The man in charge of implementing Alan Milburn's heart disease framework says he will achieve his aims by charm rather than brute force. Kaye McIntosh reports

Managers may suspect that health secretary Alan Milburn's crusade against heart disease is an order. You don't disobey the man at the top, especially when he's telling everyone he wants to save 44,000 lives each year.

But the newly appointed 'heart czar' says the campaign will begin with a charm offensive.

Dr Roger Boyle denies any suggestion that the coronary heart disease framework, launched last week, is a top-down programme.

'How people are going do it is down to local decisions, but the standards are fixed.'

While the national director of heart disease recognises that managers are having to deal with a whole raft of competing priorities handed down by ministers, he says wryly, 'I will charm people into submission.'

But no-one should doubt the importance of the framework, only the second in a series of blueprints spelling out the government's key pledges for the NHS. It is a weighty range of documents, detailing plans to help the 300,000 people who suffer heart attacks every year and the 1.4 million living with angina.

It moves from setting up 'stop smoking' clinics to registers of patients with or at risk of CHD to carrying out more investigations. Setting up fast-track chest-pain clinics, training more heart specialists and carrying out more coronary artery bypass grafts and angioplasties are also on the agenda.

Not forgetting cutting waiting times - eventually to three months for heart operations.

Dr Boyle, a consultant cardiologist at York Health Services trust, says:

'People on the ground will have to accept this is a very big political priority with a capital P.'

He has already met the NHS Executive regional directors charged with delivering the framwork. 'It (the framework) requires performance management at all levels. From the local implementation team, planning services and monitoring them, through the regional offices, which are not set up for this at the moment.'

He is establishing a CHD 'collaborative team' at the Department of Health to oversee and improve the framework.

It will look at everything from chest pain clinics to protocol-led management of CHD to open-access services and outreach clinics.

Thirty potential members have already met for a 'brainstorming session', but it will become more formal shortly. It is likely to be made up of a 'core base' of senior managers, doctors and nurses. Advisers from interested parties such as the British Cardiac Society and National Heart Forum will also be invited to take part.

Setting up 50 fast-track chest pain clinics this year and 50 more in 2001 is an early priority. Dr Boyle says: 'There will probably be seven or eight clinics per regional office.' He suggests that the clinics might end up in 'places with long waits, high need, single-handed cardiologists', but says the decision 'will vary by region'.

With this amount of planning and change to services, Mr Milburn's pledge to cut the number of deaths from CHD by 40 per cent in 10 years could be very expensive indeed.

He has announced£100m to cover training 110 more cardiothoracic surgeons, setting up the first 50 fast-track chest pain clinics, speeding up ambulance response times and buying defibrillators. But there is no extra money yet for the biggest cost pressure - prescribing cholesterol-lowering drugs to people who don't have heart disease but are at high risk of developing it.

The NHS is already spending ever increasing amounts on statins: more than£92m four years ago,£200m last year - and that's just for some of the people with heart disease. GPs will now have to register and treat every patient with raised cholesterol levels, who have at least a 30 per cent risk of having a heart attack or stroke over a decade.

The National Heart Forum says the cost-effectiveness of different statins ranges from£5,400 to£13,300 for each extra year of life. 'Stop smoking' therapy costs between just£212 and£873 on the same measure.

The framework says the main source of funding for better statin prescribing is the government's comprehensive spending review. The second review - known as CSR 2000 - is due to report later this year and prime minister Tony Blair has already indicated he is pressing for more money for the NHS.

But that won't necessarily trickle down to the primary care groups which hold drug budgets. They are already overspent, following last year's sharp increases in the price of cheaper, unbranded, drugs.

British Medical Association GPs' committee chair Dr John Chisholm praises the 'commitment to the appropriate use of aspirin, beta blockers and statins.

'However, resources must be provided to underpin these developments and to fund the increased prescribing costs that will ensue.'

Dr Michael Dixon, chair of the NHS Alliance, says: 'These seem like sensible targets but there are other national Oh Lord, deliver us: Alan Milburn, left, and Dr Roger Boyle launch the framework.

service frameworks coming. We have got mental health, we have got Calman-Hine [cancer standards].

What happens when you start adding up the implications?'

Current prescribing for heart disease is a 'hotch potch', with even the most go-ahead surgeries just about working on registers of those who have CHD, let alone those at risk, he adds. The changes from the framework 'will incur a massive increase in costs' which 'really will blow our drugs bills'.

Dr Boyle says: 'It is very difficult to earmark money for prescribing budgets. But we are not expecting the statin story all at once. We have got to get the registers in place first and proper prescribing guidelines in place.'

There is some reassurance from Mr Milburn. Launching the framework, he said: 'If the drugs budget goes up, if these are clinically and cost-effective treatments, then fine.'

On the Boyle: key dates

1948 Born, 27 January 1972 Graduates, MBBS

1976 Member, Royal College of Physicians

1983 Consultant cardiologist, York District Hospital.

1994 Member, joint committee on higher medical education.

1997 Chair, specialist advisory committee on cardiovascular medicine.

1998 Member, external reference group on coronary heart disease national service framework.

Standard-bearing: what the NHS must do

Develop and implement policies that reduce the prevalence of risk factors in the population and reduce the gap between rich and poor.

Help to reduce smoking .

Identify, advise and treat people with established, or at high risk of developing, cardiovascular disease.

Treat people having a heart attack with a defibrillator within eight minutes of a call for help.

Within an hour of a call for help, assess patients professionally and offer aspirin and thrombolytic drugs.

Put in place protocols so that people with heart attacks are assessed and treated with clinical and cost-effective therapy.

Investigate and treat appropriately people with angina.

Refer people with worsening angina to a cardiologist.

Introduce hospital-wide care systems so patients with suspected or confirmed CHD are treated quickly and appropriately.

Introduce hospital-wide systems so CHD patients are offered rehabilitation programmes before leaving hospital.