Heart failure is the most malignant form of heart disease with outcomes comparable with most of the common cancers. The main way of improving a patient’s prognosis and symptoms is through medication.
Getting the medicines right for every patient every time is possible in heart failure. However, this needs a population-level approach and the help of pharmacists across the NHS.
There is a very well-established evidence base for improving survival and decreasing hospitalisation risk for people with heart failure. We have half a dozen different drugs to choose from, from loop diuretics, ace inhibitors, beta-blockers, mineralocorticoid receptor antagonists, ivabradine to sacubitril valsartan, depending on the severity and symptom burden of a patient’s illness.
We know that the way in which we use these medications in heart failure can be improved. Both local and national audit data shows that we underuse prognostically important disease-modifying drugs. Of course, any single pharmacist can identify an individual patient and improve that patient’s care. But the challenge for the pharmacy profession and the NHS is to improve population-level cohorts of patients in an equitable and consistent way.
We need a public health approach – trying to reduce unnecessary variation in care and ensuring every patient every time is offered the appropriate care. It should not be that difficult in heart failure, where we have clear measures of good care. But delivering this is a challenge for Scotland and the whole of the UK. I sit on a number of strategic national heart failure groups, including the Board of the British Society for Heart Failure, and this is the challenge that we are trying to improve from Dingwall to Cornwall.
Our ambitions, of improving public health, are recognised by the latest update of the Scottish Government strategy Achieving Excellence in Pharmaceutical Care. Our pharmacist-led clinics are cited in this document as one of the exemplary projects. The pharmacy profession needs to show that indefinable problems with a medicine focus, pharmacists can offer population-level solutions as part of a multi-disciplinary team. We must try to get it right for every patient every time.
After fifteen years of practice in a heart failure specialist role, I see my job as being about guiding and mentoring others. As well as my clinical commitments, I spend a lot of my time developing the infrastructure needed to support other pharmacists to do more with cardiac patients, regardless of their role. Scotland is a small country and we should be aiming to support best practice regardless of geographic boundaries.
Increasingly, pharmacists are becoming independent prescribers. Our small team also clinically examined patients, including venepuncture and chests auscultation. While this may be deemed advanced practice, we are trying to support the development of these skills in other generalist pharmacists, for example, those within general practice. This type of upskilling will allow straightforward patients to be managed, up-titrated and supported in primary care nearer their own home. Our team is working with NHS Education for Scotland to try and deliver this vision, through a programme called Teach & Treat.
I also think there is a role for pharmacists working in communities to make sure that patients have access to medicines at the right time, know how to use them and adhere to therapy. Someone with heart failure potentially sees a community pharmacist more often than any other healthcare professional, and therefore community pharmacists and their teams may be ideally placed to identify patients who are starting to physically and functionally decline. The challenge is, however, that without access to their medical records, a community pharmacist can only guess whether someone has heart failure – the medicines on their own aren’t enough to be sure. So, until we have that, it’s going to be challenging for community pharmacists to be a key provider of additional interventions.
Paul Forsyth, a heart failure specialist at the West Glasgow Ambulatory Care Hospital, is one of a small but growing number of pharmacists specialising in the condition across the UK.
Paul Forsyth will be leading a session on improving population-level care in heart failure at the Celtic Conference for Pharmacy in Scotland, Wales and Northern Ireland, being held in Edinburgh on Tuesday 26 March. Registration is free for healthcare professionals at www.pharman.co.uk/celtic-conference.