First, there seems to be a ceiling effect: although some shorter interventions delivered improvement, extended follow-up (over years) in a clinic offered little benefit; and delivering 40 hours of contact gave only the same benefit of 20 hours of contact. Secondly, expertise appeared to count, as contact with a primary care nurse delivering a heart-failure intervention without specialist expertise in heart failure had no benefit. The committee agreed that the overall evidence supported the general approach that the MDT be used to stabilise and optimise patients. There was no convincing evidence for substantial changes to the previous recommendation regarding which patients should be cared for by the specialist multidisciplinary heart failure team, though the committee agreed by consensus on some clarifications to the previous recommendation text. These included a referral to the MDT should be considered when there was a need to optimise medication or consider specialist options in medication, and implantation of device therapy. The committee discussed specifying the competencies that should be present in the specialist multidisciplinary heart failure team. Clearly, a lead physician with specialist expertise in heart failure was critical, and this will usually be a consultant cardiologist, but there may be areas where other consultants would also be suitable, such as a consultant in elderly care, . The committee noted that the main professionals involved in delivering or co- ordinating interventions in the included studies were cardiovascular or heart failure specialist nurses. Based on this evidence, the committee agreed that a nursing element was needed, and emphasised that a specialist heart failure nursing competency was necessary; as the evidence suggested that it was not possible to get the same clinical improvements from generalist nurses. 