Letters

National service framework's financial implications are huge

EDITORWe are delighted that tools for assessment of risk of cardiovascular disease have been addressed in a whole issue of the BMJ.¹ It is unfortunate that so many calculators (Sheffield mark 2; New Zealand mark 2) cannot agree on definitions and may not in fact give the same results for each patient.² We have compared 10 risk algorithms, and, while the Sheffield tables underestimate risk in patients with diabetes at 3% per year, the revised (but not the old) New Zealand guidelines match the performance of other guidelines: British, European, University College London, as recommended in the national service framework for coronary heart disease.³

The only European risk calculator based on the Munster heart study has not been mentioned in the national service framework.² It is applicable to cases of secondary prevention and factors for risks owing to family history and triglycerides, and, in addition, its original database is more modern than the rather dated United States population study (Framingham).

We agree with Montgomery et al and Isles et al in the special issue that computerised calculators offer no advantage over card based methods and are more difficult to use.¹ They are also more subject to systematic bias induced by biological variation in the input variables than card based systems.

The United Kingdom has a large burden of coronary heart disease as a result of both hyperlipidaemia and hypertension. The editorial by Jackson, which says that the evaluation of risk factors should include measuring blood pressure but not cholesterol testing, follows false logic.⁴ The cost of measuring blood pressure properly (£15) far exceeds the cost of blood tests for full lipid profiles including the concentrations of low density lipoprotein cholesterol (£3-5) and total cholesterol (£1-2). This is not obvious only because costs in staff time are neglected as these are treated as a marginal cost and not as a finite limited resource. The implications of the national service framework for nursing time are such that such calculations are no longer tenable.

The challenge has now been laid down to the medical profession to deliver drug treatment for secondary prevention at 2.5% per year risk and at a higher risk threshold for primary prevention of 3% per year. The financial implications for general practice, drug budgets, pathology laboratories, and secondary sector preventive and classical cardiological services are huge. This programme is capable of absorbing a substantial part of the rise in the NHS budget even if it is properly funded. If it is not, it will fail.

Anthony S Wierzbicki, senior lecturer in chemical pathology. 
St Thomas's Hospital, London SE1 7EH

Timothy M Reynolds, professor of chemical pathology. 
Queen's Hospital, Burton-on-Trent DE13 0RB

Professor Reynolds and Dr Wierzbicki have been paid for giving talks, been reimbursed for attending conferences, and received funds for clinical research in cardiovascular disease by manufacturers of lipid lowering and antihypertensive drugs.