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LETTERS: Roger Boyle DoH explains thinking behind national service framework for coronary heart disease BMJ 2000; 321: 1083 [Full text]

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NSF and clinical governance

Jeremy F R Dobbs   (30 October 2000)

Age and the NSF for coronary heart disease

I Mahy   (9 December 2000)

The implications of the NSF for coronary heart disease

Philip H Evans   (2 January 2001)

NSF and clinical governance 30 October 2000
Jeremy F R Dobbs, GP Cerne Abbas Surgery, Dorset. Send response to journal: Re: NSF and clinical governance	Whilst it is very helpful to have clarification on the obvious ambiguity in the NSF's statement on lipid lowering targets, it is concerning that it has taken this long and that it is unlikely to reach the grass roots for equally long again. It is also frustrating that Dr Boyle does not comment on Dr Lloyd-Mostyn's valuable criticism of the NSF's definition of its audit standards. These poorly defined standards are abound at present in all primary care clinical governance causing much confusion and cynicism. This is most unfortunate when the principle is sound.
Age and the NSF for coronary heart disease 9 December 2000
I Mahy, Cardiologist Torbay Hospital Send response to journal: Re: Age and the NSF for coronary heart disease	The National Service Framework for coronary heart disease sets clear targets for the proportion of patients expected to receive a range of secondary preventive measures. It indicates that treatment should be independent of age, despite the fact that audit data is to be collected for the age group 35-74. Conversely, it is indicated that the NSF is intended to be in keeping with the joint British guidelines which expressly indicate an upper age limit of 75 for lipid lowering therapy for secondary prevention (69 for primary prevention). While we await further evidence on the role of statins in the elderly what is the intention of the NSF. Cost, secure evidence, clinical extrapolation and political correctness appear to be pulling in different directions. Whether we agree with the Joint British Guidelines or not at least they provided valuable clarity in an area where resource considerations for the population and issues germane to the individual may clash. With the publication of the NSF this clarity has been lost - what is the intention of the NSF in relation to secondary prevention in the elderly?
The implications of the NSF for coronary heart disease 2 January 2001
Philip H Evans, General Practitioner St Leonard's Medical Practice, 34 Denmark Road, Exeter EX1 1SF Send response to journal: Re: The implications of the NSF for coronary heart disease	EDITOR – We have read with interest the letter in the British Medical Journal of 28 October by Dr Roger Boyle, 1 the NHS lead for coronary heart disease. Most patients with coronary artery disease will be managed by their primary health care team. There are three problems with the National Service Framework (NSF) on coronary heart disease: the first is exactly what is the evidence for the proposal to reduce the blood cholesterol to either 5 mmol or 20%-25% of the previous total cholesterol level, i.e. precisely which research publications are being relied upon for this conclusion? None were cited in Dr Boyle’s letter. Secondly, why has such a complex target been set? This makes it unusually difficult in general practice consultations to both calculate the fall in cholesterol and also to explain this to patients. A mixed target makes it difficult to audit results. Thirdly, the NHS needs to be clear that it can afford this NSF. In our practices, the NHS prescribing budget does not, as far as we can see, allow for statin prescribing on the scale recommended by the NSF. As in many general practices high levels of statin use have led to the prescribing budget being exceeded. This situation is exacerbated further by the increasing pressures on practice staff time that will inevitably result from implementing this NSF. 2 If practices are to take on both primary and secondary prevention of CHD as recommended by the NSF then monies will have to be specifically earmarked for this activity at practice level. Philip H Evans, GP, Exeter Denis Pereira Gray, Professor of General Practice HM Dalal, GP, Truro 1 Boyle R. DoH explains thinking behind national service framework for coronary heart disease. Letter. BMJ 2000; 321: 1083. 2. Evans PH. The primary prevention of coronary heart disease with statins: practice headache or public health? Editorial. British Journal of General Practice 2000;50:695-698.