Coronary heart disease and the management of risk: Patient perspectives of outcomes associated with the clinical implementation of the National Service Framework targets

Abstract

This paper explores developments in the risk management of coronary heart disease (CHD) that have followed the implementation of the Coronary Heart Disease National Service Framework (NSF) guidelines from the patient's perspective. The CHD NSF introduced in 2000 set national threshold targets for blood pressure and cholesterol levels for primary care managed patients, it also laid down guidelines for the clinical management of those patients deemed to be at 'high cardiac risk.' Additionally, following the implementation of the revised General Medical Services contract in 2003, financial incentives were introduced to encourage general practitioners to meet these national regulatory guidelines. This paper draws upon the outcomes of a series of focus group discussions with patients with current prescriptions for both hypercholesterolaemia and hypertension carried out in Scotland and South-East England. The findings suggest that many of the patients perceived the regular monitoring of their total serum cholesterol level and subsequent titration of statin therapy as being the primary method by which their heart disease was now to be clinically managed. Patient perceptions of their role in the self-management of their condition were frequently confined to compliance with their monitoring and medication regime. The paper concludes by arguing that, for many of the patients in the study, the implementation of this national cardiac risk management guidance has had the consequence, whether intended or not, of reinforcing a position of medical dependency.

What is wrong with ‘being a pill‐taker’? The special case of statins

“…The case of statins is used here to problematise that tension, highlighting the articulation between critiques of ‘dependency’ on doctors and pills (Crinson et al . ) and the growing valorisation of the autonomous, self‐determining individual characterised by Crawford () as a ‘bourgeois ideal’. This study suggests that those offered statins negotiate a complex tangle of conflicting norms which is perhaps too seldom considered by those who advise or study them.…”

“…Within the social science literature, this trope is sometimes implicitly in tension with a broader anti-medicalisation discourse that highlights the medicalising effect of individual responsibilisation for health and identifies healthism as 'a form of medicalisation' (Crawford 1980: 381). The case of statins is used here to problematise that tension, highlighting the articulation between critiques of 'dependency' on doctors and pills (Crinson et al 2007) and the growing valorisation of the autonomous, self-determining individual characterised by Crawford (1994) as a 'bourgeois ideal'. This study suggests that those offered statins negotiate a complex tangle of conflicting norms which is perhaps too seldom considered by those who advise or study them.…”

“…A substantial body of research examines statin decisions, documenting understandings of cholesterol (Polak , Sachs ) and risk (Crinson et al . , Farrimond et al . ) and the way these get used in decision‐making (Gale et al .…”

“…Adopting this focus on the practice of pill-taking (rather than on the pills themselves), this article considers the morally-infused identity work involved in one health decision: deciding whether to take statins. A substantial body of research examines statin decisions, documenting understandings of cholesterol (Polak 2016, Sachs 1996 and risk (Crinson et al 2007, Farrimond et al 2010) and the way these get used in decision-making (Gale et al 2011, Polak andGreen 2015b); but neither these nor more general accounts of resistance to medication or barriers to adherence seem adequate to explain why Smeeth and Hemingway (2012) find the 'pill for every ill' scenario inherently 'unattractive'. An alternative explanation for their widely shared distaste centres on the identity potentially conferred by the practice of pill-taking.…”

Beyond beliefs: risk assessment technologies shaping patients’ experiences of heart disease prevention

“…There are no studies on how real users who have undergone CHD risk assessment and prevention experience this contradiction. A focus‐group study found that patients were frustrated with the restriction of heart disease prevention to the clinical monitoring of cholesterol levels and manipulating them with medications (Crinson et al 2007). Risk assessment technologies may play a greater role in influencing individuals’ experience of CHD risk, because it is considered imperceptible (Angus et al 2005).…”