Commissioning guides
Published 01 October 2011

Services for people with chronic heart failure

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg39

1 Commissioning services for people with chronic heart failure

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Chronic heart failure is a complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired. It is caused by structural or functional abnormalities of the heart. Some individuals have chronic heart failure due to left ventricular systolic dysfunction (LVSD), which is associated with a reduced left ventricular ejection fraction. Others have chronic heart failure with a preserved ejection fraction (HFPEF). Most of the evidence on treatment is for chronic heart failure due to LVSD. The most common cause of chronic heart failure in the UK is coronary artery disease, and many people with chronic heart failure have had a myocardial infarction in the past[1].

Around 900,000 people in the UK have chronic heart failure. Almost as many have damaged hearts but have no symptoms of heart failure[2]. Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 76 years[3]. The prevalence of heart failure is expected to rise in the future as a result of an ageing population, improved survival of people with ischaemic heart disease and more effective treatments for heart failure[4].

People with chronic heart failure often experience a poor quality of life; symptoms include breathlessness, fatigue and ankle swelling[5], and over one third of people with chronic heart failure experience severe and prolonged depressive illness[6]. Chronic heart failure has a poor prognosis: 30–40% of people diagnosed with chronic heart failure die within 1 year; thereafter the mortality is less than 10% per year[7],[8].

Chronic heart failure accounts for 2% of all NHS inpatient bed-days and 5% of all emergency medical admissions to hospital. Readmissions are common: about one in four people with chronic heart failure are readmitted within 3 months[9]. NICE support for commissioners and others using the quality standard for chronic heart failure indicates that although there may be cost implications in implementing NICE guidance to meet the quality standard for chronic heart failure, there is potential for overall savings as a result of reduced hospital admissions.

The NICE clinical guideline 108 on chronic heart failure recommends that heart failure care should be delivered by a multidisciplinary team with an integrated approach across the healthcare community. Effective multidisciplinary specialist services for people with chronic heart failure can have a positive effect on a person's life expectancy and quality of life[10], and evidence suggests they can help to reduce recurrent hospital stays by 30–50%[11].

1.1 Commissioning for outcomes

Commissioners should refer to NICE clinical guideline 108 on chronic heart failure and the NICE quality standard for chronic heart failure when commissioning services which contribute to delivering the following NHS outcomes (2011/12):

  • preventing people from dying prematurely

    • commissioning multidisciplinary care for people with chronic heart failure may contribute to achievement of health outcomes from domain 1 of the NHS outcomes framework

  • enhancing the quality of life for people with long-term conditions

  • helping people to recover from episodes of ill health or following injury

  • ensuring that people have a positive experience of care.

1.2 Key clinical and quality issues

Key clinical and quality issues in providing effective services for people with chronic heart failure include:

  • early identification and referral for specialist assessment, making use of echocardiography or measurement of natriuretic peptides in accordance with NICE clinical guideline 108

  • ensuring that appropriate referral pathways are in place and that a multidisciplinary specialist chronic heart failure care pathway is integrated with other services including primary, secondary and social care, and that the care pathway is seamless across services

  • providing information, education and support for people with chronic heart failure and encouraging self-management

  • providing effective pharmacological treatment as recommended in NICE clinical guideline 108

  • offering supervised cardiac rehabilitation based on group exercises for people with chronic heart failure that includes education and psychological support

  • monitoring all people with chronic heart failure, the frequency of which should be dependent on the clinical status and stability of the patient as recommended in NICE clinical guideline 108

  • ensuring that people admitted to hospital due to chronic heart failure receive input to their management plan from a multidisciplinary heart failure team and that this management plan is shared with the person, their carers and their GP

  • early identification and partnership working to meet the supportive and palliative care needs of people with moderate to severe chronic heart failure and offering advance care planning

  • providing the best possible outcomes for individuals, their carers and local communities

  • providing a quality assured service (see section 6 within this guide).


[1] Petersen S, Rayner M, Wolstenholme J (2002) Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation

[2] Petersen S, Rayner M, Wolstenholme J (2002) Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation

[3] Cowie MR, Wood DA, Coats AJ et al. (1999) Incidence and aetiology of heart failure; a population-based study. European Heart Journal 20: 421–8

[4] Owan TE, Hodge DO, Herges RM et al. (2006) Trends in prevalence and outcome of heart failure with preserved ejection fraction. New England Journal of Medicine 355: 251–9

[5] National Clinical Guideline Centre for Acute and Chronic Conditions (2010) Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care. London: Royal College of Physicians

[6] Healthcare Commission (2007) Pushing the boundaries: improving services for people with heart failure. London: Commission for Healthcare Audit and Inspection

[7] Cowie MR, Wood DA, Coats AJ et al. (2000) Survival of patients with a new diagnosis of heart failure: a population based study. Heart 83:505–10

[8] Hobbs FD, Roalfe AK, Davis RC et al. (2007) Prognosis of all-cause heart failure and borderline left ventricular systolic dysfunction: 5 year mortality follow-up of the Echocardiographic Heart of England Screening Study (ECHOES). European Heart Journal 28:1128–34

[9] National Clinical Guideline Centre for Acute and Chronic Conditions (2010) Chronic heart failure: national clinical guideline for diagnosis and management in primary and secondary care. London: Royal College of Physicians

[10] Healthcare commission (2007) State of healthcare: improvements and challenges for services in England and Wales. London: Commission for Healthcare Audit and Inspection

[11] Stewart S, Horowitz JD (2003) Specialist nurse management programmes: economic benefits in the management of heart failure. Pharmoeconomics 21: 225–40