The committee agreed that an initial care plan should be developed by the HF MDT, and that this plan and subsequent contacts with the MDT should be communicated to primary care. The patient and primary care physicians should also be informed that intense management by the HF MDT is often only needed for a limited period, and will be replaced by monitoring in primary care once their condition is stabilised. The committee considered efficient and easy access back into specialist HF MDT when needed, was very important to ensure continuity of care for the patient. This could be achieved by having an open appointment arrangement with the specialist MDT should difficulties arise. Having primary care embedded within the MDT may facilitate this transfer. The committee felt that the role of the general practitioner in offering a longitudinal and individualised approach should be emphasised. They felt that the patient s clinical record should be reviewed by the general practitioner at least every six months, whether or not the person is being routinely managed by HF specialist services. This should enable active management of comorbidities and early identification of other service needs, and prevent loss of contact, and thereby encourage continuity of management between primary care and heart failure services. The idea of a GP-led review is not to duplicate the work of the MDT, but to address the wider concerns of the person with CHF. This guideline already recommends at least 6 monthly clinical reviews of patients with heart failure, and GP- Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. 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. 