Primary care prevention of cardiovascular disease in diabetes

In the United Kingdom about 8% of National Health Service (NHS) resources are presently taken up by diabetes care, the cost of type 2 diabetes consuming 80% of that total. General practitioners are actively commissioning routine diabetes care for type 2 diabetic patients. This shift to primary care management has been accompanied by an overall change in focus for the NHS, with the introduction of evidenced‐based medicine, clinical governance and National Service Frameworks in important clinical areas including diabetes. Diabetic patients have a 2 to 5 fold higher risk of dying from coronary heart disease. In order to be most effective practices will want to prioritize patients for risk reducing interventions. People with diabetes may be stratified into three groups: those with established CHD or other atherosclerotic disease; diabetic patients who are at high risk of developing CHD or other atherosclerotic disease due to a combination of risk factors including: smoking, obesity, hypertension, hyperlipidaemia and proteinuria and close relatives of patients with early onset CHD or other atherosclerotic disease. There are now a number of clear evidence‐based interventions, which can prevent this. The ambitious National Service Framework (NSF) for coronary heart disease and the anticipated NSF for diabetes will underline the importance of these inventions, and present the primary care team with a considerable challenge. Effective protocols and audit will have to be agreed and implemented. Clinical governance is designed to ensure and improve clinical standards throughout the NHS. It could include action to ensure that risk is avoided; inappropriate clinical management is rapidly detected, openly investigated and lessons learned; good practice, such as demonstrated in the UKPDS, is rapidly disseminated; and systems are in place to ensure continuous improvements in clinical care. Adequate resources will have to be identified for these important interventions to be implemented. Copyright © 2001 John Wiley & Sons, Ltd.