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Living with heart failure can be terrifying and debilitating but for *Deirdre, it is a day-to-day reality. Thanks to an innovative Hertfordshire Community NHS Trust service, she isn't letting it hold her back from enjoying life.

Deirdre was one of the first patients of the trust's integrated heart failure service, which launched just over 18 months ago.

Her daughter became aware of the service through her role at a GP practice, and thought it might benefit her mum. Deirdre went on to work with the team to develop a self-management plan, which helped her get on top of her condition for a while. When she noticed changes, however, she requested a Patient Initiated Follow-up (PIFU), and the team are again working with her to stabilise her condition.

According to British Heart Foundation statistics, there are more than 4000 patients living with heart failure, like Deirdre, in Hertfordshire. 

Putting patients in control

The integrated heart failure service enables patients with heart failure to be monitored closer to home, in the community and benefit from earlier identification, diagnosis and management of their condition. It operates across East and North Hertfordshire.

The IHFS is part of the East and North Hertfordshire Health and Care Partnership. It provides nurse-led care at home or in clinics and is supported by consultant cardiologists, GPs, hospices, and mental health services.

Clinical Lead Rachel Hards said: "Our whole mission is to get patients on board with managing their own condition, using their self-management plan. They then notice changes and ring in whenever they need to.

Self-management plans are designed around individual patients and categorise symptoms according to a RAG rating of green, amber, red. Among the symptoms people are asked to monitor are changes to their weight, how they feel physically, using an increasing number of pillows, and chest pain.

Rachel continues: "We aim to keep patients in the green - which is stable weight, doing exercise, not using extra pillows.

"Just little signs like they can't lay flat or wake up during the night with a start can be a sign their condition is deteriorating or changing. 

“We teach them about the signs and symptoms and educate them about heart failure."

Making a difference

When asked about her experience in a recent survey, Deirdre replied: “Perfect! Everybody is lovely and being seen locally is so convenient."

She's not the only one to sing the service's praises. Other patient comments include:

"I wanted to say how excellent this new service was, I am very impressed and feel reassured that my heart is being looked after locally!"

"It is a great service; you were  able to explain what is happening with my heart and what you can do to try and make my symptoms better whilst offering a home visit."

“Thank you for your amazing support of my mum, you all do an excellent job. My mum adored Georgina and always looked forward to her visits."

“Leanne’s care, expertise and straightforwardness has changed my father's life. I feel much more confident caring for him, and I understand his condition so much more now.”

Making an impact

As well as positive patient feedback, a closer look at the data suggests the service is working well.

Patient contacts have been steadily rising since the start of the service in March 2024 and the number of patients on PIFU waitlists has steadily increased to more than 300 in July. Waiting lists are short with the majority of patients waiting for three weeks - and the DNA rate (Did not attend) is lower than the trust average at 5%.

Over 90% of patient referrals are accepted on to the service. Referrals come from acute hospitals, GPs, other community services, hospices, and include self-referrals.

In the spotlight

The service’s achievements have already been recognised. Within just a few months of launching, it achieved gold accreditation. Gold accreditation can only be attained when teams demonstrate they provide continuously improving high quality care to people.

In addition, the service has been nominated for four Leading Lights Awards, an annual staff recognition scheme, whereby submissions are invited across all 55 services run by the trust.

What next?

The service has big ambitions for the future.

Rachel added: “Sometimes we have patients on caseload, but they don't need so much of our expert help. We want to improve our relationship with integrated neighbourhood teams so we can discharge them.”

Targeted work to help improve support for patients in lower economic deciles or from ethnic minorities is also planned. 

Whatever the future holds, the team are sure of one thing that their service is making a difference, enabling patients like Deirdre to not just live with heart failure, but to live well.


*The patient's name has been changed to protect patient confidentiality.