Health checks in disarray

Success of vascular screening across England is hugely variable, as Tom Moberly reports.

Delays in the majority of PCTs rolling out vascular checks have been attributed to confusion over criteria
Delays in the majority of PCTs rolling out vascular checks have been attributed to confusion over criteria

PCTs' roll-out of the vascular checks programme has been hampered by funding difficulties, conflicting priorities and confusion over test criteria, experts believe.

An investigation by GP newspaper found that one in three PCTs have yet to begin conducting checks and just one in 20 have achieved the uptake required to hit DoH targets.

PCTs have had little guidance on how to set up vascular checks. The DoH had intended to make a 'mandated data set' - a list of factors the checks should cover - available last autumn, but this has yet to be published.

The DoH now plans to produce a voluntary data set in the spring, and hopes to make it compulsory by autumn this year.

Calls for clarity
'Everyone started with a completely blank piece of paper,' says Professor Mike Kirby, a GP in Hertfordshire with an interest in cardiovascular disease

He believes clearer advice on the benefits of screening and guidance would have given PCTs more confidence when they were putting programmes together.

Confusion over what tests the checks should cover has caused delays, Professor Kirby says: 'Whenever there is uncertainty there is a reason for people not to do it.'

York GP Dr Kathryn Griffith, who has a special interest in cardiology, points to the muddle over whether to use QRISK or the second Joint British Societies' guidelines to assess vascular risk and whether to use HbA1c or fasting plasma glucose to diagnose diabetes.

Dr Stewart Findlay, a County Durham GP and member of the Primary Care Cardiovascular Society (PCCS), agrees that what data should be collected during the checks should have been agreed from the beginning.

Debate over where to carry out the checks has also caused confusion. Professor Kirby says: 'The idea was that vascular checks could be done anywhere, which has meant there has been almost too much choice.'

The impetus to push the programme through has also been reduced by the fact that money for it was not ring-fenced, according to Dr Fran Sivers, executive director of the PCCS.

Professor Kirby agrees that this contributed to the programme not being seen as a priority within some trusts. 'PCTs are always trying to save money and this involves spending more money,' he says.

Dr Griffith said her PCT was preoccupied with resolving its budget deficit and that funding for vascular checks had 'fallen into a black hole'.

Costs and confusion
Some PCTs have also found that the cost has been much higher than anticipated, says Dr Findlay.

This has particularly been the case where trusts have set up new systems for the checks, rather than using existing primary care services, he says.

Concerns about the standard of checks currently being undertaken are raised in a confidential PCCS report seen by GP newspaper. The report suggests that PCTs are counting as 'health checks' assessments that practices were already carrying out.

Cambridge GP Dr Mike Knapton, who is associate medical director of the British Heart Foundation, says it is understandable that PCTs struggling to meet targets have taken a pragmatic approach. But in the long term, simply 're-badging' current assessments could mean that large numbers of patients at high risk are left unassessed, he warns.

But he stresses the importance of ensuring that there are services set up to which patients can be referred. 'To undertake a risk assessment on a new patient without intervention programmes in place could be regarded as negligence,' he says.

Dr Peter Brindle, the Bristol GP who helped develop the QRISK cardiovascular risk assessment score, says it is encouraging to see that some PCTs are taking what he sees as a 'considered' approach to implementation.

Some PCTs are delaying implementation so they can learn what works and what does not, he says.

'There is no point in screening millions of people unless the services - such as smoking cessation or weight management - are available and this takes time to arrange,' he says.

'When millions of pounds of public money are being spent, it is worth taking time to get it right.'

With the Conservatives planning to overhaul the whole programme, it may be those PCTs that have been slow to implement the checks that have, intentionally or not, put themselves in the best position to learn from the mistakes of others and move with the political tide.

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