This subfinding was based on three studies.26, 117, 313 Methodological limitations were rated moderate concerns overall. Two studies were rated as moderate limitations due to lack of context and role of the researcher, plus data analysis in one study and data richness in the other. One study had serious limitations due to lack of context, role of the researcher, data collection and richness of data. Coherence was rated as minor concerns overall. Agreement between papers was good and appeared to fit well with related findings in other studies. The only findings that tended to be the other way are regarding the positive experience of patients with good access to specialist nursing teams. Relevance was rated no or very minor concerns overall. The relevance of the subfinding to the focus of the review was high. The data stemmed from three studies from the UK in a relevant population. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Adequacy was rated as no or very minor concerns. The subfinding was general, and although explicitly supported by a limited number of studies, other studies found similar themes. The finding was descriptive and the richness of data was sufficient for this. The overall assessment of confidence was moderate, having been downgraded by one increment due to the combination of concerns in methodology and coherence. Review subfinding 1c: Gradual process Diagnosis was seen by healthcare professionals as a gradual process which in turn makes the communication of the diagnosis a gradual process. They emphasised the need to provide information and guidance as part of an ongoing conversation with the patient and family. Heart failure specialist nurses and GPs were seen as key to the success of this process. 