Doctors and the government are at loggerheads over the best way to tackle coronary heart disease in Scotland.
Coronary heart disease kills almost 17,000 people in Scotland every year and accounts for 70,000 hospital admissions. But now the country's most eminent doctors are attacking the government for putting too much emphasis on health promotion.
A report by the Intercollegiate Review Group on behalf of the three Scottish medical royal colleges says the Scottish Office's policy on CHD is inaccurate, inconsistent, misleading and, in places, 'mischievous'.
But their attack has bemused some since it has taken the doctors more than a year to publish their document responding to a report first published by the Scottish Office in 1996.
Scotland is acknowledged as having one of the worst records in the Western industrialised world for CHD deaths. The total cost to the country is over pounds570m a year, including more than pounds140m in direct NHS costs.
Health boards and the Health Education Board for Scotland spend pounds5.7m on CHD health education and promotion, which represents 'only 4 per cent of total expenditure by the NHS on CHD in Scotland', says the Scottish Office.
In addition there is a nine-fold variation in funding between different health boards.
The Scottish Office report urges boards to 'plan coherently, prioritise and shift resources in order to introduce a CHD strategy'. It says that 'well designed and targeted' health promotion programmes can have a significant effect on reducing risk and represent good value for money.
What is more, it calls into question the value of using drugs to lower cholesterol, the long-term benefit of bypass surgery and the merits of specialised coronary care units.
It says research has failed to provide proof of clinical benefits specifically from coronary care units as opposed to care on a general medical ward. Furthermore, CCU patients are often 'over-investigated and over-treated'.
'If a health board is presented with a proposal from one of its providers to expand, replace or establish a new CCU, it should bear in mind that while the immediate care of patients with suspected heart attacks in CCUs is considered good practice, there is some ambiguity in the scientific literature about the outcomes achieved from treatment specifically in a CCU.'
The Intercollegiate Review Group, chaired by Keith Fox, professor of cardiology at Edinburgh Royal Infirmary, denies this, saying the trials referred to were carried out more than 30 years ago and are 'seriously flawed'.
The doctors believe CCUs are valuable. 'General medical wards are neither equipped nor staffed for monitoring and treating acutely ill myocardial infarction patients,' they say.
'By implication the CHD report suggests that CCU treatment wastes money on unnecessary and ineffective treatment. This is unsupported by hard evidence and... is potentially damaging.'
The statement that patients admitted to CCUs are sometimes over-investigated and over-treated is 'mischievous', the doctors add, while there is no evidence to support such a claim.
They also take issue with the CHD report's emphasis on health promotion and education. They recognise 'that effective prevention measures are important in reducing the burden of CHD', but say that the CHD report 'overstates the possibilities of reducing the need for treatment of clinically manifest CHD'.
And they stress that the long timescale over which prevention measures are effective means there should be no reduction in the resources available for established cardiac disease.
The doctors further criticise the Scottish Office report for 'failing to satisfy published criteria for the compilation of evidence and the formation of guidelines'. Insufficient distinction is made between treatments/prevention strategies for survival advantage and those for reduced morbidity, says the doctors' report.
They accuse the Scottish Office report of 'not differentiating appropriately between what can be achieved and what can be afforded' in the prevention and treatment of heart disease.
The doctors say the Scottish Office report devotes only nine lines to heart failure, which is common for advanced CHD, is a major cause of morbidity and mortality, and cost the NHS in the UK pounds360m in 1991.
The Scottish Office report also developed a cost-effectiveness table without 'the benefits of independent expertise in health economics and cost-effectiveness', rendering the table 'misleading', they add.
In view of the 'serious shortcomings' in the evidence underpinning many of the report's recommendations, any implementation of the CHD strategy should be halted until the issues are properly addressed, the doctors conclude.
But the Scottish Office believes things have moved on significantly since the CHD report was published, and questions why it has taken the doctors so long to formulate a response.
'Since that report came out, health boards have been developing their own strategies for CHD, and the Scottish Office has set up the CHD/stroke priority action team to take forward the work in this area,' says a spokeswoman.
'This team has said it will take account of the intercollegiate report's comments.'
Trevor Jones, general manager of Lothian health board, says so far the board has not transferred any resources from treatment to prevention. 'We are still developing a coronary care strategy and we are awaiting a report from our own Lothian working group on this,' says Mr Jones.
Meanwhile, Harry Burns, public health director at Greater Glasgow health board, says he is 'bemused' by the whole argument.
'The intercollegiate report seems to think health boards swallow government documents uncritically,' says Dr Burns. 'We are no more likely to do that than we are to swallow the intercollegiate report.
'Both will be subject to the critical scrutiny of health boards. We are not going to align our purchasing policies around either document without looking at the evidence ourselves.'
The cardiologists' fears are recognised and many of their anxieties are justified, adds Dr Burns. 'But they need not worry that health boards and public health departments are in any way slavishly following what the Scottish Office says.'
Coronary Heart Disease in Scotland, report of a policy review. The Scottish Office public health policy unit, 1996, pounds18. Available from the Stationery Office. Intercollegiate Comments on Scottish Office Coronary Heart Disease Report, Intercollegiate Review Group, 1998. Royal College of Physicians of Edinburgh, 9 Queen Street, Edinburgh EH2 1JQ.