that patients with heart failure of all aetiologies should be referred to heart failure specialist nurses for management.

DISCUSSION

Treatment and management of heart failure over the past three decades has made significant progress with new treatments, new models of care and clearer guidance. These developments have increased caseload size and workload per patient. For the most part, the community heart failure specialist nurses have been expected to absorb this extra work with no additional resource. Heart failure has shifted from being a chronic illness managed by general physicians, to a sub specialty of cardiology. Cardiologists can now opt to be specifically trained in the management of this condition, and it is recommended that Trusts that receive acute heart failure admissions have a cardiologist as the clinical lead. Recommendations have led to the development of specialist multidisciplinary teams usually working alongside that clinical lead; subsequently, more patients with heart failure are identified during their admission and are able to access specialist heart failure services. This is a huge step forward from the report by Nichol et al (2008) more than a decade ago. A number of guidelines have been published to influence the quality of care each patient with heart failure receives (NICE, 2014, 2015; Ponikowski et al, 2016; The Scottish Intercollegiate Guidelines Network, 2016; (NICE, 2018). These guidelines serve as a point of reference for commissioners, Trusts, Health Boards and clinicians. Since the publication of the seminal article by Blue et al (2001) and the economic evaluation by Stewart et al (2002), according to the Nurse Forum survey and an audit by the Pumping Marvellous Foundation, most Clinical Commissioning Groups still employ 1 heart failure nurse per 100 000 (Pumping Marvellous 2018). The 2002 recommendation was made in the context of heart failure specialist nurses seeing heart failure with reduced ejection fraction alone; at that time there was no expectation that the nurses would also treat patients with heart failure with preserved ejection fraction. The recommendations from NICE in 2014 and 2015 radically changed this expectation. In England and Wales, many services are now expected to see patients with heart failure with preserved ejection fraction. As has been demonstrated, heart failure with preserved ejection fraction accounts for approximately 50% of patients diagnosed with heart failure and 35% of heart failure admissions. These patients are more complex, have multiple healthcare needs and are therefore more challenging to treat and keep out of hospital. Following the publication of the NICE Quality Standards in 2015 a recommendation should have been made to increase the number of heart failure specialist nurses, to at least 2 whole-time equivalent per 100 000; this is based on the fact that heart failure with preserved ejection fraction accounts for almost half of patients diagnosed with heart failure. Cowie (2017) has described an ‘epidemic’ of heart failure and Conrad et al

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patients with heart failure are more complex with an average of four comorbidities (NCEPOD, 2018). There is a wider number of treatment options available, particularly for heart failure with reduced ejection fraction. It has been shown that the cost of heart failure to the NHS is already high, but costs are predicted to increase substantially. GP services are currently under pressure and unable to fill vacancies, and while the NICE recommendations have recommended 6-monthly review in primary care, GPs state that this is beyond what could be achieved (Mahase, 2018). The work could be undertaken by the heart failure specialist multidisciplinary team. It is widely accepted that heart failure specialist nurses working in the community help to optimise medical therapy and keep patients well and out of hospital; thus reducing the costs associated with heart failure admissions. They also have a hugely positive impact on the quality of life of both patients and carers. We can see from the survey and the Scottish Report that, in many areas, patients are not seen quickly enough, this increases the risk of hospital admission, poor health outcomes and, ultimately, death. Heart failure is a priority of the NHS Long Term Plan (NHS England, 2019). A key focus of this plan is to remove inequity of care for groups such as older people and those of lower socioeconomic status. If we are to achieve this and reduce inequalities and treatment variation in relation to heart failure, it is vital that numbers are increased urgently to match the additional workload.

RECOMMENDATIONS

The authors recommend an increase in the number of heart failure specialist nurses in the range of 2–4 whole-time equivalent per 100 000.We recommend that 2 whole-time equivalent per 100 000 is the minimum requirement for services whose patient inclusion is restricted to heart failure with reduced ejection fraction alone. For services who include or are expected to include in the future, patients with heart failure with reduced ejection fraction, heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction, we recommend a minimum requirement of between 3 and 4 whole-time equivalent per 100 000.The minimum whole-time equivalent requirement should be increased for services who have high numbers of elderly patients (such as popular retirement areas); and/or in areas of high deprivation with higher incidences of cardiovascular disease regardless of the type of heart failure. We recommend that the Cardiac Networks of NHS England, Scotland, Wales and the Health and Social Care Executive of Northern Ireland join together to undertake a robust piece of work exploring the numbers of heart failure nurses needed to treat the rapidly increasing number of patients. This work needs to be based on patient demographics, age, comorbidities socioeconomic status and stage of disease. This would take into account the complexity of the patient group and ensure that end-of-life care is considered. It would identify how caseloads should be calculated. We recommend looking into the feasibility of standardising community heart failure data. Several services did not collect the data on referral times. A standardised approach similar to the National Heart Failure Audit would better inform service development throughout the UK and reduce geographical variation. There is scope to develop the roles of allied health professionals working within the heart failure multidisciplinary team (eg pharmacists, physiotherapists, cardiac physiologists) to take over some aspects of the heart failure specialist nurse role. We recognise that there is a national nursing shortage, which could mean that

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the heart failure multidisciplinary team would be a sensible solution and increase the skill mix of the community team. This would align with the recommendations made in the NCEPOD report of 2018. Finally we would recommend better integration of community and acute heart failure services. We recognise that patients with heart failure and the treatments available to treat them are growing in complexity. These patients require upskilled, well trained heart failure specialist nurses who have unrestricted access to a consultant physician with training and expertise in heart failure management. This clinician should be the identified clinical lead of that heart failure service.

LIMITATIONS

It is recognised that the survey mentioned in this article was small and not representative of all heart failure services across the UK. It was not able to capture the effects of patient demographics such as age, socioeconomic status or geographical area. We recognise that patient demographics play an important part in the number of patients with heart failure referred in different geographical areas.

CONCLUSION

To improve the treatment and management of patients with a diagnosis of heart failure in the UK, there needs to be a change in the recommended number of heart failure specialist nurses to match the increase in prevalence, referral eligibility, better identification of patients and the wider range of treatments available for patients with heart failure with reduced ejection fraction . Failure to address this will increase the number of heart failure admissions, which will significantly increase costs to Clinical Commissioning Groups, Health Boards and the wider healthcare economy. It will also have a negative effect on the quality of life of individual patients, slow down access to disease-modifying therapies, increase the workload of GPs and, ultimately, adversely affect the lifespan of many patients with heart failure. We recommend that this is made a national priority.

Endorsements The recommendations made in this article have been endorsed by: The British Society for Heart Failure (BSH), The Primary Care Cardiovascular Society (PCCVS), The Cardiovascular Group of the British Geriatric Society, Heart Failure Hub Scotland and The Pumping Marvellous Foundation.

Acknowledgements The authors would like to thank colleagues on the Board of the British Society for Heart Failure and the Steering Group of the Nurse Forum, BSH members who took part in the survey, the Scottish Heart Failure Nurse Forum and Dr Clare Murphy from the Heart Failure Hub Scotland for their time and comments on this work. †The late Lynda Blue was one of the key figures in the development of heart failure services in the UK and community heart failure nursing in particular. She was the first nurse member of the British Society for Heart Failure and was instrumental in setting up both the Scottish Heart Failure Nurse Forum and the British Society for Heart Failure Nurse Forum. She was involved with the planning of this manuscript and this article is a tribute to all of her work, as well as the legacy she has left, for

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Key Points

■■ This article outlines the development of the heart failure nurse role over the last 20 years, illustrating the improvement in the treatment and management of heart failure

■■ It is argued that all patients with heart failure would benefit from these improvements regardless of demographics

■■ There should be an increase in the number of heart failure nurses to match the increases in the numbers of patients, as well as treatment options

CPD Reflection Questions

■■ What is the difference between heart failure with reduced ejection fraction, heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction?

■■ What treatment options are available for heart failure with reduced ejection fraction?

■■ Why is it important for patients with heart failure to be seen by a heart failure specialist nurse?

Conflicts of interest The authors have no conflicts of interest to declare.

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