Specialist Heart Failure Nurse Services
The final item of business is a members’ business debate on motion S4M-06245, in the name of Dave Thompson, on review of specialist heart failure nurse services. The debate will be concluded without any question being put.
Motion debated,
That the Parliament welcomes the publication of the Review of Specialist Heart Failure Nurse Services by the Scottish Heart Failure Nurse Forum supported by Chest Heart & Stroke Scotland and the British Heart Foundation Scotland; understands that heart failure is a life-limiting condition for which there is no cure, that, unlike other cardiac conditions, its prevalence is rising and that it is estimated to affect up to 100,000 people in Scotland; considers that specialist heart failure nursing services reduce unnecessary hospitalisation for people with heart failure by around 35%, resulting in savings of around £1,826 per patient to the NHS; understands that NHS Highland meets the minimum Scottish Intercollegiate Guidelines Network (SIGN) guidelines ratio of 1:100,000 specialist nurses per head of population and provides specialist support to nearly 300 patients per year, but, given that NHS Highland covers 41% of NHS Scotland’s geographical area, travel times inevitably reduce the capacity of the service; considers that these pressures mean that there is limited capacity to deliver education and share skills and expertise with community staff to ensure that heart failure patients receive the support that they need; is concerned that, despite the strength of the evidence base, only four out of 14 NHS boards meet the minimum ratio of specialist heart failure nurses to population level laid out in SIGN guidelines from 2007, that the overall number of whole-time-equivalent posts in Scotland has fallen since 2008 despite the rising prevalence and that one board has no specialist heart failure nursing service in place at all, and notes calls for all NHS boards to ensure that, as a minimum, they meet the SIGN guidelines on whole-time-equivalent posts for what it sees as these crucial services.
17:42
The motion was stimulated by a discussion at the cross-party group on heart disease and stroke, of which I am a vice-convener, in March. At that meeting, we heard first hand from specialist nurses—as well as from the patients and families that they work with—about how invaluable the services are. I will come back later to examples that we heard about at that meeting, but it is important first to define heart failure in order to set our discussion in context.
Heart failure is a complex condition for which there is no cure for the majority of people. Heart failure occurs when the heart, which is a muscle, is damaged by a cardiac event—most commonly following a heart attack, or from long-term high blood pressure, or valvular disease, which I suffer from myself.
It is really important to make the distinction between heart failure and heart attack, because there is a common misconception that they are the same conditions—they are not. Heart failure can be the result of a heart attack, but heart failure is a long-term condition, whereas a heart attack is an emergency or acute event and happens when a blockage occurs in one of the arteries to the heart, which restricts the flow of blood.
Due in part to the very welcome improvements in the rate of premature mortality through heart disease, the prevalence of heart failure is rising. It is the only cardiovascular condition that is on the rise, in part because acute events such as heart attacks, which would have been fatal a few years ago, are now survivable. As a consequence, however, many people with damaged hearts end up living with heart failure. Additionally, because heart failure is more prevalent in older people, our ageing population also further increases its prevalence. Improved heart attack survival is, of course, tremendous progress, but it presents the national health service with different challenges, including how to help people to cope when living with heart failure.
Specialist heart failure nursing services are one of the most important ways that the NHS can treat heart failure patients. At the meeting in March of the heart disease and stroke cross-party group, we heard from Mr Thomas Stark, who is a heart failure patient. Thomas described his family’s and his experience of a heart failure diagnosis and his treatment and rehabilitation at Astley Ainslie hospital. Thomas, who felt that he had been well supported throughout his time at Astley Ainslie, described the value of group discussions and of listening to the experiences of others. He also shared a moving letter that his wife had written to the NHS to express their thanks. Thomas summed up the input of the specialist nurse in this way:
“I’ll no beat about the bush, but the nurse was our lifeline.”
We also heard from Mrs Lorraine Jones—a carer for a heart failure patient. Lorraine and her sister were both full-time carers for their mum since her diagnosis of end-stage heart failure. Lorraine described the journey that she and her family had been on as they had, after losing their father, then to deal with the impact of their mother’s illness, which was particularly challenging because she would not accept the diagnosis. Lorraine talked about all aspects of the support that was provided by the nurse. The support was practical, with arrangements for the end of life, and emotional, in that it supported everyone involved in coming to terms with what was happening. Lorraine summed up the support by saying,
“You can’t repay what she’s done for me and my family.”
Since 2002, the British Heart Foundation has supported heart failure specialist nurses around the United Kingdom to ease the burden and improve the quality of life for people with the disease. The British Heart Foundation has funded or pump primed many of those roles in numerous NHS board areas in the expectation that boards would mainstream the funding when the British Heart Foundation funding ended. An evaluation of the impact of the services, which was published in 2008, found dramatic reductions in hospital readmissions for patients who were cared for at home by specialist heart failure nursing services. The report concluded that every patient who is cared for by a specialist heart failure nurse equates to a saving of £1,826 per patient, including the costs of the specialist post. It seems to me essential, therefore, that NHS boards make specialist heart failure nursing services a top priority.
The Scottish heart failure nurse forum, which is the independent representative body for such nurses in Scotland and which is supported by BHF Scotland and Chest Heart & Stroke Scotland, produced the report that stimulated this evening’s debate. That report compares the provision of specialist heart failure nursing services in Scotland in 2012 to provision when it published its previous report in 2008. Unfortunately, the national situation is not a good one. Despite the fact that the prevalence of heart failure is increasing, nationally the overall provision of specialist heart failure nursing posts has fallen, from 51 whole-time equivalent posts in 2008 to 47 in 2012. Only four NHS boards meet the minimum ratio that is set down in the 2007 Scottish intercollegiate guidelines network recommendation of one nurse per 100,000 of population. One NHS board—NHS Orkney—has no specialist heart failure nursing service at all. That is simply not good enough.
We all know that NHS boards are operating in an increasingly challenging environment, but it is crucial that they up their game by improving provision of such nurses. Otherwise, as well as costing themselves more money in the medium to long term through increased hospitalisation costs, they will badly let down heart failure patients, who desperately need the kind of care that only specialist nurses can provide.
When the Parliament’s Public Audit Committee considered the issues last year during its inquiry into cardiology services, it concluded that clarification was needed from the Scottish Government on future plans for specialist heart failure nursing services. In response, Derek Feeley wrote to the committee and stated:
“On 1 November 2012 the National Advisory Committee on Heart Disease agreed to support the establishment of a heart failure short life working group. This group will be well placed to advise NHSScotland on how heart failure nurses role can be further strengthened. The group, which will include heart failure nurse representation, is expected to have its first meeting in spring 2013.”
That will be a welcome development if—it is a big “if”—the group’s recommendations are taken forward by ministers and NHS chief executives and are regarded as a priority. Perhaps in concluding the debate, the minister can inform us whether the group has met yet, when it will meet if it has not met, and what more he thinks the Government can do to get NHS boards to provide the services at a sufficient and sustainable level.
17:50
I pay tribute to Dave Thompson for securing this debate and I commend the British Heart Foundation, the Scottish heart failure nurse forum and Chest Heart & Stroke Scotland for their briefing in advance of our debate and their report, which highlights the challenges that remain in securing the provision of heart failure nurses across every health board in Scotland.
We know that heart failure is a life-limiting condition and that, unlike the prevalence of many other cardiac conditions, its prevalence is rising. It affects about 100,000 people across Scotland.
I do not think that anyone inside or, indeed, outside the chamber would disagree about the value that is added by heart failure nurses to the experiences of patients and their families. As we have already heard from Dave Thompson, their contribution can also be measured in purely financial terms. They save an estimated £1,826 per patient, due to a 35 per cent reduction in hospital admissions.
The importance of the role of heart failure nurses was identified in Audit Scotland’s report on cardiology services and the subsequent report from the Parliament’s Public Audit Committee. They made a number of recommendations, particularly about heart failure services for people from deprived and ethnic minority communities, but they also recognised that the NHS needs to improve services generally for people with heart failure.
Way back in February 2007, SIGN guidelines were put in place under the Administration of the time, but the ambition was shared across the chamber. Those SIGN guidelines set out a ratio of 1:100,000 specialist nurses to population. That was the right thing to do then and it is the right thing to do now, but it is disappointing that, some six years on, only four health boards are meeting the standard and that, across Scotland, the number of heart failure nurses dropped from 51 whole-time equivalents in 2008 to 47 in 2012.
I am very pleased that NHS Greater Glasgow and Clyde, which covers my constituency, has achieved the ratio that is set out in the guideline. It is not used to my heaping praise on it, so it should enjoy it while I do so. However, I would always encourage it to do more. The review helpfully identifies the challenges that it needs to address, such as the lack of a class for patients with heart failure and the increasing demand that will continue to add pressure to services. I encourage it to look again at how to improve access to services in some of our most disadvantaged areas.
It has just occurred to me that it was remiss of me not to mention that NHS Highland in my area is one of the four health boards that are meeting the target.
Better late than never.
That is truly wonderful. We are nothing if not parochial.
We have established that heart failure is rising, we agree that we need to try to ensure that services meet the growing demand, we acknowledge that specialist heart failure nurses make a real difference to patients and their families and ultimately to the efficiency of the NHS, and we have guidelines in place, but there is still a postcode lottery. The level of service and, indeed, whether people even get a service depends on where they live. That really is not good enough.
We have had report after report that says the same thing, but progress has been slow. The challenge is for all of us actively to encourage our local health boards, but the challenge is also for the Scottish Government to ensure that the health boards meet the minimum standards that we have set for them. If the minister does that, he will enjoy support from across the chamber.
17:54
I am pleased that Dave Thompson has drawn our attention to the recent “Review of Specialist Heart Failure Nurse Services” and that he has secured the required cross-party support to allow it to be discussed here this evening.
The support of specialist nurses for patients who are living with heart failure and their families is invaluable, both in helping sufferers to self-manage their condition at home for much of the time, which avoids unnecessary hospital admissions, and in teaching carers and others how to deal with the complexities of what is a disabling and life-threatening affliction.
The motion neatly sums up the point at issue, which is that although, unlike in other cardiac conditions, the prevalence of heart failure is increasing, the number of whole-time equivalent specialist nursing posts has fallen since 2008 with, as we have heard, only four of Scotland’s NHS boards meeting the minimum ratio of specialist heart failure nurses to population that is laid out in SIGN guidelines, and with one NHS board having no specialist heart failure nursing service at all.
To remedy that, the Scottish heart failure nurse forum seeks a national approach to planning, adequate resourcing and further development of the specialist nursing service, in order to enable the service to meet the ever-increasing challenge of the one cardiac condition that has rising morbidity levels.
Specialist nurses deliver their services in a variety of ways across the country, depending on the resources that are available to them and their geographical location. Patients are seen in various settings including hospital wards, outpatient clinics, satellite clinics and their own homes. Most specialist heart failure nurses also give telephone support for patients, carers and GPs so that they can access advice regarding symptom management.
Unfortunately, because there are not enough specialist nurses, particularly in more remote and rural areas, there is not the capacity to deliver the education to, or share the skills and expertise with, community staff who are necessary to ensure that heart failure patients get the support that they need.
In my region, the service within NHS Grampian has been operating in a fragmented way, with part-time provision in Aberdeen city, south-central Aberdeenshire and north Aberdeenshire, and no consistent management structure from which to develop the service. Funding there is an on-going and worrying issue. Following a service break from 2007 to 2009, the service was reinstated through British Heart Foundation funding from 2009 to 2011, but now has funding guaranteed only until next year, both in the city and Aberdeenshire. Work is on-going through the managed clinical network to secure an NHS Grampian-wide service with permanent funding, but as yet the details of that are unknown and nurses in Aberdeenshire could face redeployment from this autumn. The nurses there are enthusiastic and keen to develop the service, but they are hindered by lack of administrative support, which impacts on their front-line activity with patients, and by the uncertainty about future funding for the service.
This debate is an exact parallel of last week’s debate on Parkinson’s specialist nurses and illustrates once again the patchy availability of all specialist nursing provision in Scotland. The minister in his response last week indicated the Government’s engagement on the issue and its intention to seek an improvement in nursing provision across the specialities. Given the proven savings—£1,826 per patient in the case of heart failure—through reducing hospital admissions by enabling patients to self-manage their long-term conditions in the community, and given the increasing prevalence of long-term conditions and comorbidities in an ageing population, investment in specialist services looks to be a compulsive area for preventative spending, with significant rewards both economically and for patient wellbeing.
I urge the Government to do all that it can—and very soon—to facilitate a more even spread of specialist nursing services across the specialities and across the country. I congratulate Dave Thompson on securing the debate and thank him again for highlighting such an important issue for Scotland’s NHS and its patients with heart failure and other long-term conditions.
17:59
I, too, congratulate Dave Thompson on securing a debate on this important subject and bringing it to the chamber. I also thank the organisations, particularly the British Heart Foundation.
Last week, I congratulated NHS Grampian on its work with specialist Parkinson’s nurses, but the story this week is not so good for NHS Grampian. Nanette Milne referred to nursing numbers in Aberdeen. To put that figure into context, we have three specialist heart failure nurses in the Aberdeenshire Council area, two in Aberdeen City and 0.2 full-time equivalents in Moray—there is none at all in Orkney. That amounts to about six specialist nurses; in reality, there are 3.24 full-time equivalents, two short of what is needed in the Grampian area.
It is important to distinguish the difference between specialist nurses that deal with heart failure and those who deal with cardiac rehabilitation—I asked the minister about that the other week—because they are not the same. We need to identify the value of specialist nurses; their work for people with heart failure is undoubtedly immeasurable.
We have heard from Dave Thompson the testimony of people at the cross-party group on heart disease and stroke. An answer to a parliamentary question included a breakdown of the number of specialist nurses from NHS Grampian, which is why we have the numbers. The health board acknowledged that, were it to remove the heart failure nurses, it would see a rise in acute admissions. That would cause anxiety not only to patients but to their families. I urge NHS Grampian, which is carrying out a review of all its cardiac services that will report in August 2013, to consider the importance of those nurses.
Nanette Milne said that the funding is coming to an end. It comes to an end in March 2014 but, because of the nurses’ contractual agreements, they may be redeployed as early as September or October. There is undoubtedly a crisis in NHS Grampian that needs acute remedy. We need more specialist nurses. We realise that funding is difficult across all health boards. Jackie Baillie and Dave Thompson mentioned the monetary aspect, which needs to be borne in mind, but, beyond that, the issue is about the service that is provided for the patients and their families.
Nanette Milne said that treatments are not always face to face or in hospitals or their satellites, but over the phone. We can use technology, including telecare services. For example, we could sometimes use telemedicine in Orkney, as we do in other areas. We must be cleverer in remote and rural areas. I suggest to all health boards that they use the available facilities and technology to provide a heart failure service to our patients and carers.
18:03
I, too, congratulate Dave Thompson on his motion and on securing the debate. I also add my thanks to Chest Heart & Stroke Scotland, to the British Heart Foundation for its briefing, and to the Scottish heart failure nurse forum for circulating its review to members.
The review’s findings confirm that the service delivery model varies across the country, reflecting different geographic considerations and resource availability. However, it underscores that, in too many instances, boards are failing to deliver what is expected and required of them. Unlike Jackie Baillie and Dave Thompson, I can take absolutely no satisfaction from the situation in my board area, as I note that I am the member for the only board area—Orkney—where there is no specialist heart failure nurse.
I commend Bill Braby and the local heart support group in Orkney for raising the issue with me over recent months, and for their efforts in prosecuting the case for the reinstatement of a heart failure nurse in Orkney. As others have said, Dave Thompson set out very well the explanation behind the differences between heart failure, heart attacks and other cardiac conditions, as well as the increase in the prevalence against the backdrop of a reduction in the whole-time equivalents of heart failure nurses. That is a cause of concern for all of us, irrespective of how our boards are performing.
Specialist heart failure nurses can help patients to develop self-management strategies, as Nanette Milne said, so it is not surprising that the nurses are popular with patients and their families. Dennis Robertson talked about the importance of improved patient care. Specialist nurses also enable patients to be more independent and less isolated. In Orkney, as in many rural areas, that is exceptionally important.
Specialist nurses reduce unplanned hospital admissions and the length of hospital stays. In Orkney, where many patients must travel off island, that reduces transport costs and limits the number of arduous journeys that patients must undertake. Therefore, I was hugely concerned to hear that the post in Orkney ceased to exist after British Heart Foundation funding ended in 2010.
I acknowledge the excellent work of the cardiac specialist nurse in Orkney—Amanda Manson does phenomenally good work. I also acknowledge the work of the heart failure liaison service. As a result of the efforts of Bill Braby and his colleagues, and as a result of discussions with NHS Orkney, progress of sorts has been made in recent months. More administrative support has been put in, to allow Amanda Manson and her colleagues to focus on front-line delivery, and I understand that there is recruitment of a consulting GP with expertise in cardiology, although the post will not come into effect until October.
However, questions remain. What procedures will be able to take place in Orkney as a result of the recruitment of the cardiology specialist? What is happening in relation to replacing the retired cardiology lead in Orkney? There remains a lack of resilience in the liaison and cardiology services in relation to covering illness and holidays. All that points to the continuing need for a specialist heart failure nurse in Orkney.
Dave Thompson talked about the findings of the Public Audit Committee. I was unaware of Derek Feeley’s remarks in December about the establishment of a heart failure short-life working group. Like Dave Thompson, I very much hope that the group has met—indeed, I expect that it will have done so, if the deadline was spring 2013. I encourage the minister to ensure that the group considers how the specific issues that relate to Orkney might be addressed.
I congratulate Dave Thompson on securing the debate, and I look forward to hearing what the minister has to say.
18:07
I congratulate Dave Thompson on securing time for this important debate on what remains a clinical priority for NHS Scotland.
I am sure that all members recognise that encouraging progress has been made in recent years, which is underpinned by the 60 per cent reduction in the coronary heart disease premature mortality rate between 1995 and 2010. That shows the degree of improvement in clinical care and the benefits of preventative work in improving outcomes for patients.
We recognise that new challenges are emerging—Dave Thompson set out the challenges very well. More people are living longer with long-term conditions, and more people who have suffered cardiac episodes and heart failure are living with co-morbidities. Supporting such individuals puts pressure on our NHS system. It is important that we ensure that our services can address the needs of the increasing number of patients in Scotland who might suffer from heart failure.
We recognise that heart failure nurses need to be in place to meet the need. The better heart disease and stroke care action plan and the clinical standards for heart disease identify the important role of heart failure nurses in providing safe, effective and person-centred care. The action plan demonstrates our commitment in that regard and sets out how we expect boards to take the issue forward. We expect the recognition that heart failure nurses have an important role to play to inform boards’ workforce planning.
A number of members referred to the SIGN guidelines for heart failure, which were published in 2007 and which recommended that there should be a nurse-led, home-based element of post-discharge care and that patients should be considered for follow-up by a trained heart failure nurse.
The SIGN guidelines are important. They are not from, or directed by, Government, and no Government can claim some form of responsibility for them; they are commissioned and taken forward independently of Government to help inform clinical practice. However, I think that there has been some misunderstanding regarding the ratios that members have referred to, because the SIGN guidelines do not set a minimum standard for staffing provision. I can only assume that members were referring to the British Cardiac Society standards for having one heart failure nurse per 100,000 of the population.
The SIGN guidelines do not specify a specific ratio. It is important, however, that boards ensure that whatever is contained in the SIGN guidelines is taken forward at a local level and that they have adequate staffing levels and the right skills mix in place to meet the local population’s needs.
Will the minister take an intervention?
Will the minister take an intervention?
I will give way to Mr McArthur.
I am grateful to the minister for giving way. I appreciate what he said in relation to ratios but, as he will have heard, there is no ratio at all in the case of Orkney. I therefore suggest that the issue needs specific attention in order to meet patients’ needs in the Orkney Islands.
I am going to come to Orkney in a minute, when I hope that I can address that point.
I am more than happy to give way to Mr Robertson, too.
I thank the minister for giving way. With regard to the ratios, does the minister share my concern that in Aberdeen there is only one specialist nurse with a full-time permanent contract, with the other nurses being on temporary contracts? It is possible that we could end up with only one heart failure nurse, which would potentially leave us in a real crisis situation.
I will turn to those points on Orkney and Grampian after making a little progress on the wider issue.
It is important to recognise that some progress has been made since 2008 because, of the 15 heart failure nurse posts that were funded by the British Heart Foundation, nearly all, but not all, of those nursing posts are now funded by the NHS. We must ensure that we continue to build on that progress.
Given what is in the very useful report “Review of Specialist Heart Failure Nurse Services—Scotland 2013”, I intend to raise the matter specifically with directors of nursing in the NHS in Scotland in order that they ask their boards to look at the report’s findings and consider what wider measures they need to take forward at a local level to address some of the points that have been highlighted.
On the specific issue of NHS Orkney, Mr McArthur referred to the fact that the board has been reviewing the way in which it provides cardiology services in the Orkney Islands. I understand that, as a result of that review and through additional resources that have been provided, NHS Orkney has recruited an extra consulting cardiologist to help support the service and that it is working in partnership with NHS Grampian on the way in which it delivers some of the services.
I understand from NHS Orkney that it hopes that that will allow it to free up some of the time of the clinical nurse specialist that it has at present so that they can do some extra work on heart failure matters, which there is no time for at the moment. That will help to support and extend the work that can be taken forward there. No doubt Mr McArthur will wish to pursue those issues with his local health board to ensure that it continues to make progress on them.
On the NHS Grampian matter to which Dennis Robertson referred, my understanding is that an option appraisal paper is being prepared for the board’s consideration this month that will look at a number of options. Part of that work will involve looking at how NHS Grampian can support heart failure nurse services in the board area. The process should be completed by August this year. Again, of course, we expect NHS Grampian to ensure that it can meet the needs of cardiac failure patients in its area in line with what is set out in the SIGN guidelines.
Nanette Milne made an important point. Most chamber debates on long-term conditions to which I respond involve a request for more specialist nurses in one long-term condition or another. Specialist nurses have an important role to play, but they also play a role in supporting our other NHS staff to work more effectively with patients with specific conditions such as heart disease. That is why we have invested £150,000 in the heart disease education programme called heart-e, which will support our heart failure specialist nurses in training and supporting other nursing and clinical staff to deal with patients more effectively and to be more confident in managing heart failure. The programme will be launched in November and will support that area of work.
Finally, I turn to the national advisory group to which Dave Thompson referred. That group has now been established and is acting as a heart failure hub that is drawing together expertise in how we can build on progress in the use of heart failure nurses. The group took a little longer than anticipated to get established, but we expect it to meet within the next six weeks. The chairs have been appointed and its membership has been agreed.
We are also in the process of appointing a national co-ordinator to support the group’s improvement activities across NHS Scotland. By acting as a hub in drawing together good practice from different board areas, the group can help to disseminate that good practice in other board areas, and the national co-ordinator will have an overview of the progress that is made by individual boards.
I recognise the importance of specialist nurses and of heart failure nurses in particular. The Scottish heart failure nurse forum report is an important contribution to that area of work. We will work with our health boards to see what further measures can be taken to build on the progress that has been made since 2008, so that we can continue to provide the best possible service for those patients who suffer from heart failure.
Meeting closed at 18:17.