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GPs buried under trusts' workload dump

Charity requesting GP follow-ups following unapproved heart screening test

A charity is offering patients an unapproved free heart screening service and sending them to GPs with requests for follow-up tests. 

Cardiac Risk in the Young (CRY), in conjunction with St George’s University Hospitals NHS Foundation Trust, offers free ECG screening to anyone aged 14 to 35 through clinics located across the UK.

The screening programme, which is not approved by the National Screening Committee, directs patients to their GP for follow-up tests if the ECG shows any abnormalities.

GPs warned that not only does this increase their workload, but there could be ‘untoward consequences’ as there is not enough evidence that the benefits ‘outweigh the harms and costs’.

The hospital says that a similar scheme in Italy has suggested that screening saves lives.

The charity screens around 30,000 individuals each year with a health questionnaire and ECG, while St George’s collates and interprets the data.

During the screening process, a cardiologist will discuss any abnormalities with the patient, before sending a letter to the patient’s GP - advising further tests that can be conducted locally - or referring them to the cardiovascular unit at St George’s University Hospitals NHS Foundation Trust.

However, this type of screening is not approved by the National Screening Committee.

RCGP overdiagnosis group member and clinical research fellow at the University of Birmingham Dr Samuel Finnikin said: ‘There is no doubt that sudden cardiac death is tragic, and it seems heartless to oppose initiatives that aim to reduce these tragedies. But the National Screening Committee has considered screening such as that currently being undertaken by CRY and St George’s, and found that the was insufficient evidence that it was beneficial.

‘We simply don’t have the evidence that this screening will have benefits that outweigh the harms and costs. And the costs go beyond the act of screenings. CRY may be using charitable money to fund the screening, but the downstream costs will be passed to the NHS.’

He went on to question the other costs to such screening, asking if the tests are ‘good enough to prevent unnecessary worry and harm to those who have false positives’ and whether the interventions make the patients’ lives better.

‘Well-intentioned initiatives like this will always have untoward consequences. Worried parents/patients may well turn up at their practice expecting their GP to offer this screening, or interpret tests done elsewhere. This is extra work for GPs, and extra concern for patients that probably hasn’t been factored in by CRY or anyone promoting this screening,’ Dr Finnikin added.

Professor Sanjay Sharma, professor of inherited diseases and sports cardiology at the St George's, University of London, said: 'The National Screening Committee have not performed a thorough literature review and have focused only on one disease, hypertrophic cardiomyopathy. Based on a recent paper in the NEJM, the death rate in British adolescent soccer players is 1 in 15,000. If we extrapolated this to the young population, this would equate to 1400 deaths per year. We state at least 600 deaths per year at CRY but the NSC says it is 29.

'At CRY we have shown that ECG screening is possible and will identify people with serious disease. We cannot prove whether this saves lives at present, although we may well be in a situation to show this in 5 years’ time. Data from Italy (where screening is mandatory) has suggested that cardiac screening saves lives.

'We are in the process of developing an infrastructure. CRY (and St George’s University) have trained 29 doctors in screening young people and the management of diseases implicated in their deaths. Of these, 14 have become consultants in various parts of the country and could establish clinics to manage young people identified through screening.'

Dr Steven Cox, chief executive of CRY, said: 'The reason why CRY’s screening programme started (in 1993) is because fit and healthy young people die suddenly from undiagnosed cardiac conditions. Usually they will have had no symptoms and the only way to have prevented the death would have been through screening. Undiagnosed cardiac conditions are one of the most common causes of death in young people and the most common cause in young athletes.

'There are many problems with the outdated approach the National Screening Committee (NSC) is taking on this issue, but the most serious of these is the way they have massively underestimated the number of young people who are dying of these conditions. It is also unacceptable how the NSC have incorrectly evaluated the electrocardiogram (ECG) as a diagnostic test.'

Earlier this year, GPs raised concerns over Public Health England's heart age campaign, which asked everyone over 30 to take an online test to find out their ‘heart age’ and directed patients to their GP if their cholesterol level or blood pressure was unknown.

Readers' comments (16)

  • Why involve GPs? - if a problem is found they should just get on and sort it

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  • Ivan Benett

    Another hysterical headline in Pulse stemming from a fundamental misunderstanding of testing. Every test, in this context, ECG in people suspected of a critical inherited conduction or structural defect, will have less than 100% sensitivity and specificity. This means it is nnevitable that the test will miss some cases and I dentist false positives.
    In the context also of individuals the tests will highlight that persons risk and so indicate whether further diagnostic tests should be presued.
    If I had a family history of sudden cardiac death, or my son or daughter wanted to engage in extreme or elite sports, I would very much like to be sure their ECG is normal. Indeed I might well wish them to have an exercise ECG and Echocardiogram if they were engaged in very strenuous sports.
    Whether the benefits and costs work out at a population level would depend on results of randomised clinical trials and a cost-benefit assessment.
    Meanwhile, I think it is reasonable to do an ECG on this group of young people if they request it, and take it further if there is any abnormality.

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  • Ivan Benett

    *identify

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  • Ivan Bennett- I think we all get that. The question is why are GP’s being involved. If they want to start screening- great, just make sure we’re not doing the unfounded follow up.

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  • 'The question is why are GP’s being involved.'

    Because the blessing of a GP is the key to unlocking the clinic appointment tariff apparently. (although it isn't strictly but no one in commissioning or secondary care understands or chooses to understand the clear 2016 hospital contract on internal referrals)

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  • Simples, bounce them back. Screening programmes are funded but when forwarded to GPs the funding doesn't follow the work. And actually, it would be polite to have some respect for GP colleagues and ask them initially whether they were willing to waste their precious time on some screening pilots churned out from secondary care.

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  • Dear All,
    what do you do to a person who's never experienced a palpitation inviting them to have an ecg because of something that might make them drop dead and that only testing can detect?
    Prevent a -potential- 1,400 deaths a year by converting 7,500,000 15 - 24 yr olds into cardiac neurotics.
    Has St Georges worked out what the potential long term unintended costs of this might be?
    Its my local hospital and to learn that they are doing this as a private venture is a disgrace.
    Regards
    Paul C

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  • David Banner

    If in 5 years time it can be demonstrated that this approach saves young lives, the of course it should be rolled out nationally.
    But it should never come across a GPs desk, this is a secondary care issue.

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  • Here we go again;

    At first I thought this was going to be the Christmas BMJ paper.

    The issue here is, these patients attending on a busy Monday morning, stopping GP's seeing actual sick patients.

    Despite the billions of NHS pounds spent on what is called management;

    No professor

    No charity

    No pressure group, needs anybodys permission, before instigating any scheme, that prevents sick patients from obtaining access to emergency medical care.Patients seem oblivious to this and politicians utterly disinterested.

    Of course if one wished to be slightly cruel,one might postulate that terrifying large numbers of fit young people into seeking expert advice might be incredibly lucrative.Overworked GP's might consider referring to a specialist,especially if that is what the patient has been told to expect.After the usual long pointless GP consultation about waiting lists, the patient slowly comes to the conclusion that a private appointment is the only way forward.

    There might also be an increase in sales of Cardiology kit

    It would be interesting to see a list of the sponsors of this charity

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  • I could go along with us being sent a letter saying this person has been screened and an abnormality needs further investigation,please tell us if there is any reason why this shouldn’t be done (eg pt already known and investigated for it)Otherwise no reply needed - still needs us to check notes,but if evidence does turn up for effectiveness fair enough

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