Wrangles between the Treasury and the Department of Health have been 'central' to lengthy delays in publishing a national service framework for coronary heart disease, according to HSJ sources.

'The Treasury was very worried about the cost implications of some of the measures put forward,' said one insider.

Implementation of the service framework for coronary heart disease, and its counterpart in mental health, was scheduled to start in April - but the frameworks themselves remain under wraps and are expected to emerge later this month.

Doncaster health authority director of public health Dr John Radford said that goals to 'widen the net' to increase the number of low and medium- risk patients monitored for coronary heart disease would be 'hugely expensive'.

The knock-on effect on prescribing rates and the number of secondary care interventions could make 'a massive impact on public health and the mortality of coronary care patients' and marked a 'fundamental shift in the way services could be delivered', he added.

'But there is a price to be paid. I think someone at the DoH has realised the cost of this work.'

An external reference group chaired jointly by Professor George Alberti, president of the Royal College of Physicians, and NHS Executive director of health services Dr Graham Winyard began work in April 1998. Recent drafts of the CHD framework are believed to focus on eight key targets which will be measured within agreed timescales.

Barking and Havering public health specialist Dr Mark Ansell said 'delays which had dragged on and on' had weakened the potential impact of the framework to motivate staff in the field.

'I don't think anyone is holding their breath any more.'

HAs 'had not been encouraged to expect a lot of new money - if indeed any,' added Dr Ansell.

Liverpool HA consultant in public health Dr Ewan Wilkinson said delays in publishing the framework had 'caused some problems' locally, with some schemes held back because 'we didn't want to go off at half cock, before the direction was made clear.'

NHS Confederation policy director Nigel Edwards welcomed the framework as 'a good starting point' to tackle a 'daunting task ahead'.

'There is an awful lot of work to be done and there are some large variations around the country. The framework is very large and covers an awful lot of ground - my concern would be how well all that information can be used at a local level,' he said.

A DoH spokesperson denied that finance was central to the delays, which she said were caused by the 'enormous amount of work' generated by the framework.

'It is important that all the implications of the standards it will set have been fully explored and worked through before it is published,' she said.

The long and winding road

'These frameworks aren't statements of pious hope. Each of them will spell out the practical arrangements which will be put in place to prevent and treat the various conditions they cover.' Health secretary Frank Dobson, April 1998.

'The NHS, working with partner agencies, will be expected to begin to plan for implementation from April 1999.'

HSC 1998/074, April 1998.

'You can never judge how long these things are going to take. It is an enormous piece of work.' DoH, September 1999.