What will the CVD screening drive mean for GPs?
Released with a smile and a flourish earlier this year, the Government’s plans for a nationwide cardiovascular screening programme are provoking a rising sense of dread among many GPs.
By Nigel Praities
Released with a smile and a flourish earlier this year, the Government's plans for a nationwide cardiovascular screening programme are provoking a rising sense of dread among many GPs.
Ministers are convinced the plan to offer everyone aged 40 to 74 a ‘vascular check' will be a vote-winner – preventing up to 9,500 strokes and heart attacks a year. But then it is not ministers who will have to deal with the hundreds of apparently healthy adults who are set to start flooding surgeries, perhaps as early as next April.
The Department of Health estimates three million patients will be screened a year, but calculates that will amount to just seven extra appointments per practice each week. The BMA puts the figure at closer to 40.
But after a series of criticisms from members of the national screening committee, public health experts and most recently a NICE guideline committee, the Government is showing signs that it may water down its favoured birthday-based approach.
As Pulse reported in May, the timescale for screening has already slipped, with full implementation of birthday-based screening perhaps now not due until 2011.
But NICE ruled just last month, in its lipid modification guidance, that a birthday approach was unnecessary, and that it would be more cost-effective to gut GP records and prioritise those at greatest risk.
Its analysis showed a records-based approach cost just £3,960 per QALY to screen a fifth of the practice population. The approach was far more cost-effective than screening everyone over 50 years and then all those over 40 years – the planned approach for the national programme - which cost £12,222 per QALY.
Last week, the QOF expert panel also opted for a records-based approach to primary prevention, although it advised a slightly different approach to NICE. The panel proposed ‘important' new indicators for assessing cardiovascular risk in patients on practice registers for hypertension or hypercholesterolaemia.
Indeed, doubts over whether a birthday-based approach to screening is in any way necessary are shared even by the Government's own screening advisors.
Dr Surendra Kumar, a GP in Widnes in Cheshire, and member of the National Screening Committee, said it was largely a political decision to screen everyone over a certain age, rather than targeting resources at those at higher risk.
‘It is typical of this present Government It just tries to make announcements that have no substance or are deliberately misleading.
‘If you screen the whole population then the rewards might not be great enough. You are going to have the worried well coming, raising their level of anxiety, and the workload is out of the question for most practices,' he warned.
Dr Kumar said the ‘sensible approach' was to take advantage of existing practice records, as recommended by NICE.
Dr Tom Marshall, a senior lecturer in public health at the University of Birmingham who has run a number of screening trials in the UK, agrees that practices already have enough information to identify most of those at high risk of CVD.
‘We often get distracted into thinking that we need to collect more information. But we have enough information now to identify all of those at high risk, because the main predictors of risk are age, sex and smoking status,' he said.
He recommended using computer software on GP systems to create a register of patients with a 10-year risk of greater than 20%, rather than calling everyone in over a certain age for a risk check.
Dr Marshall's screening pilot in Sandwell found more than 5% of untreated adults on practice lists were potentially at high risk. As many as 40% of these were found to be eligible for cardiovascular drugs after systematic screening by a practice nurse – working out as about 120 new patients per 6,000-patient practice.
Even this approach was a ‘huge burden' on practices initially and required investment from the practice in terms of nurses and time, according to the pilot investigators.
Dr Mark Davis, an author of the Joint British Societies guidelines on cardiovascular disease and a GP in Leeds, says many GPs are already stratifying patients and that this approach could be stepped up gradually to build up the screening programme.
‘Practices like mine already look at a formal cardiovascular risk assessment in anyone with hypertension and a family history, following JBS2 guidance, and you can increase this in a step-wise approach to cover more patients and keep it manageable for practices,' he says.
There are signs the Government is listening to such suggestions. The Department of Health's heart tsar Dr Roger Boyle, told Pulse last month that ministers were looking to introduce the vascular screening programme over two years or more and were looking at various options to reduce GP workload.
Dr Boyle said initial options for the scheme included ‘interrogating' practice data and targeting higher-risk groups, such as smokers and obese patients. The final plans will be presented to stakeholders at meetings next month.
This change of tack may offer short-term relief to GPs, but there are other dangers on the horizon. The Government is looking hard at how alternative providers can provide vascular checks, such as private firms, pharmacies and community groups.
The recent white paper on pharmacy said pharmacies would play a ‘key role' in the scheme in reaching those who do not see their GPs.
Pharmacists make no secret of their desire to gain a slice of the primary care pie. A policy document published last week by the School of Pharmacy encourages pharmacists to seek more incentives to work together with GPs, including a share of the QOF. The document identifies vascular checks as one area to permanently wedge their feet in the door of primary care service provision.
‘For community pharmacists, vascular checks will provide fresh opportunities for them to offer not only individual care, but to in future lead the establishment of what may be termed community-orientated pharmaceutical care.'
The Department of Health shows every sign of being willing to provide such opportunities. In a statement to Pulse, it said: A variety of providers of vascular checks will be considered. These will include pharmacies and other providers, such as those in the third sector. This will help ensure the programme gets good take-up, including in those not in touch with formal health care.'
But even enthusiasts for screening are concerned by these proposals.
Dr Davis says there is not currently the infrastructure to support pharmacists leading on primary prevention. ‘It may be that GPs have already stratified patients and without proper systems in place to make sure pharmacists can do this well and without duplication, it will fragment care,' he warns.
And once again, the Government appears to have pushed ahead without heeding the advice of its own screening advisors. Dr Kumar is scathing, insisting pharmacists may offer cost savings, but that the quality of vascular checks would suffer.
‘Pharmacists are hardly reliable to take blood pressure readings. Quite often they only measure it once and when I see patients I have to check it again. I don't think it will be effective,' he says.
There is still some hard wrangling to be done over the details of the £250 million programme, and precisely how it is implemented will be crucial.
As concerns over the programme grow, there is a temptation among some GPs to hold cardiovascular screening at arms length.
But here too the scheme presents a challenge to general practice. If GPs do not take ownership of cardiovascular screening, they could find themselves side-lined and their role in the management of chronic disease diluted.
- Screening all those aged 40 to 74 years
- Could reach individuals who do not regularly access their GP
- Not as cost-effective at identifying those at high-risk compared with records-based approach, according to NICE
- Using existing practice records and disease registers to prioritise patients at highest risk and inviting them for screening
- Would reduce impact on workload of GPs, as many are already doing this
- Initial focus could be on hypertension register, as QOF data indicate this is the most complete
You can increase risk assessment in a step-wise approach to make it more manageable.Dr Surendra Kumar, a member of the national screening committee. Dr Surendra Kumar
If you screen everybody, the rewards might not be enough.Selecting high-risk patients from pratice records may be most cost effective. Selecting practice records