The contrast between what we know is achievable and what we know is happening suggests a systemic problem with the delivery of care to heart failure patients. Despite the difficulty in supporting trials of non-pharmacological management approaches, the report in this issue by Holland and colleagues3
shows that there is a way forward. Structured management programmes that include patient and carer education, the ready availability of advice and support, and, in particular, some home visits, improve the life expectancy of patients and reduce their need for repeated hospitalisations.
Present models of healthcare delivery are mainly reactive and focused on the relation between patient and doctor. The patient perceives a problem, and makes an appointment to see the doctor. Medicine is then done to the patient in the hospital or surgery. The challenge posed by the results of analyses like Holland’s is that we need to re-think this model, at least for heart failure care. Reaction is not the right approach: patients need to be able to become active partners in their management, and the management strategy needs to be structured to provide continuing care and support.
Changing the model is of particular importance for people with chronic disease. Chronic heart failure is a systemic disease caused by cardiac dysfunction and it is complex to manage both cross sectionally (patients may have anaemia, renal dysfunction, cardiac dyssynchrony, myocardial hibernation, associated valve disease, cardiac arrhythmia, and diabetes to mention but a few) and longitudinally (the disease is not static and tends to evolve and therefore requires regular expert review).
The role of nurses as practitioners in their own right, and the role of pharmacists and physiotherapists have to be recognised. There is some formal recognition of the possible worth of “heart failure nurses” with enthusiastic development of their roles in some areas. Uptake is, however, patchy, and depends in large part on the enthusiasm of a heart failure specialist in a local hospital. In many parts of the UK there are simply not enough cardiologists to serve the population, and certainly no heart failure cardiologist to support a demanding new role.