Heart failure (HF) is a syndrome and not a diagnosis. Aetiology and precipitants for decompensation are often not sought. Care is also often based upon protocols, with widespread prescription of drugs validated in systolic HF, for patients with other forms of HF for example HF with preserved ejection fraction which can account for almost half of patients with HF in the UK. Therefore, service design and configuration by healthcare providers should based upon quality and not only feasibility, as protocol-based treatment will inevitably diminish the quality of care for patients with HF and result in both inappropriate care in many cases as well as reduced access to advanced evidence based and NICE approved therapies. Expertise is therefore of paramount importance in managing patients with HF.