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A faulty production line

Forcing GPs to prescribe statins is the worst kind of medicine

Dr Andrew Green takes NICE to task over its QOF advice

The proposal by NICE to introduce statin prescribing at a risk level of 10% into the QOF has been met with almost universal concern from GPs yet the group’s chair, Professor Keenan, is quoted as saying that he has no idea why GPs are against the 10% statin threshold.

Evidence provided to his group from both the RCGP and the GPC was quite clear, and it is deeply troubling that there appears to be a fundamental misunderstanding in a powerful committee between accepting the value of a clinical intervention in some such patients, and concluding that prescribing activity measures quality of care.

There is without doubt one senior GP whose views he should take into account, and that is his boss Professor David Haslam.

In an open letter to the House of Commons Health Committee, Professor Haslam wrote: ‘It is only if lifestyle changes on their own are not sufficient, and that other risk factors such as hypertension are also managed, that people who are at risk should be offered the opportunity to use a statin, if they want to. They don’t have to, and their decision should be informed by an understanding of the risks.’

If GPs are to follow this advice, it will be impossible for them to hit the proposed upper reward target of 80%, and any reward will be based on the diligence with which GPs apply exception reporting rather than any clinical factors.

Professor Haslam also gave oral evidence to that same committee last September, insisting: ‘I want to stress, as well, that NICE made it really clear that we are not saying we want millions more people taking statins.’

Now that same organisation is proposing to penalise GPs unless they do just that. This discrepancy between statements to the House of Commons about intended policy and the subsequent recommendations of the QOF committee must be explained and one of them needs to be publically retracted, for they are mutually exclusive.

There are disturbing parallels here with the controversy regarding incentive payments for dementia diagnoses, where there was insufficient attention given to preserving the separation between the financial reward for the GP and the ability of that GP to give impartial advice in a controversial area. This policy has been widely felt to have been a mistake and it was not surprising that it was withdrawn, what is surprising is that lessons regarding the importance of avoiding tainting delicate clinical decisions with payments have not been heeded.

Equally concerning is the cavalier disregard for the impact on mental health services of forcing GPs to offer referral for talking therapies to patients with anxiousness or mood difficulties, many of whom in a less medicalised age would have sought help from non-professional sources. The suggestion that flooding overstretched services is of benefit as it will ‘drive an increase in facilities’ is frankly absurd in the current climate and I have never heard of this proposed as a solution to the A&E crisis or surgical waiting lists.

There is a delicious irony in the fact that this was said on the same day that the health secretary instructed the NHS to stop asking for more money. The undoubted result of this proposal if implemented will be delays to access of those in real need with potentially fatal consequences and it is difficult to view this as anything other than irresponsible.

GPs are the risk-sink of the NHS and undertake this at the cost of great stress and a degree of personal jeopardy. We do so to protect secondary care services for those who really need them and we deserve support and praise, not criticism for performing this role.

Ultimately, these are issues of trust and respect, trust by doctors in the validity of clinical trials’ data, in NICE, and in the QOF. Most importantly, it’s about retaining patients’ trust in the impartiality of their GPs advice, and their trust that facilities will be available to them in times of genuine need. Trust is hard to gain and easily lost, and we can only hope that it is not too late to prevent these misguided indicators being introduced into our payment system.

Those who seek to define quality must be made to appreciate that prescribing and referring is the easy bit of the job.

The difficult bits, the bits for which you need training, experience, time and determination, are the consultations in which you don’t prescribe, and you don’t refer.

Dr Andrew Green is chair of the GPC’s clinical and prescribing subcommittee and a GP in Hedon, East Yorkshire


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Readers' comments (10)

  • Vinci Ho

    Am I allowed to be the conspiracy theorist to suggest the 80% target was never meant to be reached by GPs to make more 'efficiency saving'?

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  • Well said!

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  • Echo what Phil says, well said...

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  • Brilliant article and how ironic that Prof Haslam is the very person who publicised the recognition of GPs as the risk sink of the NHS. Prof Keenan is simply beyond the pale. What is the department of health thinking of?

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  • Any chance we could see a clear publication of Prof Keenan's income (both direct and in terms of research grants) over the past decade from Pharma manufacturers of statins?
    Just so we can ensure no conflict of interest of course..
    Excellent and perceptive article from Dr Green.

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  • Agree fully. Evidence for this is scant and unworthy of second glance. Where there is insufficient clinical intervention and support in real and provable situations, to follow this madness is nothing short of irresponsible and stupid!

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  • What bugs me is that NICE doesn't indicate what we should give up doing to enable us to do this new work.

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  • 'I too do not understand why are so many GPs unhappy with the 10% threshold?'

    Where do we start?

    GPs are in crisis to the point where practices are closing due to lack of staff. The opportunity cost of over-prescribing is massive at a time of rising unmet need. When we don't have enough nurses as it is, we should be targeting the sickest.

    Just because a treatment is cost effective in terms of QALYs (assuming the research is not biased by industry) doesn't mean we should have our arms twisted to take this on - it's making a mockery of the GMS contract (which I suspect may be the point).

    Offering statins at 10% risk may be fine but being penalised for not medicating so many well people is just plain wrong - we all die in the end.

    'My solution ? get you nurse to prescribe cost-effective health maintaining interventions, with a 'thank-you for not bothering the doctor' compliment slip '

    Have you not noticed there are not enough nurses around these days to care for the truly sick? Furthermore only a minority of nurses want to prescribe anyway. They have more than enough on their plate.

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  • Samuel Lewis

    some glitch in the thread ?

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  • Samuel Lewis

    Forcing GPs ??? Many are all well ahead of NICE.

    " Statin prescribing increased substantially over time to patients with high 10-year CVD risk (≥20%): 7.0% of these received a statin prior to 2007, and 30.4% in 2007 onwards. Prescribing to patients with low risk (<15%) also increased (from 1.9% to 5.0%). Only about half the patients initiating statin treatment were high risk according to CVD risk score. The 5-year CVD risks, as observed during statin treatment, reduced over calendar time (from 17.0% to 7.1%). There was a large variation between general practices in the percentage of high-risk patients prescribed a statin in 2007 onwards, ranging from 8.2% to 61.5%. For low-risk patients, these varied from 2.1% to 29.1%"

    Van Staa, Goldacre et al.

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