They also spoke about how the MDT can encourage self-management, and this was more than just giving information or education, but included giving a patient confidence. They felt this was often not provided to the same level in primary care, and it may not be picked up by the studies. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 The committee heard from the general practitioners that they recognised that there were high risk HF patients who need more intensive support, particularly patients who had just been discharged from hospital after an acute decompensation. However, they felt that specialist input may not be required for people who are stable. They emphasised the importance of holistic care, which is best delivered by primary care professionals, particularly as most patients with heart failure have several other conditions. They would value a system that would offer timely extra support to patients and GPs when necessary, but kept primary care at the centre. The concept of medicines optimisation in HF was discussed. Often the studies reported adding medication and up-titration, but optimisation is about more: starting, stopping, adjusting, and monitoring, all tailored to the individual patient. It is especially important in this population that the prescriber is adjusting their approach depending on comorbidities, and whether this occurred is not well reported in the studies. The NICE guidelines on multi-morbidity (https://www.nice.org.uk/guidance/ng56) were referred to as helpful in this area. Given the large and increasing population of patients with heart failure, with limited NHS resources, the committee agreed that the recommendations needed to prioritise specialist MDT access for those in greatest need who will gain the greatest benefit. If stable patients are managed in general practice, they will need regular review, informed by their needs. 