Heart failure in Scotland remains a challenge

Over half a million people in the UK are living with heart failure. 

In Scotland, the disease caused nearly 12,000 hospitalisations in 2013, with around 25 per cent of patients requiring emergency re-admissions within 30 days of hospital discharge. Of those hospitalised, just under a quarter (23 per cent) died within 30 days of discharge.

Caused by the inability of the heart muscle to pump a normal amount of oxygen-rich blood around the body, heart failure can have a huge impact on patients’ everyday lives. It is the leading cause of hospital admissions in the over-65s, with survival rates, across all ages, worse than for breast and prostate cancer.

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It accounts for almost two per cent of the entire NHS budget, equating to an approximate spend of £2.3bn annually and is one of the five long-term conditions responsible for 75 per cent of unplanned hospital admissions.

Treatment has improved progressively over the last decade and people are managing to survive with better intervention techniques. But this too brings fiscal challenges, with estimates that in 10 years, from 2012, managing heart failure costs in the NHS will increase on top of normal inflation by 50 per cent. 

With an ageing and growing population, these issues become more pressing. 

Nonetheless Scotland has seen real progress. Dr Mark Petrie, Consultant Cardiologist at Golden Jubilee National Hospital, said there has been “a gradual accumulation of evidence” in how best to treat the disease over the past few years.

“There’s been progressive changes in drug therapy and every two or three years there has been a new drug to help people live longer, help their hearts contract better and make them feel better.”
New SIGN guidelines, released this month, include the addition of a new drug, sacubitril valsartan, which could significantly reduce the number of heart failure deaths.

He said: “There has been a whole lot of good news in heart failure and the new drug to be included in guidelines for the first time was trialled in Glasgow. So the new SIGN guidelines are exciting.

“The development of the heart failure team in the last ten or fifteen years has really been a huge bonus for patients because they meet people who know what they are talking about, who know what’s wrong with them and how to treat them. That has been a big step in the right direction.”

Jill Nicholls is a Heart Failure Specialist Nurse with NHS Tayside and one of the Scottish Government’s Heart Failure Hub Co-ordinators. She is also chair of the Heart Failure Nurse Forum in Scotland.

Key to the improvement in treatment, she says, is the expansion of services across Scotland, from the early 2000s onwards.

She said: “The focus of heart failure care is robust assessment of why that patient has heart failure, this is crucial as some causes can be reversible and they should have that managed. The longer-term management of this condition is based upon a wide body of evidence with both pharmacological and non-pharmacological interventions. With referral to the heart failure service, patient and clinicians can be reassured that the treatment plan will be individualised to meet the needs of that scenario. 

“Robust referral processes are the crux of ensuring that this level of care meets the right patient at the right time reflecting the 2020 Vision of the Scottish Government. At this time, referral can still be overlooked and a focus of the Scottish Heart Failure Hub is to ensure that high quality and consistent care can be delivered.”

Nicholls says support from the heart failure team starts right from the point of diagnosis, becoming more intense when patients are unstable and then stepping back if or when they are not. 
She said: “When patients are struggling with the symptom burden of heart failure, it is essential to support with a consistent service. This does not have to be entirely nursing led, the focus must be to ensure the suitable level of clinical competence and experience.” 

The demand for heart failure services is constantly increasing, and so bringing in other professionals within the wider health and social care will be key. 

Nicholls says she has seen significant change over the last decade, as services spread.

She said: “All services will audit their practice and we can see the shift with reduced symptom burden and reduced need for unscheduled hospital admission. I had the opportunity to undertake an economic appraisal of nursing services, this took the form of a clinical audit which demonstrated that patients with Heart Failure Nurse Liaison Service input demonstrated a reduction in hospitalisation rate by approximately 68 per cent, compared to a similar group who had no input from a heart failure service.

"This highlighted the absolute need to capture all suitable patients, to have the opportunity to improve the patients’ journey through this condition.” 

Further improvements include the creation of the Scottish Government’s Heart Failure Hub, established as a subgroup of the National Advisory Committee on Heart Disease, which is progressing a national work programme. 

The group brings together clinicians, managers, the voluntary sector and patients to ensure a coordinated approach to tackling the many challenges facing heart failure teams in NHS boards across Scotland.

The group’s remit focuses on six key areas, aiming to improve education, access to psychological support, palliative care, models of care, quality improvement, and information and coding.
Dr Petrie, chair of the hub, is positive about improvements over the past decade, describing the Scottish Government as “incredibly helpful” in the way it has supported the hub and awareness of heart failure more generally.

Nicholls agrees. “If we can improve in those areas across Scotland then the journey for heart failure patients will be considerably improved. They will have better diagnosis, improved access to specialist care, better input of evidence-based treatment and better assessment of any barriers they may face – because if a patient is anxious or depressed then their ability to be involved in their management is reduced. If we can improve levels of anxiety or depression then we have a much better chance of engaging them fully. We also know that patients are not being referred to palliative care at the most appropriate time to get the most benefit.

“These six areas of priority involve the crossing of traditional healthcare boundaries, secondary care to community care and the flow of patients to maximise their stability and ultimately reduce the need for hospitalisation.”

Petrie describes the need to manage multiple conditions as “the next frontier”.

He said: “That is one of the next steps we have to take, to make sure people are not just treated as if they are patients with heart failure, but by recognising they are patients who tend to have several things going on. The way medicine currently works is on a single organ basis, and the doctors tend to be GPs or single organ specialists. So that is something we are aware of and certainly working with social care is important, not just to think about the disease process but also about what the person’s other needs are outwith heart failure.

“That is something that probably in the first two years of the hub we have not addressed adequately … and we need to work with social care to make sure we are not just managing the heart, we are managing the patient and their other needs.”