Longitudinal evolution of heart failure specialist nurse services in Scotland: 2013-2025

Abstract Background Heart failure (HF) prevalence and clinical complexity have increased substantially over the past decade1. Heart failure specialist nurses (HFSN) are central to multidisciplinary, guideline-directed care across community, outpatient and inpatient settings2. National reviews in 2013 and 2018 identified service innovation and expanding clinical roles alongside limited workforce growth, highlighting the need for longitudinal assessment. Purpose To examine how HFSN services in Scotland evolved between 2013, 2018 and 2025, focusing on workforce capacity, service models, scope of practice, education and sustainability. Methods A comparative national service evaluation was undertaken using data from the 2013, 2018 and 2025 Scottish Heart Failure Nurse Forum reviews. Structured survey methodology was used across all Scottish health boards at each time point. The 2025 dataset included responses from all 14 boards, with 22 service-level responses where service models varied. Longitudinal analysis focused on whole-time equivalent (WTE) nurse provision, service models and scope of practice, inclusion of HF with preserved ejection fraction (HFpEF), and education, prescribing and advanced practice indicators. Results Across the three review points, workforce growth lagged behind increasing service demand, with little net WTE growth between 2013 and 2018 despite rising caseloads.. By 2025, 94 nurses representing 69.5 WTE posts were reported nationally; however, workforce growth remained misaligned with demand and was largely driven by expansion of inpatient roles, with little change in outpatient or community provision. Service models evolved over time, from predominantly community-based care in 2013 to increased inpatient involvement and multidisciplinary team working by 2018, with further expansion of admission avoidance, post-discharge and in-reach care by 2025. Provision of HFpEF services increased over time (2 boards in 2013, 4 in 2018, 8 in 2025) but remained uneven. Persistent variation was observed in access to psychological support, cardiac rehabilitation and specialist palliative care. Educational attainment and non-medical prescribing (NMP) increased substantially over time, with the number of NMP rising from 1 in 2013 to 54 in 2018 and 79 by 2025; however, access to protected education time and structured career pathways remained inconsistent. Conclusions HFSN services in Scotland have demonstrated sustained adaptation and increasing clinical complexity over more than a decade. Expansion of scope, responsibility and education has consistently outpaced workforce growth and structural support. Longitudinal findings highlight the consequences of prolonged misalignment between service evolution and workforce and education planning. Future sustainability will depend on aligning workforce planning, standardised education pathways, multidisciplinary support and data infrastructure with the realities of contemporary HF care.Comparison of HFSN services 2013-2025 longitudinal evolution of HFSN services