Nick-Hartshorne-Evans heart failure pie British Journal Cardiac Nursing Guest Editorial

Team Sky and the heart failure pie: how to optimise the MDT

Nick Hartshorne-Evans, Chief Executive Officer and Founder, Pumping Marvellous Foundation and President of iHHub, The Global Heart Failure Alliance discusses how to optimise the Heart Failure MDT (Multi-Disciplinary Team)

Published Volume 10 Issue 10: British Journal of Cardiac Nursing: Guest Editorial: Nick Hartshorne Evans.

“In January 2010, I was diagnosed with heart failure (HF). Looking back on the cycle of events that brought me to where I am now, I was a typical patient who received superior care when I finally got to the cardiac specialist. My road through primary care took 5 weeks and once through the hospital doors, I was put on a general ward as I was showing signs of kidney and liver failure. It was only after a week that a registrar on his ward round said to me, ‘you have a problem with your heart’.

He had picked up an arrhythmia and referred me to an ultrasound consultant who finally identified that I had congestive HF. The formal diagnosis was made once I had been ferried to cardiology the next day, gasping for air while being pushed in a wheelchair by a friendly nurse. It was surreal, and I was so distressed, seeking some form of comfort as everything happened at pace around me—it all became a blur, just searching for that nugget of normality.

When I see Kate, I still speak to her. Kate was a Band-6 nurse on the coronary care unit (CCU) and she was leading the team of nurses who came to my aid in my hour of need. The next morning, the cardiologist arrived. He was a kind man and gave me the reassurance of somebody who knew what they were doing.

I spent 5 days on CCU and by the end of it, I was fighting to stay on. There was something about the place that made me feel safe but bed space was at a premium, and I was dragged away to a bed on the general cardiac wards. I then realised I was part of the ‘general population’ and dropped into what had become a cyclical and systematic method of processing—not that I ever felt as though I was being processed, it was just that the days were all the same.

Here, I met my ‘Florence Nightingale’. When you get diagnosed out of the blue with congestive HF, it feels like you have just been ten rounds with a boxer. It’s not that you are necessarily hurting, but the emotional and psychological impact makes everything much harder to process and makes the positive steps you need to take a lot more complex. Retrospectively, I didn’t have any cardiovascular disease, it was a plain old virus that caused myocarditis. When I saw the petite figure of Angela enter the six-bed ward, I was kind of hoping she would come and see me as it would break my day up from the system I had been institutionalised to operate within. I see now that my pattern aligned well with the National Heart Failure Audit findings.

From the first time I met my HF nurse to today, as I write this piece, the relationship hasn’t changed—it has just grown stronger. Strength has developed from those days she saw me in crisis to seeing me at home for the first time a day after discharge, admittedly still in crisis, but definitely feeling embarrassed that I had a nurse in my home, and that I needed outside help.

The road after discharge, the 363 days of the year that I don’t see my specialist team is challenging. Fighting my way through my rehabilitation, my HF nurse referred and signposted me to services that could help, but I still had to battle my way through. While I was speaking at a conference in Seville this year, the organisers said they were expecting me to look elderly and they asked whether I needed a wheelchair to get across the road from the hotel to the conference centre. I thought, ‘thanks for thinking about me but this just underlines the inherent problems with enabling HF awareness and associated needs’.

After starting Pumping Marvellous in June 2010 and listening intently to other patients and their challenges, I quickly realised that the multidisciplinary team (MDT) wasn’t enabled in HF across the UK. An out-of-date opinion on the MDT in HF is that it must be clinically focused and that the health professionals lead it. In our surveys and interactions with our ever-growing global patient community, the carer is the most important person in the MDT, and then for those lucky enough to have a HF specialist nurse, and especially those in the community settings, the HF nurse sits at the top of the pile. So patients are the leaders in their own health, backed up by a marvellous team.

Being from Lancashire, I can relate the MDT to the ‘HF Pie’. There are many ways you can cut a pie but it isn’t whole until you put the pieces back together. So this is where the analogy comes in. No British cyclist had ever won the Tour de France. Dave Brailsford, the new general manager and performance director, was tasked with getting a British winner of the Tour de France in 5  years. Under his stewardship both for Team Sky and the British Olympic cycling team, he enabled Bradley Wiggins to win the Tour de France and 70% of the available gold medals were scooped up by the British cycling team at the 2012 Olympics. So how did he do it?

He referred to it as ‘marginal aggregation’. By identifying, mapping and breaking down the MDT around a professional cyclist’s needs, and then marginally improving each area, he thought he could make exceptional overall gains. Bradley Wiggins and the Olympic achievements happened in 3 years.

Once he had mapped the obvious segments of the MDT, his team realised they had a formula and set out to look at the whole MDT in finite detail. Brailsford, as we know, has also enabled Chris Froome to become a twice-winner of the Tour de France, but everyone acknowledges this was a team performance.

So what would happen if we could pull all the HF stakeholders together to map, deconstruct, optimise and reassemble the ‘HF Pie’? How could we continually improve each of those segments of pie and optimise this process to ensure that HF patients received the very best clinical, social and psychological care they need?”