Service : Heart Function Service (East Berkshire)

We’re a small team of specialist nurses supporting patients with a confirmed diagnosis of heart failure by echocardiogram, who are registered with a Berkshire East GP.

We see patients in a community clinic or at home for those who are housebound. We educate on all aspects of heart failure, assess symptoms and overall condition, manage any medication changes, and promote self-care.

We offer remote patient monitoring through heart failure symptom assessments that track vital signs including blood pressure, weight, heart rate, and pulse oximetry. This allows us to monitor patients more closely,

We see patients over the age of 18 who are registered with a Berkshire East GP and have a confirmed diagnosis of heart failure by echocardiogram. 

If you're in a nursing home with clinical signs of heart failure and not able to get an echocardiogram, you can be referred to our service if your NTproBNP is above 2,000.

We accept referral from: 

• Hospitals 
• GPs
• Community Health Services, including ARC, District Nurses, Community Matron, Respiratory Teams, and Lower Limb Clinics. 

To be referred to our service, you need at least one or more of the following: 

• Be initiated/titrated on ACE/ARB ARNi and/or Beta Blockers
• Are not symptom-controlled on current medication
• Have palliative care needs not currently managed by palliative care nurses/district nurses. (We can offer advice if these teams are already involved)
• Have had a recent hospital admission with exacerbation of heart failure
• Have a new diagnosis of heart failure and need information and support
• Are struggling with self-management or lack understanding of their condition

All referrals need to be emailed to the Berkshire Health Hub at integratedhub@berkshire.nhs.uk with a copy of the echocardiogram.

Patients who have previously been under our care within the last year, can self-refer by calling 0118 904 3075.

Your initial assessment will take place either at a designated clinic near your home or, if you are housebound, we're able to see you at home.

The first assessment will take approximately an hour. Follow-up appointments will be 30 minutes.

During these appointments we will: 

• Take a full medical history
• Discuss your diagnosis and educate you on signs, symptoms, and treatments
• Review your current medications
• Check your blood pressure, heart rate, oxygen levels, and listen to your lungs.
• Perform an ECG, if required
• Take a blood test, if required
• Decide a management plan with you.

Please wear loose clothing and bring a list of your current medication with you. A family member, carer, or friend may accompany you to your appointment.

Daily checklist

If you have a confirmed diagnosis of heart failure remember to:

• Record your weight daily. If your weight increases or decreases by two kilograms within three days, please contact your Heart Function Nurse.
• Maintain a healthy diet with low salt.
• Manage your fluid intake as advised by your heart function nurse.
• Observe your legs, ankles, and abdomen for any signs of swelling.
• If you have a worsening cough and need more pillows to sleep, please contact your Heart Function Nurse.
• Try and walk for 10 minutes a day, as exercise is good for your heart.

If you experience any chest pain that is not relived by 3 sprays of GTN (Glyceryl Trinitrate), contact 999.

You can download the Self Check Plan to help to monitor your health. 

Sick day rules

If you're feeling unwell with any of the following:

• Vomiting or diarrhoea (unless only minor)
• Fevers, sweats, and shaking (unless only minor)

It's easy to become dehydrated when you're ill. Dehydration may stress your body.

Pause the medications your healthcare professional has advised you to stop during illness. It's very important that you restart your medicine once you have recovered. This would normally be after 24 to 48 hours of eating and drinking normally. When you restart your medicine, just take them as normal. Do not take extra for the doses you have missed.

Please remember to keep yourself hydrated and try to weigh yourself daily.

Please contact your Heart Function Nurse if:

• You notice a weight change of 1.5kg or more over two days
• Your blood pressure is unusually low for you
• You have been ill for more than two days

Types of medication

• ACE Inhibitors & ARBs: Medicine names ending in “pril” or ARB ending in “sartan”
• MRA: e.g., Spironolactone, Eplerenone
• Diuretics: e.g., Furosemide, Bumetanide, Bendroflumethiazide, Metolazone
• SGLT2 Inhibitors: Medicine names ending in “gliflozin”
• ARNI: e.g., Sacubitril Valsartan (Entresto)

High Recommendation for the Remote monitoring project

We received the HSJ High Recommendation award in recognition of our outstanding remote monitoring work, delivering excellent care to patients from the comfort of their homes.

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Excellence in Practice award

In 2025, our team received the Excellence in Practice award from Berkshire Healthcare NHS Foundation Trust, recognising our commitment to delivering high-quality care to our patients.

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