GP chronic disease programme makes a difference for 400,000 people in Ireland

Since its launch in 2020, the HSE Chronic Disease Management (CDM) Treatment Programme in General Practice has helped over 400,000 patients. 91% of these patients now receive routine chronic disease care within the community, closer to their home.

Figures published today demonstrate the positive impact of the programme, transforming people’s health journeys and improving the quality of life of people living with chronic diseases across Ireland.

The CDM Treatment Programme is an essential element of the HSE Enhanced Community Care Programme, linking General Practice and community services, and delivering care to patients in the right place at the right time.

Clinical Lead for the Chronic Disease Treatment Programme in General Practice, Dr. Orlaith O’Reilly said: “We are incredibly proud of the transformative impact the Chronic Disease Management Programme is having on patient care across Ireland. As part of the Enhanced Community Care Programme, the programme fosters early detection and proactive management of chronic diseases within community settings. We are significantly reducing the need for hospital-based interventions and empowering patients to take charge of their health. This programme exemplifies our commitment to delivering high-quality, accessible care that improves outcomes and quality of life for individuals with chronic conditions.

Since its inception, the programme has reached over 400,000 patients, with 91% now receiving routine care in community settings, reducing their reliance on hospitals. Participants have experienced 30% fewer ED attendances, 26% fewer hospital admissions, and 33% fewer GP out-of-hours visits.

The collaboration and support from General Practitioners, with a 97% participation rate, have been instrumental in achieving these results. Together, we are making meaningful strides in the way chronic diseases are managed in our communities."

Supporting Hospital Based Care

Among the 270,000 patients participating in the programme reviewed by their GPs in the first half of 2024, only 7.6% had visited an Emergency Department (ED) in the preceding six months. This is a notable reduction compared to the 16% ED attendance rate reported in the general population by the Healthy Ireland survey in 2023, especially considering the higher age and multimorbidity of the patients in the programme. This is further supported by an audit by the Irish College of General Practice (ICGP) which revealed that patients enrolled in the CDM Treatment Programme experienced:

● 30% fewer ED attendances

● 26% fewer hospital admissions, and

● 33% fewer GP out-of-hours attendances compared to their pre-enrolment rates.

Dr Shane McKeogh, ICGP/HSE GP Integrated Care Lead for Adult Respiratory Disease added: “The new Chronic Disease Management Programme in General Practice, now in its 5th year, has been a game changer for eligible patients (patients with medical cards or doctor visit cards) living with Type 2 Diabetes, COPD, Asthma and cardiovascular illness in Ireland. 

Supported by 97% of GPs, and providing structured reviews twice yearly when patients are well as opposed to unwell, it represents a giant step forward for the provision of care outside the hospitals. It also demonstrates the power of General Practice to deliver whole country large population health impacts when appropriately resourced.”

Decreased Unscheduled Admissions

In the first half of 2024, only 8% of the 270,000 patients attending scheduled GP reviews were admitted to hospitals in the prior six months. This compares favourably with the Healthy Ireland 2023 data indicating a 12% annual admission rate among the general population.

These results highlight the CDM Treatment Programme's success in delivering proactive, community-based healthcare, reducing hospital dependency, and promoting early disease detection, ultimately enhancing the health and well-being of Ireland's population.

Early Detection Enabling Disease Management

As populations age, the prevalence of chronic conditions, including multimorbidity, rises. Early detection through the CDM Programme will prevent the need for more intensive hospital-based treatments. Since 2020, 51% of new chronic disease diagnoses have been made through the programme. By shifting the focus toward prevention and early intervention, the programme is redefining healthcare delivery, transforming people’s health journeys and promoting sustainable healthcare practices.