The committee therefore considered that the recommendation to have an MDT with a core team consisting of a physician with subspecialty interest in heart failure, a specialist heart failure nurse, competencies to manage prescribing, that could refer to other specialties if necessary, would not have an overall cost impact. Other considerations Current NHS practise in this area is variable. It was said that in some areas there is a lack of access to specialist heart failure teams, despite the previous recommendations. The committee was aware of the BHF Heart Failure Audit: this was carried out in a large proportion of NHS hospitals in England and Wales, and shows that following a decompensation 70% of patients receive an appointment for a cardiologist, and 60% of patients have a referral to a specialist cardiac nurse. The committee heard from the cardiologists in the group, who considered the HF nurses to be invaluable in managing their caseloads and clinics. The specialist nurses could often take on the management of the heart failure patients who were in need of more comprehensive support. They reported that the psychological support and care that specialist nurses provide could not be replicated by a cardiologist stand-alone clinic. They also noted that it has been the practice in the UK in many areas for specialist nurses or prescribers to optimise evidence-based medication (that is, ACE-inhibitors and beta-blockers, with MRA where appropriate), but that this is currently determined locally. From another perspective, the committee heard that patients very much valued someone to speak to about their illness, and that this is currently often delivered by HF nurses. 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. 