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Background Effective management of coexisting heart failure (HF), chronic kidney disease (CKD) and type 2 diabetes mellitus (T2D) is critical, yet evidence of adherence to guideline-recommended standards in routine care remains unclear. We aimed to assess primary care adherence to guideline-recommended standards for patients with overlapping HF, CKD and T2D in England.Methods Using UK Clinical Practice Research Datalink (1998–2020), we evaluated care adherence across 161 529 individuals with HF, CKD or T2D before and after developing a second of these conditions. We analysed disease investigation rates, medication use and predictors of guideline adherence.Results We identified 161 529 patients with CKD followed by HF (CKD+HF, 40%), CKD+T2D (51.3%) and HF+T2D (8.6%) with a median of 3.1 years follow-up after the second diagnosis. In CKD+HF, CKD+T2D and HF+T2D groups, prescription rates of renin-angiotensin system inhibitors (71%, 64.1% and 74.4%), beta-blockers (53.1%,36.2% and 55.1%), antiplatelets (56.2%, 45.2% and 54.4%) and statins (56.7%, 68.5% and 72%) were suboptimal. Advanced age, female sex, peripheral arterial disease and cancer were associated with a lower likelihood of checking blood pressure, creatinine and glycated haemoglobin (HbA1C) after HF, CKD and T2D diagnoses, respectively. The first diagnosis of HF was associated with reduced odds of having HbA1C measured after T2D diagnosis (OR 0.79, 95% CI 0.72 to 0.86), compared with CKD as the first diagnosis.Conclusions In overlapping HF, CKD and T2D, guideline-recommended care is suboptimal, with inequalities by age, sex, disease on first presentation and comorbidities. Quality improvement requires linked data collection, monitoring and action across diseases.