Over 90% of patients with chronic disease being fully managed routinely in primary care


A new review into the Chronic Disease Management programme has shown that 91% of patients with chronic disease are now being fully managed routinely in primary care, rather than attending hospital, for their ongoing chronic condition.

Dr Orlaith O’Reilly, National Clinical Advisor, Chronic Disease, said they were “committed to enhancing healthcare in the community and bringing care closer to where people live.” Learn more about the programme here:

The programme supports GPs to provide a structured treatment programme for patients with one or more of four chronic diseases – asthma, type-2 diabetes, chronic obstructive pulmonary disease and cardiovascular diseases.

It is estimated that approximately 430,000 patients with chronic disease, or at high risk of chronic disease, will be registered when the programme reaches full implementation this year.

According to Dr Shane McKeogh, ICGP/HSE Clinical Lead for Adult Respiratory Disease, “As a GP, I’m very aware that patients living with these conditions are often some of the most vulnerable people in society. It is wonderful to be in a position to provide this programme of structured reviews for our patients right in their community through their GP and practice nurse twice a year.  At ground level, feedback from the programme has been hugely positive from patients and GPs alike.”

Since 2020, about 800,000 reviews of patients were carried out by doctors, with significant improving trends for lifestyle risk factors. These included a total of 13% of patients who gave up smoking between their first and third visits to the doctor. Of those reporting inadequate physical activity on the first visit, there was a 48% improvement by the third visit, with 30% achieving adequate levels of exercise. Among those with risk of alcohol behaviour, 67% were either normal drinkers or non-drinkers by the third visit.

Improvements in patients’ blood pressure, cholesterol and blood sugar levels were also observed over time.