This paper utilizes qualitative data drawn from a series of focus group discussions with patients living with coronary heart disease which explored their understanding of and adherence to a prescribed monitoring and medication regime. These findings are drawn upon in order to contextualize, from the patient’s perspective, the outcomes of the Departments of Health’s Coronary Heart Disease National Service Framework strategy.

The paper focuses attention on the consequences of this regulatory approach to clinical and risk management for those patients already living with coronary heart disease.

Case Study

Patient is 59 yrs old and had a myocardial infarction 2 years ago. He is obese, a smoker and poorly motivated. The case exemplifies many of the difficulties that frequently arise in managing cardiovascular disease, and suggests potential avenues for improving outcomes through the application of a disease management programme.

The Coronary Heart Disease National Service Framework

By the mid 1980s, it had been generally accepted by most clinicians that there was strong evidence to support the existence of a linear relationship between cholesterol levels and cardiac mortality (Shaper et al. 1985, Stamler et al. 1986), and that therefore lowering total cholesterol levels would reduce the risk of individuals developing coronary heart disease.

This opened the way to the process of establishing a recommended cholesterol threshold level at which treatment should be instigated (Leitch 1989). Since then, the trend has been towards setting ever-lower threshold targets for treatment for those designated as being at high risk of developing coronary heart disease and for those already living with the disease.

In 2000, the Department of Health published its Coronary Heart Disease National Service Framework which set out 12 standards for the prevention, diagnosis and treatment of the disease (Department of Health 2000). The National Service Framework standard Number 3 recommended that GPs identify and develop a register of diagnosed patients and those patients at high risk of developing coronary heart disease. Dietary and lifestyle advice (what the document terms ‘modifiable risk factors’) was to be offered to these patients, and their medication reviewed at least every 12 months. It was also recommended that statins be prescribed to anyone with coronary heart disease or having a 30% or greater 10-year risk of a ‘cardiac event,’ in order to lower their blood cholesterol levels to less than 5 mmol/l or by 30% (which ever is greater). These recommendations were vigorously promoted when they were incorporated into the new General Medical Services contract that came into operation in 2003.

The relative performance of an individual Primary Care Organization in meeting each of these indicators attracts points on a sliding scale that are then converted into payments for individual GPs. In relation to the management of patients with coronary heart disease, higher payments are received if a