The changes in statin prescribing, albeit very gradual, are good and not a surprise. The nature of uptake necessarily means that there will be early adopters, who take things up before the majority.
Like all decisions in medicine, prescribing statins for primary prevention is based on balancing the opportunity for benefit, the risk of harm, the patient’s wishes and the relative priority of the system – in terms of resources, time and other considerations like opportunity costs.
The opportunity for benefit and risk of harm are understood and perceived differently by different people, however strong the ‘objective’ evidence base. A 10% risk of a cardiovascular event means different things to different people. In terms of benefit or reduced risk of harm there is great confusion amongst professionals, let alone the lay public, between absolute and relative risk. Even when professionals understand the difference, translating that into language people understand can be difficult.
In addition, the pharmaceutical industry has a vested interest in over-promoting minor benefits while cynics have seized on the down sides to intervention.
It’s therefore difficult for a ‘jobbing GP’ to translate the evidence to individuals, and you can see why they would and should be cautious. Indeed this is made even more so by the fact that the doctor carries the clinical responsibility for any decision made about interventions, especially if the intervention causes harm. Thus there is always a bias towards the status quo and non-intervention. We are driven by the injunction to ‘first cause no harm’ which paralyses us into inaction – even when the benefits are clear.
It is our responsibility, as system leaders, to put the case for change and to be optimistic, but we need also to recognise that behaviour change is slow – people need to be quite sure that they as an individual will benefit, and not be harmed, by an intervention.
A mature conversation with a knowledgeable and empathetic GP will balance the potential benefits of taking a statin against the remote risk of harm, while allowing for the patient’s autonomy to decide as well as the costs and opportunity costs. This means that not everyone who might benefit will take up the intervention. And that is perfectly acceptable – provided the patient has had the chance to make an informed decision.
Dr Ivan Benett is a GPSI in cardiology, member of the National Cardiovascular Intelligence Network and clinical director of Central Manchester CCG.