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NICE statins plan is 'unsustainable' for GPs, says BMA official response

Exclusive NICE’s proposals to offer millions more patients statins for primary prevention will leave GPs overwhelmed by increased demand for consultations, the BMA’s official response to the consultation has said.

The BMA rejected outright the proposal to lower the threshold for statin treatment to a 10-year risk of 10%, which it said is not supported by the available evidence and will lead to ‘unsustainable workload implications’ for GPs and ‘reduced access for other conditions’.

The response from the RCGP also warned there was a potential for overtreatment, which it said should be carefully managed through ‘publicity and communication’.

The draft update to NICE lipid modification, published in February, recommended halving the 10-year risk threshold for primary prevention from 20% to 10%, as determined by the QRISK2 risk algorithm, on the back of a large meta-analysis published in The Lancet showing the benefits of lowering lipid levels with statins extended even at risk levels below the 10% cutoff.

But the BMA said NICE had not taken into account the impact on primary care workloads and other patients.

It stated: ‘General practice currently does not have spare capacity, and this situation is likely to get worse due to demographic, medical, social, and workforce changes in coming years.’

‘The appointments required to assess, treat, and monitor patients according to this guidance can only result in fewer appointments being available for other reasons. With studies failing to show improvements in all-cause mortality the implementation of this guidance may well reduce and not increase the health of the nation, by denying primary care appointments for other conditions.’

The draft proposal to lower the risk threshold divided opinion when it was announced, and was met with scepticism by many GPs.

A survey of around 500 GPs conducted by Pulse revealed around 60% did not agree with the recommendation, while over half would not take a statin themselves at the 10% risk – or recommend family or friends do.

The RCGP’s response noted concern regarding the potential for overtreatment, which it said must be carefully managed through ‘publicity and communication’ on how to explain the benefits and harms of treatment in people at lower risk.

The college stated: ‘NICE have reduced the statin intervention threshold understandably in the light of recent meta-analyses which show persisting risk reduction among lower risk patients. This will lead to most of the population > 50 becoming candidates for treatment.’

‘The solution to avoiding overtreatment whilst also making available treatment to those who want it, is a clear presentation of absolute benefits and risk. This needs to be easy for patients, GPs, nurses and the media to understand.’

NICE said it has received 43 responses to the consultation from stakeholders on the proposals, which have also been criticised by public health experts.

Dr John Middleton, vice chair of the Faculty of Public Health, said the Faculty was ‘very concerned’ about the proposals.

Dr Middleton said: ‘The [Faculty of Public Health] is very concerned this draft NICE guidance will lead to the over-medicalisation of a societal issue. This challenge can actually be tackled much more effectively through policies creating healthier environments, which support healthier behaviours.’ 

‘The evidence clearly supports statin usage for patients with vascular disease, and for individuals at high risk of future events. However, we do not want society to think that statins represent a “get out of jail free” card to offset risky behaviours.’

He added: ‘We need action on all fronts to prevent over-reliance on medications. Policies are potentially much more powerful than pills.’

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Readers' comments (8)

  • The side effects of statins are crippling. I tried stopping them for a week and pains vanished, back on them two days and the agonising pain returned. Did the same again to be sure, same result!

    Whilst they may have benefits, folk need to be aware of the negative side of using theses drugs. I couldn't stand, certainly no chance of walking, the muscle cramps like pains were more than I could tolerate although I consider myself to have quite a high pain level.

    I take take 300 mg aspirin per day and so far, no problems!

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  • Personally, it is not "wrong" to consider 10% cut off as other European countries and USA does. It is more "wrong" do deny this purely on cost basis.

    However Dr Middleton makes a good case and if we are to reduce the threashold to 10%, it must be done in conjunction with promotion for lifestyle mods and increase in funding for primary care to address increased work load.

    Can government afford this? I doubt it.

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  • Vinci Ho

    This is not about arguing whether the recommendation is justified . This is about feasibility :-
    (1) lower the threshold to 'act' and hence prevent is generally welcome for all diseases . You can say the same thing about COPD, diabetes etc. BUT
    (2) one needs a HOLISTIC approach ,not one single measure.
    (3) Then where are the reserves and resources to do so? Invest and give every practice an extra practice nurse?(shall we call her the 10% CVD risk nurse)That will not happen with this government anyway!
    (4) To say there is absolutely no side effect with statin is naive and irresponsible . No drug is without any side effect . In fact , side effect of statin should be around the 15% figure .
    (5) Hence, extra effort is necessary to deal with that by primary care. It is easy for academics to send down 'holy' prescription from the top of the ivory tower without realising how difficult it is in the frontline.
    Pushing this forward blindly without obtaining a proper consensus amongst medical colleagues is 'Stalinisation' instead of the originally planned 'Statinisation'....

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  • Vinci Ho

    Remember the recent story about 25% over-diagnosis of CKD stage 3a. Even NICE has to admit to this fact and drafting a new guideline to recommend eGFR-Cystatin C instead to make the diagnosis more correctly.
    It is still about doing something justified but NOT OVERDOING it . Common sense.

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  • Many of these academic GPs and consultants semm to have problems with understanding ideas and evidence and seem to have literal interstanding of information. It seems they cannot translate and contextualise information and research and struggle to understand anyone elses perspective.
    ?Diagnosis?

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  • But we treat people all the time with far lower CVD risk with far more dangerous drugs that are far less effective...
    Hypertension!

    We should use more statins and less hypertensives, if people are really that bother.

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  • Two comments ,the metanalysis of trials suggests a saving in lives greater than the current death rate from CVD clearly impossible .The use of Qrisk in London 20% of the uk population wildly overestimates CVD risk as its weighting factors ,Rented accomodation and car ownership are first very high and second very low .This is due to political pressure ,the registrar generals social class classification and weigting by a factor of 2 for south asian ethnicity are better indicies .In any case the CVD death rate south of the wash is near japanese rates .The factors that reduce CVD are 1 stopping Smoking 2 exercise 3 avoidance of sugary foods fat is in fact negativley correlated with cvd 4 reducing weight ,Statins do not work on women or the over 70's in any of the papers i have read

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  • Samuel Lewis

    which would you rather be doing ?

    treating flaking nails, dry skin, grumbling guts, aching joints and ageing bones expensively and rather ineffectively...

    or preventing one-third of heart attacks and strokes for £1 a month ?

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