GPs face pressure to prescribe statins in lower-risk patients as NHS adopts 10% risk threshold
Exclusive GP practices face pressure to comply with advice to put millions more people on statins after public health bosses decided to adopt NICE’s new 10% primary prevention threshold for its NHS Health Checks programme.
Public Health England (PHE) confirmed to Pulse that the updated NICE lipid modification guidelines – and the lowered, 10% risk threshold – have been endorsed in best practice guidelines given out to commissioners and providers running the Health Checks programme across England.
A Pulse survey last month revealed that GPs are shunning the new threshold and continuing to offer statins only at the higher 20% threshold, but the intervention from Public Health England means that they are likely to face greater numbers of patients who have been told to see their GPs following their health check.
The intervention from PHE comes after NICE argued there was no push to put millions more patients on statins and that there should be no impact on GPs’ workloads if they adopt the guidance gradually.
But GP leaders condemned policy leaders for not discussing the move with the profession first – and warned it would add further pressure on GPs to spend time on healthy groups of patients instead of helping those patients in greatest need.
NICE pushed through a decision to lower the primary prevention risk threshold from a 10-year risk of 20% to 10% earlier this year - making millions more patients eligible for treatment with a statin in the process.
The GPC objected to the move on the grounds there was not sufficient evidence the benefits of statins outweigh the harms in patients with a 10-20% risk, and warned the pressure on general practice to deal with so many patients would be ‘unsustainable’ and mean sicker patients could find it even harder to get GP appointments.
However, the decision from PHE means the new threshold will be systematically rolled out with continued expansion of the NHS Health Checks programme.
The health checks enhanced service is commissioned locally by councils, but best practice guidance produced by Public Health England provides the basis of the service specifications.
Dr Jamie Waterall, national lead for the NHS Health Check programme at PHE, said: ‘Public Health England’s Expert Scientific and Clinical Advisory Panel has reviewed the NICE Lipid Modification Guidelines and recommended that these should be included in the NHS Health Check’s Best Practice Guidelines. Up to 8,000 lives could be saved every three years by offering statins to anyone with a 10% risk of developing cardiovascular disease. Although lifestyle modification should be our first line of intervention, for some people statin treatment should be an individual choice.’
Even if practices do not sign up to NHS Health Checks, they will likely face greater demand from patients who have been assessed as part of the programme by other services, such aspharmacists, and found to be eligible for statins.
Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee said the policy was ‘evidence-free’ and ‘unjustified’ – and warned it would have a knock-on effect on the care GPs would be able to provide to the ill.
Dr Green said: ‘Official policy on cardiovascular disease prevention is about as consistent and evidence-free as the voting on Strictly. We have no evidence that the NHS Health Checks Scheme provides benefits at a population level applying the thresholds it does at the moment, until this happens there can be no justification for reducing them further with the inevitable reduction in individual benefits that will result.
He added: ‘In assessing the overall impact of this change, you must add on the pressure that resulting activity will have on general practice, and the knock on effect there will be on the care we can offer to sick patients. GPs are likely to conclude that PHE views general practice as having an inexhaustable supply of time and expertise to be drawn on at will.
‘It is disappointing that there has been no discussion about this change between PHE and the representatives of the profession which will have to pick up the pieces of their decision.’
Dr Paul Cundy, GPC member and a GP in Wimbledon, agreed the move would inevitably mean more pressure on GPs and wasted resources.
Dr Cundy said: ‘The proportion of people who are supposed to have a discussion about their cholesterol will of course of go up. By taking this 10% non-evidence based threshold and adding it to the non-evidence based NHS Health Checks scheme, they are making the entire scheme even worse and an even greater waste of resources.’
He added: ‘The NHS Health Check scheme is not opportunistic. If it were an opportunistic scheme – driven by the people who know best when to make an opportunistic offer, ie, GPs – then it might be more supportable. But the fact they are inviting everyone whether or not they need to be invited kills that.’