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GPs face six-monthly heart failure reviews as NICE greenlights 'unrealistic' guideline

NICE has called for GPs to review the care plans of heart failure patients every six months, despite GPs expressing concerns that this will create a disproportionate workload.

Despite the concerns, raised after NICE published draft guidance in April, its final chronic heart failure guideline recommends that GPs ‘lead a full review’ of the patient's care, with follow-ups 'at least every six months' after that.

GPs said the the guidance was 'unrealistic', adding there could be 'disastrous medico-legal consequences' for GPs who not have the resources to meet the recommendations.

The new NICE guideline says that the primary care team should ‘lead a full review of the person's heart failure care, which may form part of a long-term conditions review’ and then ‘recall the person at least every six months and update the clinical record’.  

But the RCGP raised concerns about the workload implications of this during the consultation on the initial draft, asking NICE to define ‘primary care team’ to make it clear if this work would fall to GPs.

The RCGP wrote: ‘There needs to be a definition of “primary care team” in the context of a specialist heart failure multidisciplinary team.

‘The recognition that primary care physicians can form an integral part of the multidisciplinary team is welcome but due to current pressures in primary care it will not be practical for representation to occur...

‘If “primary care team” throughout this document refers to the patient’s GP, a six-monthly review and written care plan would be an increase in workload.’

Although the final guideline still simply refers to the 'primary care team', NICE wrote in a response to RCGP that 'the exact arrangements vary across the NHS but the committee identified that practitioners with competencies in primary care are a key part of the [multidisciplinary team]'.  

It added that the six-month review 'may also be part of the long-term conditions review and so would not be additional'.

RCGP chair Professor Helen Stokes-Lampard said: 'While these guidelines are certainly helpful, it’s important that they are also realistic, and that GPs have the ability to refer patients to these specialist teams in the first place.

'Without access to an appropriate multidisciplinary team, it falls to primary care teams to carry out these additional checks which, given the current pressures on our profession, is hugely challenging. We therefore need to be sure that GPs can truly rely on multidisciplinary teams.'

West Kent GP and LMC representative Dr Zishan Syed said: 'There will be a considerable amount of extra unfunded work as a consequence of this.

'There are grave concerns that unrealistic guidelines such as this from NICE could have disastrous medico-legal consequences for GPs as practices in this underfunded climate simply do not have the resources and finances to implement these guidelines.'

He added: 'This is not GP work but rather secondary care specialist work and NICE should not be pressurising GPs in this manner. I do hope that the GPC will respond robustly against these guidelines.' 

The fears follow recent news that GPs under investigation by the Parliamentary and Health Service Ombudsman due to patient complaints will be asked which clinical guidelines they followed when making relevant decisions.

Meanwhile, researchers recently reported that GPs are following heart failure guidelines more closely now than they were in 2002, with substantial increases in prescribing and referral rates.

NICE's new chronic heart failure guideline

The primary care team should carry out the following for people with heart failure at all times, including periods when the person is also receiving specialist heart failure care 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 six months and update the clinical record
  • ensure that changes to the clinical record 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. 

Source: NICE

Readers' comments (16)

  • More guidance. Just what we need.Professional freedom and common sense is now out of the window and we have people who do not see patients producing more and more guidance from different organisations. I think the move would be to quit clinical medicine and write guidances and be safe from manslaughter charges.

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  • Any reason why the hospital heart failure team can't see these patients every six months?

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  • "guidelines not tramlines" to quote NICE.

    Remember these are guidelines, and if we can justify not following them, then fine.
    The health of other patients and the GP can form part of this justification.

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  • 'The health of other patients and the GP can form part of this justification. '

    Since when do the GMC and the courts take that into account when forensically interrogating the care of a single patient?

    This is commissioning by medico legal jeopardy which, in a state controlled system, is the logical and cheapest short - medium term solution prior to the long term collapse.

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  • Not commissioned then not done

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  • which heart failure do they mean? one local CCG heart failure primary care team won't see patients with right sided heart failure problems, ie patients with copd as primary cause, as they say they don't count as proper heart failure. so can I exclude these patients too? or do they just mean patients with left sided heart failure or only if have both left and right sided heart failure? I may be being a bit pedantic here but if I am to justify my management according to NICE guidelines some clarification would be great on exactly whom I am meant to be seeing. cheers.

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  • joe bloggs is right but i'm afraid Big and Smaller is Righter... guidance may be general but it ends up being applied to individuals and believe me legal teams [and NHSE] will pursue that principle to the end..

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  • 160 patients on our HF register, 10% churn
    that's going to be around 360 appointments a year
    say 90 hours clinician time minimum

    What is going to give to make room for this?
    No wonder everyone's leaving

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  • "...and shared with the specialist heart failure MDT"
    The RCGP just might recover a tiny bit of respect if they simply said NO, GPs and the primary care team are too overburdened as it is. The specialist heart failure MDT should do the reviews and share the information with the GPs. They should then start reviewing other NICE guidance too. Formal refusal by both the RCGP and BMA to accept some NICE guidance as appropriate would probably be legally protective.
    Also, the danger of 'misuse' of NICE guidelines by lawyers could be reduced if NICE made it clear in each and every guideline that they were just suggested guidance and that alternative management may be equally appropriate. Although this is alluded to by NICE somewhere, putting it in large, heavy print at the start of every guideline would be helpful.

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  • Ffs

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