HSE publishes first report into the implementation of the Structured Chronic Disease Management programme in General Practice since it began in 2020


HSE Press Release:

Friday, 5 August 2022

HSE publishes first report into the implementation of the Structured Chronic Disease Management programme in General Practice since it began in 2020.


Today, (Friday 5 August) the HSE publishes the first review into the implementation of the Chronic Disease Management (CDM) programme.

  •  The report highlights the high level of GP engagement with the first phase of the CDM programme since its roll out began in 2020 – it has been taken up by 91% of General Practitioners.
  • Uptake of the CDM Programme by the eligible cohort of patients is excellent. The older age groups in particular have very high uptake rates.
  • Report demonstrates that GPs are actively engaging patients with appropriate lifestyle interventions and encouraging patients to make healthier lifestyle choices to help prevent and manage chronic diseases.


This initial baseline report is a preliminary description of the activity and basic demographics, morbidity and lifestyle risk factors among patients enrolled aged over 65 in the first 20 months of the Chronic Disease Management programme, since it began in 2020.


The Chronic Disease Management programme was a key development in the GP Agreement (2019), which commenced in 2020, and is being rolled out to adult patients over a 4-year period with a target uptake rate of 75%. Approximately 430,000 patients with chronic disease, or at high risk of chronic disease, are estimated to be registered as participants on the CDM Programme when the programme reaches full implementation in 2023.


The programme supports GPs to identify and manage patients, with a medical card or doctor visit card, who are at risk of chronic disease or who have been diagnosed with one or more specified chronic diseases such as COPD, asthma, cardiovascular disease or type 2 diabetes. It focuses on prevention, patient empowerment, early diagnosis and intervention, multi-morbidity and the provision of care as close to patients’ homes as possible.


Key findings

  • Uptake of the programme by GPs and patients is excellent with over 91% of GPs signed up to provide the programme and around 75% of eligible (65 years and older) patients enrolled, increasing to almost 82 per cent of those aged 75 and or older.
  • Almost 60% of the patients enrolled in the programme have one of the specified chronic diseases (type 2 diabetes, cardiovascular disease, asthma, COPD). Almost 27% were suffering from two, and 13% were suffering from three or more of the specified diseases.

The data gives information on the current risk factor profiles for the lifestyle risk factors of smoking, alcohol, BMI and physical activity.

  • An important part of the CDM contract is that GPs will offer a suitable intervention for patients who are current smokers. Only 9% of enrolled patients are current smokers. 13% of patients, who agreed to a smoking intervention, were subsequently recorded an ex-smoker status.
  • GPs carried out over 200,000 weight interventions with patients, with only 11% of patients declined an intervention. Most patients had more than one review since January 2020 and encouragingly the cohort of patients’ average weight decreased by 1.5 kilogrammes between the first and the third visit.
  • Some 52% of patients enrolled in the programme were reported as having adequate levels of physical activity.
  • Some 28% of patients with increased risk drinking patterns were identified by GPs. However, some 56% of patients with high risk/harmful drinking patterns declined any intervention at that time. It is encouraging to see that the cohort of patients with high or harmful drinking patterns reduced from 1.5% on the first consultation to 0.6% on the third visit. This emphasises the value of doctors continuing to engage this small proportion of patients who need their help.


Commenting on the launch of the report, Dr Colm Henry, HSE Chief Clinical Officer said: “The valuable data in this report provides a much clearer indication of the risk factors for ill-health, the health behaviours and the levels of the major chronic diseases that are present in a vulnerable cohort of the population. Promising trends in lifestyle risk behaviours have been shown with increasing numbers of reviews. Further reports will provide valuable information for practitioners and service planners.


“The Chronic Disease Management programme is an example of the HSE’s commitment to enhancing healthcare in the community and bringing care closer to people’s home. As the Chronic Disease Management programme is rolled out and fully implemented over time, it is envisaged that it will result in a reduction in hospital attendance by patients with the four conditions.”


Dr Denis McCauley, Chair of the Irish Medical Organisation (IMO) General Practitioner Committee said: “This report shows the remarkable progress in the roll out of the Chronic Disease Management programme since 2020. Despite the disruption to health services due to COVID-19, the high uptake rates among eligible patients is a fantastic testament to the hard work of GP teams across Ireland. The Chronic Disease Treatment Programme continues to be implemented, with the whole eligible GMS adult cohort now beginning the Disease Management Programme. In addition, the Opportunistic Case Finding and Prevention Programme commenced in the 65 year old and over cohort earlier this year and will be expanded further in the coming years.”


Dr Joe Gallagher, ICGP Clinical Lead for Cardiovascular Disease said: “As a GP, I know only too well the importance of supporting people with chronic diseases. This programme provides better healthcare outcomes for patients, reduces acute presentations and allows patients to become active partners in their own healthcare.  It is a credit to both GPs and to the HSE for extending a modified programme to those aged over 70 and for accelerating the programme in 2020 to all those over 70 years of age. GPs were working in very pressurised circumstances over the last two years and achieving excellent uptake rates, and such a high proportion of the service being provided in person was very valuable in protecting these vulnerable patients with chronic disease.”

The full report is available on the HSE website here.




Issued by the HSE Press Office


Notes to the editor

The Chronic Disease Management programme for General Medical Scheme or Doctor Visit Card patients was a key development included in the GP Agreement, which commenced in 2020, and is being rolled out to adult patients over a 4-year period with a target uptake rate of 75%.

The Programme, which is comprised of three components, envisages an uptake of 431,000 patients;

  • 120,500 on the Opportunistic Case Finding Programme, involving the opportunistic assessments to detect and diagnose diseases at an early stage, so that they can be appropriately managed
  • 253,500 on the CDM Structured Programme with 2 GP visits and 2 Practice Nurse visits a year
  • 57,000 on the High Risk Preventative Programme with 1 GP visit and 1 Practice Nurse visit a year.

First report of the Structured Chronic Disease Management Programme in General Practice:


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Last updated on: 05 / 08 / 2022