Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)

The GP chronic disease management programme commenced in 2020 and has been rolled out on a phased basis over four years to adults with either a medical card or, for GMS patients, a GP visit card. The aim of the programme is to prevent and manage chronic diseases. Since 2020, over 680,000 patients have been registered on the programme, including those who have exited the programme. Some 91% of patients now receive routine care in community settings, reducing their reliance on hospitals. An ICGP study found that for patients enrolled in the treatment programme, there were 30% fewer emergency department attendances, 26% fewer hospital admissions and 33% fewer GP out-of-hours attendances compared with their pre-enrolment rates.

The majority of patients manage their conditions through the GP chronic disease management programme. In addition, the 26 operational community specialist teams for chronic disease management, linking the care pathways between acute and community services, are delivering services from integrated care hubs located in or adjacent to primary care centres. They are fantastic. In 2024, over 354,000 patient contacts were provided by community specialist teams for chronic disease management, about 55% ahead of target, and this year to the end of quarter 1, 108,000 patient contacts had already been provided by these teams, which is about 30% ahead of target.

The conditions covered by the programme are type 2 diabetes; asthma; chronic obstructive pulmonary disease, COPD; and cardiovascular disease. The treatment programme supports patients in managing their chronic conditions. Patients receive two reviews in a 12-month period, with each review including a practice nurse and a GP visit. GMS patients over 45 years of age found to be at high risk of cardiovascular disease or diabetes are enrolled in the prevention programme and receive one annual review. The prevention programme was expanded from 30 November 2023 to include adult GMS patients with hypertension and all women who have had a diagnosis of gestational diabetes or pre-eclampsia since 1 January 2023.

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