The heart failure nurse service aims to improve the management of patients with chronic heart failure, to reduce hospital admissions and readmissions and provide a link between primary and secondary care.

The countywide service provides intensive case management of patients with heart failure, which includes home visits, telephone support and clinics. Patients will have early specialist heart failure nurse follow up within two weeks of referral to the service. The service also manages patients with supportive/palliative care needs due to end stage heart failure. It also provides support and education for primary care clinicians in the management of patients with heart failure. The service will provide dedicated education and rehabilitation programmes at home in the community or hospital setting.


  • To reduce admissions and readmissions to hospital for worsening / chronic heart failure
  • Improve patients understanding of their illness
  • Encourage appropriate lifestyle changes
  • Improve patient compliance with medication and treatment
  • Ensure evidenced based treatments for heart failure are initiated
  • Encourage patient to self manage their symptoms, enabling them to detect possible deterioration early
  • Improve the quality of life for the patient
  • To promote effective communication between primary and secondary care
  • To continually update and evaluate the service
  • Provide supportive and palliative care

Patients can be referred to the service via the referral form, a letter, email or the telephone. The patient can be referred by any health care professional and the GP will be informed before a visit is made. It is imperative that the referral form contains all the information requested on it and will be returned it not fully complete.

Patient inclusion criteria

All patients with a diagnosis of heart failure with reduced ejection fraction/heart failure with mildly reduced ejection fraction/ heart failure with preserved ejection fraction confirmed by echocardiogram. 

  • Recent admission to hospital with heart failure
  • Newly diagnosed heart failure
  • Confirmation of diagnosis by echocardiogram
  • Difficulty controlling heart failure in primary care
  • Patient consent
  • GP consent
  • The patient lives within the Cambridgeshire area
  • Over 18 years old

Patient exclusion criteria

  • Patient or GP declines Heart Failure Nurse Service
  • Abusive history towards health care professionals
  • Home visit for annual review


East Cambs and Fenland
Iceni Unit
Doddington Hospital
Benwick Road
PE15 0UG

T 0330 726 0077

Commerce Road
1 Commerce Road

T 0330 726 0077

Oaktree Centre
Room S05
1 Oak Drive
PE29 7HN

T 0330 726 0077

Further information

British Heart Foundation information is available through heart failure nurses, GP practices and BHF website



Further information

The page was last updated on 19 June 2018 by Mark.Cole.


Cambridgeshire and Peterborough NHS Foundation Trust
Elizabeth House, Fulbourn Hospital
Cambridge, CB21 5EF

T 01223 219400 (open 8:30am to 5pm)
F 01480 398501

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