ISBN: 978-1-4731-3093-7 review of the clinical record could easily be incorporated into this existing review where patients are being managed in primary care. Even where patients are being routinely seen in the MDT, those with other long-term conditions may already be attending primary care for reviews, and the HF review could be usefully added in to existing appointments. Co-ordination: The committee agreed that coordination between services should be a priority. The committee recognised that a single care coordinator was already advocated in the multimorbidity guideline, and this would be helpful in HF. It was felt that the named healthcare coordinator would usually be the HF specialist nurse where a person was being actively managed by the multidisciplinary specialist HF team, but at the point of transfer to routine management in primary care, this would usually change to the patient s GP. Members also advocated collaborative working between primary and secondary care through the MDT. Lay members emphasised that there needed to be better accountability, so that decisions were not only made, but also followed through and followed up effectively. Therefore future plans, who will do what, and when, as well as where/when the next routine review will take place, should form an essential part of the care plan. Communication: The committee felt that it was important that patients have access to their health information, for their own reference, and also to inform others. There was a suggestion that patients could hold their heart failure notes, but it was felt that this was not yet practical. However, it should be the case that they receive a copy of everything that is sent about them, as is already advised in CG138, including their current care plan after every formal review. 