Over the last 2 years, much of the NHS' effort has been rightly directed at the COVID-19 pandemic, with hospitals under pressure from very sick patients and the population-wide vaccination programme roll-out. In the wake of this redirection of effort, people with other conditions, including cancer, cardiovascular disease (CVD) and mobility issues, have had limited access to healthcare, and in many cases, delayed treatment. This is evidenced by the long waiting lists for NHS care and referral to treatment (RTT) waiting times. At the end of June 2022, 6.7 million people were waiting to start treatment, of whom 62.2% had been waiting up to 18 weeks (NHS England (NHSE), 2022), with similar waiting times elsewhere across the UK.
Heart failure affects about 920 000 people and is the only cardiac condition with an increase in prevalence in the UK, with 200 000 new cases every year. Surprisingly, most respondents (87%) in a recent survey did not know the symptoms of heart failure before they were diagnosed and 53% had not heard of the condition until they were diagnosed (Pumping Marvellous Foundation, 2022).
In 2016, the All-Party Parliamentary Group on Heart Disease published ten recommendations to improve the outcomes and experience of people living with heart failure after having reviewed current provision and spoken to those diagnosed with the condition. The recommendations included: improved education about heart failure and advanced communication training for all healthcare professionals; patients to have access to appropriate tests and specialists; an integrated care approach centred on a multidisciplinary team (MDT); exercised-based rehabilitation and the ability to engage in advanced care planning; and all patients should receive information about heart failure at diagnosis. The Pumping Marvellous Foundation (2018) heart failure nurse audit revealed that, while most heart failure specialist nurses (n=532) were employed by hospital NHS Trusts (66%), the remainder were employed by a wide range of organisations, including community Clinical Commissioning Groups (CCGs) and community NHS Trusts. This audit revealed that there were gaps in heart failure services, including access to exercise-based rehabilitation and palliative care.
The National Institute for Health and Care Excellence (NICE) has published a quality standard (NICE, 2018a) which includes: diagnosis by a specialist, access to appropriate medication, including angiotensin-converting enzyme (ACE) inhibitors and beta-blocker medications for those with a reduced ejection fraction, medication reviews within 2 weeks of any medication change to manage side-effects, 6 monthly reviews for those with stable heart failure, and access to exercise-based rehabilitation. NICE (2018b) has also published guidance with the aim of improving ‘diagnosis and treatment to increase the length and quality of life for people with heart failure’.
The first Healthcare Quality Improvement Partnership (HQIP) annual audit of GP practice (79% of English population) cardiovascular care covered the period ending March 2020 and the second audit (93% of English population) covered the period ending March 2021 (Office for Health Improvement & Disparities (OHID) and NHS Benchmarking Network, 2022). There was an enormous disruption to diagnosis/recording of cardiovascular disease (CVD) risk factors during the first lockdown due to fewer in-person consultations, with an increase in diagnoses every month for the remainder of the year. These diagnoses returned to pre-pandemic levels by March 2021, although hypertension diagnoses have recovered more slowly than both atrial fibrillation (AF) and chronic kidney disease (CKD) diagnoses. While no group missed out on blood preassure (BP) monitoring, there was an indication that women were slightly disadvantaged regarding hypertension management. The eight Quality and Outcomes Framework (QOF) prescribing indicators were unaffected by the pandemic. The second audit examined proactive case findings following evidence of CVD risk and disappointingly found that 43% of potentially at-risk individuals were not appropriately followed up.
‘Most respondents (87%) in a recent survey did not know the symptoms of heart failure before they were diagnosed and 53% had not heard of the condition until they were diagnosed’.
Over the summer of 2022, the Pumping Marvellous Foundation has attempted to raise the profile of heart failure care by publishing a report of survey of 508 respondents, five case studies of how heart failure had impacted upon individual lives, and examined the way heart failure is described in the media, fiction and the UK parliament. Heart failure is not only less mentioned than cancer but it is more often in a negative context leading to the simplistic association of heart failure with death and hopelessness (Demmen et al, 2022). Interestingly, in the UK parliament, heart failure has only been referred to in five debates (1995, 2005, 2007, 2020 and 2021) in stark contrast to the frequency of cancer and dementia (Demmen et al, 2022). The survey and case studies illustrate that many services require improvement so that there are joint decision making and understandable care plans, with high quality active lives being achievable if people with heart failure are given appropriate advice and support (Pumping Marvellous Foundation, 2022).
Pumping Marvellous Foundation (2022) has a simple message for the public and primary care: B.E.A.T-Breathless, Exhausted, Ankle swelling, Time for a simple blood test. NT-proBNP is an established diagnostic test for heart failure and its management (NICE, 2018b) and is available in GP surgeries to help identify heart failure. Daw et al (2022) found a complex matrix of barriers and facilitators to the implementation of their 12-week cost-effective home-based cardiac programme for housebound people with heart failure and their carers. They recommended the careful selection of staff with an interest in heart failure (implementation champions), having the willingness to work with the local heart failure team and getting the timing right to commence the initiative within the local context.
Perhaps community nurses can be heart failure ‘champions’ and change the nature of the discourse around heart failure so that those with heart failure do not feel forgotten in comparison to people with cancer or dementia. Improving heart failure care has the potential to save significant health service costs through avoidable hospital admissions as well as transforming the quality of life of those with heart failure.