NICE: GPs should review care plans of heart failure patients every six months
NICE draft guidelines have recommended that GPs review the care plans of chronic heart failure patients at least every six months.
The guidelines, which formally outlined that each patient with heart failure must have a care plan, said that this review should happen even if the person is being routinely managed by a heart failure specialist, as it will address ‘wider concerns’.
While many specialists agree that these 'high risk' patients need regular reviews, some GPs have said that the frequency should be determined by the patient and their clinical team.
They also stressed the need for well funded community heart failure services, which they warn are 'under threat' in many areas.
The NICE committee has agreed that while the new initial care plan will be developed by the heart failure multidisciplinary team, it should be reviewed by the patient’s GP at ‘least every six months’.
They explained that this should enable ‘active management of comorbidities’, as well as early identification of other service needs, and encourage continuity between primary care and heart failure services.
Previous NICE guidance from 2003 has already emphasized the need for GPs to conduct clinical reviews of patients at least every six months; however this has been restated in the latest advice.
It said that the GP review of the care plan could ‘easily be incorporated into this existing review’, adding that it would not to duplicate the work of the multidisciplinary team, but ‘address the wider concerns of the person with CHF’.
Former GP and University of Hertfordshire Professor Mike Kirby, who edits the Primary Care Cardiovascular Journal, said: ‘This is a sensible approach, because the patients need careful follow ups, and all of them should have a care plan put together by a multidisciplinary team’.
Dr Chris Arden, a Southampton-based GPSI in cardiology, added: ‘These are a high-risk group of patients with complex comorbidities and treatments, so it’s entirely appropriate that they are reviewed on a regular basis.’
However, Bassetlaw GP Dr Steve Kell said: 'It is unusual to recommend the frequency of reviews by just one part of the team caring for patients with heart failure. The frequency should be determined by the patient and their clinical team with more frequent reviews if needed.
'Robust, well funded community heart failure services, with access to rapid specialist advice are essential, and they are under threat in many areas. An evidence-based, well supported model for heart failure would be welcomed, with clinicians and patients enabled rather than directed.'
As this the first time these guidelines have been updated since 2010, changes in treatments are also reflected in the new draft. The most recent addition concerns sacubitril valsartan for treating symptomatic CHF with reduced ejection fraction.
The draft refers to the 2016 NICE recommendation of the drug, labelled 'game-changing' by experts, which stated that it can be prescribed as a second-line treatment.
At the time of approval, NICE said that this medication would be available to more than 100,000 patients and could reduce some of the 30,000 related hospital admissions each year. However it outlined that the treatment would not be 'cost effective' for patients with less severe symptoms.
The final diagnosis and management guidelines are set to be published on 29 August 2018.
Guidelines in full
All people with chronic heart failure need monitoring. This monitoring should include:
- a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of 6 examining the pulse), cognitive status and nutritional status
- a review of medication, including need for changes and possible side effects
- serum electrolytes, creatinine and eGFRf. [2003, amended 2018]
The primary care team as part of the specialist heart failure MDT should carry out the following for people with heart failure at all times, including periods when the person is also receiving specialist heart failure from the MDT:
- ensure effective communication links between different care settings and clinical services involved in the person’s care
- lead a full review of the person’s heart failure care, which may form part of a long-term conditions review
- recall the person at least every 6 months and update the summary and care plan (see writing a care plan)
- ensure that changes to the care plan are understood and agreed by the person with heart failure and shared with the specialist heart failure MDT
- arrange access to specialist heart failure services if needed. 
The specialist heart failure MDT should write a summary for each person with heart failure that includes:
- diagnosis and aetiology
- medicines prescribed, monitoring of medicines, when medicines should be reviewed and any support the person needs to take the medicines
- functional abilities and any social care needs
- social circumstances, including carers' needs. 
The summary should form the basis of a care plan for each person, which should include:
- plans for managing the person’s heart failure, including follow-up care, rehabilitation and access to social care
- symptoms to look out for in case of deterioration
- a process for any subsequent access to the specialist heart failure MDT if needed
- contact details for: a named healthcare coordinator (usually a specialist heart failure nurse) and local heart failure specialist care providers, for urgent care or review
- additional sources of information for people with heart failure. 
Give a copy of the care plan to the person with heart failure, their family or carer if appropriate, and all health and social care professionals involved in their care.