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This pilot initiative uses an approach that focuses on improving the whole business of primary care, its processes and its people. The Health Informatics Programme for Coronary Heart Disease (HIP for CHD) addresses the two faces of clinical governance but has a prime focus on the development of learning organisations. The project has developed a methodology and an associated set of tools that it has tested and evaluated in a small number of pilot sites. The work of HIP for CHD is focused on coronary heart disease but the methodology is equally applicable to other clinical areas. In particular, HIP for CHD provides an approach that allows the diverse strands of all of the National Service Frameworks to be handled in a joined-up way in primary care.

One of the major public health challenges facing clinicians in primary care is the effective management of the overweight, sedentary person with dyslipidaemia, hypertension, hyperglycaemia and type 2 diabetes. The culprit for this cluster of metabolic and haemodynamic abnormalities has been known since 1988 when Reaven explained the link between insulin resistance and treated or untreated hypertension, as a consequence of the high insulin concentrations found in insulin resistant people — i.e. insulin resistance is a significant risk factor for heart disease. Over a decade has passed but there are still many clinicians with little understanding of insulin resistance and the catastrophic consequences that result from underrecognition and under-treatment. This feature will seek to put a new face on old knowledge, unpack the characteristics of insulin resistance and offer a practical way forward. The size of the challenge It is estimated that two million people in the UK suffer from type 2 diabetes, although only 50% may be diagnosed. The lifetime expectation of developing the disease is thought to be greater than 10% (King’s Fund Policy Institute, 1996). The annual cost of caring for people with type 2 diabetes is £2 billion, or 4.7% of total Health Service expenditure. This is much higher than for cancer or asthma, which account for 2.1% and 1.6% of the NHS spend respectively. Life expectancy of a person with type 2 diabetes is reduced by eight to ten years (Campbell, 1997). Therefore, the cost to the individual, being premature death, is far higher.