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Gold, incentives and meh

Statin the bleeding obvious

Copperfield 

I have a question, and I’d like someone clever out there to answer it.

To explain: one of my HCAs came to see me the other day. Big panic. She was doing something wrong, she said, with the NHS Health Checks.

No matter that the individual’s health she was checking seemed faultless, blameless and therefore potentially endless, the QRISK was coming in at >10%. And this was happening repeatedly. Was she, she speculated, forgetting to subtract the patient’s inside-leg measurement, or something?

The back story is that we have, for a long time, resisted providing NHS Health Checks on the basis of all the well-aired arguments, which could be summarised by saying that these checks are a politically-driven, non-evidence based heap of dung. However, when an activity, even a bonkers one, becomes the norm, there comes a time when a principled stand starts to looks like laziness or neglect. Plus we needed to earn some more cash.

So here we are, with a confused HCA and frightened patients. Of course, there’s actually nothing wrong with the way the HCA is performing the health checks. She’s simply forgetting that the single most important parameter is the one we’re all powerless to influence: age.

Why invite men over 59 or women over 65? Just send them a pack of Atorva on their birthday

As I have mentioned before, no matter how perfect your parameters, once you hit 59 (male) or 65 (female), your risk score is inevitable above 10%. Which means that, according to NICE, we should be offering statins - and NICE’s mealy-mouthed qualifier about trying lifestyle interventions first counts for nothing in this group, unless those interventions includes a device to reverse ageing that they’ve forgotten to mention.

So here’s the question. As the end game of any NHS Health Check is the calculation of the QRISK score and therefore a take-home prize of statin eligibility, what is the point of inviting any male over 59 or female over 65, given that the outcome is a given? Why not just send them a pack of atorva on the appropriate birthday, with a repeat prescription slip for those who like the taste?

While I’m waiting for someone to enlighten me, I can console myself with the fact that a green paper was produced last month on ‘Prevention in the 2020s’. Everything about it is ‘Bold’, not least the adjective ‘Bold’, which has clearly replaced ‘Robust’ as the politician’s go-to word for when they’re trying to convey that they mean business. It appears countless times in the document, almost always followed by the word ‘action’.

And the ‘Bold action’ with NHS Health Checks will apparently make them more ‘intelligent’. Which sounds good until you realise that means maximising uptake (so much for informed consent), increasing the range of checks offered (so much for evidence) and considering a ‘retirement MOT’ (so much for feeling carefree when I hang up my stethoscope).

I sent in my above questions to the consultation. And I pointed out that my personal future vision for NHS screening and prevention would be one that delinks scientific medicine from political propaganda. Now, that would be bold.

Dr Tony Copperfield is a GP in Essex. Read more of Copperfield’s blogs at http://www.pulsetoday.co.uk/views/copperfield or follow him on Twitter @doccopperfield

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Readers' comments (13)

  • "delinks scientific medicine from political propaganda"

    And how do you propose that? I know the answer for the only way to do so... but I wonder if you do...

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  • Correct of course.
    So you retire at 60, decide to get a healthcheck efore you go to visit your brother in Australia for the trip of a lifetime.
    Suddenly you have "cholesterol" and your travel insurance doubles in cost!!
    Great

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  • CH
    No one cares!

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  • Ivan Benett

    DrDeath | GP Partner/Principal17 Sep 2019 12:08pm

    Correct of course.
    So you retire at 60, decide to get a healthcheck efore you go to visit your brother in Australia for the trip of a lifetime.
    And a Senior Railcard. Don't forget that

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  • Ivan Benett

    Well, while you wait for someone clever to respond...
    First of all QRISK 3 doesn't put above 10% until you get to about 63yrs, if all other factors are OK for men.
    The 10% threshold is not arbitrary, but at a point where NICE judges the benefits of intervention with statins to outweigh the harms. In the USA the threshold is lower, 7.5%. This is NICE recommendation, not mandated.
    Of course risk goes up with age. I would submit that having a discussion about heart health at or before you get to 60 is a good idea. Most heart attacks and stroke happen after that age. It doesn't have to be a GP, but it is usually us who prescribe the Statin, if needed.
    The recommendation to achieve lifestyle change is not frivolous, indeed everyone accepts that stopping smoking is a must. Then its management of risk factors including BP and diabetes.
    People with Diabetes, Chronic Kidney Disease (GRF

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  • Only at 60 do we realise quitting, losing weight and taking exercise??
    Having done all that we have to treat cholesterol
    Of course there is an increased risk of diabetes if you take a statin-1 in 204 is the "number needed to harm"

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  • So 2 groups of patients at 60, neither have ever had a heart attack or stroke, can choose to go onto statins. Those that do all die at the same rate and date (statistically) as those that don't. Those that do have fewer strokes/chd than those that don't, therefore those that don't have fewer NON strokes/cod (whatever those may be). Who is to say that those in the the statin group have had a better life? They certainly haven't had a longer one. Meanwhile the £££ cost mounts, as do the side effects.

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  • Once you have put the NNT/NNH for all the interventions to prevent illness in the asymptomatic into the mixer, you are left with a poker hand the playing of which depends on your philosophy.

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  • Vinci Ho

    Yawn
    Aren’t you guys bored of this kind of Brexit-like polarised debates , especially on primary prevention with statin ? As I wrote before , I am more fascinated by this nocebo effect and the less one told the patient about statin side effects , the less likely they would have them . Let the pharmacists do the ‘shit job’ of hard selling high dose statins to them . The government is pushing it anyway .
    Ultimately, again , it is not about deserve , it is about what one believes.

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  • So we are still recommending statins in primary prevention despite lack of benefit and definite harms, and we ignore the massive weight of evidence about the benefit of regular exercise. Bonkers !

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