Project Name: The Development of an Integrated Heart Failure (“HF”) Service

Project Summary: 

This joint working project will involve the extension of the current hospital-based specialist HF service through the addition of a senior nurse consultant  “in-reach” nurse with  the purpose of coordinating the existing nurse team identifying and triaging HF patients (both at acute medical receiving units and non-Cardiology departments) so they can be appropriately referred to the relevant Cardiology service and receive specialist HF input and subsequently coordinating the discharge of patients and liaising with community teams, including primary care, to ensure continuous appropriate care for HF patients after their discharge from hospital.

In addition, the project implemented additional Multi-Disciplinary Team (“MDT”) care for HF patients delivered by HF Consultants, HF nurse specialists, Pharmacists, and, where appropriate Physiotherapist, Palliative Care specialist, Psychologist, Occupational Therapist and/or Administrators. The MDT will review and deliver integrated patient care which may include interventions such as clinical review, medicines management, cardiac rehabilitation, education, self-monitoring and management, telemonitoring or telephone support for the HF patients identified described above.

Finally, due to the Covid – 19 pandemic many of the HF team were redeployed and as they have returned to cross-site working, a 1 day Novartis workshop is to be run to support the reduction in the variations of care across the service.

Planned Milestones:

- Advertise posts and secure nurse employment; nurse on-boarding and familiarisation (Milestone 1);

- Develop in-patient strategies/protocols and implementation procedures governing the clinical operations of the HF service (Milestone 2);

- Carry out clinical operations according to the developed protocols, monitor and collect data, provide anonymised report containing such data (Milestones 3, 4, and 6 at 6, 12, and 18 months);

- Submit attendance list for Novartis provided Advance + Business Skills and NHS Insights Workshop facilitated by JSL Consulting and Associates Limited (Milestone 5).

- Analyse data, and prepare business case for funding of this service by the NHS (Milestone 7);

- Submit HF service business case to relevant body within Imperial College Healthcare Trust (Milestone 8);

- Submit final JWP report to Novartis (Milestone 9).

Expected Benefits:

For the Patients:

  • improved access to diagnosis and optimised treatment;
  • more equitable and consistent care and access to care;
  • enhanced experience for patients and their carers who live with HF.

For the NHS:

  • increased quality of care and improved equity of access to specialist care for patients with HF;
  • improve patient flow and reduced total number of inpatient bed days and  readmissions due to HF;
  • increase proportion of patients identified with HF being managed in accordance with NICE guideline standards;
  • insight into benefits of inpatient HF service which may inform ongoing redesign and workforce planning.

For Novartis:

  • further opportunities for the appropriate use of cardiology licensed medicines in line with NICE guidelines, including Novartis’s medicine;
  • enhanced reputation;
  • ethical, professional and transparent relationship and trust between Novartis and the NHS.

Start Date & Duration: September 2019, 29 months


Project Name: The Development of an Integrated Heart Failure (“HF”) Service

Partner Organisation(s): Imperial College Healthcare Trust

Completion Date: February 2022

Outcome Summary:

The recruitment of a senior In-reach nurse consultant to Imperial college Healthcare Trust was achieved and is now continued by the NHS so the benefits in patient outcomes can be maintained.

The post was able to coordinate care to the highest clinical standards with 100% of the clinical protocols updated, reducing the variation of care across the multiple hospital and community sites

Achievement of the minimum clinical thresholds which are set out to achieve best practice tariff. (These clinical standards achieved despite the change during covid-19 pandemic to block contract.)

The integrated HF team at Imperial has developed as an exemplar service over the JWA period to improve responsiveness, care, quality and leadership, locally regionally and nationally. Business cases to support the continued success of the service redesign and development long term have been submitted. Further planned innovation is in progress.

Key Projects Outcomes Data:

At the start of the project, an In-reach nurse was secured and on-boarded. The in-patient strategies/protocols and implementation procedures that would govern the clinical operations of the HF service were developed.

In Jan-2020 clinical operations started according to the developed protocols, monitor and collect data, provide anonymised report containing such data.

During the period of Apr-2020 to at least Apr-2021, all HF staff members were either redeployed entirely to other areas or had their inpatient HF focus of work significantly affected.  The In-reach nurse alongside a few other team members was able to upscale outpatient care for HF patients so as to avoid admission wherever possible, and led of various novel ways of working to maintain HF patient safety both as inpatients and outpatients.

The In-reach nurse service continued virtually with minimal inpatient referrals, and recorded patient outcomes data.

Team members attended a 1 day workshop to reduce the variations of care across the post covid service.

Data from the JWP was analysed and business cases to support the continued success of the service redesign and development long term has been submitted.



Quality impact

  • All CQC domains have been met - safe, caring, responsive and well led.
  • Pathway redesign has ensured improved responsiveness across care settings and increased safety for patients with earlier diagnosis and greater access to prognostic therapies.  Integrating primary and secondary care pathways ensures seamless transition of care and accessibility to specialist services for escalation of care needs.
  • Online advice and guidance for GP’s is undertaken monthly for HF, ensuring accessibility to HF specialist team, upskilling of primary care teams and meeting all CQC domains.
  • Remote monitoring (RM) reduces need for face-to-face appointments reducing resource pressures but not replacing them entirely. Additional benefits from earlier recognition of deteriorating symptoms to avoid decompensation and avoiding hospital admission.
  • MDT now routinely includes a HF specialist pharmacist, geriatrician and palliative care consultant.  In addition Imperial College Healthcare Trust now has two monthly complex MDT”s where renal & cancer patients can be discussed.  Increasing members and skill-set of MDT and frequency of meetings to include specialist MDT’s has significantly improved ensuring timely escalation of care needs and access to other specialist services (amyloid MDT, cardio-oncology MDT).
  • Responsive and accessible HF Consultant lead and Nurse Consultant lead with regional and national profiles ensure seamless service delivery with clear lines of communication. Additional strategic/Leadership positions (see main report).

Financial impact:

  • Trust to support HF nurse consultant role salary in full
  • Full financial impact of further recommendations set out in business case
  • Financial resource to train staff appropriately
  • Financial impact of continuing to support ambulatory unit offset by admission avoidance cost savings and improved morbidity and mortality outcomes.

Workforce impact:

  • As an exemplar HF service model, recruitment and retention of staff is expected to improve, with enhanced staff experience, engagement and performance.
  • A Consultant nurse with national/international profile acts as role model to HFSN and CNSs within the trust, locality and nationally.
  • The first specialist HF Pharmacist role has been created within the team. Expanding expertise of multi-disciplinary team to include HF pharmacists and renal physicians. New HF nurse and HF admin posts created.
  • Organisational reputation improvement for wider workforce
  • HFSN now submitting abstracts and presenting work at international conferences, supported by Consultant HF Nurse
  • Increase in nursing led publications 


The expansion of the Heart Failure team to include a senior nurse consultant to co-ordinate care for a large population of heart failure patients across multiple sites was successful in achieving the highest clinical standards and reducing the variation of care. This benefit of the service has been recognised by the Trust by funding the post to continue as part of the expanded team.