'More patients should be offered statins if they want them'
Prominent GP academic Professor Richard Hobbs speaks to Caroline Price about why he agrees with the new primary prevention threshold for statins and how GPs can encourage more students into general practice.
The calm, airy offices of Oxford University’s Primary Care Health Sciences department, nestled in the heart of the ‘city of dreaming spires’, seem a long way from the hectic day-to-day business of general practice.
Department head Professor Richard Hobbs has carved out a highly distinguished academic career that has seen him publish numerous articles, including some of the most influential research in cardiovascular medicine, oversee national and international guidelines and advise the Government on NHS clinical policy.
Yet, despite being one of the most influential academics in the land, Professor Hobbs is still a jobbing GP, practicing part-time in an inner city Birmingham practice where, he insists, his patients are largely unaware of his ‘other life’ as a professor of primary care health sciences.
Nevertheless, these two worlds inevitably collide, which is evident when Pulse gets him talking about NICE’s recent controversial decision to lower the primary cardiovascular prevention threshold from a 10-year risk of 20% to 10%.
With his GP hat on, he says he can understand the concerns – but he is still a staunch defender of the decision itself.
He argues that there is ‘the biggest evidence base available in medicine’ on statins and NICE is right to rule that it is cost-effective to offer more people the treatment, if they want it.
‘All NICE has done is say, “overall this is cost-effective” and in the end, I’ll discuss with the patient what to do – lifestyle changes where you can, such as stopping smoking, but also, potentially, offering a statin,’ says Professor Hobbs.
But he also recognises GPs’ complaints about the increased workload this will bring.
‘I think what’s more important at the moment is that GPs are feeling overwhelmed,’ he says. ‘And yes, if you get guidance that dramatically increases the proportion of people you might then offer treatment too and have to follow up then yes, you will think “enough is enough”.
‘There is an access issue in general practice and if [the] argument is that the wider cost implications of this have not been sufficiently thought through then that’s a perfectly appropriate argument, I agree with that.’
Professor Hobbs’ views in this area hold considerable weight - his research interests have largely focused on cardiovascular disease and stroke risk, as well as heart failure, on which he has published hundreds of papers, many in leading international journals such as the Lancet, the Annals of Internal Medicine, BMJ and Stroke.
He has also advised on numerous European and UK guidelines on cardiovascular disease prevention and management, while his own groups’ work has informed major changes in practice through NICE guidelines, including recently the introduction of natriuretic peptide testing in diagnosis of heart failure, as well as the drive to improve use of anticoagulation for stroke prevention in patients with atrial fibrillation.
But his influence is felt much more widely. In addition to heading up the Oxford research department, Professor Hobbs is also director of the National Institute for Health Research School for Primary Care Research, and has recently been re-appointed director of the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR).
The School, which includes eight university teams spearheaded by Professor Hobbs’ Oxford department, is about to start work on a new £30 million, five-year national programme of research and training in general practice.
Not surprisingly, Professor Hobbs is passionate about the role of GP academics. He stresses that the importance of having GPs actively involved in research is not only to pose the right research questions but to educate the next generation of doctors in the principles of general medicine.
He explains: ‘There are many skills that students recognise, as they get closer to becoming doctors, that are well represented in general practice – the idea of engagement with patients, attending to patient issues as well as our own in the consultation, how to diagnose when you have huge numbers of patients presenting with numerous problems - how, for example, you even begin to differentiate a serious headache from all the common headaches.
‘These are issues I think undergraduates recognise they need to develop tangible skills in – and GPs are often very good teachers in these more uncertain aspects of clinical practice.
‘But I also think the research questions we develop are very important, not just in the UK but internationally… We make contributions that help guide the way practitioners deliver medicine in the future.’
While cardiovascular medicine forms a key focus for the Oxford department, there are also groups carrying out leading research into obesity, smoking cessation, cancer and childhood infectious diseases, with plans to expand these areas as the department grows – three new professors and four associate professors of primary care have recently been appointed, and a further two ‘high profile’ senior-level recruits will join in 2015.
Professor Hobbs insists that Oxford University medical school punches above its weight when it comes to producing academics - and refutes the very public accusation made recently at the RCGP conference by NHS England chief executive Simon Stevens that Oxford and Cambridge Universities are not doing enough to encourage medical graduates into general practice.
On the contrary, he says, there is a limit to how far GP lecturers can influence trainee doctors’ long-term choice of career, which will inevitably be determined by wider issues around salaries and work-life balance.
He says: ‘Certainly what’s more important are the conditions once they get into their discipline. So, for example, if you have a pay differential between disciplines then that is very motivating for career choice - obviously.’
He adds: ‘A higher proportion of our graduates seek an academic career and that is important as well. I think Oxford would say we’re contributing to that national pool and although yes, it is incredibly important to get more GPs, it is also important to get better trained academics as well – we need to think about training in the totality. It is easy to take a pop, but there are other issues.’
Furthermore, he argues that making sure graduates are exposed to good experience of general practice through placements is critical.
‘We need to be more active in ensuring the clinical placements students are exposed to in primary care provide a positive experience, where they have a good learning environment.
‘That’s exactly how I ended up a GP – I thought I was going to be a cardiologist. I had very little primary care exposure, two weeks was all I had, it was a token add-on. One week was terrible, but one was fantastic and I suddenly realised you could practice medicine in the community, which I hadn’t realised you could do until then.
‘So to some extent my own career was based on, not a charismatic teacher, but the environment in this one - in retrospect rather an ordinary - practice, which I found quite motivating.’
His career has also seen him take on the role of co-director of the original independent panel that drew up the list of indicators to be included in the QOF when it was first introduced. Despite this, he is fairly pragmatic about the framework’s impact.
He says the scheme undoubtedly led to a rapid shift in practice, but agrees with the widely held view that some more recently developed indicators were unsuitable – and even questions whether it should be linked to pay.
‘I think having feedback of how well our clinical practice relates to indicators with evidence of benefiting patients, having that data is useful. If it is done automatically – as it is with QOF - I think that is desirable at practice level, but whether you link that to payment becomes a moot point.’
He argues that any such audits needs to be done according to a national standard as he warns that the current trend to develop local QOF arrangements could end up exacerbating geographical variations in the standards of care the NHS delivers.
‘One of the Achilles heels for us now is there is too much variation in performance,’ he adds. ‘There is obviously a danger, if you make everything local, it will be similar to what we see in local authorities, with the big variations in expenditure. I don’t think that would be good for health care, the one thing the NHS tries to avoid is the “postcode lottery” of care.
‘If postcodes become the basis for decisions about healthcare provision – if areas emphasis different work – I am not sure that will be taking us in the right direction.’
Education Medical school training at University of Bristol 1972-1977, graduated as GP in 1981
1981-present: GP partner in Edgebaston, Birmingham
2011-present: Professor and Head, Nuffield Department of Primary Care Health Sciences, University of Oxford
2009-present: Director of the NIHR School for Primary Care Research
2014-present: Director of the NIHR Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC)
2007-present: President of the European Primary Care Cardiovascular Society (EPCCS).
2007-2013: Chair, Prevention and Care Board, British Heart Foundation
2005-2009: Co-director of the QOF Review Panel
1992-2011: Head of Primary Care Clinical Sciences, University of Birmingham
Recent key publications
McManus RJ et al. Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SRrandomized clinical trial. JAMA 2014; 312: 799–808
Hodgkinson J et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension:Systematic review. BMJ 2011; 342: d3621
Mant J et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study,BAFTA): a randomised controlled trial. Lancet 2007; 370: 493–503
Hobbs FDR et al. Performance characteristics of N terminal pro brain natriuretic peptide (NT-proBNP) and BNP assays in the diagnosis of symptomatic and asymptomatic leftventricular systolic dysfunction in primary care. J Am Coll Cardiol 2001; 37: 146A–146A