Grampian region

Service commenced in 2004 (break in service 2007-2009).

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Patients per year


from 250 in 2012.

Urban / rural split


from 64% in 2012.

Total region population


from 550,620 in 2012.

Specialist HF nurse WTE posts

5.5 WTE (6 staff)

from 2.65 WTE, from 4 staff in 2012.

Service provision

2012 2018
HF post MI HF post MI
Valvular HF Valvular HF
Congenital HF Congenital HF
Palliative Care General palliative care with referrals to specialist services
Cardiac Rehabilitation for HF
Screening for psychological distress- no direct referrals to psychology

Service model

2012 2018
Home Home
Clinic Clinic
In-pt education In-pt education
In-pt management In-pt management
GP surgery GP surgery (stand alone clinics)
Virtual Virtual

Additional notes

Service achievements

  • Successfully set up the permanent service which is Grampian wide ensuring equity of care and access to service for patients, carers and colleagues.
  • Participation in the Heart Failure Hub supportive palliative care programme resulting in development of a medical anticipatory care plan and a pathway to palliative day unit services.
  • Adoption of PHQ-4 as part of our psychological screening clinical assessment following the Heart Failure Hub programme.
  • Development of MDT which runs 6 weekly.
  • Secured a prescribing budget for the Non-medical prescribing for the Heart Failure nurses.
  • IT development resulted in migrating service database to Trak for monitoring all referrals and reviews. Letters are via Winscribe.

Service challenges

  • Recruiting and training the new permanent team which required intensive planning to ensure each new Heart failure nurse had equal access to training and development.

Future improvements

  • The possibility of introducing a hospital based HF Specialist Nurse to identify and triage HF patients so they can be promptly treated and appropriately referred to Cardiology and receive specialist HF input.
  • Launch a HF education programme including three levels: Carers and Support Worker, DN’s and Registered Nurse and thirdly Practice Nurse and ANPS. The programme aims to enhance patient and carer education about HF and self management.
  • Psychology input within Cardiology/HF Service to support HF patients


The following details are from our 2012 report and may not reflect the current state of the Grampian Health Board.

Further details

(Actual number of staff)2008 - 2 WTE (4 staff)
SIGN Ratio1:207,781 (2008 1:264,944)
Ave. caseload per post100 patients (community)
Individual patients managed by service (average year)250 patients
Service ProvisionHome visits 80% / Clinic appointments 20%
Provision for HF-PEFNo
Administration support per week3 hours (across service)
Providing education to non-specialist staffYes – limited to primary care sessions within Aberdeen City
Doctor with specialist interest in Heart FailureNone
Cardiac Rehabilitation available/number seenNo
Access to psychological support referral pathwayNone

Notes on current service provision

The service has been operating in a fragmented manner with part-time provision in Aberdeen City and South/Central and North Aberdeenshire and there is no consistent management structure from which to develop the service.

Funding in comparison to 2008

Funding is an ongoing issue; currently guaranteed for only a further two years 2012-2014, in both Aberdeen City and Aberdeenshire. Following a service break 2007-2009, service was recommenced through BHF funded period (2009-2011).


The inadequate administration support impacts on the service as Specialist Nurses take on the majority of the administration work.

Development opportunities

The nurses have worked hard to resurrect referral pathways following the break in service and are keen to share their knowledge with primary care colleagues and improve sustainability of provision against high caseloads and high demand in a challenging geographical area.