One patient reports If you have a heart issue you have to shout and speak for yourself and keep at somebody And if you re not feeling well that s not what you want to be doing .207 p 108 This is contrasted with patients who have cancer, who found their condition was a door-opener , so they did not have to assert their needs in the same way. The inconsistent way care is offered is to people with CHF was also demonstrated by the impression from HF nurses that GPs have differing thresholds to refer back for specialist help, such that some GPs can leave people struggling in the community. This sub-finding was based on 3 studies126#2749, 207 . Methodological limitations were rated serious overall. Two papers were rated serious limitations as they were secondary analysis with a lack of information about how the data had originally been collected. One paper was rated as moderate limitations due to lack of description of participants. Coherence was rated no or very minor concerns overall. Agreement between papers was good. Agreement with general, related findings in other studies was also good. Relevance was rated minor concerns overall. The relevance of the sub-finding to the focus of the review was high, as movements in and out of HF specialist care are essentially about accessing routine care. Concern was due to two studies being from prior to 2010. Adequacy was rated as minor concerns. This sub-finding was fairly general, and so the number of studies was a little lower than would be preferable to support it, but there were no concerns about the richness of data. The overall assessment of confidence was low, having been downgraded by two increments due mainly to methodological concerns plus the minor concerns regarding relevance and adequacy. 