Annual Chronic Disease Management Prevention programme

The annual chronic disease management prevention programme is for people who:

A chronic disease is a long-term health condition that needs ongoing treatment and management. Cardiovascular disease and diabetes are chronic diseases.

The prevention programme is being rolled out over 2 years for eligible patients. You'll be invited to join the programmes based on your age.

  • 2022 - 65 years old and over
  • 2023 - 45 years old and over

Benefits of the programme

The programme is designed so that you and your GP can work together on reducing your risk of developing cardiovascular disease, diabetes or both.

The Prevention Programme supports you by providing:

  • an annual review with your GP and practice nurse
  • a review of your medicines
  • a plan to help you manage your risk factors
  • health promotion advice
  • appropriate medical treatment
  • referrals to support services, if needed
  • care in your community, close to your home

Registering for the programme

If you are at risk of cardiovascular disease, diabetes or both, your GP will ask you if you want to take part in the programme.

Your GP or practice nurse will arrange a review with you and register you for the programme.

How the programme works

The programme is free and includes one review in every 12 month period.

Each review includes one visit with the practice nurse followed by a visit with your GP. You can see your GP and practice nurse during the same review or separately at different times.

Your GP or practice nurse will give you advice on lifestyle changes that will help you manage your risk factors.

They will refer you to support services if you need them. For example, they may refer you to help to stop smoking or to manage your weight.

Your review will include tests such as blood tests. There is no charge for any tests that are part of your programme review.

You can still visit your GP as normal outside of the scheduled programme reviews.

Care plan

You will get a written care plan after each review. This care plan will help you learn about your risk factors and the steps you can take to improve your self-management.

You can work with your GP to set your own goals.

Your information

Your GP or practice nurse will record certain information about you at each structured review.

This will include your:

  • name and age
  • chronic disease risk factors
  • medical history
  • details of any symptoms or tests you have had since your last visit

Your GP will send information to us at the end of each structured review. This will include your name and address, medical or GP card number, and medical history.

Your personal information is stored in line with current data protection regulations. You will have full and open access to the personal information we keep about you. You can ask for it from us at any time.

Read the privacy statement for the Chronic Disease Management Programme (PDF 472KB, 1 page)

How we use your personal information

The information we gather is important in helping us to improve our understanding of chronic diseases.

It will improve the way we detect, treat and prevent chronic disease. It will also help us deliver an improved service to people with a risk of developing cardiovascular disease or diabetes.

Opting out of the programme

It is your choice to take part or not. You can leave the programme at any time by letting your GP know. This means that you will not receive reviews and other care planning under the programme. You can always rejoin the programme if you wish

Speak to your GP or practice nurse if you have any questions about the programme.