As NICE consults on draft guidance to offer statins to millions more adults in England, Emma Wilkinson considers the implications for GPs
Up to 15 million more people could be eligible for statins to prevent future heart attacks and strokes under updated NICE guidance, the headlines blared.
As reported by Pulse last week, the update to guidelines on cardiovascular risk assessment and prevention now advises that statins can offered as an option in individuals with a 10-year CVD risk score of less than 10%.
The recommendations, out for consultation until the 2 February, are based on evidence that the more people that take statins, the greater the reduction in cardiovascular events. Statins are cheap, dealing with the aftermath of heart attacks and stroke is expensive.
NICE calculates that for every 1,000 people with a risk of 5% over the next 10 years who take a statin, about 20 people will not get heart disease or have a stroke, that increases to 40 prevented events at a risk level of 10%.
It is population level maths, which may be tricky to explain to an individual during a consultation on how to reduce their cardiovascular risk.
For example, Swindon GP and QOF expert Dr Gavin Jamie calculated that at 5% risk you would need to take statins for an average of 500 years – 180,000 tablets – to prevent one event happening. As he puts it: ‘I would have had to start taking it during the reign of Henry VIII in order to expect a benefit this year.’
Figures like these, and the millions who would potentially be eligible, have prompted questions around whether money would be better spent on other forms of prevention; on people living healthier lives and not just longer lives with more diseases.
NICE has not changed its view that lifestyle changes should be the first port of call – once you have used the updated QRISK3 tool, to assess risk across the 25-to-84-year-olds in your practice.
It has added that GPs could also consider using a lifetime risk tool to help motivate lifestyle changes particularly for those with lower 10-year risk scores.
Dr Helen Salisbury, a GP in Oxford, points out that weight loss, exercise and smoking cessation services have been cut due to funding pressures, and therefore may only be available for the most high-risk. In reality, there are few options for GPs to offer in the way of support for patients.
‘We really should be investing in smoking cessation, diet and exercise and making this much more accessible than it is currently,’ she says.
What is not clear is to what extent GPs would be expected to do this as a systematic programme of identifying and consulting with everyone who may fall into this category and also how many of those at lower risk would be willing to start taking a daily pill for life.
‘Above a certain age, if you were going to do this properly you would have to have an in-depth conversation with all your patients about whether they should or should not be taking a statin,’ Dr Salisbury adds. ‘I don’t know that anyone has done the calculation about how many hours of consultation that would be.’
Yet unless it becomes part of QOF or the IIF, it is not mandated work. The NICE recommendations still advocate focusing on those with the highest risk where the greatest benefit is seen, despite simultaneously offering this more ‘individualised’ approach for those with risk scores under 10%.
Current national data suggests less than 50% for people with QRISK scores between 10% and 20% take a statin and this is likely to be an even smaller proportion at a risk under 10%.
Dr Emma Nash, a GP in Portchester, Hampshire, says most likely it will just mean a chat within other consultations if the patient brings it up. ‘It’s interesting because we’re being told to deprescribe as much as possible because of polypharmacy and its effects, but this obviously goes the other way.’
Professor Carolyn Chew-Graham, professor of general practice research at Keele University says unless it’s in QOF, practices are unlikely to do this on any great scale. ‘It does not seem to recognise the tremendous pressure primary care is under and [what that would mean] if you were to follow these guidelines to the letter.’
And while she welcomes the move to use QRISK – despite QRISK3 not yet being available on EMIS – she also has concerns about an updated recommendation to consider everyone over the age of 85 to be at risk on the basis of age alone. ‘We don’t want to start every one aged 85 or older on a statin,’ she adds.
Beyond noting there are ‘practical considerations’ and increased medication and monitoring costs to the NHS, the guidelines do not go into detail on what this might mean for GP time.
Dr Martin Brunet, a GP in Guildford, said putting aside questions around the number needed to treat to prevent cardiovascular events, his increasing concern is what is means practically.
He points to an analysis recently published in the BMJ calling for guidelines to take into account clinician time in their assessment of cost effectiveness. NICE says the impact to the NHS will depend on uptake ‘but is not considered likely to be significant as the additional annual cost of medication per person is small’, he adds.
‘The implication is that the only resource being considered is the cost of the statin,’ he says. Yet looking at the headline figure of 15 million – that would equate to about 4% of the current annual consultation figures or about two weeks’ solid work for every GP in the country, he calculates.
‘NICE has always looked at cost effectiveness and we need to make a fundamental change to NICE guidelines where clinician time is considered as a limited resource and that a proper cost benefit analysis of clinician time is made before guidelines are agreed,’ he added.
Dr Ben Allen, a GP and director of primary care in Sheffield also has questions about economic decisions that are based solely on the cost of statins versus the risk reduction they offer.
‘Because general practice gets a fixed fee for a year of patient care, the financial cost of this to the NHS may appear minimal.’
But he adds: ‘If we use more appointments discussing statins, we have less for people who are acutely unwell, have worrying new symptoms or vulnerable people.
‘What is the true cost of lowering the threshold for recommending statins,’ he says.
Dr Lis Galloway, a GP in Surrey says at the population level it’s clear that there may be a positive benefit in statin taking at lower QRISK, especially with recent evidence suggesting the side effects and harms of statins are in fact very small.
However, is this the right approach, she asks. ‘To even consider placing a huge burden on primary care at a time when we are failing to meet the demand of those at much higher risk of over 20% would be questionable.’
She adds: ‘Discussions around statins are rarely brief consultations as patients often have many questions, and rightly so. ‘Sadly, I imagine there won’t be additional resource attached to a change in guidance. I would also add that preventative medicine starts with systems changes, not medication. That’s much bigger than the NHS.