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Vascular screening vision blurred by primary care trusts

PCTs take hugely varying approaches to vascular screening, with some completely excluding GPs. By Nigel Praities investigates.

By Nigel Praities

PCTs take hugely varying approaches to vascular screening, with some completely excluding GPs. By Nigel Praities investigates.

It will cost £332m a year to run, involve all patients between 40 and 74 and give GPs their biggest public health task ever. Yet with just weeks to go before the launch of the Government's national programme of vascular checks, there remain huge questions over its implementation.

This week a Pulse investigation reveals just how fragmented are the plans by PCTs to tackle the initiative, with vast differences from one area to the next. A picture emerges of wildly different systems, great disparities in how they are paid for and a very different type of experience for patients, depending on where they live.

The Government hopes the programme will prevent 9,500 heart attacks and strokes a year and help to narrow health inequalities across the country.

But attempting to achieve those lofty goals is proving, thus far, chaotic. PCTs have been given the freedom to roll out vascular screening in the manner and at the pace that they choose, using ‘innovative and proactive approaches'.

The result is that some PCTs are set to pay practices thousands of pounds to screen and treat patients and others are offering GPs nothing at all.

Information obtained by Pulse from 44 PCTs reveals all are already planning schemes to screen people for vascular risk and more than half will have one up and running by April.

GPs are the main drivers behind the checks, with 88% of schemes involving them, but pharmacies are also major contributors and have involvement in more than a third of trusts. In some areas, GPs have been froz-en out of the schemes completely, with pharmacists paid to take on all aspects of screening.

Pharmacists plan

In North Somerset PCT, practices will have to provide lists of patients aged 40 to 74 who are not on a disease register and have not been to their practice in the past 12 months. Community pharmacists will then send invitations to these patients for a vascular check and will be paid £25 per patient.

The plans were revealed by the PCT at a meeting of the GP forum on practice-based commissioning, to a room full of outraged GPs.

Dr Miriam Ainsworth, a GP in Weston-super-Mare and a member of Avon LMC, says the PCT has been taken aback by the opposition to the scheme, which she claims undermines local GPs and is a waste of resources. ‘It would be far more beneficial for people to attend their GP for screening, rather than their pharmacist, because they can then be screened for other things as well,' she says.

‘We feel GPs should provide continuity of care. They are not investing in general practice and the whole process fragments primary care, is a backwards step and is not a cost-effective use of public funds.'

Yet in other areas, GPs are to be paid handsomely for their involvement. Hammersmith and Fulham PCT is offering up to

68 extra QOF points under its QOF-plus scheme for screening and direct payments for interventions.

Waltham Forest PCT is handing practices a lump sum payment of £5,000 to set up the service and paying £5 for identifying patients at risk, £10 per risk assessment made and £5 for any follow-up visits.

Dr David Schubaker, a GP in Ilford, East London, and chair of Redbridge and Waltham Forest LMC, says the support for the scheme enabled practices to employ extra staff and ensure patients were taking their medicines properly.

‘In some cases big practices have employed a retired GP for a couple of sessions only to do this. They come and look at the computers, bring out all the information, chart them, identify the risk factors and invite the people for a medical check-up.

‘It not only helps financially and cuts mortality but will also reduce expense in the long run,' he says.

GPC negotiator Dr Peter Holden is appalled at the Government's scattergun approach and the failure in many areas to provide GPs with sufficient resources. ‘This is a recipe for exploitation and is a recipe for postcode medicine,' he says.

‘It is going to be a massive job in terms of the amount of morbidity you are going to find in some areas.

‘Nobody minds doing it fully costed, but it is too damned easy for someone to stand up in parliament and get a nice sound-bite and a warm feeling, but leave the poor bloody troops making bricks without straw.'

Experts are also worried that the inclusion of outside pro-viders will simply duplicate work. Dr Tom Marshall, clinical lecturer in public health at the University of Birmingham and a member of the NICE lipid modification guideline group, says he has serious concerns over the use of pharmacists.

‘It's very difficult to get the information back to the practice. Often, even if you do, then it is in paper form and somebody has to enter it.

‘Also practices may not have confidence about how it was done so they tend to repeat it. That is just duplicating the work rather than reducing it,' he adds.

There are also major differences in the resources PCTs are providing. Practices are paid much less than pharmacists to carry out the checks, with GPs receiving an average payment of £10 per patient, compared with £26 for pharmacies.

In South West Essex, the PCT is providing equipment to measure cholesterol to carry out risk checks to both practices and pharmacies, but pharmacists are paid £35 per assessment and GPs receive nothing.

Dr Richard Vautrey, deputy chair of the GPC, is furious at the differences in funding between pharmacists and GPs and says practices need support for the ‘surge' in the number of patients identified through the programme.

‘This is complete nonsense. It reflects what appears a deliberate attempt to exclude GPs and use vascular screening to put a wedge between professional groups, and that just seems nonsensical at a time when practices and pharmacies need to be working together as closely as possible.

‘You are going to have a lot of new patients who have been given figures they don't understand. They will be seeking interpretation of the figures and further advice or information about treatments and they are going to go to their GP for that.'

A number of areas have yet to decide how to reward practices, but others say they will rely on the QOF to reward practices for managing patients. Stockport PCT says it will not provide payments as it ‘should be routine care of the patient population'.

Other major question marks hang over the programme, with plans set to be plunged into further chaos after the Department of Health instructed NICE to look again at the evidence for using QRISK rather than the Framingham charts for risk assessment.

Pulse has reported how some GPs fear huge disruption if work begun under Framingham then has to be redone with the new tool.

NICE is aware of the need to review the Government's evaluation of QRISK as quickly as possible, with documents released under the Freedom of Information Act this week revealing it has been pressing officials for a publication date.

But to complicate things further, an Israeli study last week piled fresh pressure on the institute by suggesting statins could cut deaths by up to 50% in people without heart disease, and should be used even more widely for primary prevention.

NICE is holding a review to consider whether it needs to change its guidance on the risk level at which statins should be initiated and the result, due next month, could also have huge implications for the screening programme.

Such an ambitious project was never going to be easy. Over the next few months we will learn whether the Government has bitten off more than it can chew – and whether it was wise to place so much faith in PCTs to carry out its bidding.

Vascular screening: All PCTs will test blood glucose, cholesterol and blood pressure - but under a wide variety of screening models Vascular screening: All PCTs will test blood glucose, cholesterol and blood pressure - but under a wide variety of screening models What types of schemes are there?

By GPs

Practices manage risk assessments themselves in-house. Some PCTs provide lump sums for equipment and payments for each patient screened. For example, Wirral PCT gives GPs £750 initially plus 75p per patient on their practice list, and £1 for each patient screened.

By PCT staff

These take the pressure off practices, but often provide no extra income. For example, Sandwell has a team of PCT-employed nurses who come into practices to identify and prioritise patients from practice lists and then do the risk checks. Practices receive no extra payments under this scheme.

Pharmacy-led

Pharmacies are paid to conduct screening and refer those at risk to GPs for tests or treatment – sometimes with resources for practices, sometimes not. For example, South Birmingham PCT will pay pharmacies £10-20 per patient, depending on whether they need equipment or not.

On the street

Screening is taken out into unusual locations, such as football matches or shopping centres, to target hard-to-reach groups. For example, Hull PCT has commissioned a private provider to do assessments in the community and workplaces, with a target level of assessments to deliver per year to fulfil its contract.

FAQs

What will the vascular checks programme involve?

Checks include a basic risk assessment – including smoking status, cholesterol and BP tests – and referral for lifestyle interventions. Those at higher risk will be referred for treatment. People at risk of diabetes will be offered blood glucose and glucose tolerance testing, and hypertensive patients testing for CKD.

When will vascular screening begin?

The official start date is from April 2009, with PCTs receiving funding for schemes in their allocations for 2009/10. The Government wants the full rollout to be complete by 2013, but it is up to individual PCTs how fast they go.

Will screening be included in the QOF?

Indicators for primary prevention were recommended for this year's QOF, but were not included. New indicators for 2009/10 will incentivise GPs for conducting risk assessments in newly diagnosed hypertensive patients and giving lifestyle advice.

Dr Richard Vautrey, GPC deputy chair Dr Richard Vautrey

This is complete nonsense. It reflects what appears a deliberate attempt to exclude GPs.

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